Assignment Two - Distinction Mark PDF

Preview

Summary

Distinction Mark...

Description

Running head: REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 1

Critical Review of the Effectiveness of Applying Cognitive Behavioural Therapy (CBT) in treating social anxiety disorder, with a precise focus on acceptance and commitment therapy.

Unit: PSY30010 Due Date: Monday the 10th May, 2021

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 2 Abstract

Social Anxiety Disorder (SAD) is a widespread mental health disorder that can have long-term devastating impacts on the social functioning and on the interpersonal self (Shin & Newman, 2019). Cognitive behavioural therapy (CBT) is a well established empirically based treatment that depends on cognitive restructuring to address behaviours. Regardless of its effectiveness, some patients do not respond to CBT, therefore, alternative treatments such as, acceptance and commitment therapy have been investigated. The aim of this review is to critically evaluate the effectiveness of CBT in the treatment of SAD, with a precise focus on acceptance and commitment therapy (ACT) when treating SAD. Subsequently after an in-depth examination of the existing literature, this review’s results have shown that ACT was equally as effective as CBT for treating SAD. More empirical research into ACT is required and additional research is required to investigate ACT and its long term effectiveness in treating SAD.

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 3 Introduction

People have an evolutionary need to be accepted, loved, and respected in social relationships and within the wider social context they inhabit (Vansteenkiste et al., 2020). Nevertheless, the deep fear of negative evaluation obtained from others may lead to unfavorable effects on individual self-esteem and interpersonal functioning (Vansteenkiste et al., 2020). The extreme fear of evaluation obtained from others in social settings is one of the underlying symptoms of SAD (American Psychiatric Association (APA), 2013). Social anxiety disorder is a widespread and chronic disorder characterised through extreme fear of social situations and can cause substantial impairment in both educational activities, and in social relationships (Iverach & Rapee, 2014). Social anxiety disorder is one of the most widespread psychological disorders in Australians, with lifetime prevalence rates of 10% (Australian Bureau of Statistics, 2008). Social anxiety disorder is one of the top psychiatric illnesses in the world, though, one third of people diagnosed with SAD for 10 or more years seek treatment (Social Anxiety Disorder/Anxiety and Depression Association of America, ADAA, n.d.). In research from Auyeung et al., (2020) it was suggested that people do not seek treatment for SAD, due to negative evaluation of others and evading social interaction. Further research is necessary to explore the usefulness of Cognitive–Behavioral Therapy (CBT) due to CBT recognised as the most used treatment for SAD (Kampmann et al., 2016). This critical review will review the current available literature. This aim of this report is to critically review the efficiency of CBT in the treatment of SAD, with a precise focus on acceptance and commitment therapy (ACT) and establish their efficacy in treating SAD.

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 4

This report will evaluate the clinical success of CBT with the available research to date, to explain the effectiveness of CBT in treatment of SAD (Iverach & Rapee, 2014). Nevertheless, there is a shortage of randomised control experiments that critically investigate the specific effectiveness of cognitive restructuring in decreasing SAD symptoms. Both treatments will be reviewed in detail and conclude with the most effective treatment. This review will conclude by considering key directions for future investigation in CBT treatment of SAD.

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 5 Overview of Social Anxiety Disorder Social anxiety disorder was previously known as social phobia and the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) defines social phobia as, the irrational and excessive anxiety, fear, self-consciousness, and embarrassment due to daily social interactions (American Psychological Association, 2013). The two subtypes of SAD recognized in the DSM-5 are performance anxiety and an example of this is public speaking. The second subtype involves performance type situations, an example of this is eating in front of others in public (American Psychological Association, 2013). For a person to be formally diagnosed with SAD, a medical practitioner will need to interview the person in relation to the intensiveness of the social anxiety symptoms. It is suggested that the medical practitioner completes a physical examination to rule out additional medical disorders that may be the cause of symptoms, and a self-reported questionnaire is required. The requirements to meet the DSM-5 diagnostic criteria are, a person must report persistent occurrences of intense fear or anxiety and evasion typically lasting 6 months, that causes significant impairment to the interpersonal functioning, where a person recognizes excessive or irrational fear. (American Psychological Association, 2013). The prevalence and occurrence of social anxiety disorder is more common in western cultures with the average age of onset of symptoms at 19 years (Leigh & Clark, 2018). Social anxiety disorder causes considerable impairment in the interpersonal self and decreased quality of life, and regularly occurs alongside other mental health disorders, including anxiety and mood disorders (Social Anxiety Disorder: Recognition, Assessment and Treatment., 2013). Social anxiety disorder is more common among females (Social Anxiety Disorder: Recognition, Assessment and Treatment., 2013). Various viewpoints exist about the maintenance factors involved in the development of SAD. In research from Cuncic (2021) an underlying cause of

