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Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: assessment (2nd post)

Yesterday I wrote an introductory post on using self-practice & self-reflection (SP/SR) to improve my understanding of David Clark's treatment for social anxiety.  In today's post I want to look at assessment - of social anxiety disorder, of skill with Clark's CBT approach, and at SP/SR initiation.

Back in May, in a first post on the new NICE guideline, I wrote that to identify adults with probable social anxiety disorder it is recommended that one "Ask the identification questions (to clarify whether there is likely to be some form of anxiety disorder present) using the two-item generalised anxiety disorder scale (GAD-2) in line with NICE guidance (downloadable here as a Word doc or a PDF file), and if social anxiety disorder is suspected use the three-item mini-social phobia inventory (Mini-SPIN) or consider asking the following two questions: Do you find yourself avoiding social situations or activities? Are you fearful or embarrassed in social situations? If the person scores 6 or more on the Mini-SPIN or answers yes to either of the two questions above, refer for or conduct a comprehensive assessment for social anxiety disorder."  Note the Mini-SPIN, the full SPIN and several other relevant questionnaires and handouts are downloadable from this website's "Good knowledge" page on "Social anxiety information & assessment".

I also wrote "Some degree of concern about how we are evaluated by others is normal.  Humans are social animals and not to give a sh*t about what others think of us isn't adaptive.  However being over-concerned isn't adaptive either.  As usual "the middle way" is likely to be most helpful ... to pay some attention to how others are reacting to us, but not to be governed by their opinions.  Sadly a worryingly high percentage of us will have excessive levels of social anxiety.  Often this persists for many years.  As highlighted in today's post, identification of those who are suffering troublesome social concerns makes very good sense."  So there are pretty strong arguments about the value of better identification of social anxiety problems.  I have already mentioned this website's "Good knowledge" page on "Social anxiety information & assessment" as a source of potentially helpful assessment questionnaires.  At David Clark's July workshop on state-of-the-art cognitive therapy treatment for social anxiety disorder, he discussed assessment in some detail and I have written a blog post about this at "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder".  

So that's a bit about clarifying severity of social anxiety, what about clarifying skill with Clark's CBT approach, and what kind of assessment is helpful in setting up Self-practice/Self-reflection (SP/SR)?  To measure therapist skill in treating social anxiety, Clark & colleagues have impressively developed a specific assessment scale - see "Assessing therapeutic competence in cognitive therapy for social phobia: Psychometric properties of the cognitive therapy competence scale for social phobia (CTCS-SP)."  Then, crucially, they have shown that skill measured in this way is predictive of patient outcomes - see "Treatment specific competence predicts outcome in cognitive therapy for social anxiety disorder."  I don't see myself getting access to trained raters to evaluate videotapes of my therapy sessions (as used in the research trials), however both of these papers are freely downloadable in full text so one can see what the raters were looking for when using the CTCS-SP.  As the authors of the "Treatment competence" paper comment " ... informal use of the cognitive therapy rating scale by students themselves is likely to be helpful. Certainly, we have found that many therapists who are learning CT for social anxiety learn a great deal about how particular procedures should be implemented by studying the particular items on the CTCS-SP and rating their own sessions according to the scale." Here is the CTCS-SP downloadable as a Word doc and here as a PDF file.

The CTCS-SP consists of 16 items that are assessed using a 7 point scale running from 0 indicating poor competence to 6 indicating excellent competence.  In the reported research trial, therapists were expected to reach at least an average of level 3 on assessed videotapes.  Dropping below competence level 3 triggered "feedback and additional supervision".  The "Assessing therapeutic competence" paper states "The final scale consisted of 16 items: agenda; dealing with questions, objections, problems; clarity of communication; pacing and efficient use of time; interpersonal effectiveness; resource orientation; review of social-phobia diary, questionnaires and other measures; reviewing previously set homework; use of feedback and summaries; guided discovery; focus on social-phobia-related cognitions, self-focused attention, safety-behaviours, and biased imagery (cognitive model); rationale; selection of appropriate strategies for change in social phobia related cognition and maintaining factors; appropriate implementation of techniques for change in social phobia related cognition and maintaining factors; integration of discussion and experiential techniques; homework setting."  The item labelled "resource activation" is interesting.  It is not specifically a cognitive therapy technique, but in a previous CBT trial for social anxiety it was found to predict improved outcome.  The authors describe it by saying "we expect the therapist to enable the patient to be aware of the patient's positive characteristics and skills and focus on how these can be used to reach self-set goals in therapy."  This overlaps very neatly with similar findings in depression - see the series of three posts from earlier this year starting with "New research suggests CBT depression treatment is more effective if we focus on strengths rather than weaknesses"

