Treating Social Anxiety in Adolescents with Cognitive Behavioral Theory

Research Supporting Social Anxiety Groups

Group therapy research has continuously suggested that it is an efficient form of treatment for various disorders (DeLucia-Waack, Kalodner, & Riva, 2014; Yalom, 2015). Group therapy has several benefits including the safe environment to develop social skills to work on interpersonal interactions and dynamics, cost effectiveness, and group therapeutic factors (Yalom, 2015). DeLucia-Waack, et al. (2014) reported that there is an abundance of research that has accumulated over the past century that highlights the effectiveness and efficiency of group psychotherapy and counseling. A review of group psychotherapy authored by Bednar & Kaul (1978) suggested that group treatments are more effective than no treatment, placebo, and other forms of psychological treatments.

A study conducted by Abraham, Lepisto, & Schultz (1995) assessed adolescent perceptions of process group therapy. The participants in this study were 82 adolescent clients (mean age 16.4 years old, 29 females and 53 males) living in a residential treatment center. The article reported that the adolescents rated ongoing process groups as significantly improving their impersonal relations to others and increasing their comfort levels with peers. The article also reported that the adolescents engaging in cognitive-behavioral groups perceived them to be helpful for cognitive oriented tasks such as making decisions, handling feelings and stress, and understanding problems. Furthermore, Brabender & Fallon, (1993); Kaplan & Sadock, (1971); and Moss, (1992) all reported that group therapy is a common treatment modality for emotionally disturbed adolescents in psychiatric facilities, outpatient centers, and residential treatment facilities. In summary, as Yalom (2015) reported, there is extensive support for group therapy as its own entity, compared to other forms of psychotherapies.

Research has indicated the need for the detection and treatment for social anxiety disorder (Evans, Foa, Gur, Hendin, O’Brien, Seligman, and Walsh 2005). Increased self-consciousness and preoccupation with social matter is prevalent during late childhood and early adolescence. Research has suggested that SAD is common among adolescents with prevalence rates between 5 to 15% of adolescents in the United States (Kashdan & Herbert, 2001). Furthermore, research has indicated that Social Anxiety Disorder is said to be one of the most common anxiety disorders and the third most prevalent psychiatric condition in the United States, affecting up to 13% of the population sometime during their lifetime (Kashdan & Herbert, 2001).

Kashdan & Herbert (2001) reported the onset of Social Anxiety disorder occurs at a typically young age, with a mean onset of 15.5 years and children diagnosed as young as 8. Children with social anxiety present a wide range of interpersonal difficulties that could affect them long term. Children and adolescents with social anxiety fear various situations and activities such as conversating, eating, school refusal writing, performing in front of others, speaking, attending social gatherings such as parties or after-school activities, speaking to authority figures, difficulties with assertiveness, and informal social situations (Beidel, Turner, Morris 1999; Hofmann, Albano, Heimberg, Chorpita, Barlow, 1999). LaGreca & Lopez (1998) further reported, “High levels of social anxiety exert a negative impact on the interpersonal functioning and perception of friendships and social support in adolescents” (p. 84). Other researchers have suggested that long-term untreated social phobia is associated with a number of personal costs for the individual and their support systems, such as impairments in role functioning and overall quality of life (Forthofer, Kessler,Story, & Gotlib, 1996; Kessler, Foster, Saunders, & Stang, 1995 as cited in Velting & Albano, 2001).

Research has indicated that adolescents with social anxiety are at increased risk for with lower perceived social support and close relationships, higher levels of negative affect, social pessimism, and alcohol abuse (Kashdan & Herbert, 2001). Comment by Mott, Andrea: page number for quote Comment by Mott, Andrea: You can't quote a source from another source unless you don't have access to the original. It is said to avoid this in the APA standards, only to use if the original source is no longer available. In summary, social phobia places an adolescent at great risk for long-term problems with education, employment, independent adult functioning, possible suffering with comorbid disorders, and impaired social functioning, as reported by Velting & Albano (2001). Therefore, it is clear that treatment that fosters adolescent growth and full functioning status as well as managing anxiety is necessary for preventive measures and treatment of social anxiety.

Overview of Cognitive Behavior Therapy for Adolescent Social Anxiety Groups

There has been an increased amount of research regarding the treatment of adolescents with social anxiety disorder. Evans et al. (2005) has reported that the two treatments which have the greatest foundation of empirical support are Cognitive Behavioral (CBT) approaches and pharmacotherapy. Wergeland, Fjermestad, Marin, Haugland, Bjaastad, Oeding, Heiervang, (2014) conducted a randomized controlled trial to investigate the effectiveness of cognitive behavioral therapy (CBT), both the effectiveness of individual (ICBT) and group (GCBT), and in relation to other treatment approaches for anxiety disorders in children and adolescents. The sample consisted of 182 youth aged 8-15 years referred from seven public child and adolescent mental health outpatient clinics from 2008 to 2010.

