Person-Centred/Experiential Approaches to Social Anxiety: Initial outcome results Robert Elliott & Brian Rodgers University of Strathclyde

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)

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

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

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

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”

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

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

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

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%

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

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

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)

Results: Post-therapy Outcome for Combined Sample Mea- sure Cut-off value Pre-TherapyPost Therapy Effect Size (sd) N Clients Reliable change nmsdnm PQ> **14 (18) CORE> *8 (11); 1 SPIN> **9 (16) IIP> *7 (13); 1 Strath< **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)

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

Results: SPIN Outcome Benchmarking Measure:PrePost Pre- post Effect Size NMSDM (sd) PCE Connor et al 2000: Medication Placebo Antony et al 2006: Group CBT

Results: SPIN Subscale Analyses (w Benchmarking) Sub- scale: Pre-therapyPost-therapyPCE Effect Size (ES) Antony 2005 ES MSDM (sd) Fear **.93 Avoid- ance **.81 Physio- logical **.69 N = 16 (pre), 14 (post) Significance tests are pre-post for PCE therapy: *p <.05; **p<.001

PCT vs. EFT Pre-post Effect Sizes Measure PCTEFT PQ CORE SPIN IIP Strath Mean Pre-post ES: EFT vs. PCT Difference in ES: +.37

Worse than expected Better than expected

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%

Late Drop-outs  Quit before indicating they were done with therapy or finishing sessions  Session 3 -5  Pre-therapy mean PQ = 6.24 (vs for completers)  Last session mean PQ = 5.55  Included 3 of the 4 most initially distressed clients

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

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)

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

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

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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