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 6 SAD is the environment people grow up and if a family member has SAD, a person is more likely to develop this throughout their life. Behavioural theorists suggest that SAD initiates from direct learning through either classical or operant conditioning, by way of experiencing social embarrassment due to perceived social defeat in social settings. (Ollendick et al., 2001). Hostile social events in early childhood by way of, trauma, abuse, bullying, rejection, and embarrassment between friendships are related together with the onset of SAD (Hofmann, Sawyer, Fang, & Asnaani, 2012). The biopsychosocial model of SAD indicates genetic susceptibility to stress may be a contributing factor. Additionally, psychological susceptibilities including, dysfunctional views that may impact as a maintenance (Narmandakh et al., 2020). In research from Koban et al., (2017) suggests people tend to have cognitive biases and believe others negatively evaluate them. Koban et al.,(2017) suggests that people with SAD tend to think about past rejection or past failures and development a negative image about themselves. People with SAD often display poor eye contact and have minimal conversation during social interactions with others (Leigh & Clark, 2018). The cognitive model by Beck (1964) believed people with SAD misjudge the way in which people evaluate their performance which in turn can lead to considerable mental anguish and functional impairment.

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 7 Overview of Cognitive Behavioural Therapy The theoretic framework for CBT is founded on Beck’s (1964) cognitive model. Cognitive behavioral therapy is a psychotherapeutic method that focuses on negative behaviours and overall can result in a person feeling distress (Fenn & Byrne, 2013). CBT can be useful in controlling a variety of illnesses including, anxiety, depression, and personality disorders. CBT pursues to address cognitive disorders and beliefs a person has that can lead to unhealthy behaviors and emotions. (Gaudiano, 2008). When treating a person with CBT according to Beck (1976) the therapist will be required to work together with the individual to create a positive therapeutic relationship during therapy. CBT uses techniques including, behavioural activation, cognitive restricting, exposure therapy, images, social skills, and positive data log. (Chawathey & Ford, 2016). CBT interventions are well structured, goal oriented and time limited session involving the therapist working to address symptoms, providing reframes and in between session homework. (NCBI Bookshelf, 1999). At the beginning of therapy, the therapist discusses the direction and how the therapy is structured for the individual needs of the person. The therapist aims to educate the person to ensure they develop skills to work and become their own cognitive therapist and confront abnormal thinking patterns independently. (Ackerman, 2021) Cognitive behavioural therapy is designed for the treatment of SAD and involves shifting the perception of social difficulties, increasing emotional regulation abilities and avoidance behaviours. (Reeck et al., 2016). CBT uses two common techniques, cognitive restructuring, and exposure therapy. Cognitive restructuring gives individuals the chance to identify and confront negative automatic feelings, and unhelpful core views to build a more reasonable and helpful image of their individual self (Price, & Anderson, 2011).

