He stated that he had experienced problematic social anxiety since his childhood in Central America. The therapist was a European American man in a doctoral program in clinical psychology. The SASCI is a 4-item self-report measure that is typically administered weekly prior to session. 419 0 obj <> endobj xref 419 20 0000000016 00000 n official website and that any information you provide is encrypted as the Social Phobia Safety Behaviours Scale (SPSBS).10 Rationale: Use of safety behaviors may, at times, be maladaptive and prevent the patient from addressing the issues related to social Nevertheless, the overall data suggest that treatment did result in significant gains for Ling, and she repeatedly expressed this to her therapist toward the end of treatment. Mr. Ms scores prior to treatment of 38 on the BFNE, 43 on the SIAS, and 26 on the SPS at the start of treatment suggested high levels of social anxiety. Lings symptoms of social anxiety primarily entailed irrational beliefs about her inadequacy in interpersonal situations, as well as overt and subtle behavioral avoidance of anxiety-provoking situations. Thus, CBT may be particularly useful for Asian clients, given the short-term, problem-focused nature of the treatment modality, in addition to its focus on contextual factors (Iwamasa et al., 2006). Thus, the purpose of this case study was to demonstrate culturally sensitive delivery of individualized treatment, with only modest adaptations needed, with two culturally diverse clients - Mr. M1, a client originally from Central America, and Ling, who recently immigrated to the United States from China. She expressed difficulty in adapting to the perceived importance of socializing at work, whereas she had felt more comfortable with her colleagues in China who acted in a more reserved manner and did not consider socializing at work an important aspect of ones career. We were able to complete only three in-session exposures. Cite; Favorites Assessment of anxiety in social interaction and being observed by others: The Social Interaction Anxiety Scale and the Social Phobia Scale. However, it appeared that the cognitive skills were only marginally effective for her when conducted in English, as she reported that some of her thoughts and dialogue while using disputing questions did not translate effectively. As with Mr. M, it is worth noting that it was possible to implement culturally sensitive treatment with minimal necessary modifications to the treatment protocol. Session 17 was the termination session. However, few studies specifically examine the applicability of such treatment for ethnic minority clients. Walsh K, Hope DA. The Severity Measure for Social Anxiety Disorder (Social Phobia)Adult is a 10-item measure that assesses the severity of symptoms of social anxiety (social phobia) in individuals age 18 and will also be available for a limited time. At post-treatment, Ling was still experiencing SAD, though there is some evidence of reduction in severity compared with prior to beginning treatment. Encouraging the client to complete cognitive restructuring activities in Spanish, addressing his perceived difficulties with English and his physical separation from his family, and following Organista and Muozs (1996) guidelines appears to have had a beneficial effect on treatment. Level of anxiety is rated via a Subjective Units of Discomfort (SUDS; Wolpe & Lazarus, 1967) rating, which ranges from 0 (No anxiety) to 100 (Very severe anxiety, the worst ever encountered or can imagine experiencing). Social anxiety disorder is not simply medicalized shyness. Lings responses to a modification of Borkovec and Naus (1972) measure of treatment credibility revealed that she believed that the treatment seemed logical (rating of 8 on a 1 to 10 scale), she was confident that this treatment would be successful in eliminating her fear (rating of 7), and she expected her symptoms of social anxiety to decrease during treatment (ratings of 4 and 5 for immediately and one year following treatment, respectively). Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. 0000105573 00000 n The client agreed that speaking up in front of a group would be similar. Mod Probl Pharmacopsychiatry 1987;22:141-173 Pt Name: Pt ID #: Date: Clinic #: Assessment point: Fear or Anxiety: Also, she no longer met diagnostic criteria for MDD. Ling indicated that her symptoms of social anxiety and depression caused her occupational problems. The https:// ensures that you are connecting to the He indicated that being observed in social situations (e.g., writing in front of others, talking in front of a group of people) was particularly problematic. Respondents are asked to rate how characteristic of them each item is on a scale ranging from 1 (Not at all characteristic of me) to 5 (Extremely characteristic of me). Her scores on the BDI-II decreased dramatically over the course of treatment. Lings post-treatment ratings for her Fear and Avoidance Hierarchy are presented in Table 3. The SPS was administered during the first and last treatment sessions. Respondents are asked to indicate how much they feel they have changed since the beginning of therapy in terms of anxiety during or in anticipation of social situations, avoidance