by Thomas A. Richards, Ph.D.,
What is Comprehensive Cognitive – Behavioral Therapy?
How is Comprehensive CBT used to Overcome Social Anxiety Disorder?
It wasn’t long ago that very few people had heard the term "cognitive - behavioral therapy."
With the outpouring of research in the 1980s, and the studies on anxiety disorders that were published in the 1990s, the term "cognitive – behavioral therapy", or CBT, gained acceptance and became well known. But even though the term itself became well known, just what "cognitive- behavioral therapy" involved was less well understood.
Meanwhile, in study after study, cognitive – behavioral therapy began to prove to be the therapy of choice for many mental health care problems, including depression and the anxiety disorders.
In fact, large-scale, long-range (i.e., longitudinal) studies over the past decade have consistently shown cognitive – behavioral therapy to be the only therapy that can be dependably relied upon to help people overcome clinical anxiety disorders.
While this was good news, some rather large questions continued to cloud the horizon. For example, each study defined CBT in a different way, and most studies were rather vague in their explanation of just what CBT was considered to be. The other big problem was that people began to think of cognitive-behavioral therapy as a "unified" therapy, or as a therapy that was "set" or always the same for every mental health care problem.
*If you are seeking treatment for social anxiety, start here*
"Pulling Together" Everything That Works
In fact, CBT is a combination or a "pulling together" of any and all methods, strategies, and techniques that work to help people successfully overcome their particular emotional problems.
The cognitive part of the therapy refers to thinking or learning and is the part of therapy that can be "taught" to the person. The person then needs to take what has been taught, practice it at home, and through means of repetition, get that new "learning" down into the brain over and over again so that is becomes automatic or habitual.
This is essentially the same process as school or college learning. You are taught some new information or skills, and then you learn them. When you learn them well enough (through repetition), this affects your memory processes (and physiologically your brain’s neural pathways) and allows you to begin thinking, acting, and feeling differently. This takes persistence, practice, and patience, but when a person sticks with this therapy, and does not give up, noticeable progress begins to occur.
The behavioral component of CBT involves participation in an active, structured therapy group, consisting of people with clinical social anxiety. In the behavioral group, people voluntarily engage in practical activities that are mildly anxiety-causing, and proceed in a flexible, steady, scheduled manner. By moving forward in this manner, step by step, and through the use of repetition, the anxiety felt in social situations is gradually reduced.
The behavioral therapy group should consist of people with social anxiety only. People with other emotional problems should not be mixed into this group. Even an "anxiety" group will not work. Because the problems are very different from each anxiety disorder to the other, the behavioral group and its activities would prove to be ineffective for people with panic, generalized anxiety, or obsessive-compulsive disorder, even though these are clinical anxiety disorders as well.
At the same time, the social anxiety behavioral group builds confidence and produces a more rational perception in the persons’ mind concerning their own abilities and competencies. The behavioral group must be structured in a step-by-step hierarchical fashion, and should include consistent cognitive reminders before and after people actively work on their specific, individualized anxiety hierarchies.
Thus, the cognitive-behavioral therapy we do for social anxiety does not contain the same information or proceed in the same manner as cognitive-behavioral therapy for other mental health care problems.
For example, CBT for depression is very different in nature than CBT for social anxiety. Because the problem is different, CBT for social anxiety contains different methods and strategies than CBT for depression, panic disorder or generalized anxiety disorder. Thus, cognitive-behavioral therapy, while always being active, structured, and solution-focused, must employ different ways of overcoming the particular emotional problem in question.
CBT is not a "set of methods" that work for all disorders. There are not simply two, three, or four strategies that work to help everyone with all kinds of mental health care problems.
Thus, the specifics or details of CBT are not universally applicable. This has been a thorny issue for professionals who do not really understand what cognitive-behavioral therapy involves. With the advent of managed care, the insurance companies now want therapists who say they can do "cognitive-behavioral" or "solution-focused" therapy. So, in order to be included in these groups and panels, professionals now will usually say they do "cognitive-behavioral therapy".
But what exactly does this mean?
Knowing the Terminology is Different Than Doing Effective CBT
At this point in time, almost every licensed therapist knows the accepted terminology. The question becomes do they understand CBT and can they do it? This is only the first relevant question and the first hurdle to cross.
The second issue the professional must understand and must be able to accomplish concerns their ability to use specific CBT methods and strategies to help people with a particular disorder, such as social anxiety.
When specific cognitive-behavioral therapy for social anxiety is not understood or put into place, then people with social anxiety disorder will not receive the help and assistance they need to overcome this debilitating anxiety disorder.