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 8 Acceptance and commitment therapy is a behavioral therapy that aims to develop a person’s psychological flexibility that combines mindfulness skills and teaches self-acceptance. (Ackerman, 2020). Therapy works to channel behavioural change, acceptance, and cognitive diffusion. (Hinton & Gaynor, 2010). The theory of ACT evolves from the theory of Relational Frame Theory that centers around the impacts of language, behaviour, emotion, cognition and where language triggers psychopathology by way of certain behaviours that are discarded to support cognitive activity (Rector, 2013). ACT requires managing language to participate in valued behaviour, which in turn, could lead to a psychological flexibility state. Additionally, to improve psychological flexibility, ACT applies mindfulness and acceptance approaches as well as behaviour alter methods (Hayes et al., 2013). The difference between ACT and CBT is that ACT theory relies on accepting cognition and learning to be mindful compared to CBT that seeks to alter conditions and the symptoms of SAD.

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 9 Distinguishing between CBT and ACT While CBT is a successful and well-founded treatment for social anxiety disorder, numerous patients continue to be symptomatic (Cognitive Behavioral Therapy in Anxiety Disorders: Current State of the Evidence, 2011). To enhance therapy results, past research found matching a person to a treatment based on the individual needs to be more successful, and as a result, ACT was introduced. In research from Hofmann et al. (2010) traditional CBT and ACT differ in their patterns of change. Additionally, from a CBT perspective, SAD is theorized by dysfunctional thoughts about avoidant behaviour and social interaction. From the viewpoint of ACT, SAD is preserved by psychological obstinacy including, attention, avoidance, and cognitive fusion control over behaviour associated with direct experience and personal values. (Krafft et al., 2020). CBT and ACT are similar in the way they are mutually behavioural treatments and have similar methods including, behavioural evasion and rigid attention (Hofmann et al., 2010). The main difference is that ACT concentrates on how a person connects to their own fear and anxiety and discovers how to adjust it, such as seeking to understand their own thoughts as a continual process as a replacement for negative portrayal of the world. CBT, on the other hand, concentrates on dysfunctional cognitions including, overestimating social risk, how they can be identified and modified (Candida et al., 2016).

CBT strategies to regulate emotions. Experimental evidence and cognitive models believe that people with SAD develop distress due to their inability to regulate emotions (Jazaieri et al., 2016). These theories suggest

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 10 people with SAD tend to suffer from an irrational fear of social situations and prevent any kind of social interaction, which produces a constant negative emotion. Emotional regulation can influence on emotions that a person is experiencing, and in some cases influence how they are expressed (Jazaieri et al., 2016). Emotion regulation difficulties have been directly associated to psychopathology, particularly anxiety and mood disorders. Emotion regulatory approaches may become problematic for people with SAD due to the elevated inclination to feel negative emotions. (Jazaieri et al., 2016). Numerous individuals do not believe they have self-control over their emotional responses, due to this it is impossible for emotion regulation strategies to have a positive effect. Consequently, to assist and enhance the life of people with SAD, a comprehensive insight of emotion regulation and encouraging emotion regulation strategies is crucial (Jazaieri et al., 2016). While research suggests emotional regulation, studies were positively associated with health and wellbeing outcomes, there was minimal research to suggest how these strategies influenced SAD and worked to improve wellbeing and overall life fulfillment. (Jazaieri et al., 2017). Additionally, two studies were conducted by Jazaieri et al (2017) seeking to address this gap in research. In the first experiment using cognitive reappraisal and expressive suppression to investigate the differences amongst people with SAD (n = 128) and healthy adults (n = 42). It was hypothesised individuals with SAD would encounter reduced life enjoyment, less cognitive reappraisal and more expressive suppression when related to healthy adults (Jazaieri et al., 2017). Individuals were asked to complete 3 surveys including, Emotion Regulation Survey, Cognitive Reappraisal survey and the Expressive Suppression questionnaire. Results were measured on a likert scale with responses varying from strongly agree to strongly disagree and were also measured using their own life satisfaction on a satisfaction with Life Scale. The three hypotheses

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 11 were supported, and the second study was conducted to investigate if CBT related variations in emotional regulation could predict life fulfillment by using CBT scores for predictor variables including, cognitive reappraisal, expressive suppression, and life fulfillment. Using a simple linear regression to predict Pre-CBT scores and Post-CBT scores researchers were able to compare the Post CBT values of the variables. It was shown that people with SAD when compared to the control group reported an enhanced satisfaction with life and reported enhanced cognitive reappraisal in the CBT treatment. Follow up results suggest that people reported their symptoms returned and they had at least one symptom that did not entirely dissipate. (Jazaieri et al., 2016).

