Self-assessment

Cognitive Behavioural Therapy (CBT) for Social Anxiety

Cognitive Behavioural Therapy or CBT is a collaborative talking therapy, working together with a CBT therapist on mutually agreed goals. CBT for social anxiety works to help us notice and change problematic thinking styles or behaviour patterns in social situations. This includes; psychoeducation, attention training, cognitive restructuring, and exposure therapy.

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Usability Rating

4

Supports Rating

5

Evidence Rating

4 - 5

Fit Rating

NYR

Capacity Rating

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Need Rating

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The Hexagon: An Exploration Tool

The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.

Evidence

4 - 5

Fit

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Capacity

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Supports

5

Usability

4

Need

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Usability - Rating: 4

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.

Supports - Rating: 5

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.

Evidence - Rating: 4 - 5

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.

Children and Young People - Rating: 4

Research Design & Number of Studies – Children and Young People

Some of the best evidence for CBT in SAD management in CYP include meta-analytic studies. These are described below.

A meta-analysis was conducted to determine the efficacy and acceptability of psychological interventions for SAD in children and adolescents (Yang et al, 2019). The review included 17 RCTs (n=1134) that involved patients (aged 7-18 years) who had primary clinical diagnosis of SAD. Psychological interventions evaluated included CBT and behavioural therapies. Intervention duration ranged from 9-20 weeks.

Another meta-analysis evaluated the effectiveness of CBT in children and adolescents (6-18 years) with SAD diagnosis (Scaini et al, 2016). The meta-analysis included 13 studies. CBT included those delivered with or without Social Skills Training, CBT delivered with or without Unstructured Social Time sessions, as well as those delivered in clinical and school settings.

Outcomes Achieved – Children and Young People

Compared to treatment as usual or inactive controls, the following outcomes were observed;

Significantly reduced SAD symptoms at post-treatment (Yang et al, 2019; Scaini et al, 2016), maintained at 6-12 months follow-up (Scaini et al, 2016)
Significantly reduced depression symptoms at post-treatment (Yang et al, 2019)
Significantly improved quality of life at post-treatment (Yang et al, 2019)

Adults - Rating: 5

Research Design & Number of Studies - Adult

Some of the best available evidence for CBT in the treatment of SAD comes from meta-analytic studies. Seven of these are described below (most recent first).

The first meta-analysis evaluated the efficacy of internet-based CBT (iCBT) for SAD (Guo et al, 2021). The review included 20 studies (n=1743) and involved adults aged 18 to 79 years who met diagnostic criteria for SAD. iCBT was delivered over 9-12 weeks.

The second meta-analytic study evaluated the long-term outcomes of CBT on anxiety-related disorders (van Dis et al, 2020). The study included 69 randomised clinical trials with 4118 adult outpatients diagnosed with generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), panic disorder (PD), specific phobia, posttraumatic stress disorder (PTSD) or SAD. 7 studies were specific to SAD and meta-analyses for these participants were reported separately. CBT was delivered in individual, group, or internet formats.

The third meta-analysis was conducted to evaluate the effectiveness of CBT in anxiety and related-disorders (Carpenter et al, 2018). The study included 41 studies with 2835 participants (aged 18-65 years) diagnosed with acute stress disorder, GAD, OCD, PD, PTSD, or SAD. 12 studies (n=753) were specific to SAD and meta-analyses for these participants were reported separately. CBT was delivered face to face in either group or individual formats. Mean treatment duration across studies was 11.0 sessions.

The fourth meta-analysis was conducted to evaluate the effectiveness of computer/ internet delivered CBT on anxiety and depression disorders (Andrews et al, 2018). The study included 64 trials of participants (n=8279) diagnosed with major depression, PD, GAD or SAD. 11 of these trials (n=950) included participants with SAD, and meta-analysis for these participants was reported separately.

The fifth meta-analysis evaluated the effectiveness of technology-assisted interventions for social anxiety disorder (Kampmann et al, 2016). The study included 37 RCTs (n=2991). Of these, 21 trials evaluated internet delivered CBT, and meta-analysis for this was reported separately. Participants were adults (aged at least 18 years) who met diagnosis criteria for SAD.

The sixth was a systematic review and network meta-analysis conducted to evaluate the effectiveness of psychological and pharmacological interventions for SAD (Mayo-Wilson et al, 2014). Participants were adults (aged at least 18 years) who fulfilled diagnostic criteria for SAD. The study included 101 trials (n=13164 participants). Of these, 43 studies evaluated CBT delivered in individual and group formats, while 25 studies evaluated self-help interventions that were usually CBT based.

The seventh meta-analysis was conducted to determine the effectiveness of CBT in the management of anxiety disorders (Hofmann and Smits, 2008). Participants were between ages 18 and 65 years, and met the diagnostic criteria for an anxiety disorder or anxiety related disorder including PTSD, PD, OCD, acute stress disorder (ASD), GAD, and SAD. 27 studies were included in the review. Of these, 7 studies were specific to SAD, and meta-analysis for these participants was reported separately.

Outcomes Achieved - Adult

Compared to usual care, psychological or pill placebo, or wait-list control, the following outcomes were observed;

Significantly reduced SAD symptoms/ severity at post-treatment (Guo et al, 2021; van Dis et al, 2020; Carpenter et al, 2018; Andrews et al, 2018; Kampmann et al, 2016; Mayo-Wilson et al, 2014; Hofmann and Smits, 2008) and follow-up (i.e. up to 6-12 months follow-up) (Guo et al, 2021; van Dis et al, 2020; Carpenter et al, 2018; Kampmann et al, 2016)
Significantly reduced depression symptoms at post-treatment (Kampmann et al, 2016). Significant improvement in depression and anxiety symptoms were also reported in pooled data for all included anxiety and related disorders at post-treatment and at 6 months follow-up (Carpenter et al, 2018)
Significantly improved quality of life at post-treatment (Kampmann et al, 2016). Significant improvement in quality of life was also reported in pooled data for all included anxiety and related disorders at post-treatment and at 6 months follow-up (Carpenter et al, 2018)

Self-assessment

Cognitive Behavioural Therapy (CBT) for Social Anxiety

Compare

Usability Rating

4

Supports Rating

5

Evidence Rating

4 - 5

Fit Rating

NYR

Capacity Rating

NYR

Need Rating

NYR

The Hexagon: An Exploration Tool

The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.

Evidence

4 - 5

Fit

NYR

Capacity

NYR

Supports

5

Usability

4

Need

NYR

Children and Young People - Rating: 4

Adults - Rating: 5

Need

Fit

Capacity

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