Social anxiety and its treatment
- Extra Reading
Anxiety is a common experience that can be a useful motivator or even life-saver in situations that are objectively dangerous. However, when the anxiety is out of proportion to the danger inherent in a given situation, is persistent and is markedly disabling, an anxiety disorder is likely to be diagnosed.
Social Anxiety Disorder is the most common anxiety disorder. It often starts in adolescence or earlier and affects around 1 in 10 individuals at some time during their life. Sufferers fear, and whenever possible, avoid social and performance situations (i.e. meeting strangers, talking to authority figures, working while being observed, public speaking). The fears often lead affected individuals to under-perform at school and work and can make forming close relationships difficult. Complications include markedly increased risks of alcohol or drug abuse, depression and suicide. Thankfully treatment trials have shown that several medications (e.g., selective serotonin reuptake inhibitors such as prozac and monoamine-oxidase inhibitors) and psychological treatments (exposure therapy and group cognitive-behaviour therapy) are effective but a substantial proportion of people continue to have significant social fears after a well-conducted course of either type of treatment.
In an attempt to further improve treatment effectiveness, we adopted a particular research strategy. First, a psychological model that attempted to explain why social fears persist was developed. Second, the maintaining factors specified in the model were tested in experimental studies. Third, specialized psychological treatment procedures that focused on the maintaining factors were developed and refined in clinical case series. Finally, the resulting treatment programme (a form of cognitive therapy) was evaluated in randomized controlled trials in our clinic and elsewhere.
The lecture covered the main features of social anxiety disorder, explained why it persists, described the cognitive therapy approach to treatment and summarized the evidence for the effectiveness of this approach. Future developments in the field are anticipated.
Social anxiety and its treatment
Introduction: Raj Persaud, Visiting Gresham Professor
Welcome ladies and gentlemen. My name is Dr Raj Persaud; I am a consultant psychiatrist at the Bethnal Royal Hospital and a Visiting Gresham Professor for the Public Understanding of Psychiatry. It gives me great pleasure to welcome you all here this evening for this, which is the last in our season of lectures on mental health given by distinguished professors of psychology and psychiatry at the Institute of Psychiatry, which is the research arm of the Hospital where I work and I practise in the NHS.
I am delighted to introduce to you this evening an extremely distinguished Professor of Psychology, David Clark, whose unit at the Institute of Psychiatry has done pioneering work in developing new treatment approaches, which are evidence-based, of a psychological nature, for problems around things like anxiety. This work is very important and increasingly moving up the political agenda. Some of you may be aware that government ministers have been talking about establishing a new programme of rolling out psychological therapies so that they should be more available to the public, but in particular evidence-based psychological therapies. David Clark is possibly the world authority on evidence-based psychological therapies, so I think it is going to be a very interesting evening.
But one final point I want to make is that he is going to be talking about social anxiety in particular. This is something that many people often have not heard of. We have often heard of things like depression, but it is possibly the case that anxiety might actually be more common than depression. Social anxiety is certainly one of the commonest anxieties. Many people are aware of phobias - things like spider phobias - but social anxieties, which are fears to do with being with other people, are probably some of the most common anxieties. These are fears and anxieties that have dramatic implications for people’s lives. Children with social anxiety are much more likely to drop out from school, and social anxiety as a child is a key predictor of whether you go on to develop alcohol problems or drug addiction problems as an adult, and may be these are children who are trying to medicate their social anxiety away.
So I hope you will join me in welcoming Professor David Clark, talking on a very important subject this evening: anxiety and its treatment.
David M Clark
Thank you very much Raj. It is a great pleasure to be here with you this evening. What I would like to do in the next 40 minutes or so is take you briefly through some of the general features of social anxiety, and then take you through some of the work we have been doing at the Institute of Psychiatry trying to develop more effective treatments for this very troubling problem.
Firstly, a word or two about the distinction between anxiety and anxiety disorders. Anxiety is an emotion that we all experience from time to time, and we do that for very good reasons. It has been built into us; we have inherited it from our evolutionary past, because, in general, anxiety has a survival function. If there is a real danger, for a primitive man, if there is a sabre-toothed tiger in the background and you just get a sign that the tiger may be there from a rustling in the trees, then anxiety kicks in in an adaptive way. You freeze, you stop doing whatever you were doing, you devote all of your attention to that spot where the tiger might be, and your body reacts with a big release of adrenalin, an increase in blood flow to the muscles, getting you ready to run as fast as you can. If there is someone else with you who does not run quite so fast, then you might survive because the sabre-toothed tiger will get that person instead!