CBT using (ICBT) According to the NCBI Bookshelf (2013) individuals with SAD have difficulties with any type of social interaction due to fear, and the number of people that obtain treatment is relatively low. Face to face therapy is essential for treatment and individuals are less likely to do so due to fear of social judgement and social interaction. The expansion of internet-based CBT (ICBT) was developed for an online platform for people diagnosed with SAD to feel secure and allow them to engage in treatment. Prior research discovered that ICBT was comparable to CBT in the successfulness of treating SAD, and long term advantageous outcomes (Nordgreen et al., 2018). Research by Dryman, McTeague, Olino and Heimberg (2017) comprised of 3,439 online participants who participated in the ICBT program which consisted of cognitive restructuring and exposure therapy and the duration of this study lasted for 17 months. The results suggest that anxiety symptoms reduced, majority of participants did not complete the study, with only 16%. This may reveal those individuals with SAD tend to have difficulties

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 12 undergoing therapy. A limitation of this study was that it did not explore the modules of treatment and results do not suggest whether the results occurred due to exposure therapy or cognitive restructuring. Even So, research supports the effectiveness of ICBT in decreasing the intensity SAD symptoms (Nordgreen et al., 2018).

In similar research from Gratzer and Khalid-Khan (2015) comprised of 3440 participants and were measured on the key outcome measure, social phobia inventory. Participation in the study lasted for 84 days in duration and results suggest symptoms were considerably reduced for those participants who remained in the study. (Gratzer and Khalid-Khan., 2015). The results suggest that ICBT is efficient in reducing SAD symptoms and helps more people to seek out treatment, via online therapy.

ACT approaches for controlling emotion. ACT is a new treatment utilised to decrease the symptoms of SAD.ACT uses modern cognitive theory and is identified as the third wave of treatment, similar therapy is applied in CBT. ACT aims to focus on the argument that a person’s beliefs and processes may be harmful. (Hofmann et al., 2010). Past literature of psychological interventions including, CBT, suggest individuals experience SAD symptoms after treatment and in some cases symptoms, symptoms remain. In research from Hofmann et al. (2012) ACT was found to be more efficient compared to CBT in reducing SAD symptoms when using emotion control strategies. Research was completed as part of a clinical trial, individuals were split among two groups, the first group, a control group of 12 participants was on the waiting list and the other group, an experimental group of 12 participants. Individuals in the experimental group contributed to twelve sessions, questionnaires were utilised to evaluate the individuals and SPSS used to evaluate the data. The

REVIEW OF TREATING SOCIAL ANXIETY DISORDER USING BOTH ACCEPTANCE AND COMMITMENT THERAPY 13 results of the research suggest that ACT was more beneficial in supporting individuals to control their emotions and individuals recorded an increase in their overall life satisfaction score, and able to reduce symptoms. (Hofmann et al., 2012). The results of ACT have revealed while in between therapy the symptoms of SAD did not return. ACT using online therapy. Prior research suggests ACT can be effective in treating certain types of anxiety disorders, including SAD. Furthermore, there is little known on the effectiveness of treating anxiety disorders utilising online technology. (Kumar et al., 2017). According to Kumar et al (2017) through face-to-face therapy can work to reduce anxiety symptoms. A previous study by Saxon et al (2016) suggests that expanding therapy online and utilising an application may work to reduce the necessity for direct therapeutic interaction. A major benefit for utilising an application for therapy is the increased prospect to incorporate cognitive and behavioural learning as part of everyday life and more accessible. (Saxon et al., 2016). In research from Hofmann et al. (2010) a smart phone application and website was used to investigate the effectiveness of an ACT program for treatment of SAD and Panic disorders. It was hypothesised that there will be highe...