Because each mental health care problem is different, and because people with social anxiety disorder respond to different CBT methods, strategies, and approaches, the professional should be cognizant of how to lead, guide, and help people with social anxiety overcome this specific anxiety disorder.
I receive dozens of e-mails and other correspondence each day, with one of the recurring themes being, "I went through cognitive-behavioral therapy and I didn't get any better. What’s wrong?"
The answer to this question is another question: "Did you receive appropriate, comprehensive cognitive therapy and appropriate, comprehensive behavioral therapy, and were the cognitive and the behavioral components of the therapy "reinforced together" in your mind by your therapist?
This, of course, leads to the question: "What exactly is comprehensive cognitive – behavioral therapy, and how does it differ from traditional cognitive behavioral therapy?"
The traditional answer to "what is cognitive-behavioral therapy" has been "restructuring" the mind (i.e., thought processes) by means of disputing irrational thoughts and beliefs and substituting rational thoughts and beliefs in their place. There is usually mention of breathing exercises and relaxation techniques as well.
"Cognitive restructuring" or "learning to think rationally" are essential components of cognitive therapy for social anxiety disorder. However, while learning to notice and eradicate automatic negative thinking (and slowly moving the thinking up to automatic rational thinking) is essential for overcoming social anxiety, there are fifteen to twenty specific steps that need to be learned to be able to do this.
You cannot tell a person with social anxiety to simply stop thinking negative thoughts. Obviously, the person does not want to think negatively, and if they could choose to stop thinking negatively, they would do so in a heartbeat.
Specific Solutions to Anxiety Symptoms Must Be Taught and Learned
We must employ very specific ways to allow the person to begin to (a) catch their own automatic negative thinking, (b) find distractions to use while therapy is in progress, and (c) begin to turn the tables on automatic negative thinking gradually.
The mind will not accept "irrational positive" statements or beliefs. Repeating "I will wake up in the morning and be happy, content, and less anxious" will do absolutely nothing, because this statement is irrational, given the current state of the mind. Therefore, emphasizing positive thinking and giving out positive thinking statements to people with social anxiety disorder is going to be ineffective, and will only prove to the person that the therapist does not understand and does not know how to successfully treat social anxiety.
The mind cannot work overnight and cannot be pressured into learning things faster. So, it is important, in the cognitive process, to turn the tables on automatic negative thinking slowly.
To do this, people with social anxiety learn to catch their automatic negative thoughts and then make them rationally neutral. As they find this process easier, they begin to catch more of their automatic negative thinking. This, in turn, leads to consciously turning this negative thinking into rational neutral thinking. Then, this neutral thinking is gradually moved up, always in a step-by-step manner, to a more realistic level, so that with time and repetition, the person’s thinking moves slowly upward and becomes more realistic.
At first, this is a conscious process, but the more it is practiced and repeated, the more it becomes an automatic process.
Now, to get even more specific, how do we accomplish these cognitive goals? We use a series of printed handouts that accompany the office visits. The role of the therapist is to know what to do and at what pace therapy can proceed with each individual.
People with social anxiety need printed handouts that explain, with specificity, (a) how to stop automatic negative thinking, (b) how and why to use distractions, (c) how to turn automatic negative thinking neutral, (d) the importance of repetition and consistency in this process, and (e) how to gradually keep turning the tables on the automatic negative thinking until it becomes realistic and rational. We use approximately twenty (20) handouts (i.e., printed methods, strategies, concepts, and techniques) that guide the person along the road to rational and realistic thinking in this step-by-step manner.
Even though automatic negative thinking and feeling are an essential part of cognitive therapy, there are many more facets to this therapy. If cognitive therapy is seen only as a thinking change process, then this therapy will not be strong enough, in most cases, to overcome social anxiety.
At this point, there are many other cognitive issues that must be presented and solved. For example, there are many cognitive methods of lessening anxiety, especially as it applies to interpersonal relations and groups. These methods must be presented, practiced, and used to give the person with social anxiety the feeling, even though it is small at first, that they have some control over their anxiety, particularly in social situations.
The use of only one method, such as relaxation, is never enough. Not everyone with social anxiety can learn to relax enough so that it becomes practical and usable in real-life situations at first. So, it is the therapist’s responsibility to have many ways (i.e., methods, techniques, strategies) to allow the person to begin to control their own emotions.
Learning, Repetition, Written Strategies, Verbal Explanations are All Important
We have found that it is important to have the cognitive therapy written out in handout form for the patient. In this manner, they understand it better, recognize the rationale behind it, and then can practice this method or strategy (over and over again) when they are at home during the week.
