At the University at Albany's Center for Stress and Anxiety Disorders, cognitive restructuring and exposure therapy have been integrated into a highly structured package for the treatment of social phobia. The first two sessions of cognitive-behavioral group therapy (CBGT) for social phobia are devoted to training clients in the basic tenets of cognitive therapy, especially the link between faulty assumptions or irrational thinking about social situations and anxiety experienced in those situations. Clients learn to identify their own irrational thoughts and to dispute/challenge the content of these thoughts. Each of the remaining ten sessions begins with a review of homework assignments followed by two or three restructuring/exposure exercises. Sessions conclude with assignment of homework for each group member.
Cognitive restructuring/exposure exercises constitute the bulk of the CBGT session. For each targeted client, a period of cognitive restructuring precedes a simulated exposure to a feared situation. Setup procedures prior to the exposure consist of:
Finally, concrete behavioral goals are established for the client in the exposure situation.
Criteria for appropriate goals are that they be observable by anyone in the room, measurable, reasonable or attainable given the allotted time and circumstance, within the control of the client, and focused on the specific and immediate task at hand (e.g., the aim of social interaction is to become better acquainted with another individual and to let them become more acquainted with the client). Thus, goals often take the form of number of comments made or questions asked by the client during an interaction or ideas discussed in the case of public speaking. While goals like these may appear mundane, goal setting of this sort is a critical skill in the treatment of social phobics who often harbor vague, unrealistic, and sometimes perfectionistic goals for themselves in social situations. Measurable goals allow for immediate feedback at the conclusion of the exposure, making judgment of success or failure a relatively straightforward process. With practice, focus shifts from the affective experience of the client in the situation (e.g., "I failed because I was anxious") to the tasks required by the situation (e.g., "I was able to ask three questions and make three comments").
Exposure situations are based upon individualized hierarchies of anxiety-provoking situations and clinical experience with each client. Exposures last approximately ten minutes, and subjective anxiety ratings are elicited initially and at one-minute intervals. At the same time, the client reads his/her rational response(s) aloud. Following the exposure, another period of cognitive processing is conducted. The client's goals are reviewed, and goal attainment assessed. The occurrence of ATs, expected and unexpected, is reviewed as is the use of rational responses. The covariation of ATs, rational responses, and subjective anxiety ratings is examined. The restructuring/exposure procedure concludes with a summary by the client of the main points learned.
CBGT has been evaluated in controlled trials with favorable outcomes. Heimberg et al. (1990) compared CBGT with a placebo-therapy group developed to control for therapist attention, treatment credibility, and outcome expectancy. Treatment credibility was virtually equivalent between CBGT and the attention-placebo group when assessed after one and four sessions.
Forty-nine social phobic clients were randomly assigned to either CBGT or the attention-placebo condition. Four to seven clients met for 12 weekly 2-hour sessions conducted by a doctoral level therapist and an advanced doctoral student, both trained extensively in these procedures. At posttreatment assessment, CBGT clients, as compared to attention-placebo clients, reported less anxiety during an individualized behavior test and were rated as less severely impaired by clinical assessors. At six-month follow-up, CBGT clients maintained their gains and also reported more positive and fewer negative thoughts during the behavior test than attention-placebo clients. Seventy-five percent of CBGT clients were judged to have made clinically significant improvements at posttest while 40% of attention-placebo clients were improved. At six-month follow-up, eighty-one percent and 47% of CBGT and placebo clients, respectively, were improved.
Nineteen clients from the original study agreed to participate in a long-term follow-up evaluation conducted an average of 5.5 years after they completed treatment (Heimberg, Salzman, Holt, and Blendell, 1993). Clients participating in the follow-up differed from those not participating, limiting the generalizability of the conclusions. However, differences were equivalent across CBGT and attention-placebo treatment conditions allowing us to compare these two subgroups. Even after more than five years, CBGT clients rated their phobia as less severe and reported less social avoidance compared to attention-placebo clients. Independent assessors rated CBGT clients' social fear as less severe and their symptoms as interfering less with work, social activities and family life. Assessors rated CBGT clients as barely symptomatic while attention-placebo clients maintained a need for continuing treatment. Judges, blind to treatment condition, observed CBGT clients to be significantly less anxious and to exhibit superior performance during a behavior test when compared with attention-placebo clients.
Heimberg et al. (1994) reported preliminary results of an ongoing multicenter collaborative study comparing CBGT with the monoamine oxidase inhibitor phenelzine. Clients were randomly assigned to either CBGT, attention-placebo, phenelzine, or pill-placebo. After 12 weeks of treatment, CBGT and phenelzine clients were more likely to be classified as positive treatment responders by an independent assessor than clients receiving attention-placebo and pill-placebo. While phenelzine resulted in greater posttest improvements on some measures than CBGT, cognitive-behavioral treatment was associated with significantly less relapse during the follow-up period. The next study by our collaborative group will examine the efficacy of combining CBGT and pharmacological treatment.
Burns, D.D. (1980). Feeling good: The new mood therapy. New York: William Morrow & Co., Inc.
Heimberg, R.G., Dodge, C.S., Hope, D.A., Kennedy, C.R., Zollo, L., & Becker, R.E. (1990). Cognitive-behavioral group treatment of social phobia: Comparison to a credible placebo control. Cognitive Therapy and Research, 14, 1-23.
Heimberg, R.G., Juster, H.R., Brown, E.J., Holle, C.H., Makri, G.S., Leung, A.W., Schneier, F.R., Gitow, A., & Liebowitz, M.R. (1994, November). Cognitive-behavioral versus pharmacological treatment of social phobia: Posttreatment and follow-up effects. Poster presented at the Annual Meeting of the Association for Advancement of Behavior Therapy, San Diego, California.
Heimberg, R.G., Salzman, D.G., Holt, C.S., & Blendell, K.A. (1993). Cognitive-behavioral group treatment for social phobia: Effectiveness at five-year follow-up. Cognitive Therapy and Research, 17, 325-339.
Persons, J.B. (1989). Cognitive therapy in practice: A case formulation approach. New York: W.W. Norton & Co.
Heimberg, R.G., Juster, H.R., Hope, D.A., & Mattia, J.I. (in press). Cognitive behavioral group treatment for social phobia: Description, case presentation, and empirical support. In M. B. Stein (Ed.), Social phobia: Clinical and research perspectives. Washington, DC: American Psychiatric Press.
Heimberg, R. G., & Juster, H. R. (1994). Treatment of social phobia in cognitive behavioral groups. Journal of Clinical Psychiatry, 55(Suppl.), 38-46.
Hope, D.A. & Heimberg, R.G. (1993). Social phobia and social anxiety. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (2nd ed.) (pp.99-136). New York: Guilford Press.
Training in the techniques of CBGT for social phobia can be arranged through the offices of the Social Phobia Program at Temple University. Contact Dr. Heimberg: firstname.lastname@example.org.