At his July workshop, Clark showed a slide where he highlighted "five treatment innovations" in his cognitive therapy approach for social anxiety - 1.) self-focused attention & safety behaviours experiments; 2.) video (and still) feedback; 3.) attention training; 4.) behavioural experiments; and  5.) then v's now discrimination training & rescripting for early socially traumatic memories.  I'm a very experienced cognitive therapist and I have trained with David Clark in the past, but I'm not skilful with this current social anxiety treatment focus.  Exciting.  Great to know that I can do this better.  Back in the 1990's, meta-analysis showed no additional benefit of adding cognitive approaches to basic exposure therapy for social phobia and this result was replicated in a further meta-analysis in the early 2000's. 

In general, simple exposure therapies still stand up well when compared to more complex cognitive-behavioural interventions for anxiety disorders - see, for example, the 2011 paper "Efficacy of exposure versus cognitive therapy in anxiety disorders: Systematic review and meta-analysis."  But the abstract of this paper makes it very clear that this is no longer the case for social phobia - "There is growing evidence of the effectiveness of Cognitive Behavioural Therapy (CBT) for a wide range of psychological disorders. There is a continued controversy about whether challenging maladaptive thoughts rather than use of behavioural interventions alone is associated with the greatest efficacy. However little is known about the relative efficacy of various components of CBT. This review aims to compare the relative efficacy of Cognitive Therapy (CT) versus Exposure (E) for a range of anxiety disorders using the most clinically relevant outcome measures and estimating the summary relative efficacy by combining the studies in a meta-analysis. METHODS: Psych INFO, MEDLINE and EMBASE were searched from the first available year to May 2010. All randomised controlled studies comparing the efficacy of Exposure with Cognitive Therapy were included. Odds ratios (OR) or standardised means' differences (Hedges' g) for the most clinically relevant primary outcomes were calculated. Outcomes of the studies were grouped according to specific disorders and were combined in meta-analyses exploring short-term and long-term outcomes. RESULTS: 20 Randomised Controlled Trials with (n=1,308) directly comparing the efficacy of CT and E in anxiety disorders were included in the meta-analysis. No statistically significant difference in the relative efficacy of CT and E was revealed in Post Traumatic Stress Disorder (PTSD), in Obsessive Compulsive Disorder (OCD) and in Panic Disorder (PD). There was a statistically significant difference favouring CT versus E in Social Phobia both in the short-term (Z=3.72, p=0.0002) and the long-term (Z=3.28, p=0.001) outcomes. CONCLUSIONS: On the basis of extant literature, there appears to be no evidence of differential efficacy between Cognitive Therapy and Exposure in PD, PTSD and OCD and strong evidence of superior efficacy of Cognitive Therapy in Social Phobia."

In fact, as of June 2013, David said that one-to-one cognitive therapy for social anxiety disorder had been assessed in seven randomized controlled trials (in the UK, Sweden & Germany) where it was shown to be superior to exposure therapy, two versions of group CBT, interpersonal psychotherapy, psychodynamic psychotherapy, medication (SSRI's), placebo, and no treatment (see too the major study reported in July's American Journal of Psychiatry).  Typically there has also been careful balancing of therapist affiliation effects.  As David points out, he doesn't know of any other psychological disorder with such clear differences between the preferred treatment and other active treatments.  Wow!  The crying shame is that there is huge client need in this area and very few therapists who have adequate experience in providing this type of treatment.  Learning to upgrade my work to current state-of-the-art cognitive therapy for social anxiety disorder makes very good sense. 

For specific details that take this general wish into nitty-gritty intentions, see the next post in this sequence "Self-practice, Self-reflection (SP/SR) & David Clark's treatment for social anxiety: personal aims (3rd post)"

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social anxiety, assessment ctcs-sp.pdf119.25 KB
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