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Person-Centred/Experiential Approaches to Social Anxiety: Initial outcome results Robert Elliott & Brian Rodgers University of Strathclyde
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Why Study Social Anxiety (SA)? Some research on PTSD/trauma and Generalized Anxiety, but social anxiety neglected Common but debilitating problem, affects social adjustment, work functioning Relevance to government initiatives targetting anxiety/depression in chronic unemployment Risk factor for depression, substance misuse (self-medication)
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What is Social Anxiety? (DSM-IV) A. Marked and persistent fear One or more social or performance situations The individual fears that he or she will act in a humiliating or embarrassing way B. Consistency: Exposure to feared social situation almost invariably provokes anxiety C. Recognition: Person experience fear as excessive or unreasonable D. Avoidance, or endurance with intense distress E. Interference: interferes significantly with functioning or wellbeing
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Why Person-Centred-Experiential (PCE) Therapies for Social Anxiety? This client group has been virtually ignored by humanistic psychotherapies PCEs shown to be effective with Major Depression SA Commonly accompanied with clinical depression, substance abuse, employment problems Resonance with key theoretical formulations: Standard Person-Centred Therapy: Conditions of worth Emotion-Focused Therapy: Anxiety splits: externalized inner critic
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SA: Driven by Powerful Emotion Processes Key emotions: primary maladaptive (overgeneralized) shame and fear Organized by core emotion schemes: Self as socially defective Others as harshly judging/rejecting (=internalized critic) SA organized around core emotion scheme of Self as socially defective Basis of SA: Fear that this core defective self will be seen & negatively judged by others
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Core Defective Self-scheme Socially Defective Self (Experiencer) Typically grounded in early physical/emotional/sexual abuse or rejection/bullying Organized around primary maladaptive shame/fear Symbolized by one or more key phrases/images, e.g., “rubbish”, “crazy”, “stupid”, “ugly”, “a freak”
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Shaming Internalized Critic Scheme Complementary emotion scheme: Harsh, shaming internal Critic Introject of early rejection/abuse Emotion scheme primes monitoring for social dangers Attribution to current others But: also has protective function (prevent social rejection) Motivates social withdrawal/avoidance & emotional avoidance
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Strathclyde PCE Therapy for Social Anxiety Project Therapy development/ Pilot study Open clinical trial In progress; n = 19 completers to date Two arms of study (non-randomized but unsystematic): Standard Person-centred (PCT) Including nondirective & broader relational versions Emotion-focused therapy (EFT) PCT + active tasks: Focusing, Unfolding, Chairwork
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Method: Clients Community sample Brief telephone screening Face-to-face diagnostic assessment (2 X 2 hrs): SCID-IV Personality Disorders Questionnaire (PDQ) Create Personal Questionnaire Inclusion criteria: Consider self to have problem with social anxiety Meet DSM-IV criteria for social anxiety Willingness to be recorded, fill out forms
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Method: Clients Specific SA (one specific situation: public speaking): 49% Generalized (multiple situations): 51% Axis 2: mean 3.3 Axis 2 diagnoses Avoidant Personality pattern: 92% Borderline: 35%
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Mean Problem Duration Ratings of Personal Questionnaire Items n 17 Mean 6.24 SD 0.78 “6.2”: somewhat more than 6 to 10 years Client presenting problems = chronic
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Method: Therapy & Research Parameters Up to 20 sessions; less if client feels finished Assessments/data collection at: Pre Mid: After session 8 Post (end of therapy) 6- & 18-mo follow-ups
