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Section 7
Cognitive of Treatment Change in Social Phobia

Question 7 | Test | Table of Contents

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In the last section, we discussed developing self awareness.  Three techniques for developing self awareness which we discussed are eliciting automatic thoughts, self observation, and in vivo exercises. 

In this trac, we will discuss directing clients.  Methods for directing clients include active affective statements, replacing ‘why’ with ‘how’, experiencing feelings, and fostering honesty.

Four Methods for Reducing Phobias

♦ #1  Active Affective Statements
First, let’s discuss the benefits of active affective statements.  As we have said, the anxious person does not really "own" her emotions but often attributes them to other people and to external events.  This passive role makes phobic clients like Jill unable to see how they are creating their own feelings.  

Jill, age 49, experienced speech phobia.  Jill’s phobia was not limited only to large assemblies, but also to groups as small as 5 or 6.  Like the typical phobic client, Jill often said "he," "she," or "it" was making her anxious.  Jill was encouraged to make such affective statements in the active ("I was making myself anxious") rather than the passive ("They were making me anxious").  I continued to point out this distinction throughout Jill’s therapy.  

How might your Jill benefit from making active affective statements as opposed to passive affective statements?

♦ #2  Replacing ‘Why’ with ‘How’
Next, let’s discuss replacing ‘why’ with ‘how.’  I felt that Jill could have benefited from being taught to replace "why" questions with "how" questions.  For example, when Jill asked herself why she was anxious or why she could not control her anxiety, she elicited more thinking, and less awareness.  By focusing on how she was making herself anxious, she switched out of the thinking self and into the observing self. 

Jill, like most clients, was unable to identify her automatic thoughts and specific fears in my office, but needed to be in the anxiety situation to do so.

I had to work with Jill to design ways for her to experience the anxiety so that she could discover her thinking.  Because Jill often succeeded in avoiding the fear stimulus of speaking in front of people, experiencing anxiety became an integral part of therapy.  

For example, at the beginning of therapy, Jill had no speeches scheduled and was avoiding social atmospheres.  I stated, "Consider asking questions at meetings you attend—a procedure that will usually produce the same or similar anxiety responses.  If someone else is giving a speech, you might think, ‘if I was up there right now, what would I be afraid of?’"

Jill often attempted to block her fearful thoughts and thus achieve temporary closure.  However, her frightening thoughts reappeared all the stronger.  Jill stated, "Yesterday we had a pitch in lunch at work.  I brought a casserole.  As I was setting it on the table, a coworker asked me what was in it.  So I started to tell her what was in it.  Well, more people walked in and I found myself on the verge of panic as they gathered around the table to hear what I was saying!" 

For this reason, I encouraged Jill to think through the unpleasant scenarios she was trying to block out of her mind.  I stated, "When you become afraid of losing control in public, try to stay with this feeling until you can identify your ultimate fear.  The more you try not to think about something, the more you think about it."  I asked Jill to not think about her nose, and then to observe what goes on in her mind.  Clearly, she thought about her nose.

I stated, "Images and thoughts that cause you to "shudder" are rich sources of automatic thoughts and fear-producing beliefs."  Another client, Drew, had a fear of getting cancer.  By thinking this through, Drew was able to pinpoint fears not only of dying but also of social disapproval.

♦ #3  Experiencing Feelings
In the same vein a client is encouraged to experience the feelings he or she is trying to shut off.  The anxious client often tries to divert him or herself from painful feelings; consequently, he is unable to see what is causing negative feelings. 

For example, Jay, age 24, stated, "I hum to myself whenever I start to feel anxiety."  While humming provided Jay with a temporary coping device, it hindered his awareness of the thoughts behind his anxiety.  Once Jay stopped using this strategy, he became aware of his automatic thoughts.  Up until this time, he had not believed that any thoughts preceded his anxious feelings. I suggested Jay take an active approach to life instead of reacting to it.  I stated, "Err on the side of inclusion rather than exclusion." 

Another client, Rhetta, was anxious about going to a high-school reunion and had decided not to go.  Her therapist encouraged her to go so she could explore what in the situation triggered her fear.  In the past, Rhetta refused many invitations and deprived herself of a chance to learn more about herself.  After successfully going to the highschool reunion, Rhetta’s therapist gave her a homework assignment.  Rhetta was to say Yes to every social request made of her.  By following through on this task, she was able to learn how many social invitations she normally turned down, and also what thoughts preceded her social anxiety.

Do you find that clients often cover up and lie to avoid the experience of anxiety?  I find that this dishonesty not only stops clients from pinpointing fears but may cause feelings of shame and guilt.  Dishonesty can hinder a phobic client from experiencing feelings.  Therefore, you might encourage your client, in a non moralistic way, to be more honest with others.  I find it helpful to present the client with a "no lose" proposition that, by becoming aware of when he does lie, he can learn more about himself and gain valuable information.  Think of your phobic client.  How might you encourage honesty in your client?

♦ #4   Fostering Honesty
I find that fostering honesty can be done by questioning inconsistencies.  Consider focusing on where and when the client’s thoughts, feelings, and actions are going in different directions.  For example, Rhetta observed that she would tell people she would attend certain social functions, and then not show up.  By looking at her inconsistencies, she was able to become more aware of how she was frightening herself.  Rhetta also came to see why many people discounted her stated intentions.