So some anxiety is adaptive, not only for primitive man but in modern society as well. It helps us to focus on things when we have deadlines. If we are crossing Holborn Viaduct and someone is coming too fast round the corner, it helps us to jump out of the way quickly. So there is nothing wrong with anxiety in general, and in fact we would have problems if we did not experience it to some extent, but of course it can get problematic if the danger is one that is imagined rather than real, or the danger is something which is exaggerated. In those cases, particularly if the perceived danger is out of proportion to the real danger, and it is persistent and disabling, then we would diagnose an anxiety disorder. About 17% of the population will have an anxiety disorder at some stage in their life.
This is a very costly problem in terms of society. In some figures which are now 15 years old, in the US it cost £42 billion in one year in terms of lost productivity and in terms of excessive medical investigations that many people with anxiety seek, often thinking they have a physical problem. And of course an enormous amount of personal hardship.
I am going to focus today on one of the anxiety disorders, social phobia or social anxiety disorder. It is the most common of the anxiety disorders. It has a lifetime prevalence of 12%, so 12% of people will develop it at some stage in their life. It is a persistent fear of social or performance situations. A classic performance situation is mine today: giving a public presentation. That problem alone is really very common. About 30% of people will have a fear of public presentations. Thankfully, one can have a perfectly decent life without having to sing for your money in front of an audience, and so most people organise their lives so they do not have to do public speaking and so they do not need to come in for treatment. So it is really the people who have not only a fear of public speaking but also have a broader range of social fears that tend to be the people who seek treatment. Social fears would be people who are anxious about meeting strangers, people who are anxious about working while being observed (so working in an open plan office), eating in public, eating in restaurants, talking on the telephone while being overheard. Sometimes the people are particularly concerned about talking to strangers, but for other people the fear is much more intense, so if you are talking to people that you know well, you then think well, if they spot the things I am concerned about, I have got to face them again and it will be much more humiliating than if it was with a stranger.
In general in social phobia, it is said that people recognise their fears as excessive or unreasonable, but I think that is only true after the fact. Most people with social phobia think their fears are very realistic when they are anxious, but afterwards, when they calm down, they can see perhaps they were somewhat exaggerated.
Because of their concerns of course, they tend to avoid the situations which trigger their anxiety, but modern life is such that all of us have to meet other people. At work, we have to have contact with people, we have to give small presentations, and so people with social anxiety disorder find that on a daily basis, however hard they try to avoid it, they still have to encounter some of their most feared situations.
One of the paradoxes for us in psychiatry is: why don’t they get better from that sort of naturalistic exposure? Because it is rarely the case that they get clear-cut negative feedback from other people. It is generally not the case that an adult with social phobia summons up all their courage to go to a party that they have been invited to, and they go and knock on the door of their host and the host opens the door and says, “Oh my god, why did you think you were invited? You are the most boring person I know and we would never have invited you! You are going to spoil the whole party!” It does not happen like that in general, but they think as though it is going to happen that way, and even if they get into the party, they are thinking other people are thinking these things about them. So although there is no unambiguous negative feedback, they are not benefiting from that naturalistic exposure. That is a puzzle, and it tells us that people must be processing the social situation in a particular way which prevents their fears from extinguishing, prevents them from getting over their fears. If we can understand that, then that helps us with where we are going in treatment.
A couple of other points about the general characteristics of social phobias, some of which Raj has already mentioned. It typically starts in childhood. The average age of onset is 13, and many people will say that they developed this social phobia before the age of 10, although there are a minority of people who develop it later in life. It also has, for the anxiety disorders, a particularly low natural recovery rate. In one very clear-cut study that followed people up over 12 years, just over a third of people recovered in that period, and that is much less than with any other anxiety disorder, where a much larger group of people will recover on their own. It is a pretty persistent problem. It brings with it an increased risk of suicide, and also alcohol and drug abuse, which often seem to develop as a way of trying to deal with the social anxiety. People often will take a few drinks in order to summon up courage to go to a party and then find that they are self-medicating in order to get through the day. It also vastly increases your risk of subsequently developing depression and other anxiety disorders, and in general, people with social phobia under-achieve, both at school and at work. They are more likely, as you heard, to drop out of school early because of their social anxiety. At work, they are less likely to be promoted than would be warranted given their abilities because, sadly, in life, promotion is not simply about how good you are at doing something, it is also about social networking, which they find very difficult.