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Method: Outcome measures 1. Personal Questionnaire(PQ): Individualized/weekly problem distress; used for progress monitoring 2. CORE-Outcome Measure (CORE): General problem distress 3. Social Phobia Inventory (SPIN): Problem specific 4. Inventory of Interpersonal Problems (IIP): Interpersonal problem distress 5. Strathclyde Inventory (Strath): Person-centred outcome measure 6. Self-relationship Scale (SR): EFT Outcome measure (Self-attack, Self-affiliation, Self-neglect) Qualitative: Change Interview (used in case studies)
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Results: Post-therapy Outcome for Combined Sample Mea- sure Cut-off value Pre-TherapyPost Therapy Effect Size (sd) N Clients Reliable change nmsdnm PQ>3.5185.55.81183.341.17 2.20**14 (18) CORE>1.25171.58.6715.95.72.91*8 (11); 1 SPIN>1.12172.48.66141.50.66 1.54**9 (16) IIP>1.5171.89.66141.26.54.96*7 (13); 1 Strath<1.95171.94.50152.66.56 1.33**10 (8) mean Pre-Post ES: 1.39 *p <.05; **p <.01 (using both independent & paired samples t-tests) n of clients showing reliable improvement (p <.05) (n of client in clinical range pre-therapy) n of clients showing reliable deterioration (p <.05)
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Clients Showing Reliable Change X Measures (Positive Change unless otherwise noted)N Global Change: At least two measures10 Some change: At least one measure16 Limited Change: One measure but not others3 Negative/mixed change (evidence of deterioration)2 No reliable change on any measure2
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Results: SPIN Outcome Benchmarking Measure:PrePost Pre- post Effect Size NMSDM (sd) PCE142.48.661.40.67 1.54 Connor et al 2000: Medication 282.53.622.16.81 1.28 Placebo252.4.812.16.75.31 Antony et al 2006: Group CBT742.64.851.81.92.94
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Results: SPIN Subscale Analyses (w Benchmarking) Sub- scale: Pre-therapyPost-therapyPCE Effect Size (ES) Antony 2005 ES MSDM (sd) Fear2.80.761.55.82 1.64**.93 Avoid- ance 2.69.591.63.74 1.64**.81 Physio- logical 1.611.00.79.63 1.03**.69 N = 16 (pre), 14 (post) Significance tests are pre-post for PCE therapy: *p <.05; **p<.001
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PCT vs. EFT Pre-post Effect Sizes Measure PCTEFT PQ 2.112.23 CORE 0.681.09 SPIN 1.611.68 IIP 0.751.21 Strath 0.961.76 Mean Pre-post ES: 1.221.60 EFT vs. PCT Difference in ES: +.37
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Worse than expected Better than expected
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Results: Analysis of Drop-out Patterns PCTEFT Completers99 Early drop-outs (1 -2 sessions)42 Late drop-outs (3 - 5)40 Changed to other therapy31 Total (re)starts2012 % Completers45%75%
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Late Drop-outs Quit before indicating they were done with therapy or finishing 16-20 sessions Session 3 -5 Pre-therapy mean PQ = 6.24 (vs. 5.59 for completers) Last session mean PQ = 5.55 Included 3 of the 4 most initially distressed clients
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Clients who changed therapies Early drop-outs included 4 clients who switched between arms of the study 1 client changed from EFT PCT Scheduling issue 3 clients changed PCT EFT Negative reaction to lack of structure in session 1
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Discussion – General Conclusion EFT (also PCT) for Social Anxiety Promising new approach Substantial change over therapy On long-standing problems Comparable to benchmark treatments (medication, CBT)
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Discussion – EFT vs PCT? Slight advantages to EFT over PCT? On CORE, IIP, Strath, but not on SPIN, PQ +.37: Same order as York I study (Greenberg & Watson, 1998), but smaller than York II (Goldman et al., 2006) Some clients react negatively to PCT in early sessions; fewer drop-outs in EFT Appears related to greater structure in EFT
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Discussion - Cautions But: Not statistically significant (low power), but current best guess Nonrandomized design Possibility of treatment diffusion (Chairwork in PCT condition?) Some clients refuse EFT Chair work Need to collect more data: target n = 30
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Next Steps RCT: Primary Care client population PCE therapy (PCT & EFT) vs. NHS Primary Care Mental Health Team Treatment as Usual (group & individual CBT) Continue developing EFT therapy for SA Piloting PCT & EFT Adherence Measures
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E-mail: Fac0020@gmail.com Blog: pe-eft.blogspot.com
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