ارزیابی جلسه پیشرفت کارآموزی در جلسه ای در درمان اختلال اضطراب اجتماعی: شاخص تغییر اضطراب اجتماعی

Abstract Frequent assessment during therapy can improve treatments and provide accountability. However, clinicians often do not monitor progress because of the time it takes to administer and score assessments. In response, the Social Anxiety Session Change Index (SASCI) was developed. The SASCI is a short, easily administered rating of subjective improvement that asks clients with social anxiety disorder how much they have changed since the beginning of therapy. Change on the SASCI was related to change in fear of negative evaluation, a core aspect of social anxiety, and to clinician-rated improvement, but not to ratings of anxiety sensitivity or depression. Because it is brief and easily interpretable, the SASCI can be used in a variety of clinical settings to monitor change across therapy. The SASCI is presented along with examples of how the information gathered from frequent administration can inform clinical practice.

Results Table 1 presents the means and standard deviations of SASCI and BFNE scores for each session. Table 2 presents the pre-and posttreatment means for each of the outcome variables. Overall, clients improved on all outcome measures. There were no site differences on any of the session or outcome ratings. Table 1. Means and standard deviations of SASCI and BFNE scores Session 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 SASCI M - 16.33 14.74 14.69 13.64 13.57 13.57 12.78 12.68 12.13 11.85 11.57 10.94 10.89 9.85 9.68 SD - 2.80 3.63 3.15 2.78 2.83 3.06 3.54 2.87 3.01 2.95 3.66 3.50 2.88 3.29 3.10 N - 39 39 41 42 42 42 40 37 35 33 33 34 33 33 30 BFNE M 48.56 48.57 48.12 47.19 46.14 43.95 44.17 43.19 44.19 42.53 42.15 42.06 41.09 40.35 38.80 37.55 SD 7.75 6.74 7.42 7.55 8.16 8.06 8.22 9.12 6.64 6.41 6.35 6.47 6.86 6.94 7.30 8.23 N 41 42 42 42 42 42 42 40 37 36 34 33 34 34 32 31 Note. SASCI = Social Anxiety Session Change Index; BFNE = Brief Fear of Negative Evaluation Scale. Table options Table 2. Pre- and Posttreatment means and standard deviations for each outcome variable Pretreatment Posttreatment F M SD M SD CGI - - 2.00 0.78 - CSR 5.83 0.85 3.69 1.65 50.53⁎⁎⁎ LSAS 73.56 19.02 50.83 21.85 38.72⁎⁎⁎ SIAS 49.64 13.21 30.41 13.43 59.23⁎⁎⁎ BDI 17.38 10.57 8.83 9.37 19.31⁎⁎⁎ ASIa 33.19 9.01 20.19 9.30 17.16⁎⁎⁎ Note.aThe ASI was only completed by clients from the University of Nebraska–Lincoln (n = 26). CGI = Clinical Global Impressions Scale Improvement Rating; CSR= Clinician's Severity Rating of the Anxiety Disorders Interview Schedule; LSAS= Leibowitz Social Anxiety Scale; SIAS= Social Interaction Anxiety Scale; BDI= Beck Depression Inventory–II; ASI= Anxiety Sensitivity Index. ⁎⁎⁎p < .001. Table options A growth model was constructed which simultaneously estimated the change in SASCI and BFNE scores across treatment. Based on this linear growth model, on average, clients began the second therapy session with an SASCI score of 15.31 (SD = 2.77), which decreased by 0.44 points per session to end at 9.15 (SD = 3.84) (see Fig. 1). In other words, at the beginning of the second session clients reported little change from the beginning of treatment; however, by the end of treatment, they reported moderately less symptoms than at the beginning of treatment. This growth rate indicates that there was a statistically significant decrease in the SASCI scores across treatment (Z = -11.68, p < .01). The average BFNE score at the first session was 49.43 (SD = 7.06), similar to the mean of a large clinical sample of persons with social anxiety disorder (M = 46.91, SD = 9.27; Weeks et al., 2005), which decreased by 0.83 points per session to end at 36.98 (SD = 10.41) (see Fig. 1). This growth rate indicates that there was also a statistically significant decrease in the BFNE scores across treatment (Z = -7.46, p < .01). Average Social Anxiety Session Change Index (SASCI) and Brief Fear of Negative ... Figure 1. Average Social Anxiety Session Change Index (SASCI) and Brief Fear of Negative Evaluation Scale (BFNE) growth curves. Figure options Validity of the SASCI As shown in Table 3, the session-by-session change and ending score on the SASCI correlated significantly with the session-by-session change and ending score of the BFNE. In other words, clients who improved more rapidly on the BFNE also improved more rapidly on the SASCI. Clients with lower scores on the BFNE at the final session also reported lower scores on the SASCI at the final session. Finally, clients who demonstrated a more rapid decrease across sessions on both the SASCI and BFNE also had lower scores on both measures at the final therapy session. Table 3. Correlations between the session-by-session change and final session scores on the SASCI and the BFNE 1. 