Cognitive Behavioral Group Therapy for Social Anxiety Disorder

By Lora Rose Hunter

Most people can remember a time when they were concerned about what other people were thinking. Whether it was a private meeting with an overbearing boss or speaking to strangers in the grocery store, chances are your fearful thoughts were accompanied by things like sweaty palms, shaky knees, and trouble concentrating. Sometimes you may have even considered avoiding the situation altogether! When social concerns or shyness contribute to enough impairment and distress, an individual may meet criteria for a syndrome called social anxiety disorder (American Psychiatric Association, 2000).

            Social anxiety disorder (previously called social phobia) is a chronic, debilitating condition with an early age of onset (e.g., American Psychiatric Association, 1994, 2000; Andrews et al., 2001; Brown et al., 1995; Schneier et al., 1994). Moreover, the diagnosis is associated with comorbid depression and problematic substance use (Kessler et al., 1997, 1999; Grant et al., 2005; Schneier et al., 2002). Fortunately, for the millions of individuals suffering from social anxiety disorder (approximately 12% of the population; Kessler, et al., 2005), there is ample reason to be hopeful. Numerous studies have demonstrated cognitive behavioral therapy (CBT) for social anxiety disorder is highly effective (e.g., Clark et al., 2003; Gould et al., 1997; Hofmann & Smits, 2008; McEvoy, 2007; Rodebaugh et al., 2004; Taylor, 1996).

            CBT is a well-established form of psychotherapy based on the work of Aaron Beck (see Beck & Emery, 1985). From Dr. Beck’s ideas, many successful psychotherapy interventions for depression and anxiety have been developed. As applied by Richard Heimberg and colleagues, CBT for social anxiety disorder typically includes three main components: 1) cognitive restructuring, or logically challenging the content of fears; 2) systematic-graduated exposure, using behavioral exercises to short-circuit avoidance and facilitate a process for safely “facing” fears; and 3) homework assignments, planned activities that allow clients to practice their skills (Heimberg & Becker, 2002; Hope et al., 2000). These components are included in individual CBT and cognitive-behavioral group therapy (CBGT) for social anxiety disorder, which is equally effective (e.g., Clark et al., 2003; Heimberg, 2001).

            I know what you’re probably thinking… Why would someone with social concerns consider group therapy? Isn’t that like asking someone who’s afraid of germs to meet you every week at the city dump? As it turns out, CBGT for social anxiety disorder may offer some important therapeutic advantages over individual CBT. For example, many people with social anxiety disorder have convinced themselves that they are the only one with such an impairing fear of embarrassment. This belief can provoke feelings of hopelessness, isolation, and even shame. Meeting others with similar concerns can help to mitigate the negative emotions associated with feeling like the only one. Group members can also learn new ways of understanding their thoughts and experiences by observing other group members’ approaches to cognitive restructuring and exposure. Additionally, because people diagnosed with social anxiety disorder tend to have an extended history of avoiding social interactions, they probably only practice important social skills on rare occasions. Group therapy allows for ample opportunity to practice social skills in a truly social environment. Finally, working together as a team may provide additional motivation to complete homework assignments and attend sessions.

            Wouldn’t people use social skills, make new friends, and feel motivated to contribute to any number of groups, including book clubs, softball teams, and Bible study? Yes! Are these groups also likely to successfully reduce social anxiety? No! Remember, the active ingredients in CBGT for social anxiety disorder are cognitive-restructuring and systematic-graduated exposure. The added benefits of the group format are only beneficial to the extent that they facilitate engagement in the components that really reduce anxiety.

            CBGT for social anxiety disorder typically consists of 12 to 20 weekly sessions (ranging in duration from one hour to two and a half hours for bigger groups; see Heimberg & Becker, 2002). Groups are composed of five to nine clients and one or two therapists. Because the group format offers important logistical advantages over individual treatment, some have even called it “the treatment of choice” for social anxiety disorder (e.g., Heimberg, 2001; McEvoy, 2007). The cost of each group treatment session is usually a fraction of the cost of each session in individual therapy (Let’s face it, most people are not exactly eager to spend $150 per session on their mental health in the current economic climate!). The fact that CBGT lasts only three to four months magnifies the overall savings associated with group treatment compared to individual. In addition, it can sometimes be difficult to find an individual therapist offering CBT and accepting new clients. Groups allow a therapist to treat multiple individuals in the same amount of time. New groups begin several times a year and may be more likely to have space, another logistical reason to consider CBGT.

            Naturally, these same factors could conceivably limit access to CBGT for social anxiety disorder as well. For example, because groups start at specific times during the year and clients are almost always required to be on board from the beginning, some folks have to wait weeks or months for therapy to start. Likewise, groups last a finite amount of time (12 to 20 weeks)… whether or not individuals feel ready to be finished. And most notably, there is evidence that CBT in general is not broadly disseminated to the majority of mental health providers (e.g., hospitals, private practices, inpatient facilities), beyond academic settings (e.g., McManus et al., 2008). If you’re seeking CBGT for social anxiety disorder and you live near a major research university with a clinical psychology doctoral training program and an associated outpatient training clinic… lucky you! In these settings, highly supervised doctoral graduate students usually offer CBT at dramatically reduced costs. Depending on where you live, there may also be community therapists offering CBT and, more rarely CBGT in private practice, although this option usually costs more.

            Perhaps the greatest barrier preventing impaired and distressed folks from getting CBGT is that it seems so counterintuitive. Sometimes the idea provokes a visceral response akin to, “Are you kidding me!?”  Actually, no… Decades of research hardly kid. Unfortunately, most people nowadays believe either a chemical imbalance causes emotional problems and medications are the only solution, or psychotherapy is a self-indulgent, unstructured process that inevitably involves conversation about early childhood (Truly, psychotherapeutic interventions have failed to compete for the hearts and minds of the American public!). To ameliorate the concerns of would-be group members, clinicians and those attempting to convince a socially anxious loved one to seek treatment should consider offering information about 1) the noninvasive components of CBGT, 2) the time and cost effectiveness of group formats, and 3) the potential for added therapeutic benefits. Remind reluctant, “just shy” friends, family, and clients that, as with any challenge (e.g., weight loss, quitting smoking, running a marathon), an investment in some discomfort is required in order to experience tremendous rewards in the long run. Of course, if all else fails, flaunt the brevity of the commitment relative to the distress of a life hindered by social anxiety disorder. What do you have to lose? You may as well try it…

Lora Rose Hunter is a doctoral student in clinical psychology at Florida State University and a therapist at the Anxiety and Behavioral Health Clinic.