Social anxiety disorder, or ‘social phobia’, manifests through fear, self-consciousness, embarrassment or extreme anxiety in social interactions. It may feel very distressing for those suffering from it and may impact their ability to function in everyday situations.
What is it like to treat social anxiety disorder from a clinician’s perspective? Kate Tilbury, a Senior Clinical Supervisor at ieso, had a conversation with CBT therapist Peter O’Brien, one of ieso’s affiliate clinicians who consistently achieves outstanding outcomes in his treatment, about his approach.
Kate: Hi Peter, thank you for speaking with us. Please could you start by explaining how you approach your online therapy sessions?
Peter: Using language in a positive way to instil hope early on is important. I normalise what patients are experiencing and might say ‘I understand what’s going on here, and I'm going to help you understand’, so they feel confident you can help.
Kate: How do you make sure the patient engages in the session?
Peter: Detailed assessment and formulation are crucial to solidify engagement, and ensure we target the most firmly-held beliefs. I use a version of the Clark and Wells protocol from Stopa, which contains prompt questions. For example, ‘Do you have an image of how you come across? What does that look like?’
Kate: In your opinion, what is the most important element of treating social anxiety disorder?
Peter: It’s important to get a sense of who the person is beyond their presenting problem. You find clues like Sherlock Holmes; triggers, what shaped them, when it started, what maintained it. I do a longitudinal formulation leading into the disorder specific, if I sense the problems are longstanding – exploring early situations, beliefs, and rules of living – and then the triggers which activate those early rules.
Kate: What is your advice around setting goals?
Peter: In terms of setting therapy goals, keep them simple. What will make a difference to the patient? What do they want to be happening at the end of therapy, which isn't happening now? And make them SMART (specific, measurable, actionable, realistic and time-orientated).
Kate: Can you share an example of one of the techniques you use to help patient’s cope with social anxiety disorder?
Peter: For patients who are very self-focused, I help them increase external focus by not getting pulled into a dialogue with that critical ‘inner voice’ every time; to mindfully notice what's going on around them instead, and concentrate when other people are talking. I also challenge the idea that others are thinking about them all the time: ‘Do you think that person's got other things going on in their life?’
Kate: We understand that people with social anxiety disorder could avoid or escape the situation to reduce their anxiety levels. How would you approach this as a clinician?
Peter: Safety behaviours can be subtle – and the only way to draw out those that even the patient may not be aware of is to ask lots of questions. When they’ve done an experiment to test a prediction, for example, ‘What time did you go to the shop? How many people were there at that time?’ Then consider what’s fostering the avoidance. Step back and think ‘What's this really about?’
Kate: How do you measure and monitor the effectiveness of an online therapy session with the patient?
Peter: I do use the SPIN (social phobia inventory) tool, and bring it up in sessions. If a score isn’t changing much, we’ll explore why, and use it to build an agenda for where our focus and interventions need to go. Of course, some people will never have to give a speech, for example! So not all measures are relevant. I might say ‘score those that are problematic to you’.
Kate: Any final advice to other clinicians treating social anxiety disorder through online therapy sessions?
Peter: Because it’s written therapy, it’s important to put yourself in the patient’s shoes. I use my own imagery to experience their view of the world, and really try to imagine what they might see.
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