Cognitive Behavioural Therapy (CBT) for Social Anxiety

Core Components

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies dysfunctional cognitive structures, facilitating emotional and behavioural changes.

In the context of social anxiety disorder (SAD), CBT helps patients identify and challenge thoughts, beliefs and behaviours that are associated with distress and anxiety in social environments. CBT for SAD targets the drivers of the feelings of self-consciousness, with the goal of reducing or eliminating SAD symptoms.

Core components of CBT for SAD can include;

• Psychoeducation: Provides information about the different features of SAD which helps patients see their symptoms as features of the disorder. It also provides an overview of the CBT treatment model and helps patients conceptualise their SAD in the context of the CBT model
• Attention training: Training helps patients shift attention from self to other people. Increasing externally-focused attention allows patients recognise that their typical thoughts and beliefs are rarely in line with what is being discussed
• Cognitive restructuring: Challenges the range of cognitive processes that result in maladaptive thinking patterns and beliefs that social failure and rejection are likely. The cognitive therapy techniques help change the patient’s perception and thinking process, in turn supporting the development of a more balanced, rational thought process
• Exposure therapy: Involves controlled exposure to anxiety-provoking situations in order to help patients confront their fears, address distorted associations, and reduce avoidance behaviours. Exposure therapy is continued in a graded manner until habituation occurs. Variations of exposure therapy can include imaginal exposure and in-vivo exposure.

CBT for SAD also includes homework components which provide opportunities for patients to practice building and implementing their skills independently.

Fidelity

Practitioners delivering CBT should receive training and ongoing clinical supervision. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording of treatment sessions and use of fidelity checklists to determine practitioner adherence to CBT manual.

Modifiable Components

CBT for SAD can be delivered to individuals, groups or families, either in-person (e.g. in outpatient settings, hospitals, and residential treatment settings) or remotely (using video conferencing applications). People with SAD can receive about 16 sessions of CBT for SAD over 4 months, each session offered weekly and lasting about 60-90 minutes. CBT for SAD can also be offered as a self-help intervention, delivered in about 9 sessions over 3 to 4 months. Guidance for self-help delivery can be provided by a healthcare professional either face to face or remotely. CBT for SAD can be delivered to children, young people and adults.

For children and young people (CYP) there should be consideration of parental or carer involvement, taking into account the CYP’s cognitive and emotional maturity. Psychoeducation and skills training can be delivered for parents, particularly of young children, to promote and reinforce the child's exposure to feared or avoided social situations and development of skills. Where young people may have the cognitive and emotional capacity (typically aged 15 and over), consideration should be given to psychological interventions developed for adults^. There is very little evidence to guide the treatment of social anxiety disorder in children aged under 7 years. It is likely that treatment will be most effectively delivered either wholly or partly by parents.

Support for Organisation / Practice

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology Adult mental Health and CAMHS workstreams, including webinars, and supervisor training.

Start-up Costs

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations. 

Building Staff Competency

Qualifications Required

Staff will usually hold an undergraduate degree in a relevant area (e.g., nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).

Training Requirements

Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in adapting CBT for Social Anxiety CBT is available through the NES Psychology and CAMHS workstreams and also available through professional organisations such as the British Association of Behavioural and Cognitive Psychotherapies (BABCP).

Supervision Requirements

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:

• NES Generic supervision competences training (GSC) (or equivalent)
• NES Specialist Supervision Training: CBT (adult or child focus)

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information about supervision of psychological therapies and intervention can be found here). There is additional training available that specifically supports CBT supervision skills. 

Theory of Change

CBT for SAD treatment should either delivered according to the Clark and Wells model or the Heimberg model.

The Clark and Wells model proposes that earlier experiences shape the beliefs and assumptions that are activated on exposure to a feared social situation. These beliefs and assumptions increase the predispositions to maladaptive appraisals and negative predictions of social situations and self-performance. This, in turn, automatically activates an ‘anxiety programme’ which is intended to protect the patient from harm, but unintendedly sustain the social anxiety. Clark and Wells CBT therefore aims to address the dysfunctional processes that sustain the maladaptive beliefs and assumptions, and hence, the SAD. This is expected to prevent attentional inward bias and negative self-evaluations in patients, as well as to help patients refrain from engaging in safety and avoidance behaviours.

The Heimberg model proposes that SAD may arise from maladaptive appraisals of cues as predictive of threat, and the heightened extent of threat predicted by the cues. According to the model, a person with SAD has an orientation to threat, or a bias towards attending to external cues in the social environment that signal negative evaluation. This results in a distorted mental representation of themselves as seen by the audience. CBT therefore aims to address patient’s negative evaluations of themselves as seen by the audience, and which is believed to lie at the heart of SAD.

Values

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. In the context of SAD, CBT helps patients to identify and challenge thoughts, beliefs and behaviours that are associated with distress and anxiety in social environments.

• Does the SAD focus align with the requirements of your organisation?

Priorities

CBT for SAD targets the drivers of the feelings of self-consciousness, with the goal of reducing or eliminating SAD symptoms. It can be delivered according to the Clark and Wells model or the Heimberg model. CBT can be delivered to children, young people and adults; in individual, group or family formats; either in-person or as a remotely delivered intervention. CBT for SAD can also be delivered as a self-help intervention. 

• What model of CBT delivery will your service adopt?
• Does the CBT focus that includes the drivers of self-consciousness and SAD symptom reduction/ elimination align with your service priorities?
• What population will your service like to deliver this intervention to?
• In what format will CBT be delivered (in-person vs online; individual, group or family)?

Existing Initiatives

• Does your service currently deliver interventions to treat SAD, or do the interventions address a range of anxiety disorders?
• Do existing initiative show evidence of effectiveness for mental health conditions that could co-exist with SAD?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g. psychologists, mental health nurses) who have undergone training to support its delivery. CBT for SAD can be delivered weekly in about 16 sessions over 4 months. CBT can be delivered face to face, remotely, or as a self-help intervention.

• Does your service have qualified practitioners who are available and interested in learning and delivering CBT?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?
• Will your practitioners deliver CBT face-to-face or remotely (including guided self-help CBT)?
• If delivered face-to-face, is there capacity to support its delivery?

Technology Support

CBT can be delivered without access to technology but access to video platforms for remote delivery can be useful as is access to methods of recording sessions for supervision.

• Will CBT be delivered in-person or remotely?
• Does your service have the technology to support CBT remote delivery?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

CBT can be delivered face to face (individual or group) or as a remotely delivered intervention (including guided self-help). In-person delivery can be held in several settings including outpatient settings, hospitals, and residential treatment settings. CBT for SAD management in children and adolescents can include parent sessions. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what format will CBT be delivered (in person vs online; individual vs group)?
• In what setting will CBT be delivered?
• Does your service have a venue to deliver CBT sessions?
• Can administrative supports be provided to deliver CBT?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.

• Can your service financially support practitioner training costs if accessed outside NES?

Comparable Population

CBT has been shown to be effective when delivered to children, young people, and adults with SAD. Comparable populations also include people with other anxiety disorders, e.g. GAD, OCD, PD, and specific phobia.   

• Is this comparable to the population your service would like to serve?

Desired Outcome

CBT for SAD management has been associated with significant improvement across several outcomes. These include post-treatment improvements in SAD symptoms, depression symptoms, and quality of life. Some of the effects have been maintained at 6-12 months follow-up.

• Is delivering CBT for SAD management a priority for your organisation?