2. 3. 1. SASCI Session-by-Session Change - 2. SASCI Final Score .70⁎⁎ - 3. BFNE Session-by-Session Change .71⁎⁎ .75⁎⁎ - 4. BFNE Final Score .62⁎⁎ .78⁎⁎ .77⁎⁎ Note. SASCI= Social Anxiety Session Change Index; BFNE= Brief Fear of Negative Evaluation Scale. ** p < .01. Table options Table 4 presents the correlations between the SASCI and BFNE session-by-session change and final scores and the outcome variables. The final scores on the SASCI and BFNE were compared to the posttreatment scores on the outcome measures, whereas the session-by-session change scores were compared to the pre- to posttreatment change on the outcome measures. Similar to the BFNE, lower posttreatment scores on the CGI, CSR, and LSAS were significantly associated with lower SASCI scores at the final therapy session. Lower scores on the SIAS were significantly associated with lower scores on the final SASCI score and a trend toward significance for the final BFNE scores. Session-by-session improvement on both the SASCI and the BFNE was related to more improvement from pre- to posttreatment on the CSR and LSAS. There was a trend for change on the SIAS to be related to change on the SASCI and the BFNE. In other words, subjective improvement based on the SASCI, and the BFNE, was related to clinician-rated improvement at the end of treatment. Table 4. Correlations between growth parameters and outcome measures SASCI BFNE Final Scorea Session-by-Session Changeb Final Scorea Session-by-Session Changeb CGI .56⁎⁎ − .55⁎ − CSR .63⁎⁎ −.53⁎ .65⁎⁎ −.60⁎⁎ LSAS .62⁎⁎ −.58⁎ .73⁎⁎ −.54⁎ SIAS .54⁎ −.52^ .43^ −.34^ BDI −.05 −.10 -.22 −.25 ASIc .12 −.39 .12 −.64⁎ Note.aThe Final Score of the SASCI and the BFNE is compared to the posttreatment score on the outcome measures. bThe Session-by-Session Change of the SASCI and the BFNE is compared to the change from pre-to posttreatment on the outcome measures. cThe ASI was only completed by clients at the University of Nebraska (n = 26). CGI = Clinical Global Impressions Scale Improvement Rating (n = 27); CSR = Clinician’s Severity Rating of the Anxiety Disorders Interview Schedule (n = 25); LSAS= Liebowitz Social Anxiety Scale (n = 23); SIAS= Social Interaction Anxiety Scale (n = 24); BDI= Beck Depression Inventory – II (n = 27); ASI= Anxiety Sensitivity Index (n = 16). ^p < .10; ⁎p < .05; ⁎⁎p < .01. Table options To examine whether the SASCI is specifically detecting change in social anxiety symptoms rather than change in general distress or global improvement, ratings on the SASCI were also compared to scores on measures of anxiety sensitivity and depression. As can be seen in Table 4, pre- to posttreatment change on these measures (BDI-II and ASI) was not significantly related to session-by-session change on the SASCI; however, more rapid change on the BFNE was associated with more improvement on the ASI. As expected, the final SASCI and BFNE scores were not significantly related to final scores on the BDI-II or the ASI. Clinical Utility of the SASCI If the SASCI is completed by clients prior to each therapy session, it can quickly alert the therapist to changes that have occurred over the week so that the therapist can focus session time on such changes if necessary. This approach allows the therapist to adapt therapy as necessary, which may lead to improved clinical outcome. To illustrate how the SASCI could be used to enhance therapy, four examples are presented in Fig. 2. Social Anxiety Session Change Index (SASCI) scores during therapy for case ... Figure 2. Social Anxiety Session Change Index (SASCI) scores during therapy for case vignettes of the clinical utility of the SASCI. Figure options Little Improvement Over