Given all of these points, it is rather sad that it also has a rather low treatment seeking rate. Only about 10% of people with social anxiety disorder will seek treatment. That seems to be largely because people do not realise there are effective treatments available. They tend to think they have had it for most of their life so it is just their personality and you cannot change your personality, and so they feel rather hopeless about it. There is really a need for a public campaign to publicise the fact that this problem is very treatable, as you will see in a moment.
The typical thoughts that someone with social phobia might have in a difficult social situation are: what I say sounds stupid; I’m boring; I will make a fool of myself; the other people will not like me; they will see I am anxious – the most common thought of all; and, I won’t have anything to say. There are particular components of being anxious: I will blush; I’ll shake; I will lose control of myself.
There are already a range of treatments available for social anxiety, and I should mention them first before going on to the latest treatment work. There are a number of medications that have been shown to be effective. Broadly speaking, they are all medications that were originally developed as anti-depressants. The first, and actually the most effective, is Phenelzyne. That has the problem, unfortunately, that you cannot take alcohol with it, and so although it is helpful for many social phobics, it is not a viable treatment because they use a lot of alcohol, and it is actually very dangerous in that combination. Some of the selective serotonin inhibitors – Fluoxityne is an example, Prozac is its common name – are also effective. But both classes of drugs have the problem that when people stop taking them, there is a fairly high relapse rate. About 50% of people relapse when they stop taking medications. As you have probably seen in The Guardian newspaper recently, there are also other problems with medications to do with increased suicide risk.
The alternative is psychological therapies, and the first psychological therapy that was shown to be effective was exposure therapy, which essentially encourages people in a graded way to go into feared situations and stay in them as long as they can and build up their confidence that way. Then group cognitive behaviour therapy is exposure therapy plus adding in some coping technique – conversational skills training, relaxation training, some training in how to improve your eye contact. Which coping technique is added depends rather on the country that it is in. If it is in Germany, there are a thousand different components of social skills that are taught in one particular programme. If it is in Sweden, it is a particularly wonderful form of relaxation which allows you to relax all the muscles in your body when you are at a bar other than the muscles that are necessary to stay standing upright while you are holding your beer! If it is in America, it is very much conversational skills and chat-up routines that you are taught. So the skills really very much reflect the sort of culture that they come from. The treatment is given in groups because it is thought that people with social phobia may benefit from meeting other people with a similar problem, and it allows them to do role plays and practise difficult tasks together.
Both of those types of treatments work, but the problem is only about 50% of people will fully recover with that treatment, so only about 50% will no longer have a social phobia. But compared to drugs, they have the advantage that if you do recover, you stay well so, five or ten years later, people are essentially in a similar position to where they were at the end of treatment, which is very good news.
I would like to move on to more recent work, where the fact that only at best 50% of people recover with existing treatments really got us interested in the problem, and we wondered if it was possible to do better. We have a particular approach to developing new psychological treatments which always involves firstly developing a model which would try and explain why people do not get better on their own, so why their fears persist despite the fact that the world is a lot less dangerous than they think it is. Then we test that model to see whether it is correct, and if we get good support for it, then we use that to develop a new treatment, where we focus on the things in the model which are preventing people from recovering naturally. If we find problems with the model, we change it until we are happy with it, and then devise a treatment.
In social phobia, Adrian Wells and I, a few years ago, suggested that there are three main reasons why social fears persist. The first is what happens when people are anxious in terms of their attention. There seems to be a shift of people’s focus of attention. So when people with social anxiety are meeting other people, they often say they become very self-conscious; their attention shifts on to themselves rather than on to other people, and they become very aware of how they feel and how they think they are coming across, but they are paying very little attention to other people. This is a problem because of course; if things go well, the chances are they will not notice and so they will not benefit from that. But, sadly, it is much worse than that, because, when they focus on themselves, they then become aware of information in themselves which they take as evidence that their fears are realistic.
