Limitations Of CBT For Social Phobias

Limitations Of CBT For Social PhobiasSocial phobic disorder, overly cognize as Social fretfulness Disorder (SAD) is considered as virtuoso of the nigh special K psychological swages on its own, and in addition as a comorbid incommode (Kessler, McGonagle, Zhao, et al., 1994). Current explore literature suggest Cognitive Behaviour Therapy (CBT) as the fore roughly preaching choice for societal phobic neurosis, un slight in the solecism where the lymph gland opt for music or if the lymph node is suffering from comorbid effect or a nonher psychological disorder that makes medication essential (Veale, 2003 Social Anxiety Disorder, 2006 NICE guideline, 2004c).The aim of this musical composition will be to discuss the occupation of CBT in the intervention of Social Phobia. However, it is important to emphasise that it will not attempt a detailed discussion on the historical development, or speculative frame realizes of CBT. These aspects of therapy will be emphasised, discussed and analysed where necessary, to comprehend its practicableity in the manipulation of friendly phobic disorder. Furthermore, the s sleep together of this paper will be limited to examining the consumption of CBT for sermon of adults with loving phobic neurosis gain ground, it will not focus on interposition of tender phobia in children and adolescent groups.CBT was initi each(prenominal)y developed by Aaron T. Beck as a structured, short-term, establish-oriented psych otherwiseapeutics for depression, directed toward solving current tasks and modifying dys operational thinking and behaviours (Beck, 1995). The basic assumptions of cognitive model suggest that distorted or dysfunctional thinking that influence the patient/clients mood and behaviour is common to all psychological disturbances (Beck, 1995). CBT is a collection of therapies that argon designed to process clients suffering from phobias, depression, obsessions compulsions, judge disorders, dru g addictions and/or spirit disorders. CBT attempts to help heap identify the internet sites that whitethorn produce their physiological or emotional symptoms and expurgate the manner in which they cope with these situations (Smith, Nolen-Hoeksema, Fredrickson, Loftus. 2003).The strength of CBT has been astray tested since the scratch line chew over on interposition success in 1977 (Beck, 1995). Westbrook, Kennerley and Kirk (2007) utter that CBT has some a(prenominal) features common to other therapies. However, they acknowledged that CBT is diametric from the other psychotherapies with nigh distinguishing characteristics. This alterative approach is a conclave of Behaviour Therapy (BT) and Cognitive Therapy (CT). However, these will not discuss in detail. However, as a terminus of having been evolved from a combination of both BT and CT, modern CBT consist important elements of them both. Westbrook, et al. (2007) beats the CBT model of viewing business developme nt.For instance, individuals develop cognitions (thoughts beliefs) through life experiences ( intimatelyly based on childhood experiences, but sometimes with later experiences). These rear end be functional (ones that allow make sense of the world around and deal with life issues), as surface as dysfunctional beliefs. Most of the time, functional beliefs permit individuals to reasonably cope well with life situations. Whereas dysfunctional beliefs may not ca expenditure problems unless/until encountered with an impression or a series of hithertots (also known as critical incident) that violates the force beliefs or the assumptions, to the extent of macrocosm unable to handle ones confirmative/functional beliefs. This situation may activate the forbid/dysfunctional thoughts over the positive thoughts resulting or provoking unpleasant emotional status such as fretting or depression. Thus, Westbrook et al. (2007) highlighted the interactions amongst negative thoughts, emot ions, somatic reactions, and behaviours as responses to distinguishable life events. These dysfunctional patterns lock the individual into vicious cycles or feedback loops resulting in the lengthening of the problem.Focussing on the effectiveness of CBT as a therapy, the UK national Institute for Clinical morality (NICE) guideline recommends CBT for several major psychological health problems including depression (NICE, 2004a), generalise worry and scourge (NICE, 2004c), and post-traumatic stress disorder (PTSD) (NICE, 2005). Furthermore, Westbrook et al. (2007) highlighted the findings of Roth and Fonagy (2005) in their book What works for whom? a landmark summary of psychotherapy efficacy. This book presents march on the success of CBT as a therapy for most psychological disorders.However, though in that location is evidence bread and butter the roaringness of CBT for legion(predicate) psychological disorders, CBT has some limitations as well. Firstly, it is not suita ble for everyone. One should be committed and persistent in finding a solution to the problem and improving oneself with the guidance of the therapist (Grazebrook Garland, 2005).Secondly, it may not be cooperative in certain sees. Grazebrook Garland (2005) mentioned that there is increasing evidence of the successful remedy use of CBT in a wide variety of psychological conditions. However they commited that there is a great indigence for further enquiry to gather evidence on the therapeutic success of CBT in these different types of psychological disorders.Social PhobiaSocial Phobia is categorised as an Anxiety Disorder in the Diagnostic and Statistical Manual-IV-TR (DSM-IV-TR) of the American psychiatrical Association (2000). This disorder is characterised by persistent excessive solicitude and veneration of examination by others, oft accompanied by disquiet symptoms such as tremulousness, blushing, palpitations, and sweating (Social Anxiety Disorder, 2006). The DSM-IV- TR (2000) presents the at a lower placementioned diagnostic criteria for kindly phobia (SAD).Marked and persistent charge of neighborly or achievement situations in which the person is exposed to unfamiliar plenty or to perceived scrutiny by others. This includes the fear of embarrassment or humiliationExposure to fe ared favorable or surgical procedure situations that almost invariably provoke anxiety. This may even take the invent of a disquietude attack. In the case of children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from well-disposed situations with unfamiliar hatful.The person recognises that the fear is unreasonable and that it is excessive. However, this fear and knowledge may be absent in children.The feared complaisant situation or the doing is avoided or else it is endured with intense anxiety or distress.The scheme, anxious anticipation, or fear causes significant distress or impaired functioning.Fear or avoidance are n ot due to some other psychological, or physiological condition (e.g., a in-personity disorder such as paranoid personality disorder, a specific phobia, or due to the influence of amount use/abuse)Specify generalised, if the fears include most cordial situations (e.g., these may range from initiating or defying conversations, participating in small groups, dating, speaking to authority figures, or care parties hindering most parts of a personal societal life) consort to the criteria stated above, social phobia can be generalised or non-generalised, depending on the breadth of social and performance situations that are feared. While generalised social phobia hinders a vast range of social and performance situations, non-generalised social phobia may hider/restrict only performance of some social activities or engagements.According to health statistics from year 2002, social phobia affects 3% of the Canadian adult population (Social Anxiety Disorder, 2006). In ground forces 13. 3% of the population suffer from social phobia at some point in their life (Kessler et al., 1994). Statistics indicate a life time preponderance of about 8% to 12% making social phobia one of the most common anxiety disorders (Social Anxiety Disorder, 2006 Kessler, et al., 1994). Apart from being a high prevalence disorder, social phobia is also known to pack a high comorbidity, specially substance abuse and/or alcohol dependency (Schad, A., Marquenie, L., Van Balkom, et al., 2008 Amies, Gelder, Shaw, 1983 Schneier, Johnson, Hornig, Liebowitz, Weissman, 1992).Kessler et al. (1994) stated that composition the lifetime prevalence of social phobia is as high as 13.3%, the prevalence propounded in a 30-day design is amid 3% 4.5%. In addition, other identical conditions, such as shyness, behavioural inhibition, self-consciousness, selective attention and embarrassment are seen to be correlated with social phobia (Beidel Morris, 1995 Beidel Randall, 1994 Leary Kowalski, 1995 Rosenbaum, Biederman, Pollock, Hirshfeld, 1994 Stemberger, Turner, Beidel, Calhoun, 1995). According to Schneier, Johnson, Hornig, et al. (1992), comorbidity of two or more psychological disorders, is also fairly common with social phobia. seek has also indicated that social phobia is also characterised with a higher absolute frequency of suicide attempts (Schneier et al., 1992).Foc apply on the furbish up of the disorder on the prime(a) of life, social phobia is described as an illness of missed opportunities, because its early on onset hinders future social progression such as married success and career growth (Social Anxiety Disorder, 2006). The authors of this article stated that these individuals were less likely to be well educated, belong to lower socioeconomic status, and are possibly unmarried. In addition, they also suffer greater functional, health, and physical impairments than individuals without social phobia (Social Anxiety Disorder, 2006). Thus the disorder h as a significant impact on the quality of life, in particular, socially and emotionally. Emphasising on this point, the authors of this article highlighted that in a community health survey in Canada, people with social phobia were twice as likely to report at least(prenominal) one disability day in the past two weeks, compared to people without social phobia (Social Anxiety Disorder, 2006).Aetiology of social phobia can be traced to Bio-Psycho-Social factors (Smith, Hoeksema, Fredrickson, et al., 2003). Looking at the neuro-biologic factors, query data up to date, provides evidence of dopaminergic, serotonergic, and noradrenergic systems (Stein, Tancer, Uhde, 19992 Tancer, Stein, Uhde, 1993 Yeragani, Blalon, Pohl, 1990). However, Stein, Tancer, Uhde (1995) stated that the evidence for these neuro-biological factors in the predisposition, precipitation, and perpetuation is far from clear. The authors also present the same shaming the effect of antidepressants on social phobia s tating that further work is warranted, although preliminary evidence indicates that antidepressants are not entirely effective on social phobia.From a cognitive-behavioural perspective, a person with social phobia develops a series of negative assumptions about themselves and their social world based on some negative experience (Kessler, et al., 1994). These assumptions of behaving inappropriately and being evaluated negatively and/or being humiliated will give rise to anticipatory anxiety that