Cognitive and Behavioral Therapies


for Social Phobia and Public Speaking Anxiety

Status: Strong Research Support

Description

Cognitive and behavioral therapies for social phobia and public speaking fears refer to a variety of techniques that can be provided individually or in combination. The basic premise underlying the therapy approaches is that thoughts, feelings and behaviors are inter-related, so altering one can help to alleviate problems in another (e.g., changing thoughts about fears of negative evaluation will lead to less anxiety). From a cognitive perspective, the excessive fear in social and performance situations is thought to be maintained by negative beliefs about the likelihood and catastrophic nature of embarrassing oneself and performing inadequately, and the probability and seriousness of negative scrutiny by others. The cognitive therapy techniques thus focus on modifying the catastrophic thinking patterns and beliefs that social failure and rejection are likely (termed cognitive restructuring). From a behavioral perspective, social anxiety is maintained by avoiding anxiety-provoking situations so that the individual does not have the opportunity to learn that they can tolerate the anxiety, that the anxiety will come down on its own without avoiding or escaping, and that their feared outcomes often do not come true or are not as terrible as they imagine. Avoidance can occur either by not entering a situation at all or by entering the situation but not experiencing it fully (e.g., because of consuming alcohol). Exposure therapies are thus designed to gradually encourage the individual to enter feared social situations and try to remain in those situations. The selection of situations to try follows an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared encounters.

Other common cognitive and behavioral techniques include behavioral experiments, applied relaxation, and social skills training. Behavioral experiments involve testing out predictions about the likelihood and consequences of social disappointments to see whether the feared outcomes actually occur, thereby challenging the distorted predictions. Anxiety symptoms can also be reduced through relaxation exercises, including progressive muscle relaxation and diaphragmatic breathing. Social skills training is recommended for those individuals who lack basic abilities in initiating and maintaining positive interpersonal interactions (more common among individuals who have the Generalized subtype of social phobia), and involves behavior rehearsal of social interactions and training in communication skills.

The research evidence suggests that combining cognitive therapy and exposure techniques, which is typical of most Cognitive Behavior Therapy (CBT) packages, is recommended. Therapy usually lasts from 12-16 sessions (though there is evidence that briefer therapies lasting 4-8 sessions can also be effective), and can be conducted in individual and group formats. The research literature also suggests that exposure therapy on its own can be an efficacious treatment. Cognitive therapy often adds to the effectiveness of behavioral interventions, but may be most consistently helpful when it is combined with behavioral approaches, rather than delivered as a stand-alone intervention. There is also some evidence that relaxation training on its own can be helpful, but like cognitive therapy, it seems to work most effectively as a component of CBT. Similarly, social skills training on its own is sometimes found to be equal to other established therapies (e.g., cognitive therapy, exposure), but rarely more effective than these other treatments. It is recommended that social skills training be used as an additional component of CBT for individuals who need it. (Many individuals with social phobia have adequate social skills, and do not require this component.)

Finally, early behavioral approaches used systematic desensitization (exposing participants to anxiety provoking images and thoughts, while pairing the exposure with relaxation to decrease the normal anxiety response). While there was some initial support for the utility of this technique, these studies typically had small samples or lacked rigorous control groups, and there is little recent evidence to suggest this approach should be selected over other exposure approaches that have stronger research support for treating social phobia and public speaking anxiety. Notwithstanding, given that this approach has been defined as probably efficacious in previous reviews (see Chambless et al., 1998), references supporting this technique are listed below.


Key References (in reverse chronological order)

Cognitive Behavioral Therapy (treatments typically combined exposure techniques and cognitive restructuring)
Cognitive Therapy (these interventions typically also included some behavioral techniques, such as modifying safety behaviors and attentional training)
Exposure Therapy
Social Skills Training
Relaxation Training
Systematic Desensitization
Meta-analyses and treatment reviews of Cognitive and Behavioral Therapies

Clinical Resources

See description of CBT techniques, including exposure techniques, in the following clinical resources/manuals:
See description of cognitive techniques in the following clinical resources/manuals:
See description of social skills training in the following clinical resources/manuals:
See description of relaxation training in the following clinical resources/manuals:
See description of virtual reality treatment in the following clinical resource:

Training Opportunities

Center for Cognitive Therapy
Cory Newman, PhD, Director
Mary Anne Layden, Ph.D., Director of Education
University of Pennsylvania Medical School
3535 Market Street, 2nd Floor
Philadelphia, PA 19104-3309
Phone: 215-898-4100
psycct@mail.med.upenn.edu

Beck Institute for Cognitive Therapy and Research
Judy S. Beck, PhD, Director
One Belmont Avenue, Suite 700
Bala Cynwyd, PA 19004-1610
Phone: 610-664-3020

San Francisco Bay Area Center for Cognitive Therapy
Oakland, CA (Rockridge)
Phone: 510.652.4455

Training in the techniques of cognitive behavioral group therapy for social phobia can be arranged through the offices of the Social Phobia Program at Temple University. Contact Dr. Richard Heimberg

Padesky's Center for Cognitive Therapy
PO Box 5308
Huntington Beach CA 92615-5308 USA
Phone: 714 963 0528

Teaching Resources

CBT for Social Anxiety Disorder Slide Set