There are two examples of this. Remember I said that the most common thought in social phobia is that other people can see that you are anxious? Well, if you ask people with social phobia “How do you know?” occasionally they will say, “Well, someone said that they saw I was anxious,” but in general, they don’t say that. In general, they will say, “Well, I feel very anxious, and if I feel very anxious, I must look very anxious.” So they are using their feelings to decide how they appear. It turns out that is a terrible mistake, because there is a lot of research that shows the more anxious you feel, the more you over-estimate how anxious you look.
It goes beyond that though. For most people with social anxiety, they report little mental pictures or images that pop into their head when they are anxious, and the image has particular problematic qualities. It is as though there is a video camera in the corner of the room and they can see themselves as if observed by someone else, what we call an observer perspective. Now, Robbie Burns said it would be wonderful to be able to observe ourselves as others see us, but, sadly for the social phobic, that is not what their image is. Their image is not how they really appear to other people, but instead, it is all their fears visualised.
For example, one of my patients a little while ago was a young teacher, and her biggest fear was the coffee break at school, where she would have to sit with other teachers and chat to them, and she thought that if she opened her mouth, everyone would think she was stupid. So she rarely talked, and when she was summoning up her courage to try and talk, she would then feel tense around her lips, and that feeling of tension around her lips would get transformed into an image where she would see herself looking very strange. If you asked her, “What does that look like?” she would say, “The village idiot!” She did not need to observe how other people responded to her because she already knew they could see she was stupid, because she had this picture in her mind.
So we have a real problem that people are focusing on themselves rather than other people, and then they are generating very misleading ideas about how they appear, and these distorted images look very realistic and they believe them, and they also jump to conclusions from their feelings in a way which is misleading. Those two alone are quite powerful ways of keeping your fears going but, sadly, there is another influence which is even more dramatic, and that is what we call safety behaviours.
A safety behaviour is something that someone would do in order to prevent a feared event from happening. So if you take the patient I have just talked about, she is afraid that if she speaks, other people will think she is stupid, and she then has a lot of strategies to try and prevent that from happening. One obvious one of course is to try and avoid speaking. Another one is to write out, before the coffee break, a list of 10 interesting topics that she could introduce into the conversation to the other teachers. The last one is, if she does manage to summon up her courage to speak, while she is speaking, she will memorise everything she has already said and compare it with what she is about to say in order to check that it makes sense, that it is interesting and clever enough. This is an enormous mental load, so what happens of course is that when she is speaking to other people, it appears as though she is not interested in them. It appears as though her mind is somewhere else, which it is – it is on all this memorising. Of course, in general, if someone is talking to you or you are in a conversation with them, but they do not seem to be very interested in you, how do you respond? Not many of us become much more friendly. Most of us withdraw in reaction, don’t we? We are less friendly back. So the real paradox here is that these safety behaviours do two very unhelpful things. Firstly, if the conversation does go all right, the patient can say, “Well, that is only because I did all this memorising and thought of all these clever topics. If I had just been myself, everyone would have realised what a stupid, boring person I am.” So the fear persists. But it is worse than that, because of course this distracted,‘mind-elsewhere’ appearance affects the person that you are talking to, and they are less friendly to you, and so some of the things that the patient is afraid of actually happen, as a consequence of the things they are doing to try and protect themselves. So it is a very problematic system.
Well, that is the theory and, in psychiatry, we think of theories as rather like bedtime stories: they may be true or they may not be. Mostly they are not, it turns out. So the first thing you have to do with a theory is test it; see if you can get any good evidence for it. I am quickly going to take you through some of the tests of the key points that I have been mentioning.
The first thing is: is it the case that people with social anxiety do shift their focus of attention, so they are not observing other people and are focusing on themselves when they get anxious?
This was a study that we did looking at that, with one of my team, Warren Mansell. He took high and low socially anxious individuals, and he gave them two things to do at the same time. On a computer screen, they saw different people, and every now and again, a dot appeared on the face of one of the people, and they just had to detect it as quickly as possible, press a button – so that is detecting something in the external world. They also were wired up with very impressive cardiac and sweating monitoring systems, and then they were told that a little vibrator that they had on their finger, if that started to vibrate, it meant we detected a change in their physiological responding – their heart rate had gone up or their skin conductance had changed – the sort of things of course that people with social anxiety are concerned about, because they think, “Oh, I’m getting a bit more of an anxious reaction. Other people will see it.” Being a psychology experiment, actually this was all false feedback, so they just got the buzzer on a fixed schedule, but they did know that we could monitor these things, so they thought it was realistic.
