شناخت درمانی برای هراس اجتماعی: درمان فردی در مقابل درمان گروهی

Cognitive-behavioural group treatment is the treatment of choice for social phobia. However, as not all patients benefit, an additional empirically validated psychological treatment would be of value. In addition, few studies have examined whether a group treatment format is more effective than an individual treatment format. A randomized controlled trial addressed these issues by comparing individual cognitive therapy, along the lines advocated by Clark and Wells (Clark, D.M. and Wells, A., 1995. A cognitive model of social phobia. In: R. G. Heimberg, M. Liebowitz, D. Hope and F. Schneier (Eds.), Social Phobia: Diagnosis, assessment, and treatment (pp. 69–93). New York: Guilford.), with a group version of the treatment and a wait-list control condition. 71 patients meeting DSM-IV criteria for social phobia participated in the trial, 65 completed the posttreatment assessment and 59 completed a six-month follow-up. Social phobia measures indicated significant pretreatment to posttreatment improvement in both individual and group cognitive therapy. Individual cognitive therapy was superior to group cognitive therapy on several measures at both posttreatment and follow-up. The effects of treatment on general measures of mood and psychopathology were less substantial than the effects on social phobia. The results suggest that individual cognitive therapy is a specific treatment for social phobia and that it’s effectiveness may be diminished by delivery in a group format.

Cognitive-behavioural group-treatment (CBGT) is considered to be the psychological treatment of choice for social phobia (DeRubeis and Crits-Christoph, 1998 and Heimberg, 2001). Controlled trials have repeatedly demonstrated the effectiveness of CBGT. Favourable comparisons between CBGT and attention placebo (education-support) and pill placebo conditions have shown that CBGT is a specific treatment in the sense that its effectiveness exceeds that attributable to non-specific therapy factors such as therapist attention, a plausible rationale, goal setting and symptom monitoring. Meta-analytic studies (Fedoroff and Taylor, 2001, Feske and Chambless, 1995, Gould, Buckminster, Pollack, Otto and Yap, 1997 and Taylor, 1996) that have compared CBGT with other active psychological treatments have failed to show significantly greater efficacy for CBGT than exposure alone or social skills training. However, only cognitive-behavioural treatments (including CBGT) have achieved effect sizes which are significantly greater than placebo control conditions (Taylor, 1996). In addition, the improvements observed with CBGT are well maintained after the end of treatment. For example, Heimberg, Salzman, Holt, and Blendell (1993) found that patients who received CBGT retained their gains at 5 year follow-up and remained significantly less symptomatic than patients who had received an education-support treatment. Despite the positive findings reported for CBGT, it is generally agreed that there is scope for further development of psychological treatments for social phobia. Two particular issues stand out. First, some patients fail to achieve optimal benefit from well-conducted CBGT. For example, in an intention-to-treat analysis Heimberg et al. (1998) reported that less than 60% of patients who received CBGT were classified as treatment responders. Using a stricter criterion of improvement, Mattick and Peters (1988) reported that only 38% of patients who completed their CBGT programme were considered optimally improved (achieved high-end state functioning). Second, the logistics of CBGT can be difficult. Patients may have to wait longer for treatment to start than in individual treatment because it takes time to assemble a group. Also there is less flexibility about when sessions can be scheduled, which may lead to less complete attendance than in individual treatment. The present study addresses both these issues by: (i) providing an evaluation of a relatively new psychological treatment for social phobia and (ii) comparing the effectiveness of the treatment when delivered in individual and group formats. The new psychological treatment is the cognitive therapy programme developed by Clark, Wells, and colleagues on the basis of their cognitive model of social phobia. The cognitive model (Clark & Wells, 1995) largely focuses on the maintenance of social phobia and attempts to explain why patients with social phobia fail to benefit from the naturalistic exposure that is provided by their everyday interactions with other people. Four maintenance processes are particularly highlighted. First, an increase in self-focused attention and monitoring with a linked reduction in observation of other people. Second, the use of misleading internal information (particularly anxious feelings and spontaneously occurring, observer perspective and distorted images of themselves) to make excessively negative inferences about how one appears to others. Third, extensive use of safety behaviours which are intended to prevent feared catastrophes but have the consequence of maintaining negative beliefs, increasing feared symptoms, and making patients come across to others in ways that are likely to elicit less friendly responses. (Although termed ‘behaviours’, a substantial proportion of the safety behaviours are cognitive strategies). Fourth, negatively biased anticipatory and post-event processing. The cognitive therapy programme includes a series of procedures that are specifically focused on reversing the maintaining processes specified in the model. The procedures include: generating with patients an idiosyncratic version of the model; systematically manipulating self-focused attention and safety behaviours in role plays in order to demonstrate their adverse effects; training in attentional redeployment; extensive use of video and audio feedback to correct patients distorted observer perspective images; and behavioural experiments in which patients confront feared situations while redirecting attention and dropping safety behaviours in order to test out their fearful predictions. Group treatment is the most common method of delivery for CBT in social phobia studies and it is often suggested that group treatment may be superior to individual treatment. Potential benefits of group treatment include: greater ease in simulating social situations in role plays, the exposure of simply being in a group, mutual support from group members, potentially helpful social comparisons, and vicarious learning while other group members are performing role plays (Heimberg, Juster, Hope, & Mattia, 1995). Potential disadvantages of group treatment include: the possibility of less attention to individual problems and dysfunctional beliefs, and an intensification of avoidance behaviours in a group situation that might interfere with response to treatment (Scholing & Emmelkamp, 1993). To date, few studies have directly compared group versus individual cognitive-behavioural treatment and those that have failed to convincingly demonstrate superiority for group treatment. Wlazlo, Schroeder-Hartwig, Hand, Kaiser, and Münchau (1990) compared individual exposure therapy, group exposure therapy and social skills training. There were no significant differences between the treatment conditions in short-term or long-term treatment outcome. However, methodological shortcomings (e.g. no control group, no randomization, differences in treatment duration), limit the validity of this study. Based on Heimberg’s cognitive-behavioural group-treatment program, Lucas and Telch (1993), cit. from Heimberg & Juster, 1995) compared individual with group treatment both comprising similar treatment components and found no differences in symptomatic outcome, although group treatment was considered more cost-effective. Scholing and Emmelkamp (1993) contrasted different combinations of exposure and cognitive restructuring in an individual and group setting and found no significant differences in either short-term or long-term. The cognitive therapy programme developed by Clark, Wells and colleagues was originally intended as an individual treatment. Case reports and case series (Bates and Clark, 1998, Clark, 1999 and Wells and Papageorgiou, 2001) have suggested that as an individual treatment it may have a substantial effect on social phobia. This was confirmed in a recent randomized controlled trial (Clark et al., 2002) in which the cognitive therapy programme was shown to be superior to combined medication and behaviour therapy (SSRI plus weekly self-exposure exercises). To date, no controlled evaluations of a group version of the cognitive therapy programme have been reported. The aims of the present study were to provide a further controlled evaluation of the individual cognitive therapy programme and to compare its effectiveness with a group version of the programme. Therapists in the trial were not involved in the original development of individual cognitive therapy and had a modest amount of training in the programme. For this reason, the trial should be considered as a dissemination project.