Cognitive and Behavioral Therapies
for Social Phobia and Public Speaking Anxiety
Status: Strong Research Support
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)
- Davidson, J. R. T., Foa, E. B., Huppert, J. D., Keefe, F., Franklin, M., Compton, J., et al. (2004). Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Archives of General Psychiatry, 61, 1005-1013. *This treatment also included a social skills training component in addition to exposure techniques and cognitive restructuring.
- Hofmann, S. G. (2004). Cognitive mediation of treatment change in social phobia. Journal of Consulting and Clinical Psychology, 72, 392-399.
- Cottraux, J., Note, I., Albuisson, E., Yao, S. N., Note, B., Mollard, E., et al. (2000). Cognitive behavior therapy versus supportive therapy in social phobia: A randomized controlled trial. Psychotherapy and Psychosomatics, 69, 137-46.
- Heimberg, R. G., Dodge, C. S., Hope, D. A., Kennedy, C. R., Zollo, L. J., & Becker, R. E. (2000). Cognitive behavioral group treatment for social phobia: Comparison with a credible placebo control. Cognitive Therapy and Research, 14, 1-23.
- Otto, M. W., Pollack, M. H., Gould, R. A., Worthington, J. J., McArdle, E. T., Rosenbaum, J. F., et al. (2000). A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia. Journal of Anxiety Disorders, 14, 345-58.
- Heimberg, R. G., Liebowitz, M. R., Hope, D. A., Schneier, F. R., Holt, C. S., Welkowitz, L. A., et al. (1998). Cognitive behavioral group therapy versus phenelzine therapy for social phobia. Archives of General Psychiatry, 55, 1133-1141.
- Heimberg, R. G., Salzman, D., Holt, C. S., & Blendell, K. (1993). Cognitive behavioral group treatment of social phobia: Effectiveness at 5-year follow-up. Cognitive Therapy and Research, 17, 325-339.
- Gelernter, C. S., Uhde, T. W., Cimbolic, P., Arnkoff, D. B., Vittone, B. J., Tancer, M. E., & Bartko, J. J. (1991). Cognitive-behavioral and pharmacological treatments of social phobia. Archives of General Psychiatry, 48, 938-945.
- McNally, R., Bryant, R.A., Ehlers, A. (2003). Does early psychological intervention promote recovery from posttraumatic stress? Psychological Science in the Public Interest, 4, 45-79.
Cognitive Therapy (these interventions typically also included some behavioral techniques, such as modifying safety behaviors and attentional training)
- Clark, D. M., Ehlers, A., McManus, F., Hackmati, A., Fennell, M., Campbell, H., et al. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: A randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058-1067.
- Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41, 991-1007.
- Taylor, S., Woody, S., Koch, W. J., McLean, P., Paterson, R. J., & Anderson, K. W. (1997). Cognitive restructuring in the treatment of social phobia: Efficacy and mode of action. Behavior Modification, 21, 487-511.
- Salaberria, K., & Echeburua, E. (1998). Long-term outcome of cognitive therapy's contribution to self-exposure in vivo to the treatment of generalized social phobia. Behavior Modification, 22, 262-84.
- Scholing, A., & Emmelkamp, P. M. G. (1996). Treatment of generalized social phobia: Results at long-term follow-up. Behaviour Research and Therapy, 34, 447-452.
- Hope, D. A., Heimberg, R. G., & Bruch, M. A. (1995). Dismantling cognitive-behavioral group therapy for social phobia. Behaviour Research and Therapy, 33, 637-650.
- Turner, S. M., Beidel, D. C., & Jacob, R. G. (1994). Social phobia: A comparison of behavior therapy and atenolol. Journal of Consulting and Clinical Psychology, 62, 350-358.
Social Skills Training
- Herbert, J. D., Gaudiano, B. A., Rheingold, A. A., Myers, V. H., Dalrymple, K. L. & Nolan, B. M. (2005). Social skills training augments the effectiveness of cognitive behavior group therapy for Social Anxiety Disorder. Behavior Therapy, 36, 125-138.
- Wlazlo, Z., Schroeder-Harting, K., Hand, I., Kaiser, G., & Münchau, N. (1990). Exposure in vivo versus social skills training for social phobia: Long-term outcome and differential effects. Behaviour Research and Therapy, 28, 181-193.
- Mersch, P. P. A., Emmelkamp, P. M. G., Bögels, S. M., & van der Sleen, J. (1989). Social phobia: Individual response patterns and the effects of behavioral and cognitive interventions. Behaviour Research and Therapy, 27, 421-434.
- Olsson-Jerremalm, A. (1988). Applied relaxation in the treatment of phobias. Scandinavian Journal of Behaviour Therapy, 17, 97-110.