At least a dozen more cognitive problems must be solved besides the two already mentioned. Lack of space prohibits a detailed discussion, but some of the every day problems that must be worked on and solved if we say we are helping people overcome social anxiety, are the person’s
(a) misperception of themselves in terms of appearance, ability, and self-worth,
(b) feelings of guilt and embarrassment arising from past social situations,
(c) anger arising from past situations,
(d) self-assertion strategies to show the person they do not need to be a doormat,
(e) perfectionism and how to become more realistic, and
(f) procrastination habits that exist because of social anxiety worries and doubts.
In one sense, you could lump all of these things together as "irrational beliefs", but these problems do not fit neatly into this category, like automatic negative thinking.
Each of these additional problems must have solutions, too, that are practical and viable in the real world. Thus, from the cognitive therapy standpoint, the therapist should have the methods and strategies in handout form so that each of the above mentioned problems may be addressed and solved.
Each handout is a solution to a particular social anxiety problem. The more areas of social anxiety that are addressed, and the more solutions that are found, the quicker, easier, and stronger the healing becomes.
Again, I do not mean to imply that the social anxieties I have mentioned so far are a complete listing. There are many other issues relating to social anxiety that should be resolved. Again, we feel strongly that a written handout with the problem, the rationale, and the solution on it are essential to adequate progress in this area.
Then, it is up to patients and their motivation to carry through with the cognitive therapy. The therapy must be "practiced" at home (when they are alone and not feeling self-conscious) for approximately thirty minutes a day.
Persistency is the next key. These solutions must be practiced every day for three months or longer. It is essential that the brain receive these new, rational, forward-moving messages so that thinking can be changed (i.e., the neural pathways in the mind "absorb" the cognitive therapy and it begins to become a part of the person). This constant repetition of the material that solves the social anxiety puzzle is what allows permanent change to occur in people.
This is just an introduction to the intricacies of cognitive therapy for social anxiety disorder. But it takes the mastery of these concepts (and many more) before a program for social anxiety can be successful.
Since the term "cognitive-behavioral therapy" is being thrown about indiscriminately, we feel that the need to define CBT differently as it is employed for social anxiety. Thus, we are beginning to use the terminology "Comprehensive Cognitive – Behavioral Therapy" to refer to the therapy that is most efficacious for social anxiety disorder.
This also differentiates social anxiety CBT from the mistaken idea that relaxation strategies, keeping a journal, and changing some irrational beliefs is all that it takes to overcome this disorder.
So far, we have discussed the cognitive component of the therapy.
Behavioral therapy is also essential for people with social anxiety disorder. Behavioral therapy, by definition, is active and structured. But here’s where the typical understanding of "behavioral" breaks down, when it is applied to people with social anxiety disorder.
The behavioral component of the therapy has typically been explained as "exposure" (i.e., exposing people with social anxiety to situations which they fear, so that they will habituate, or get used to, the feared situation.)
As you may notice, this definition has two problems. While being fairly accurate, it (a) is too vague and contains no specifics, and (b) does not explain or address adequately why "exposure" for social anxiety must be done differently than "exposure" for people with other mental health care disorders.
Most therapists think of "behavioral therapy" as "exposure" to real-life anxiety-producing situations. Anyone familiar with social anxiety disorder knows that exposures do not work, they only cause damage, and they keep the person locked in the vicious cycle of anxiety, irritation, frustration, anger, and depression.
Unstructured "Exposures" Do Not Work
People with social anxiety know why these "exposures" do not work. For example, at the worst stages of my own social anxiety, I was constantly "exposed" to anxiety-producing situations. There were many situations I could not avoid. I had no choice. I had to "expose" myself to these anxiety-producing situations even though I did not want to do so.
For example, at one point in my life I was a teacher. I did fine with students, but when it came to parent-teacher conferences, I would dread the experience (the "exposure") weeks and weeks ahead of time. The anticipatory anxiety and fear was so strong that it gripped at my stomach and made me feel like it was bloody and raw.
Over the course of nine years, I was required to go through thirty-three weeks of parent-teacher conferences. I was exposed to one of my greatest fears, and the repetition and further exposure to this fear did not cause me to lose my anxiety and feel more comfortable. Instead, I faced my fears and my fears became even stronger.
This is only one example of why traditional "exposure" techniques are counterproductive for people with social anxiety disorder.