People were tested under two conditions. One is just sitting quietly, under no particular threat; and then the other is they are told that in a minute you are going to have to give a speech to an assembled audience. This particular study, we did on Oxford undergraduates, who tend to be on average fairly self-confident people, so we had to rack up the threat, ans we said that, “The people who are watching you are experts in non-verbal behaviour, and their judgements over a number of years have been shown to be very good predictors of your final income level” This is a wonderful threat for Oxford undergraduates! Even the low socially anxious ones got anxious in this task! It was not true, by the way – the psychologist cannot predict those sort of things.
What happened? Well, in the ‘no threat’ condition, a positive score means you are better at detecting things in the external world; you are focused externally. A negative score means you are better at detecting things in your body, you are focused internally. Without a threat, both the low socially anxious group and the high socially anxious group tend to be more external. If you take the low socially anxious people and you threaten them with having to speak to a critical audience, something very interesting happens: they become more external. It is like they are focusing on the audience, trying to engage them mentally already. But the high socially anxious people do the exact opposite: they now go into an internal focus of attention and they are not paying any attention to the external world. They are locked in on themselves and their self-monitoring.
When they do that, they had these particular images, but is that really true? Psychiatrists and psychologists tend to come to these conclusions from talking to one or two people and then generalising for the rest of the universe, and that is a very dangerous thing, so we wanted to check whether, in this case, this generalisation was true. We did an interview study where we took people with social phobia and other individuals and asked them whether they had an image the last time they were anxious in a social situation, and then enquired about the content of the image and whether it was an observer perspective image or not. The finding was quite remarkable. If you just take the last time people felt anxious in a social situation, the people with social phobia, 80% of them reported having a spontaneously occurring, just pops into your head, negative observer perspective image, which at the time seemed realistic but afterwards many of them thought was perhaps somewhat distorted – a very negative image. The non-social phobics do not do that to anything like the same extent, just 10%, and when you look at the images, they are much less negative.
Where do these images come from? A chance question in this study led us to the answer. The interviewer happened to say to someone, “Do you know that image of seeing yourself beetroot red with white globules of sweat dripping down your forehead at that dinner that you were invited to, have you ever had that image before?” The patient said, “Yes.” “How often?” “Well, whenever I get very anxious, I have the same image. It may be in a different place and a bit has changed, but the essential picture of how I look is the same.” Then the interviewer said, “When did you first experience that image?” It tracked way back into childhood for this particular patient. So this led us to the idea that may be these images are laid down quite early in life, on the basis of traumatic experiences, and then they just keep on getting rolled out, irrespective of whether they are realistic or relevant.
In a follow-up study, we looked at that. We first looked at whether it was generally the case that people had these repeated images, and we found 100% of our social phobic patients said they had recurrent images. Then we looked at how those images clustered with respect to the onset of their social phobia. These were people who were coming in for treatment, on average, 20 years after developing the problem, but the images were first experienced clustering around the onset of the problem. It is often something like standing up at school, having to read out a Longfellow poem or something like that, and then starting to feel a bit hot on your face, your hand shakes a little bit, and then you have an image of looking a shaking, gibbering wreck, and that image, whether it is realistic or not, then seems to get stuck, and whenever you feel anxious again in the future, it gets wheeled out, and it is believed, even if it may not be at all relevant now.
I also said that these particular safety behaviours that people do – the memorising and other things – are one reason why their fears persist. To test this, we did a little experiment where we asked people with social anxiety to do a particularly difficult task, which was individualised. For one of our patients, who was a priest, his particular most feared situation was giving communion, and it was actually the communion cup, and so his task was to do that. For other people, it might have been giving a public presentation or talking to strangers.
People did it under one of two conditions. In one condition, they were asked to do all the things they normally do to try and manage their anxiety – to prepare in advance, to do the memorising if they normally do that, and in the case of this particular priest, to hold the chalice very tightly to avoid shaking. That seemed very credible to people. They thought, well, it is a good thing to do, we are using all our coping techniques and we are confronting the situation. But the other group were told to do the task but were told it will be of no benefit unless you learn something new about your fears, unless you discover that the fears are unrealistic, and the only way of doing that is to drop all these self-protective strategies; so not to do the memorising. In this particular case, the priest would have to hold the chalice with one hand and just hold it on the bottom. Patients also thought this was quite credible, as it happened, but what happens in terms of the outcome?
