Person-Centred/Experiential Approaches to Social
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Transcript Person-Centred/Experiential Approaches to Social
Person-Centred/Experiential
Approaches to Social Anxiety:
Initial outcome results
Robert 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 unemployment
Risk 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 anxiety
C. Recognition: Person experience fear as excessive
or unreasonable
D. Avoidance, or endurance with intense
distress
E. 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 psychotherapies
PCEs shown to be effective with Major
Depression
SA 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: Clients
Community sample
Brief telephone screening
Face-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: Clients
Specific SA (one specific situation:
public speaking): 49%
Generalized (multiple situations):
51%
Axis 2: mean 3.3 Axis 2 diagnoses
Avoidant Personality pattern: 92%
Borderline: 35%
Mean Problem Duration Ratings of
Personal Questionnaire Items
n
Mean
SD
• “6.2”: somewhat more than 6 to 10 years
• Client presenting problems = chronic
17
6.24
0.78
Method: Therapy & Research
Parameters
Up to 20 sessions; less if client feels finished
Assessments/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)
Results: Post-therapy Outcome for
Combined Sample
Measure
Cut-off Pre-Therapy
value
Post Therapy
n
m
sd
n
m
sd
Effect
Size
(sd)
N
Clients
Reliable
change
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); 1
SPIN
>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); 1
Strath
<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)
Global Change: At least two measures
Some change: At least one measure
Limited Change: One measure but not others
Negative/mixed change (evidence of
deterioration)
No reliable change on any measure
N
10
16
3
2
2
Results: SPIN Outcome Benchmarking
Measure:
PCE
Pre
Post
N
M
SD
M
SD
Prepost
Effect
Size
(sd)
14
2.48
.66
1.40
.67
1.54
2.53
.62
2.16
.81
1.28
2.4
.81
2.16
.75
.31
2.64
.85
1.81
.92
Connor et al 2000:
28
Medication
Placebo 25
Antony et al 2006:
Group CBT 74
.94
Results: SPIN Subscale Analyses (w
Benchmarking)
Subscale:
Pre-therapy
M
SD
Fear
Avoidance
2.80
2.69
Physiological
1.61
Post-therapy
M
.76
.59
1.0
SD
1.55
1.63
0.79
.82
.74
PCE
Effect
Size
(ES)
Antony
2005 ES
(sd)
(sd)
1.64**
.93
1.64**
.81
1.03**
.69
.63
N = 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
2.23
CORE
0.68
1.09
SPIN
1.61
1.68
IIP
0.75
1.21
Strath
0.96
1.22
1.76
1.60
Mean Pre-post ES:
EFT vs. PCT Difference in
ES:
+.37
Worse than expected
Better than expected
Results: Analysis of Drop-out Patterns
PCT EFT
Completers
Early drop-outs (1 -2
sessions)
9
9
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-outs
Quit 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 - Cautions
But:
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 Steps
RCT: Primary Care client population
PCE therapy (PCT & EFT) vs. NHS
Primary Care Mental Health Team
Treatment as Usual (group & individual
CBT)
Continue developing EFT therapy for
SA
Piloting PCT & EFT Adherence
Measures
E-mail: [email protected]
Blog: pe-eft.blogspot.com