Person-Centred/Experienti

al Approaches to Social Anxiety:

Initial outcome resultsRobert 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 unemploymentRisk 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 anxietyC. Recognition: Person experience fear as excessive or

unreasonableD. Avoidance, or endurance with intense distressE. 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 psychotherapiesPCEs shown to be effective with Major DepressionSA 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: ClientsCommunity sampleBrief telephone screeningFace-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: ClientsSpecific SA (one specific situation: public

speaking): 49%Generalized (multiple situations):

51%Axis 2: mean 3.3 Axis 2 diagnosesAvoidant Personality pattern: 92%Borderline: 35%

Mean Problem Duration Ratings of Personal Questionnaire Items

n 17Mean 6.24SD 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 finishedAssessments/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-Therapy Post Therapy Effect Size (sd)

N Clients Reliable change

n m sd n m sd

PQ >3.5 18 5.55 .81 18 3.34 1.17 2.20** 14 (18)CORE >1.25 17 1.58 .67 15 .95 .72 .91* 8 (11); 1SPIN >1.12 17 2.48 .66 14 1.50 .66 1.54** 9 (16)IIP >1.5 17 1.89 .66 14 1.26 .54 .96* 7 (13); 1Strath <1.95 17 1.94 .50 15 2.66 .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)

Clients Showing Reliable Change X Measures

(Positive Change unless otherwise noted) NGlobal Change: At least two measures 10Some change: At least one measure 16Limited Change: One measure but not others 3Negative/mixed change (evidence of deterioration) 2No reliable change on any measure 2

Results: SPIN Outcome Benchmarking

Measure: Pre Post Pre-post Effect Size

N M SD M SD (sd)

PCE 14 2.48 .66 1.40 .67 1.54Connor et al 2000:

Medication

28 2.53 .62 2.16 .81 1.28

Placebo 25 2.4 .81 2.16 .75 .31Antony et al 2006: Group CBT 74 2.64 .85 1.81 .92 .94

Results: SPIN Subscale Analyses (w Benchmarking)

Sub-scale:

Pre-therapy Post-therapy PCE Effect Size (ES)

Antony 2005 ES

M SD M SD (sd) (sd)Fear 2.80 .76 1.55 .82 1.64** .93Avoid-ance

2.69 .59 1.63 .74

1.64** .81Physio-logical

1.61 1.0 0.79 .63

1.03** .69N = 16 (pre), 14 (post)Significance tests are pre-post for PCE therapy: *p < .05; **p< .001

PCT vs. EFT Pre-post Effect Sizes

Measure PCT EFT

PQ 2.11 2.23CORE 0.68 1.09SPIN 1.61 1.68IIP 0.75 1.21Strath 0.96 1.76Mean Pre-post ES: 1.22 1.60EFT vs. PCT Difference in ES: +.37

Worse than expected

Better than expected

Results: Analysis of Drop-out Patterns

PCT EFTCompleters 9 9Early drop-outs (1 -2 sessions) 4 2

Late drop-outs (3 - 5) 4 0

Changed to other therapy 3 1

Total (re)starts 20 12

% Completers 45% 75%

Late Drop-outsQuit 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

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 - CautionsBut:

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 StepsRCT: Primary Care client populationPCE therapy (PCT & EFT) vs. NHS Primary

Care Mental Health Team Treatment as Usual (group & individual CBT)

Continue developing EFT therapy for SAPiloting PCT & EFT Adherence Measures

E-mail: Fac0020@gmail.comBlog: pe-eft.blogspot.com