The participants were diagnosed with various anxiety disorders and were randomly assigned to ICBT, GBCT, or a waitlist control group (WLC). The results indicated that CBT was superior to WLC, in relation to symptom improvement and loss of anxiety diagnoses. DeLucia-Waack, et al. (2014) reported that social anxiety research has indicated the effectiveness of CBT, exposure techniques, and psychoeducation. Heimber & Becker (2002) (as cited in DeLucia-Waack, et al. 2014) has suggested that the superior treatment for social anxiety disorder is Heimberg’s cognitive-behavioral group treatment. Other studies have indicated that group cognitive behavioral therapy can be as efficient as individual CBT (McEvoy, 2007). In all, it is apparent there is researcher supporting the use of cognitive-behavioral therapy for social anxiety disorders. Since this project utilizing focusing on CBT as a treatment modality for social anxiety disorder, pharmacotherapy is not discussed beyond this section. In the next section will be an introduction to cognitive behavior therapy. Comment by Mott, Andrea: Same thing here. Can you get the original source? Maybe check with the professor if you have permission to do this.

Cognitive Behavior Theory

Cognitive-behavioral theory has been characterized as a short term, skill-focused, structured treatments aimed at altering maladaptive emotional responses by helping the client with changing their thoughts, behaviors, or both (Kaczkurkin & Foa, 2015). Both Albert Ellis (1994) and Aaron Beck (1991) as cited in DeLucia-Waack, et al. (2014), believed that most psychological dysfunction stemmed from faulty or damaged mental processes of experience. The origins of CBT, as suggested by Kaczkurkin and Foa (2015) can be traced back to B.F. Skinner and Joseph Wolpe, who pioneered the behavioral therapy movement in the 1950s. Behavioral therapy suggests that changing individual behavior leads to change in both cognitions and emotions. This theory emphasizes on how thoughts, behaviors, and emotions all effect and alter one another. Cognitive therapy places the emphasis on changing cognitions, which is proposed to change emotions and behaviors.

In short, CBT is the combination of both cognitive and behavioral therapy components and has been empirically supported as an efficient treatment for social anxiety disorder (Kaczkurkin & Foa, 2015). CBT is a treatment that can be administered in various formats such as: individual, child or adolescent, group, parents and family, and so on (James, James, Cowdrey, Soler, & Choke, 2015). Cognitive-behavioral therapy typically consists of teaching skills, processing and working through maladaptive thought patterns, and focusing on the development of skills to foster personal growth. Velting and Albano (2001) reported that cognitive behavioral treatment (CBT) involves specific psychoeducation, skills training, exposure methods, and relapse prevention plans for addressing the nature of anxiety and its components. The next section will be utilized to explore some of the cognitive-behavioral techniques utilized in the following group sessions. Comment by Mott, Andrea: I don't think you have to cite Beck and Ellis, just use DeLucia as a source.

Cognitive-Behavioral Techniques

Psychoeducation, social skills training, coping skills or relaxation training, and exposure are all components of cognitive-behavioral that have been included in the following group therapy sessions. Psychoeducation provides clients with information regarding specific diagnosis (anxiety) and feared stimuli, various coping skills, cognitive restructuring skills, working through maladaptive thoughts and teaching realistic, coping-focusing thinking (Kaczkurkin & Foa, 2015). Yalom (2015) reported that leaders may describe the physiological cause, somatic symptoms, and role of arousal in relation to specific disorders. The leaders may provide homework to be completed for the following group sessions regarding different learned topics.

Social skills training (SST) is a type of behavioral therapy technique used to improve social skills. Essentially this is a technique that helps with interpersonal functioning. This type of training typically begins with identify individual social difficulties and the goal is to identify specific targets of your social impairments. Once individual targets have been have identified, various techniques for improving social skills are introduced and practiced (Olivares, Ortiz González, & Olivares, 2019). The leaders have the opportunity to role model appropriate social behavior during group sessions (DeLucia-Waack, et al. 2015).