The Worst General Advice: Face Your Fears
Equally annoying and discouraging to people with social anxiety is the oft-mentioned "face your fears" and you will become anxiety-free. Several books on the market have this terminology in their title and it is not only a wrong course of action to take with social anxiety, it is an action that leads to doubt, depression, questioning, and even more anxiety.
Some of the worst advice given to people with social anxiety is to "buck up and face your fears". This will not work. It will backfire, cause more anxiety and depression, and damages lives.
The term "systematic desensitization" is also used as a behavioral technique for social anxiety. This is actually a strategy that will work, given that the therapist knows how to adequately and to appropriately implement it.
The "systematic" part of systematic desensitization is highly important. In behavioral therapy for social anxiety, the progress must be systematic, step-by-step, hierarchical, and repetitious. If it moves too fast, or if it is too much, this therapy will backfire. It is very important that any process of desensitization be gradual and systematic.
However, we tend to shy away from this terminology as well, because (a) not everyone means the same thing when they use it, and (b) it can easily be misunderstood and misused.
Thus, we are more prone to consider behavioral therapy for social anxiety as a gradual, step-by-step process, one that is never helped by force, pressure, or flooding. We have begun to call these behavioral activities "experiments" to differentiate them from other behavioral terminology that may be confusing when applied to the treatment of social anxiety disorder.
When we began our behavioral therapy group in 1995, we held it on a week day evening for two hours. As more people with social anxiety joined the program, we had two or three evenings a week dedicated to social anxiety behavioral group therapy.
While this schedule worked, there were several problems with it, principally tiredness and time. Most people came directly from a full day of work, and were understandably tired. There was also the growing realization that the time allotted (i.e., two hours) was not optimal to accomplish all that was needed.
Therapy Time and A Relaxed Group Makes Overcoming Social Anxiety Easier
At the beginning of 1999, we began using Saturday as the cognitive therapy day for new people (mornings) and the behavioral therapy group for new and returning people (afternoons). By taking this approach, we found we could lengthen the behavioral therapy time by an hour and have a group of people who were more rested and relaxed, relative to a weeknight group. Thus, while still providing individual appointments for cognitive therapy, and maintaining an evening behavioral therapy group, we launched an all-day Saturday CBT group.
In general, we believe the Saturday approach works better, is easier for patients, and most likely shortens therapy. In our initial assessment, the behavioral therapy group on Saturday afternoon has proven to be a more effective approach to group therapy relative to a weeknight group.
The behavioral therapy group must be individualized to allow for each person to work on their own specific anxiety hierarchy. While many of the behavioral activities will be the same for people with social anxiety, some of the behavioral experiments necessary will be different from person to person, due to specific fears.
For example, the vast majority of people with social anxiety list "presentations/speeches" and "making introductions" as part of their anxiety hierarchy. "Mingling" or making small talk, especially with strangers, usually makes the anxiety hierarchy as well. Everyone in the group works on these anxiety problems and we do most of these activities together.
Other behavioral experiments that the majority of people practice on in the behavioral therapy group are self-assertive role plays and the ability to deliberately do something foolish in front of a group of people. However, these behavioral experiments do not fall on every person’s hierarchy. If a person does not have anxiety with these particular social activities, they do not need to be doing self-assertive role plays and/or foolish things in public.
An experiment that is essential to some group members, such as learning to look other people directly in the eye, is not a problem for many other group members. So, members who need to work on this will use one of our behavioral therapy experiments, such as the Stare Chair, the Stand Stare, or the No-Personal-Space Stare. While these techniques are very helpful to people with eye contact anxieties, many other people do not have this anxiety and, therefore, do not need to work on this experiment.
The purpose of the behavioral group is for everyone to work on their own individualized anxiety hierarchy. The focus is on doing what is needed for the individual to overcome social anxiety.
We have found that the best and most permanent results do not occur in the first behavioral group. Thus, we encourage people with social anxiety to continue with the behavioral group therapy for as long as it takes to fully eradicate social anxiety.
Most people notice a large amount of progress after completion of cognitive therapy and the first behavioral group. This, of course, is good, but people also realize by this time that they can make more progress and conquer more social anxieties. As a result, over 90% of people at The Social Anxiety Institute choose to continue on into a second behavioral therapy group where they continue to build upon the successes experienced in the first group.
Therapists should encourage group participation and continuance at this point, because even the most motivated of people cannot get to the place where they want to be (i.e., relatively free of anxiety) with just one behavioral group under their belt.
Again: Persistence and Consistency Win the Day
The persistence and consistency in the behavioral group program pays off well, and the improvement over anxiety is even clearer as time progresses. I should mention that our therapy costs are low, relative to other programs, we use sliding fee scales, and when people choose to continue group behavioral therapy, the cost is more than cut in half, thus allowing everyone access to continue with therapy, regardless of financial situation.