This was an experiment, so it was just one session of therapy, and we looked at people’s anxiety before and afterwards in another difficult social situation, and we found that if you were encouraged to keep your safety behaviours, then there was really no improvement in your anxiety, very little change, just a little bit of a drop, and very little change in your fearful beliefs. However, if you do the same task but you drop these safety behaviours, sometimes just strategies you are doing in your head, the memorising, then you get a very big improvement in anxiety and a big change in your fears as well. So it does seem as though those little safety behaviours are really crucial in keeping the fears going.
I would now like to move on to how those ideas pan out in therapy, and I would like to show you some stages of the therapy. Firstly, it involves working out, with the patient, an individual version, a sort of model of these maintaining factors, and they see how they fit together, and we often write that up on the board.
Take the example with the teacher that we were talking about. In the coffee break, which was the situation, she has had the thought “I will sound stupid,” and that would give her an image of looking very strange, the twisted and rigid mouth, and when she had that, she would be even more convinced she would sound stupid. But she also does a lot of safety behaviours: before speaking, she delays asking questions, trying to calm down, and she takes deep breaths in order to relax more. When she feels that she is ready, she will then speak quickly because she does not want to be the centre of attention for long, and she will tend to mumble and put her hand over her mouth. This unfortunately has the consequence that people cannot hear what she says and so stare at her, which produces the exact wrong reaction, from her point of view, but she is also doing all this rehearsing and memorising and checking. All of these make her more self-conscious and more aware of this image of herself and more convinced that things are going badly.
Once you develop the model with the patient, and have checked out that that makes sense, that it really seems to describe their experience, and they are happy with that, you then try to break into the cycles in the model. The first thing we do is show people how these safety behaviours and focusing on yourself are unhelpful. Rather than telling people that, we let them experience it, and we do it by a little experiment, what we call the self-focused attention and safety behaviours experiment. In the clinic, we get them to do something that is quite difficult but they think they could manage, like talk to a stranger or stand up and give a short presentation. They do it twice. Once, while they are doing it, they focus their attention on themselves, keep on thinking: “How am I coming across?” “Am I looking anxious?” “What is the other person thinking about me?” “What does my voice sound like?” – all the things they would normally do. In the other condition, they are asked to do something which they would not normally do, which is not monitor how they think they are coming across, not try and cover up their anxiety. If they are worried about their hands shaking, instead of holding something very rigidly, just hold it gently and not try and control it, and not think of lots of clever topics, just say things as they come into their head. We get them to do each of those things and then compare how they felt and how they think they came across. It is a miraculous exercise, because what happens is that in general people find that they feel a lot less anxious when they drop all of these self-protective strategies and when, rather than trying to hide how they come across to other people or put on a front, they just let themselves say what comes into their mind and be themselves. So they feel less anxious. They also think they come across much better, and so they are very pleased with the first step of therapy; they think this is going to be helpful.
But the next thing we move on to is dealing with these images. Of course, all that we have got so far is that they think they are coming across better, but it is still the case that they think they come across pretty badly. It is just a small improvement as far as they are concerned. The next thing we do is video feedback. Every second of the therapy is videoed, and in the next session, you get an opportunity to watch the video of this role play and see how you came across. This is a wonderful thing, because it really does allow you to see your true observable self.
For those people who are worried about blushing, for example, we have, unbeknownst to them, this series of books with different shades of red on the bookshelf behind them, and if they feel they have blushed, we ask them to turn round and point to the red that they think it was. Although sometimes of course the blushing is visible, they will always point to a much deeper red than the real one, and it is a very nice way of showing them that whatever is observed, their image is much more negative. This turns out to be a very powerful technique for people to realise that their self images are extremely distorted and it moves us on to the next stage in the therapy, which involves saying: so all the evidence you have been using so far to decide how you come across – your feelings and your images – is poor evidence. It does not tell you how you appear to other people. So what we have now got to do is get good evidence; things that are realistic. That involves teaching people to shift their focus of attention so they are out of their head and in to the social interaction, and to do even more than that, to try and test their beliefs by doing little experiments.