of social/performance situations, concern regarding humiliation and embarrassment, and interference association with social anxiety symptoms. Brown EJ, Turovsky J, Heimberg RG, Juster HR, Brown TA, Barlow DH. He identified his automatic thought as I will be nervous (translation). The therapist made an effort to make the presentation of material more interactive with an emphasis on the application of the material to Mr. Ms social anxiety. Social anxiety Cognitive-behavioral therapy (CBT) for the treatment of Social Anxiety Disorder (SAD) has demonstrated efficacy in numerous randomized trials. Certainly an important future direction would be to examine this treatment with various cultural groups when the therapist and client are from the same culture and language group. Mr. M reported that he was born in Central America but that he immigrated to the United States as an adult over 30 years prior to treatment. The client reported that she found the cognitive restructuring far more effective when completing it in Chinese given that is the language in which she experienced thoughts. Thus, for Ling, completing the cognitive restructuring exercises in her primary language led to a much deeper identification and activation of her core beliefs, which facilitated the process of effectively challenging those beliefs. The .gov means its official. Results are discussed in terms of adapting treatment to enhance acceptability for and better fitting the needs of ethnic minority clients and non-native speakers of English. 0000005656 00000 n Ling did express a desire to change her behavior in social situations and noted that her anxiety in such situations superseded the cultural aspect. LGB-affirmative cognitive behavioral treatment for social anxiety: A case study applying evidence-based practice principles. Table 2 contains Mr. Ms fear and avoidance hierarchy with the corresponding anxiety and avoidance SUDS ratings. As demonstrated here, the therapist need not share that language for successful outcomes. Dramatic improvements were evident, especially on the avoidance ratings. Panic The first step in cognitive restructuring is reporting of automatic thoughts. 0000012733 00000 n Vestibulum ullamcorper Neque quam. However, it is interesting that her avoidance increased for both initiating small talk and maintaining conversations with coworkers. Mattick and colleagues (Mattick & Peters, 1988; Mattick, Peters, & Clarke, 1989) found change in fear of negative evaluation was a good predictor of positive long-term outcome in CBT for social anxiety disorder. More information from fewer questions: The factor structure and item properties of the original and brief fear of negative evaluation scales. Her research interests the psychopathology and treatment of social anxiety disorder, the outcome and process of psychotherapy and mental health impacts of discrimination. For Mr. M, it was apparent to his therapist, and quickly to him, that his perception was distorted and decreasing avoidance gave him naturalistic feedback to disconfirm his automatic thought. In such cases, fears of rejection would not be considered irrational and should not be treated as such. By session 11 it became apparent that his writing fears were not continuing to decrease with regular in vivo practice as expected, so in-session exposures again focused on writing. He came to understand how his avoidance behavior prevented him from gathering evidence of his competence, which became apparent in exposure. He considered the exposure a success as he met his behavioral goal of writing until the therapist asked him to stop. During session 12, a safety behavior of writing slowly to avoid mistakes was identified. Ledley DR, Heimberg RG, Hope DA, Hayes SA, Zaider TI, Dyke MV, et al. Hays PA. Multicultural applications of cognitive behavior therapy. The limited change on the BFNE is particularly concerning given that changes in fear of negative evaluation have been shown to be the strongest predictor of long-term functioning (Mattick & Peters, 1988). Social media and news might make you feel connected, but it creates distance, Dr. Rosmarin says. Instead, call or conference people you know personally, one-on-one. Playing online games or other virtual activities can also help you maintain feelings of remaining connected when avoiding in-person visits. Avoidance is rated on a similar scale that ranges from 0 (No avoidance) to 100 (Complete avoidance). For example, Ling reported that her social anxiety became more severe after moving to the United States. 0000008342 00000 n Journal of Consulting and Clinical Psychology. 