As a result of our "intensive" CBT sessions in which people from all over the world come for comprehensive CBT, we found that therapy was more effective if we took what we were learning and applying in the therapy group out into the real world.
So, beginning in 1998, we formally added these outside-of-the-clinic "experiments" to our comprehensive cognitive-behavioral therapy program. For example, when the group is ready for this, we go to a local shopping mall, a university campus, or a downtown area in which we know there will be people milling around. Then, depending on the individual’s anxiety hierarchy, the "experiments" that are available to us in our progress against social anxiety are numerous.
When the group goes to a shopping mall, for example, one of the activities we use to decrease self-consciousness and become more comfortable with being the center of attention, is finding a table at the mall’s food court, ordering some food or drinks, and staking out a table. Then, one of the members goes and gets a bagel or muffin and we put a candle in it, light it, and sing happy birthday to the group member who has chosen to do this "experiment".
Before every experiment we talk about it from a cognitive perspective, and each person who participates in an "experiment" has volunteered to do it because they know it will help them overcome their social anxiety. The birthday party experiment in public places is effective because the birthday person is asked to slowly look around the mall at other people while the birthday song is being sung to them and while they are the center of attention.
They are generally surprised that people’s reaction is either positive (i.e., many people smile at us and some even sing along) or neutral (i.e., many people simply ignore us). We have performed this particular experiment over a hundred times now, with no adverse response.
Space again does not allow us to discuss each and every behavioral technique we use in the real-world "experiments". Some of the other outside-the-clinic experiments we have found helpful include initiating conversations with salespeople, going "up" the down escalator, skipping through the mall like schoolchildren, yelling at each other to "wait up for me" in a crowd, and talking to strangers in stores concerning a product or an item that they are looking at (e.g., "That looks like an interesting book. Does it seem to be pretty thorough?")
The opportunities for outside-the-clinic experiments are too numerous to list. We have found that having the entire group there, plus an anxiety mentor, ensures that everything goes smoothly.
We work out everything first, before we leave the clinic. That is, people know what experiment would help them with social anxiety, and they know how much they can do at any given time. We work with people to ensure that their choices are reasonable, hierarchical, and are proceeding in a rational way.
In addition, a pre-experiment rationalization is given (i.e., what to look for and expect during the experiment) and a post-experiment rationalization (i.e., a debriefing) is provided to ensure that the person interpreted the experiment correctly and was thinking along rational lines.
So, for the above reasons we are beginning to use the term "comprehensive cognitive-behavioral therapy". It is important that professionals and people with social anxiety disorder understand that treatment for social anxiety must be thorough and comprehensive.
Using only a few methods, concepts, statements, and techniques will prove unsuccessful.
Cognitive therapy alone, while helpful, will not provide adequate relief from social anxiety. Behavioral therapy alone does not allow the brain to change its perceptions and beliefs unless a feared activity is done hierarchically and successfully and then cognitively reinforced. It is important to integrate the cognitive and the behavioral therapy, although this does not need to occur at the same time.
Comprehensive cognitive-behavioral therapy implies that we will use every method, strategy, and concept useful to us. We will provide many options to reach the goal and not be dependent on one cognitive strategy to work miracles.
We must use all the cognitive strategies at our disposal, reinforce the necessity of persistency and consistency in social anxiety therapy, and make available any form of behavioral activity or experiment that will help the person slowly move up their anxiety hierarchy in the behavioral group.
As with the cognitive therapy, the behavioral activities or experiments must be thorough and comprehensive. The therapist should have a list of several dozen behavioral activities that should give the person with social anxiety more peace and confidence as they work on these activities as the group progresses.
For the successful treatment of social anxiety, both the cognitive and behavioral therapy must be thorough and comprehensive. Reinforcement must be continuous, and the person must be motivated to stick to a thirty-minute a day practice routine.
This course of action is not the path of least resistance for either the therapist or the patient. However, it is the best way we know to overcome social anxiety disorder. Most people with social anxiety will tell you that, even though they can see there is much work ahead, they are willing and motivated to do it, because the work is nothing in comparison to the daily nightmare of living with social anxiety.
This hope, progress, and eventual success is what keeps all of us in a positive frame of mind and moving forward to our ultimate goal.
*If you are seeking treatment for social anxiety, start here*
-- Thomas A. Richards, Ph.D., Psychologist
Director, Social Anxiety Institute