precedes the social situation adding an extra source of concern and perceived danger. absorbed with these fears, clients with social phobia have difficulty focussing their attention on the social cues or their own strengths that help them to effectively cope in the phobic situations. In addition, biased memory and focused attention towards negative signs will prevent the individual from perceiving the positive signs (e.g., acceptance, success, admiration) giving rise to performance deficienc ies. These may contribute towards producing patterns of negative interactions that may further contribute to the perpetuation of the phobic condition experienced at the time (Elting Hope, 1995). These explanations are convertible to the generic CBT model, of problem development. Thus the research by Kessler et al (1994) has provided supporting evidence to the general CBT explanation and theoretical framework of problem understanding, estimation and give-and-take.Another dimension of the aetiology of social phobia is the lack of social skills and/or the lack of awareness of ones own social skills. According to hummock (1989), clients with social phobia vary widely in their knowledge of socially appropriate behaviour skills. Many of these individuals seem to have adequate social skills when assessed in a non-threatening environment such as the clinicians office, but they break up to use these skills when laden with anxiety in an unfamiliar social situation that is perceived as t hreatening. mound (1989) further described that there is another group of individuals suffering with social phobia who may be unwitting of socially appropriate behaviours in certain situations and therefore encounter reiterate failures and disappointments. Thus, Hill (1989) suggest that apart from medication and/or conventional CBT, individuals in this group will gain more from specific training in social skills each through role playing or casting as appropriate.In addition to the above dimensions, there are developmental and psychodynamic issues associated with the aetiology of social phobia as well. In this view, children who are rejected, belittled, and censured by their parents, teachers or peers may develop feelings of low self-esteem and social lunacy (Arrindell, kwee, Methorst, 1989). The authors of this article further stated that clients with social phobia tend to report, having had overcritical parents. The article further examine the condition of social phobia f rom a psychodynamic perspective hypothesising that avoidant behaviour may be caused by an exaggerated bank for acceptance, an intolerance of criticism, or a willingness to constrict ones life to maintain a sense of control. Furthermore, they claim that traumatic embarrassing events may lead to expiry of self-confidence, subjoind anxiety, and subsequent poor performance, resulting in a vicious wad that progress to social phobia.Concentrating on discussion seeking behaviours for social phobia, Hill (1989) highlighted that clients rarely see a physician for symptoms relating to social anxiety. More often seeking help will be for conditions such as substance abuse, depression or any other anxiety disorder (e.g. panic attack).Treatment for Social PhobiaAs mentioned above, social phobia is the result of biopsychosocial factors. Thus, the interference choices may also vary which may include pharmacotherapy, and/or different types of psychotherapy. Veale (2003) stated that treatment c hoice for social phobia is up to the client to decide. Medication is indicated if it is the clients first choice, or if CBT has failed or if there is a long waiting list for CBT. Similarly, pharmacotherapy becomes the choice of treatment when social phobia is comorbid with depression (Veale, 2003). Considering the first treatment choice, UK National Institute for Clinical truth (NICE) does not have a specific guideline specific for social phobia. However, in its guidelines for anxiety disorders (NICE, 2004), it recommends pharmacotherapy as treatment if the client opts for medication, or if the client opts for psychological treatment, CBT is given as the first choice of therapy. NICE guidelines (2004) as well as recommend CBT as the first choice of psychological therapy for generalised anxiety disorder and other anxiety disorders. The National Institute for Clinical Excellence provides evidence that CBT is more effective than no intervention and that CBT has been found to maintain its effectiveness when examined after long term follow up of eight to fourteen years. This can be used as a monetary value and time effective therapeutic intervention in group settings and most clients have maintained treatment gains at longer terms (NICE 2004). It further stated that CBT is more effective than psychodynamic therapy and non-specific treatments. Apart from CBT, clients who receive anxiety focussing training, relaxation and breathing therapy have been proven to be effective compared to having no intervention.Apart from CBT, Veale (2003) also discusses Graded self-exposure as a psychological therapy for social phobia. This therapeutic intervention which is based on the learning theory hypotheses has been the treatment of choice for social phobia for umteen years. However, as this method of therapy using exposure to previously avoided situations in a graded manner until addiction occurs was only successful with limited amount of clients, alternative approaches such as CBT have become a more frequent therapy choice.NICE guidelines (2006) on computerised cognitive behaviour therapy (CCBT) for depression and anxiety recommend CCBT for flaccid depressions and anxiety disorders, including