The standard treatment model of social anxiety and other anxiety disorders is exposure therapy and the literature supports that¹.
Can we do better?
ABSOLUTELY. The 2006 trial by Clark et al² showed that cognitive therapy outcome was superior to exposure and applied relaxation. 84% of people who received cognitive therapy and 42% of people who received exposure and applied relaxation got better. Both treatments were better than waiting list controls.
It is all about the IMAGE
One of the specific approaches in Clark’s model is the detection of self-image distortions in social anxiety. The clients literally imagine themselves through the eyes of other people who they believe are judging them. Such distortions may include excessive blushing or imagining specific body movements like tremors. The social judgment they expect is based on these images.
Body image distortions also found in other disorders like eating disorders and body dysmorphic disorder. In social anxiety, they are usually limited to the social situation.
The first assessment
Getting into the imagery details in the first assessment helps understand the cognition, distress and the safety behaviours in social situations much more accurately.
Imagery work in Social Anxiety is the secret sauce
Since social situations are variable with multiple factors at play, focusing on the imagery cognitions gives us the specificity to design the treatment. This may be a reason cognitive therapy was superior to exposure treatment in this study. There are, of course, other components to the treatment model, which contribute to its effectiveness.
In social anxiety, take the therapy beyond exposure and target 80% recovery
It is critical to go beyond exposure therapy in the treatment of social anxiety. Cognitive therapy with the understanding of imagery approximates more closely to the individual’s experience and produces better outcomes. The recovery rates are close to 80%!
What else should the therapist consider
Consider co-morbidities like depression or other anxiety disorders that may change the course of social anxiety.
Click here to sign up for our cognitive behaviour therapy web workshop for social anxiety
Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry. 2014; 1(5): 368-76.
Clark DM, Ehlers A, Hackmann A, McManus F, Fennell M, Grey N, et al. Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of consulting and clinical psychology. 2006; 74(3): 568-78.
About the Author
Dr Sanjay Rao is an experienced teacher and Associate Professor of Psychiatry at the University of Ottawa In 2018 he was awarded a Fellowship of the Canadian Association of Cognitive Behavioural therapy for his contribution to CBT in Canada. He has received an award from the Department of Health, UK for CBT development. He is the Director of Unified CBT training.