An example of that is here with the same teacher that I will keep the story going with. This was her first behavioural experiment. We took the coffee break, which is her feared situation, sitting with other teachers, trying to join in the conversation. The first thing you do is you ask her to predict what is the worst that you think could happen, and she says, “Well, if I just say things that come into mind, without monitoring it, without thinking of clever things, they will all think I am stupid.” She believes that 50%, so that is her prediction. Then we sit down together and think, how could we test that, how could we find out whether that is true? We decide on an experiment, and the experiment is, well, this time I have to do something very risky, but may be it will be worthwhile because maybe I will discover the truth. What I am going to do is I am going to try and say whatever comes into my mind and watch the other people like a hawk, like a bird of prey. I do not focus on myself because this only gives me misleading information – she has discovered that from the video – and means that I cannot see the other people. That is the plan and that is written down on a little sheet.
Then next morning, she goes into the school and she tries out the experiment, and so she has to record the outcome, what actually happened. She writes down, “Well, I did it, and I watched the others. One of them showed interest in me and we talked. She actually seemed to quite enjoy it.” Then the last column is: what have I learnt from that? She says, “Well, I’m probably more acceptable than I think” – she says “I believe that 70%”. That is good, we are moving in the right direction, but you notice the “probably”? That is a doubt, isn’t it? The art of cognitive therapy is always to listen for the doubts and not push them under the carpet but get them out and discuss them.
So I said to her, “Well, what was unconvincing about that to you?”
She said, “I don’t know…em…well, I don’t think they really saw the real me. If they had, may be it would have been different.”
I said, “Well, in what way did they not see the real you? Remember we agreed you wouldn’t plan any topics to introduce into the conversation, you would just say things as they came into your mind? Was that true? Did you manage that?”
She said, “Well, you know, I normally have a list of ten and I was really good and I only took in two”!
I said, “What do you think would have happened if you hadn’t brought in two topics?”
She said, “Oh well, then people would have realised I’m stupid.”
“Okay, that is a prediction again, isn’t it? How can we test that?”
She says, “Okay, I’m getting the hang of this…so no topics tomorrow?”
“Yes, okay, let’s try that.”
So she then goes in, no topics, and actually the conversation goes swimmingly, because for the first time for her colleagues, it is a real conversation! She is not changing the topic all the time to go on to a new, clever topic; she is following what everyone is saying and it flows nicely. So actually three people stay a bit longer and chat with her. Now the outcome is: “I really am more acceptable than I thought.”
Cognitive therapy involves a vast number of behavioural experiments like that which people use to test their beliefs, and you can see a lot of fine-tuning and expressing doubts, taking them seriously and then testing them out. One of the later stages of therapy is something that I thought I would mention which is that these sorts of experiments build people’s confidence, and so what you tend to do in the later stages is look at the worst possible outcomes. So say, “Okay, well you can see that the things you are afraid of are much less likely to happen than you thought, but let us consider the worse and see how bad that would be.” What we then often do is we get people to behave in ways that they feel are unacceptable, to do things that are breaking their rules, because they often have very rigid, high performance rules and we get them to break them.
For example, someone who is worried that they might sound stupid when they are talking may have a rule that they must never have a pause in their conversation, they should never put a big gap in the conversation, because if they do, people will notice it, will stare at them, think they are dumb. I have just tested that rule a moment ago. There is a pod-cast I think or a video-cast and you can look at it on the internet later. About eight or nine sentences ago, I paused mid-sentence and counted to myself 1,000, 2,000, 3,000, 4,000 while watching you all to see whether you noticed. I don’t know whether anyone noticed, but certainly people did not react with horror. For the social phobics, this would have been a terribly frightening thing to do, but the reaction would have been the same and they would have realised this is okay, it is acceptable.
Similarly, to give you an example, one of our patients was very worried about underarm sweating. He would sweat a lot and he felt so humiliated by this concern that eight or nine times every day he would lock himself in the gents’ toilet, and you know those blow dryers where you can dry your hands without a towel, he would turn it the other way round and dry his armpits. He was horrified that people in the company would come in and see this – his worst possible fear. So I said, “Well, you know, if it gets really bad, what is the worst that you think it could be?”