social phobia. With reference to two Randomised Controlled Trials (RCTs) and two non-RCTs comparing CCBT (programme for panic/phobic disorders FearFighter) with therapist led CBT (TCBT) the NICE guidelines recommend the use of CCBT for mild phobic/panic disorders. When results of CCBT and TCBT were compared after a three month period of therapy for global phobia, both groups showed statistically significant gain. Similar results were shown in two non-RCT studies excessively. When these scores were compared with a group who genuine relaxation techniques as therapy, this thirdly group did not show statistically significant improvement while the other two groups (CCBT TCBT) did. However, it must be noted that the RCT and the non-RCT studies does not report cl inically significant improvement. Nevertherless, the dropout rate of FearFighter group was twice as many as the TCBT dropout rate. However, from a positive point of view on the practicality of CCBT on phobias, delivery of FearFighter programme at the clinical setting for one group, and the other group having access to the programme at home over a 12 week period showed that both groups showed statistically significant improvement in all measures (NICE guidelines, 2006). In terms of client satisfaction too there was no statistically significant difference between TCBT and CCBT (NICE guidelines, 2006). Thus, though further research is warranted to evaluate the clinical significance of CCBT for social phobia specifically, the NICE guidelines recommend CCBT as a choice of therapy for mild levels of depression and anxiety disorders. In addition to the observed effectiveness of CCBT, NICE guidelines also recommend it as a cost effective therapy alternative. Thus, CCBT for social phobia at mild levels could be useful at a practical level too.In a paper by Rosser, Erskine Crino (2004), the researchers studied the treatment success of CBT with antidepressants and CBT on its own as treatment for social phobia. The results did not show a statistically significant difference in the treatment progress between the two groups allowing the researchers to conclude that pre-existing use of antidepressants did not enhance or detract from the positive treatment outcome of a structured, group-based CBT programme for social phobia. Application of medication and CBT is common practice in treatment for social phobia (Rosser et al., 2004). Yet, there are not many studies that have studied the unite effectiveness for social phobia. Citing Heimberg (2002) Rosser et al., (2004) describe that there are three possible outcomes from cartel medication and CBT. Combined treatment may produce a better outcome than each treatment completely, by potentiating the gains achieved by CBT and also reducing relapse rates following the discontinuation of medication. Alternatively, there may be no difference between the combined approach and each approach individually, if both therapies (pharmacotherapy and CBT) are sufficiently compelling on their own. Also, depending on how individual clients attribute treatment success, effectiveness of CBT might be detracted by medication in a combined approach of treatment. Referring to literature on treatment success for social phobia Rosser et al., (2004) highlighted that combination treatment (CBT and pharmacotherapy) or pharmacotherapy alone has not been found to be of significant advantage. CBT has mostly been successful in overcoming symptoms, minimising relapses and also effective in terms of cost minimisation (Rosser et al., 2004). Focussing on the conclusions Rosser et al. (2004), there were no significant differences between the combination treatment (CBT antidepressants) and CBT alone could be construe in different ways. It i s possible that since antidepressants and CBT are both reasonably powerful treatments individually, and thus a combination of the two did not contribute to a significantly to improve the outcome. Alternatively it may be that the group who were already taking antidepressants may have been prescribed with the medication because they were more wicked in terms of social phobic or depressive symptoms prior to commencing treatment programme. Thus, it may be possible to argue that the combined therapy may not have contributed to a significant improvement compared to the group that that only received CBT, because there was a difference in symptom severity between the two groups. In addition there was no control in allocating (randomly) participants and or having a control over the medication dosage. Thus, the research findings of the study are subjected to the limitations of these variables that were out of the researchers control. However, it has to be noted that it does not devalue the proportional treatment success on the CBT (alone) group. The researchers of this study therefore emphasise the need for further research on combined therapy for social phobia as in real life clinical settings most clients are on medication while receiving CBT.Moreover, Rodebaugh Heimberg (2005) recommends CBT combined with medication as a widely used successful treatment method for social phobia. However, while recommending the above, they also emphasise the need for further research in this regard as the current data reveals mixed results. According to available evidence and theoretical considerations they suggested that some methods of combination could provide short-term benefits, but long-term decreases in efficacy compared to either treatment alone. In this paper Rodebaugh Heimberg (2005) emphasised that most research on the effects of CBT combined with medication had the common research gap of