0000001697 00000 n Also, she avoided social interactions at work since she believed that her co-workers did not like her. If the symptom is Mr. M reported experiencing excessive social anxiety since childhood. For example, interpersonal harmony is highly valued in Asian culture (Iwasama, 2003); thus, they might place great importance on the quality of their interpersonal interactions, which is quite relevant to take into account for Asian clients presenting with social concerns. Correspondence concerning this paper should be addressed to Debra A. National Library of Medicine Treatment was conducted over 16 sessions using the same treatment protocol as Mr. M. Sessions were conducted twice a week due to the clients impending relocation for a new job. Participants rate how characteristic each item is of them on a scale from 0 (Not at all characteristic or true or me) to 4 (Extremely characteristic or true of me). SUDS and avoidance ratings were obtained during the fourth and last treatment sessions. Laguna LB, Healey EC, Hope DA. As can be seen in Figure 1, Mr. Ms final score on the SASCI indicated that he felt as though his social anxiety was much less than when he started treatment, even though his initial scores were very low. Journal of Psychopathology and Behavioral Assessment. Although the technique was used with a variety of initial automatic thoughts, one problematic core belief was revealed multiple times: I will be lonely. Mr. M was tearful in session when discussing the idea that he will be lonely in the future following rejection by others due to their perceptions of him when he was less than perfect because his hand shook or he made one error when speaking or writing in English. The Social Phobia and Social Interaction Anxiety Scales: Evaluation of psychometric properties. Without the physical separation from his family in Central America, it is possible that Mr. Ms social anxiety would have been less severe as he might not have been so concerned with making mistakes that would lead him to be alone. Note. Credibility of analogue therapy rationales. Also, it is unclear why Ling rated that her anxiety increased at post-treatment for initiating small talk with coworkers, which is inconsistent with her self-report during session and on homework assignments. Weeks JW, Heimberg RG, Fresco DM, Hart TA, Turk CL, Schneier FR, Liebowitz MR. Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder. Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV). Mr. M completed a peeling the onion worksheet in Spanish at home, and then some in session peeling the onion work was done in session in English. It is notable that the necessary adaptations to perform culturally sensitive treatment were modest and did not require substantial deviation from the treatment protocol. Truthfulness Scale, 2. An interdisciplinary intervention for a woman with associated speech difficulties was described Laguna, Healey and Hope (1998). Managing Social Anxiety: A Cognitive Behavioral Approach manual. endstream endobj startxref %%EOF Such an abbreviated timeframe for treatment might partially account for the modest change in BFNE scores compared to the ADIS-IV Clinicians Severity Rating. Mr. M recalled that having an accent in Spanish that significantly differed from the accent of his classmates in the city in which Spanish was the primary language was an important childhood experience that might have contributed to the development of his social anxiety. Mr. Ms cultural background influenced his treatment in a number of ways. His homework for in vivo exposure involved writing in front of others. Indeed, Ling experienced difficulty completing the SASCI but did not seek assistance. Depression Scale, Anxiety Scale,3. He described feeling worried that others might think poorly of him because he did not speak Spanish as well as they did. 0000013111 00000 n Mr. M recalled that these incidents were very embarrassing for him and likely contributed to his social anxiety. Going for a walk or runHanging out with friends in a casual settingDoing something that you enjoy The BFNE (Leary, 1983) was administered pre- and post-treatment. Learn more 1989) and Anxiety is a medical problem when it is persistent, overwhelming, and interferes with your day-to-day functioning. It is particularly notable that few modifications to the protocol were necessary, while still increasing acceptability and effectiveness of treatment procedures. It is important to actively assess the clients understanding of session material, particularly if the clients native language is different from which the treatment is being conducted. Hayes SA, Miller NA, Hope DA, Heimberg RG, Juster HR. Treatment had to be terminated prior to fully remitting the clients symptoms of social anxiety due to her relocation for a new job. Bethesda, MD 20894, Web Policies A 2011 Aug; 10(4): 324342. Scores on the SPS range from 0 to 80, and a cutoff score of 24 has been suggested to be indicative of diagnostic status for SAD (Heimberg et al., 1992). 0000105170 00000 n The therapist and Mr. M discussed ways to continue to make progress towards reducing social anxiety such as engaging in more exposures, using cognitive restructuring skills, and continuing to attend social meetings such as Bible study. %PDF-1.4 % sharing sensitive information, make sure youre on a federal H*w6PH/w5Pp Hope, PhD, is a professor of psychology at the University of Nebraska-Lincoln. 