He said, “Oh it could be just an enormous patch like that. Now of course I am feeling a lot more confident so it is not really happening now, but it could one day.”
So we said, “And what do you think would happen if that was the case.”
He said, “Oh well, people would be absolutely disgusted and horrified if they ever saw sweat like that on a man.”
“Well, shall we test that?”
He said, “Well, I’m not sweating very much now.”
“Well, that’s alright, because it’s the appearance that we need.”
So we both got a large bottle of mineral water and went out of the clinic – it was about six o’clock in the evening – around the corner to a local store, I think it was a 7/11 store, and then we decided we had to produce the appearance of intense sweat, so basically we used something like this(speaker throws water over his shirt) both arms actually, but I won’t do that with the microphone here! Then I said to him, “Okay now, if we go into the store and ask for something and people can see that, how do you think they will react?”
He said, “Oh, well, they’ll be disgusted.”
”And how will you know?”
“Well, it could go one of two ways. One possibility is they’ll just be so embarrassed that they’ll look anywhere other than my armpit. They’ll look around like this, but they won’t look at me. The other thing is they’ll be so disgusted they won’t be able to take their eyes off my armpit, but it will be one or the other.”
“Okay, well let’s test that. Now, who should do it first? Do you want me to do it and you watch, or the other way round?”
He said, “Well… why don’t you do it?”!
So I went in and went up to the checkout. There was a very nice young lady behind it, and I said (pointing, so my wet underarm was very visible), “Excuse me, can you tell me how much those AA batteries are there, just behind you?” She said, “Oh, £1.80” or something. I said, “Well, thank you very much, a bit expensive for me. What about the Ever Ready sort over there (pointing again) are they any cheaper?” She said, “Still £1.80.” “Well, thanks, maybe another day,” and wandered along to the patient who was here by the bread counter watching all of this, and said, “Well, what did you make of that?”
He said, “I couldn’t believe it! I mean, you were that close, there was no possibility that she didn’t see it, but she just answered your question. I mean she may not have thought it was great, but she obviously wasn’t totally disgusted in the way I thought.”
“So what does that tell you?”
“Well, sweating isn’t as bad as I thought it was…at least on you.”!
I said, “Well, tell me about that.”
He said, “Well, may be it wouldn’t work the same for me.”
”Why is that?”
“Well, we’ve had five sessions of therapy now, I’m getting used to you. You’re a pretty extrovert chap. I think you can get away with some things that I can’t.”
“Okay, that’s a prediction. How can we test that out?”
So he gets out the mineral water and we go to the next store and he asks essentially the same thing, for a packet of cigarettes, and it turns out his armpits are of no more interest to the man behind the counter as mine were… a wonderfully liberating experience for him.
That I hope gives you a flavour for what is in the therapy, and I would like to just wind up by looking at the question “Does it work?” and showing you a couple of bits of data. The first is a clinical trial where people with social anxiety, severe social anxiety, are randomly allocated to either cognitive therapy, Prozac, or a placebo medication. You find that people will improve actually in all three conditions, but people with cognitive therapy show twice as much improvement as people on Prozac and that difference is maintained one year later. Then the second study looks at how cognitive therapy compares with the best alternative existing psychological treatments. You will remember that exposure therapy was one of the key ones, and this is no treatment, and you find that those people who have exposure therapy do much better than people without any treatment, so it is an effective treatment, but cognitive therapy again does about twice as well. 84% of the patients in the cognitive therapy no longer had the diagnosis of social phobia at the end of the treatment, as opposed to 38% of those people with exposure therapy.
So it works very well, in our clinic; however, there is always a concern in psychotherapy that may be these things don’t travel so well to other places, and so the last thing I would like to show you is a study that was done in Stockholm, by another group of clinicians, who particularly thought group treatment would be the ideal. They developed their own version of a group cognitive treatment and contacted us to ask if we could train them in our treatment as the placebo control, so their belief obviously was that they would do much better with the group treatment. They also compared it with treatment as usual in Sweden, which is getting Prozac and other SSRIs. You can see that individual cognitive therapy still does very well, significantly better than the Swedish group treatment, although that was what everyone thought was going to do well, and both of them are doing somewhat better than the medication.
Thank you very much for joining me on this trip through social anxiety.
© Professor David M Clark, Gresham College, 17 May 2006
This event was on Wed, 17 May 2006
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