Clark and Wells model of CBT

People suffering from social anxiety disorder (previously known as social phobia) experience persistent fear or anxiety concerning social or performance situations that is out of proportion to the actual threat posed by the situation or context. They fear negative evaluation and worry excessively about social events and outcomes, both before social situations and afterwards. Common fears include speaking or acting in ways that they think will be embarrassing or humiliating, such as shaking, sweating, blushing, freezing, appearing stupid or incompetent, or looking anxious. They fear that other people will judge them negatively, for example that they appear anxious, stupid, crazy, boring, dirty, or unlikable. They therefore make efforts to ensure that their fears do not materialize, resulting in clinically significant distress and impairment, often across multiple domains of their life.

The following link describes the original Clark & Wells (1995) cognitive model of social phobia.

Subsequent research has led to the refinement of treatment techniques but the original interventions included:

  • Helping clients to develop specific and measurable goals for therapy.
  • Helping clients to understand how the different components of the “model” maintain their anxiety.
  • Changing safety behaviors and self-focused attention with behavioral experiments. Early approaches of the model might video-record the client taking part in two brief social interactions with a stranger: first while focusing attention on themselves, monitoring their performance, and using safety behaviors; and second, while focusing externally and dropping safety behaviors. Client ratings of attention, anxiety, and self-consciousness would be taken and compared.
  • Attention training to shift the focus of attention, prior to conducting behavioral experiments where the focus of attention is directed outwards during conversations.
  • Behavioral experiments to test negative predictions and assumptions, and negative self-images and self-impressions. Warnock-Parkes et al. (2020) recommend that while early experiments focus on dropping safety behaviors, experiments later in therapy focus on decatastrophising – intentionally testing what happens if the thing that the patient is afraid of were to happen (e.g. deliberately appearing sweaty in a conversation, deliberately saying something boring and monitoring other’s reactions).
  • Handling anticipatory worry and post-event rumination. This might include exploring the advantages and disadvantages of worry & rumination, rehearsing answers to common worries, and switching to actively testing out worries by using behavioral experiments.
  • Updating negative self-images and impressions. Warnock-Parkes et al (2020) suggest that attempts should be made to update self-images and impressions during the course of gathering new information from behavioral experients. Some patients benefit from interventions which directly process and update their self-image, especially where such images are linked to past experiences of social trauma.
  • Addressing dysfunctional negative beliefs and assumptions. The cognitive model suggests that dysfunctional assumptions predispose socially anxious individuals to appraise social situations in a negative light. These beliefs are addressed directly throughout the course of therapy to incorporate new information gathered from behavioral experiments and other interventions.