failing to control the medication dose and the allocation of participants in to ra ndom samples. However, the authors of this paper emphasised that in most studies combined therapy for social phobia had not shown significant evidence of treatment success compared to either pharmacotherapy or CBT.Rodebaugh Heimberg (2005) highlighted that there is supporting evidence to the treatment success of trust CBT with relaxation training. While mentioning this, they also noted that relaxation training alone has not proven to have any clinically significant benefit for the clients. Thus, it is when combined with CBT that clients have had a successful experience with relaxation training. Rodebaugh Heimberg (2005) stated that all forms of CBT aim to reduce the experience of fear through modification of avoidance and other maladaptive behaviours, thoughts, and beliefs (e.g. through exposure with cognitive restructuring). Thus, in the process of therapy most clients may experience an increase in stress and negative affect and distress in the short-term, but the modification of these earlier components of these earlier components of a behavioural-emotional chain leads to reduction of symptoms over time.In regard to combining treatment methods with CBT as treatment for social phobia, Rodebaugh Heimberg (2005) highlighted the fact that all treatment methods have its own limitations and strengths. Thus when combining two therapies (either pharmacological and CBT or CBT with another psychotherapy), the strengths as well as the weaknesses of the two approaches could be magnified, depending on the nature of the combination. Hence, Rodebaugh Heimberg (2005) stated that an empirically supported method of combining medication and CBT for social anxiety disorder is yet to be established, although under varied circumstances clinicians use different combinations of CBT along with other psychotherapies and medication to maximise effectiveness on a case by case level.Concluding RemarksAs discussed in this paper, social phobia may literally be a common mental disord er and it is categorised as an anxiety disorder under the DSM-IV classification system (DSM-IV-TR, 2000). While being highly prevalent, it is also a disorder that may have a large impact on a persons quality of life, hindering opportunities for personal growth and/or social interaction/relationships. Therefore, it is an important area of study and clinical practice in mental health, which has the aim of improving the lives of people suffering from this disorder, and minimising its effect on the society.Research literature on social phobia recommends certain types of medication, and CBT as a psychotherapeutic intervention as the first choice of treatment for this debilitating condition. As it is out of our scope, this paper did not pay detailed attention to the types of pharmacotheraputic interventions that may successfully be used to control symptoms of this disorder and enable clients live a sanguine life.From a psychological perspective, CBT is widely recommended through evidence based research as the first choice of psychotherapeutic treatment for social phobia. As discussed in this paper, evidence on the successful combinations of therapeutic methods at present denotes the need for further research in order to determine the best(p) combinations for successful treatment. Another area that needs similar attention is combining different types of psychotherapies with CBT as treatment for social phobia.Focusing on CBT for social phobia, although there is supporting evidence for therapy success, and though it is widely considered as the first choice of psychotherapy for this disorder, it is not always successful with all individuals. Thus, form a practical point of view, it is important that clinicians are able to tailor and combine different therapeutic methods (pharmacotherapy and psychotherapy), not only to maximise treatment success, but also to make it useful with different types of clients/clients from different priming and life-experiences. Furthermor e, although CBT is recommended as the first therapy choice, there are practical issues regarding meeting the admit for services. This becomes an issue in terms of finance as well as in terms of the limited amount of professionals available to deliver treatment. few successful methods of overcoming these difficulties would be Group CBT for social phobia and CCBT.However, it must be emphasised that these issues become a much grave problem in countries where psychotherapists trained in CBT are rare, and even methods such as CCBT could be unaffordable and inaccessible for certain groups. In addition, there are also limitations in being able to use programmes such as CCBT in countries where face is not used, or it not the first language. Thus, from a global perspective, the use of CBT as a therapy choice is practically challenged due to limitations of resources and trained personals, raise pharmacotherapy as the most practical mode of therapy for a large numbers game of people suffe ring from social phobia.To conclude, it must be stated that move research on the successful use of CBT as a therapeutic tool for social phobia and other disorders should be go on as it proves to be a successful therapy for many psychological disorders (Westbrook et al., 2007). Thus, it can be stated that CBT is a useful and successful therapeutic intervention for social phobia. The practical use of it could be further improved through continued research, and through therapist training programmes to meet the demands for therapy, as it would further increase the effectiveness of CBT as a therapy for social phobia.