Time — The Case of Mr. A Mr. A was a 21-year-old man treated for social anxiety disorder and comorbid depression. Over the first 10 weeks of therapy, Mr. A consistently reported on the SASCI that he did not feel any different than at the beginning of treatment. Over this time, he reported slight increases and decreases on the SASCI; however, these differences were not large enough to be clinically significant. His therapist noticed this pattern and became concerned since most clients make improvements by this point in the therapy protocol. This observation prompted Mr. A's therapist to ask Mr. A during Session 10 what he felt was and was not working in therapy. Mr. A revealed that he was feeling frustrated because even though he was engaging in more social situations, he still experienced heightened anxiety during them. His therapist then pointed out that Mr. A engaged in more difficult situations and that the situations that used to make him anxious were no longer anxiety provoking. This reframing helped Mr. A to understand that what makes him anxious in the present will not be anxiety provoking in the future. Sudden Worsening — The Case of Mrs. B Mrs. B was a 48-year-old woman who sought treatment because of her anxiety about giving presentations at work following a promotion. Over the first several weeks of therapy, Mrs. B's SASCI scores were decreasing steadily. During this time, her verbal reports to her therapist were equally positive. In her sixth session, Mrs. B completed her first in-session exposure, giving a presentation to the therapist. She endorsed minimal anxiety during the exposure, reported that the experience was very useful, and stated that she was ready to try a presentation at work. Before the next session Mrs. B reported a sudden and large increase in her SASCI score. In response to her therapist's inquiry, Mrs. B reported that she had given a presentation at work and that it had not gone as well as she hoped. In the resulting discussion, the therapist was able to challenge some of Mrs. B's negative assumptions regarding the quality of the presentation. Furthermore, the therapist realized that Mrs. B's level of anxiety may have been more severe than she had previously revealed. For the next couple of sessions, therapy progressed at a slower pace so that Mrs. B was able to gain experience with less anxiety-provoking situations before returning to situations near the top of her anxiety hierarchy. Sudden Improvement — Ms. C Ms. C was a 31-year-old woman initiating treatment for generalized social anxiety disorder. Through the first several sessions, Ms. C's SASCI scores indicated that she felt that she was improving. However, between Sessions 8 and 9, Ms. C's SASCI responses indicated a large improvement. Ms. C's therapist used her SASCI scores to start a conversation about what had changed. Ms. C reported that she finally realized that if she told herself that the anxiety would not last forever, then she could make it through almost any situation. Ms. C and her therapist were able to use this new rational response throughout the rest of therapy and she continued to make progress. Several Changes Over Time — The Case of Mr. D Mr. D was a 46-year-old man who initiated treatment for generalized social anxiety. Through the first several sessions, Mr. D reported little change in his anxiety; however, at Sessions 5 and 7, his SASCI scores indicated that he felt worse than at the beginning of treatment, especially on the second item of the measure (avoidance). His therapist noticed this pattern and, during Session 7, asked Mr. D to describe his behavior during the worse weeks compared to the better weeks. Mr. D revealed that, during the worse weeks, he let his anxiety get the better of him, avoiding all anxiety-provoking situations. This led to increased feelings of hopelessness and a sense that he would never change. Identification of this pattern allowed the therapist to provide evidence to Mr. D that he feels better when he does not avoid situations. Mr. D then agreed to decrease his avoidance. This proved to be a turning point in Mr. D's treatment, as once he stopped avoiding situations his hopefulness for treatment increased and his anxiety began to decrease.