Cognitive Behavior Therapy - Theory

As noted in the introduction, people with SA are able to experience anxiety through their thoughts alone, without being in the actual situation. However, the thoughts themselves may often be distorted. Since there is avoidance of the feared situation, this thinking does not get corrected by reality.

With CBT the therapist helps the client to identify distorted thought patterns and learn to correct them. A thought journal is often used for this process.

There is cumulative evidence that individuals with SA process information differently from people who are not socially anxious. It is found that they place much more importance on making a favorable impression on others, yet, they believe that they will act incompetently in social situations.

As a result of these concerns, people with SA use various processes intended to protect themselves in feared situations, which, unfortunately, often fail to help.

These processes include intensified attention on oneself, including paying attention to one's internal state; viewing oneself from an observer's perspective; overuse of safety behaviors. When in social situations, people who are anxious about how they are seen, commonly pay more attention to themselves and ignore useful and necessary social cues from others. This paying attention to oneself is encouraged by the presence of the physiological sensations of anxiety.

Another consequence of this inward attention is that people with SA usually construct a negative image of themselves, based on how they think others see them and how they feel.

Practice

Duration

Usually cognitive therapy is time limited. Commonly 10 to 20 sessions are required. If there is a more specific limited problem it could be dealt with in fewer sessions. Sometimes if there are complex problems more sessions may be required.

Therapeutic Alliance.

The therapist will work with the client to set up a collaborative relationship. It is important that the client be an active participant in the whole process. He or she cannot expect to make any improvement unless they are prepared to follow through and do the homework assignments. However, the client's opinion and agreement will be sought throughout the process.

Set Agenda for Sessions

The therapist in collaboration with the client will set an agenda for each session. The activities will include giving constructive feedback, and employ cognitive therapy techniques on a regular basis and assign homework to link the sessions together.

Use Cognitive Techniques

Identifying Automatic Thoughts

Many people with SA commonly have thoughts which come into their mind in response to either a situation or to an emotion. They may be aware of the feeling but not recognize the thought. With SA these thoughts are commonly predictive of some disastrous event happening. Examples of these are given in Table II.

The therapist will guide the client in identifying these thoughts and then proceeding to the next step:-

Modifying Automatic Thoughts

Examining the Evidence for These Thoughts

The therapist will collaborate with the client in examining the evidence for these beliefs. This challenge also helps the client to more easily identify automatic thoughts in the here and now. There are common patterns of cognitive distortions which the therapist can help the client to recognize.

De-catastrophizing

Clients typically predict that dire consequences will happen if they engage in the feared social behavior. The therapist helps by challenging these assumptions.

Assign Homework

Homework assignments are routinely given in the course of CBT. Commonly a thought journal is kept in which the client records a triggering event, his or her emotional response to that event and the thoughts that accompany it. He or she is then requested to write down the evidence for this thought or to identify in what way it is distorted.

The therapist will be coaching the client in identifying these distortions. The homework and journal will be used as a basis for a subsequent session.

In addition to the thought journal graded exercises with exposure to the feared situation may be assigned.

Cognitive Therapy coupled with graduated exposure to the feared situation has been demonstrated to be an effective treatment for SA.