Lastly a key CBT procedure is exposure (James, James, Cowdrey, Soler, & Choke, 2015). The authors describe an element of treatment known as systematic desensitization which “involves pairing anxiety stimuli, in vivo or by imagination, in a gradually increasing hierarchy with competing relaxing stimuli such as pleas-ant images and muscle relaxation.” Kaczkurkin and Foa (2015) also describes exposure techniques which involve graduated, systematic and controlled exposure to feared stimulus. This in turn helps participants become more able to cope with difficult social situations, including but not limiting to, applying coping or relaxation skills taught throughout the sessions.

Seven Week Plan for GCBT for Social Anxiety Disorder

Screening Process

This seven-week planned is based off the current research on CBT that has been cited throughout this proposal. The goals of the seven-week group therapy plan is to help the clients create a basic understanding of their disorder, identify maladaptive patterns, work through difficult thoughts, emotions, and behaviors, and alleviate symptoms of anxiety in social situations. The first step the leaders would take to facilitate the group is client selection. According to Yalom (2015), this is an extremely important factor, because group selection is significant to positive therapeutic process and a safe environment. During this phase the leaders will screen for members who are most suitable for the group. We will utilize the brief version of the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, Dancu, & Stanley, 1989) as a screening tool for assessing the severity of individual symptomology. Members who have severe forms of social anxiety with comorbid disorders may not be able to function efficiently within the group. The group members We will be screening for clients who may be overly aggressive or hostile, present severe psychosis symptoms, overly narcissistic personalities, and clients who may be in the state of a crisis. All the clients should be 12-18 years old. The group is not created to meet the demands of adult and child populations. The clients should ideally be an equal mixture of female and male participants. Confidentiality, the purpose of the group, and any additional questions, comments, or concerns shall be discussed during the intake and screening process (Yalom, 2015).

Session One

Group will start off with both facilitators introducing ourselves then asking all members to introduce themselves and share any information with us they think will be helpful for us to know. Then, facilitators will explain group norms/expectations to group and provide the opportunity to members to ask any questions or make any other suggestions for group norms/expectations.

Facilitators will discuss and explain group goals and objectives and will also ask each member to identify an individual goal they would like to accomplish throughout treatment. Facilitators will supply index cards for members so they can write down their goals. Members will be asked to share goals but can also choose not to share. Group will then focus on psychoeducation of social anxiety and CBT which will be the treatment modality for the group. At the end of the session, the facilitators will provide time for members to process and debrief.

Session Two

Group still start off with visiting group norms/expectations. Then, the session will go into check-ins and open topics. This consists of asking members how they are doing and if there is anything they would like to discuss before group starts. For this session’s activity, members will compete two worksheets: ‘exploring social anxiety’ and ‘physical symptoms of social anxiety that I experience’. The facilitators will explain the objectives for worksheets. After members complete the worksheets, they will be asked to participate in sharing their worksheets but can also choose not to share. The facilitators will also introduce relaxation training in this session. After, group will process and debrief about the session. The facilitators will assign and explain homework assignment as homework is an effective factor of CBT.

Session Three

Group will start off with visiting group norms/expectations. Session will go into check-ins and open topics. Then, group will go over last week’s homework assignment. For this session, group will focus on coping skills and interpersonal skills psychoeducation. Facilitators will provide the members a handout of coping skills and will hand out supplies for members to make a coping skills booklet. Members will be asked to come up with 5 coping skills during the session. Facilitators will explain the objectives for activity. After, members will be asked to share at least one coping skills they wrote down. Members can choose not to participate. After the activity group will process and debrief. Facilitators will assign homework which will be for members to finish their coping skills booklet (3-5 more coping skills).

Session Four

Group will start off with visiting group norms/expectations. Then session will go into check-ins and open topics and go over last week’s homework assignment. For this session, group will focus on social skills training. Facilitators will have a social skills self-assessment for members to complete. Members will ask to participate in a social skills activity but can choose not to participate. Facilitators will explain the objectives for the activity. After the activity group will process and debrief. Facilitators will assign homework and explain homework.

Session Five

Group will begin with visiting group norms/expectations proceeding with check-ins and open topics. After, group will go over last week’s homework assignment. Then facilitators will explain exposure therapy with psychoeducation and handouts. The activity for this session will be an exposure therapy worksheet. The facilitators will explain the objectives. Members will be asked to participate by sharing their worksheets but can choose not to. After the activity and sharing, group will process and debrief. The session will end with the facilitators assigning and explaining the homework assignment which will be an exposure worksheet.