0000002079 00000 n The To his surprise, his hand did not shake. Behavior PMC legacy view Aliquam sollicitudin venenati, Cho php file: *.doc; *.docx; *.jpg; *.png; *.jpeg; *.gif; *.xlsx; *.xls; *.csv; *.txt; *.pdf; *.ppt; *.pptx ( < 25MB), https://www.mozilla.org/en-US/firefox/new. She described being reserved in school and not having close social contacts. Mr. M endorsed a number of symptoms consistent with social anxiety disorder (SAD; non-generalized type) on the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994), with no secondary or additional diagnoses. She also reported that she had been experiencing intermittent feelings of depression since moving from China. This is consistent with Mr. Ms expressed enthusiasm for treatment and should be taken into account when interpreting his subsequent SASCI scores. He reported that he learned that he could speak in front of others with less anxiety than he expected. Her depressive symptoms dramatically decreased. Sessions Seven and Eight involved in session exposures of writing in front of the therapist. A fear and avoidance hierarchy was developed in sessions five and six. Culturally responsive cognitive-behavioral therapy: Assessment, practice, and supervision. Session-by-session BDI-II scores for Ling. Hope, Ph.D., Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE, 68588. Mr. M completed an in vivo exposure during which he read out loud in front of a co-worker. Fink CM, Turner SM, Beidel DC. He identified automatic thoughts concerning the ability of others to understand him, the shakiness of his voice, and his certainty that he will be anxious. Leary MR. A brief version of the fear of negative evaluation scale. Mr. M discussed his concerns about reading in front of a group of people and identified the following automatic thoughts: They will laugh, I will be nervous, My heart will beat faster, I will look stupid, everybody will notice. Mr. M identified logical errors associated with his automatic thoughts and that anxiety, nervousness, and embarrassment were products of his automatic thoughts. His automatic thoughts were again related to making a mistake and shaking. She expressed confidence that she would be able to continue reducing her avoidance in the future since she had learned skills to manage her anxiety. Thus, it is imperative when working with ethnic minority clients for therapists to be aware of such cultural considerations that might impact treatment. Given her proficiency in English was lower than Mr. M, working in her native language was even more important for her. Both clients demonstrated improvement on a semi-structured interview and self-report measures. Cognitive restructuring sessions focused on identifying and challenging automatic thoughts. During Session Eight, Mr. M and the therapist reviewed his in vivo exposure that he completed for homework. Toyokawa T, Nedate K. Applications of cognitive behavior therapy to interpersonal problems: A case study of a Japanese female client. During treatment, it became apparent that some of Mr. Ms anxiety-provoking automatic thoughts were related to Mr. Ms core belief that he would be alone eventually with no one to care for him. He was able to identify logical errors associated with these thoughts (e.g., catastrophizing) and develop more rational responses (e.g., If I make a mistake, I can usually fix it.). Overall, results indicate that Ling had begun to respond to treatment but would benefit from additional sessions focus on social anxiety. His SUDS ratings appeared to decrease more quickly with the use of a Spanish rational response. Also, many ethnic minority groups have experienced significant oppression and may initially have concerns with trusting their provider (e.g., Barcus, 2003). However, he indicated that he needed therapy to truly overcome his anxiety. An ADIS-IV Clinicians Severity Rating of 6 (out of 8) was assigned for this diagnosis. He was able to identify logical errors in his automatic thoughts and use disputing questions to develop a rational response (Even if my hand shakes, I am still going to [complete the task].). Osman A, Gutierrez PM, Barrios FX, Kopper BA, Chiros CE. FOIA Also, he appeared to be more engaged than usual when cognitive restructuring was reviewed. Ling reported during this session that she felt less anxious in social situations and had reduced her avoidance of such situations, particularly with regard to assertiveness. Readings from the client workbook supplemented information presented in treatment sessions. `GGCGtp4d4 y@pSQ2H1xjm6M The client reported that he found it helpful and appeared to be better able to dispute his automatic thoughts in Spanish and the thoughts appeared to be more emotionally-laden. CBT for SAD conducted in a group format has been shown to lead to superior outcomes compared to educational supportive group treatment (Heimberg et al., 1990; Heimberg et al., 1998) and pill placebo (Heimberg et al., 1998), as well as maintenance of treatment gains at a five-year follow-up (Heimberg, Salzman, Holt, & Blendell, 1993) and considerably lower relapse rates than phenelzine (Liebowitz et al., 1999). Cognitive behavioral group therapy vs. phenelzine therapy for social phobia. Cognitive behavioral therapy with Latinos. HWM_}x#6 >#FH rYvRl QTufJhm ha7{}+z-8G__/5-H-AZuW_>Ew?|prx>P?v8S{?a;@k~?e=C\rmjvyCY\H+~)7EW$sA@i. For the majority of situations, her anxiety and avoidance decreased somewhat. Mr. Ms beliefs about the visibility of his anxiety symptoms and the disastrous consequences of being seen as anxious appeared to be distorted. Sessions One through Three focused on psychoeducation about the nature of social anxiety and its treatment.