♦ Technique:  Third Person Referencing
Clients like Rhetta can increase self-awareness by voluntarily choosing to distance herself from her anxiety.  Rhetta did this by referring to herself as "it" or by her first name.  In this exercise, Rhetta referred to herself as a separate entity throughout the day and commented on her anxiety from a distance. 

For example, Rhetta stated,  "Rhetta seems to be scared.  Her heart is beating.  She seems to be concerned that others are thinking poorly of her.  Rhetta is focusing on the impression she is making."  By so distancing herself from her anxious response, Rhetta began to gain a more objective picture of herself.

♦ Technique:  The Thought Record
The most common method by which clients can become aware of thinking between sessions is the thought record.  Jay, who hummed when he felt anxious, was asked to record on dysfunctional thought forms, or in a notebook, situations where he was anxious and then to bring this into therapy.  Jay used his anxiety as a cue to write out frightening thoughts.  

Jay stated, "I even said ‘thank you’ to myself after pinpointing a thought.  Then I then continued to ask myself what else was frightening me.  The ‘thank you’ was like a reinforcement for identifying the thoughts."

Jay then tracked his fears back to the original stimulus.  For example, Jay said he started to be anxious about the possibility dying in a car wreck.  Jay said, "This just came out of the blue, I had no reason to be afraid!"  After careful questioning, Jay discovered that his anxiety was due to seeing fatal car accident in a television movie. His anxiety stemmed from the thought, "This could happen to me," and the image of "ending up a grease spot on some deserted highway."  From this experience, Jay learned to trace his fears back to their original stimulus and then to find out how he was frightening himself. 

Think of your Jay.  How might he benefit from the thought record?  How might you teach your client to track fears back to the original stimulus?

In this section, we discussed directing clients.  Methods for directing clients include active affective statements, replacing ‘why’ with ‘how’, experiencing feelings, and fostering honesty.

In the next section, we will discuss approaches to cognitive restructuring.  In general, cognitive therapist’s use three basic strategies or questions to help client’s restructure phobic thinking.  Nearly all effective lines of questioning can be broken down to one of three basic approaches to cognitive restructuring.  These three basic approaches are separating fact from fiction, generalizing alternative interpretations, and decatastrophizing.

- Jensen, Vicki L.; Hougaard, Esben; Fishman, Daniel B. Sara, A Social Phobia Client with Sudden Change After Exposure Exercises in Intensive Cognitive-Behavior Group Therapy: A Case-Based Analysis of Mechanisms of Change. PCSP: Pragmatic Case Studies in Psychotherapy. 2013, Vol. 9 Issue 3.

-Moldovan, Ramona; David, Daniel. One Session Treatment of Cognitive and Behavioral Therapy and Virtual Reality for Social and Specific Phobias, Preliminary Results from a Randomized Clinical Trial. Journal of Evidence-Based Psychotherapies. Mar 2014, Vol. 14 Issue 1, p67-83.

Update
Prevention and Treatment
of Social Anxiety Disorder in Adolescents:
Protocol for a Randomized Controlled Trial
of the Online Guided Self-Help Intervention SOPHIE

- Walder, N., Berger, T., & Schmidt, S. J. (2023). Prevention and Treatment of Social Anxiety Disorder in Adolescents: Protocol for a Randomized Controlled Trial of the Online Guided Self-Help Intervention SOPHIE. JMIR research protocols, 12, e44346.

Peer-Reviewed Journal Article References:
Bonsaksen, T., Lerdal, A., Borge, F.-M., Sexton, H., & Hoffart, A. (2011). Group climate development in cognitive and interpersonal group therapy for social phobia. Group Dynamics: Theory, Research, and Practice, 15(1), 32–48.

Bowers, W. A., & Yates, W. R. (1992). Cognitive therapy during discontinuation of alprazolam for social phobia. Psychotherapy: Theory, Research, Practice, Training, 29(2), 285–287.

Hofmann, S. G. (2004). Cognitive Mediation of Treatment Change in Social Phobia. Journal of Consulting and Clinical Psychology, 72(3), 392–399.

Querstret, D., Morison, L., Dickinson, S., Cropley, M., & John, M. (2020). Mindfulness-based stress reduction and mindfulness-based cognitive therapy for psychological health and well-being in nonclinical samples: A systematic review and meta-analysis. International Journal of Stress Management. Advance online publication.

Ranđelović, K., Smederevac, S., Čolović, P., & Corr, P. J. (2018). Fear and anxiety in social setting: An experimental study. Journal of Individual Differences, 39(2), 61–75.

Shikatani, B., Fredborg, B. K., Cassin, S. E., Kuo, J. R., & Antony, M. M. (2019). Acceptability and perceived helpfulness of single session mindfulness and cognitive restructuring strategies in individuals with social anxiety disorder: A pilot study. Canadian Journal of Behavioural Science / Revue canadienne des sciences du comportement, 51(2), 83–89.

QUESTION 7
What are four methods for directing clients? To select and enter your answer go to Test.