Session Six

Group will begin with visiting group norms/expectations then check-ins and open topics to follow. Group will go over last week’s homework assignment. This session will continue focusing on exposure therapy and members will be asked to participate in an exposure therapy-based activity. Facilitators will explain the objectives. Group facilitators will remind members of coping skills and relaxation training. Group leaders will encourage members to use skills during exposure activity. After the activity, the facilitators will discuss termination with the group since next week will be our last session. The facilitators want to prepare members for termination and we will process and debrief not only the activity, but termination as well. A homework assignment will be assigned and explained.

Session Seven-Termination

Group will start off with visiting norms/expectations and check-ins and open topics. Group will then go over last week’s homework assignment. As this is our last group, the whole session will be dedicated to termination. Members will be given the opportunity to process thoughts and feelings. The facilitators will validate members feelings and offer support. The facilitators will also ask each member what they will take away from this group and want each member to self-reflect over the course of treatment. After this conversation, members will debrief and be able to ask any questions or make any comments.

Special Considerations for Adolescents

There are several considerations to keep in mind while working with the adolescent population. According to Kingery, Roblek, Suveg, Grover, Sherrill, Bergman (206) clinicians need to be mindful of an adolescent’s level of cognitive, social, and emotional development. These skills can largely impact his or her ability to participate effectively and benefit from treatment. Clinicians need to be able to implement various activities while remaining flexible and understanding to each individual adolescent needs.

Kingery et al. (2006) reported youth are often resistant at first to engage in therapy due to the uncertainty of what treatment may entail. Counselors often have the challenge of finding creative ways to engage the youth in treatment. Adolescence are more prone to engage in treatment when the therapist is someone who provides strategies or suggestions versus an authority figure telling them what to do. The youth’s emotional, cognitive, and social abilities should be thoroughly assessed to adapt exposure and other exercises more accurately. Clients need to be capable of understanding the importance and implementation of various activities to benefit from treatment. Emotional development, such as understanding and regulation, play a large role in the improvement of treatment outcomes (Kingery et al., 2006)

The adolescent development is marked by a variety of physical, mental, and emotional changes. During this time adolescence are beginning to development a better sense of self while adapting to these changings as well as face the challenge of social statuses and confusion in reorientation a peer group and the adult world (Kraft, 1961). Clinicians face the challenge of distinguishing level of severity regarding adolescent concerns, such as with social skill development, identity formation, peer acceptance, body image, and so on.

Various defense mechanisms are prevalent during this time such as denial, projection, intellectualization, of which the adolescent may shift through vastly and change in context as the youth goes through adolescence (Kraft, 1961). Kraft (1961) suggested that the counselor must be aware that the adolescent may be prone to switching from one defense mechanism to another, some may utilize aggression as a way to solve problems, and others may withdraw and attempt a solution by denying a problem. Adolescence with SAD can at times with highly withdraw which may pose as a great challenge for the clinician. Kashdan & Herbert (2001) reported that adolescence with SAD mirror adults with higher rates of suicidal ideations, excessive self-focused attention in social situations, and alcohol abuse. Clinicians need to be highly aware of any presentation of comorbid disorders and symptom severity. Clinician will need to assess for safety when needed.

DeLucia-Waack, et al. (2015) suggested that development issues such as age and maturity need to be considered when choosing group participants. Furthermore, the clinician should try to select group ages that are closer together as this will aid with implementing more developmentally appropriate activities for the group. Clinicians need to be mindful and understand of gender, family, community, and individual roles during treatment planning. Kingery et al. (2006) suggested that clinicians need to be mindful about the youth’s age when determining the level of family involvement. For example, private meetings with adolescence could pose a great risk to the therapeutic relationship, as the adolescent could believe they are being treated like children and therefore will lose trust and comfort with the clinician. For adolescence, individual participation with less family involvement during session, creates a sense of autonomy and independence (Kingery et al., 2006).

Lastly, clinician should address any possible conflicts or issues within the group, or when warranted, individual context, that best fits the needs of the group. Clinicians should always adhere to the ethical and legal guidelines. It is critical for professionals to educate themselves about the different cultures and ethnic groups they may be working with. As a specific consideration for this population, the counselor needs to be highly knowledgeable about the limits of confidentiality while working with minors. A clinician should discuss the limits of confidentiality with all participants. Minors cannot typically consent to treatment, therefore parents or guardians need to consent on the minor’s behalf. A parent who consents to the adolescent’s treatment, has the right to access to access the youth’s documents and to know the content of the treatment. It is important for the clinician to explain to the adolescence the nature of the conversation and information that will be conversated about with their parents or guardians. If the leader in uncertain about a situation with a member or group as a whole they should seek consultation from other professionals and refer to the APA ethical guidelines.