- Jerremalm, A., Jansson, L., & Öst, L.-G. (1986). Cognitive and physiological reactivity and the effects of different behavioral methods in the treatment of social phobia. Behaviour Research and Therapy, 24, 171-180.
- Öst, L.-G., & Jerremalm, A., & Johansson, J. (1981). Individual response patterns and the effects of different behavioral methods in the treatment of social phobia. Behaviour Research and Therapy, 19, 1-16.
- Lent, R. W., Russell, R. K., & Zamostny, K. P. (1981). Comparison of cue-controlled desensitization, rational restructuring, and a credible placebo in the treatment of speech anxiety. Journal of Consulting and Clinical Psychology, 49, 608-610.
- Paul, G. L. (1967). Insight versus desensitization in psychotherapy two years after termination. Journal of Consulting Psychology, 31, 333-348.
- Paul, G. L., & Shannon, D. T. (1966). Treatment of anxiety through systematic desensitization in therapy groups. Journal of Abnormal Psychology, 71, 123-135.
Meta-analyses and treatment reviews of Cognitive and Behavioral Therapies
- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17-31.
- Rowa, K., & Antony, M. M. (2005). Psychological treatments for social phobia. The Canadian Journal of Psychiatry / La Revue Canadienne de Psychiatrie, 50, 308-316.
- Zaider, T. I., & Heimberg, R. G. (2003). Non-pharmacologic treatments for social anxiety disorder. Acta Psychiatrica Scandinavica, 108 (s417), 72-84.
- Heimberg, R. G. (2001). Current status of psychotherapeutic interventions for social phobia. Journal of Clinical Psychiatry, 62, 36-42.
- Federoff, I. C., & Taylor, S. (2001). Psychological and pharmacological treatments of social phobia: A meta-analysis. Journal of Clinical Psychopharmacology, 21, 311-24.
- Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Yap, L. (1997). Cognitive-behavioral and pharmacological treatment for social phobia: A meta-analysis. Clinical Psychology: Science and Practice, 4, 291-306.
- Taylor, S. (1996). Meta-analysis of cognitive-behavioral treatment for social phobia. Journal of Behavior Therapy and Experimental Psychiatry, 27, 1-9.
- Feske, U., & Chambless, D. L. (1995). Cognitive behavioral versus exposure only treatment for social phobia: A meta-analysis. Behavior Therapy, 26, 695-720.
See description of CBT techniques, including exposure techniques, in the following clinical resources/manuals:
- Antony, M.M., & Rowa, K. (2008). Social phobia. Göttingen, Germany: Hogrefe and Huber Publishers.
- Turk, C. L., Heimberg, R. C., & Hope, D. A. (2007). Social anxiety disorder. In D.H. Barlow (Ed.), Clinical handbook of psychological disorders (Fourth Edition). New York: Guilford.
- Hope, D. A., Heimberg, R. C., & Turk, C. L. (2006). Managing social anxiety: A cognitive-behavioral therapy approach therapist guide (Treatments that work). Oxford University Press.
- Heimberg , R. G., & Becker, R. E. (2002). Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York, NY: Guilford Press.
See description of cognitive techniques in the following clinical resources/manuals:
- Clark, D. M. (1997). Cognitive therapy for social phobia: Some notes for therapists. Unpublished manuscript.
- Wells, A. (1997). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. Chichester, England: Wiley.
- Beck, A. T., & Emery, G., with Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. New York: Basic Books.
- Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Citadel.
See description of social skills training in the following clinical resources/manuals:
- Trower, P., Bryant, B. M., & Argyle, M. (1978), Social skills and mental health. London, UK: Methuen.
- Liberman, R. P., King, L. W., De Risi, W. J., & McCann, M. (1975). Personal effectiveness. Guiding people to assert themselves and improve their social skills. Champaign, IL: Research Press.
See description of relaxation training in the following clinical resources/manuals:
- Öst, L.-G. (1987). Applied relaxation: Description of a coping technique and review of controlled studies. Behaviour Research and Therapy, 25, 397-409.
- Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press.
- Lazarus, A. (1972). Behavior therapy and beyond. New York: Random House.
- Wolpe, J. (1969). The practice of behavior therapy (First Edition). New York: Pergamon.
See description of virtual reality treatment in the following clinical resource:
- Roy, S., Klinger, E., Légeron, P., Lauer, F., Chemin, I., & Nugues, P. (2003). Definition of a VR-based protocol to treat social phobia. CyberPsychology and Behavior, 6, 411-620.
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
Beck Institute for Cognitive Therapy and Research
Judy S. Beck, PhD, Director
One Belmont Avenue, Suite 700
Bala Cynwyd, PA 19004-1610
San Francisco Bay Area Center for Cognitive Therapy
Oakland, CA (Rockridge)
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