Eehac. Res. Thu. Vol. 28, No. 3, pp. 181-193. 1990 Printed in Great Britain. All rights reserved
Copyright
0005-7967190 $3.00 + 0.00 cl 1990 Pergamon Press plc
EXPOSURE IN VII/O VS SOCIAL SKILLS TRAINING FOR SOCIAL PHOBIA: LONG-TERM OUTCOME AND DIFFERENTIAL EFFECTS* ZYGMUNTWLAZLO,KARINSCHROEDER-HARTWIG, IVERHAND, GRAZYNAKAISERand NICOLEM~~NCHAU Behavior
Therapy
Outpatient
Unit, Psychiatric 2000 Hamburg
University Hospital 20, F.R.G.
(UKE).
Martinistr.
52.
(Received 6 September 1989) Summary-This study examined the long-term effectiveness of specific exposure in vice (individual IE or group GE) and of office-based social skills training (group SST) in two groups of patients with social inhibition (primary social skills deficits or primary social phobia). Seventy-eight outpatients were divided into these two subgroups according to clinical assessment. Twenty-seven patients received SST which consisted of 25 twice a week 90-min group sessions: 32 patients received GE and 17 IE. Exposure in civo consisted of 4 weekly (8-hr in the group condition included 2 hr discussion; 3 hr in the individual condition included 1 hr discussion) sessions. Self-rating-assessments were carried out at pre- and post-treatment, at 3 months- and 2.5 yr follow-up. The general results indicate that all three treatment modes led to clinically and statistically-significant improvements in the main problem area (social anxiety, skills deficits), in other neurotic complaints (depression, obsessions, psychosomatic complaints) and in attribution-style. Patients with the diagnosis of primary phobia seemed to get the same profit from either treatment and showed slightly better gains (in all treatment modalities) than patients with skills deficits at long-term follow-up. Within the subgroup with skills d&icits there was a tendency for superior outcome of group exposure. These results and recommendations for future research are discussed.
INTRODUCTION
The effectiveness of exposure in uitlo treatments for agoraphobics and for obsessive-compulsives is well established. Successful application of exposure seems to require (a) in vivo, (b) prolonged and uninterrupted until anxiety subsides, (c) repeated, (d) the stimuli should be functional, i.e. anxiety provoking. Intense emotional, cognitive and behavioural involvement during exposure seems to enhance positive outcome. Other methods like modeling, relaxation, self-instructions or other cognitive techniques did not add to the effectiveness of exposure (Barlow, 1988; Marks, 1987). In contrast to this advanced state of research on exposure for most phobias and OCD, few attempts have been published on exposure in Go for social phobia or social inhibition. To our knowledge, a first attempt in using exposure in rho for social phobia was described by Hand et al. (1974, ‘social spin-off of exposure treatment) in their group study with agoraphobics; they modified the exposure treatment for those of their agoraphobics who showed severe symptoms of social phobia in the agoraphobic situations. Specific exposure in vivo for social phobics was first described and investigated by Wlazlo (1983) and Butler et al. (1984; Butler, 1985). While the first study employed a specific therapist-guided individual exposure in vivo, the second was based on manual-guided self-exposure, similar to the Home Based Treatment for agoraphobics (Mathews et al., 1981). Most of the few other clinical studies in this area showed a superiority of exposure in viuo when compared with other methods or with waiting list groups (Alstr6m et al., 1984; Biran et al., 1981; Hayes & Marshall, 1984). Yet, major methodological problems limit their generalizability. On the other side, social skills training programmes (SST) for social skills deficits are very well established in behaviour therapy; their effectiveness has been shown in numerous studies with clinical samples (Damm-Baggen & Kraaimaat, 1986; Hall & Goldberg, 1977; Falloon et al., 1977; Liberman et al., 1986; &t et al., 1981; Stravynski et al., 1982; Trower et al., 1978), where SST was superior to placebo, systematic desensitisation or cognitive modification. *This paper is based upon a doctoral dissertation submitted to the University of Hamburg, F.R.G. Portions of the study were presented at the annual convention of the Association for Advancement of Behavior Therapy, New York, 1988.
182
~~.~MUNTWLAZLO
et a/.
The main assumption in the literature is that anxiety reduction is the main mechanism of change for patients with social phobia and that skills acquisition is essential for patients with skills deficits. Nevertheless, till now no study has been published comparing a group exposure in viva approach with SST. In either of these subgroups, even worse, their diagnostic differentiation outside the behaviour therapy literature appears inadequate: in the DSM-III (APA, 1980) and DSM-IIIR(APA, 1987) patients with social skills deficits are rather diagnosed mainly on Axis II, as avoidant personality disorder indicating greater disturbance and unfavourable treatment response (Liebowitz, 1986; Liebowitz et al., 1985). an assumption without empirical support. Among the few clinical investigations examining differential treatment effects for these subgroups, &t et al. (1981) found that the effectiveness of applied relaxation (AR) vs SST depends on patients’ response patterns, i.e. physiological reactivity vs skills deficits. Trower et al. (1978) found better effects of SST for patients with social phobia, as well as with social skills deficits, compared to systematic desensitisation (SD). Although additional ‘neurotic’ symptoms are frequently reported in social phobia (Amies et al., 1983; Solyom et al.. 1986; Greenberg & Stravynski. 1985; McCann et al., 1987), little attention has been paid to treatment effects on these symptoms, except for an indirect reduction of depression (Alstrom et al., 1984; Butler et al., 1984; Trower et al., 1978; Stravynski et al.. 1982). There are only three long-term follow-up studies with at least a 1 yr follow-up (Alstrom et al., 1984; Biran et al., 1981; Falloon et al., 1977). Other studies reported 6 months (Butler et al., 1984; Marziller et al., 1976; Shaw, 1979; Stravynski et al., 1982; Trower et al., 1978). 3 months (Hall & Goldberg, 1977), or no follow-up (Emmelkamp et al.. 1985; bst et al., 1981). Differential success/failure analyses are missing. The only predictor of treatment failure so far identified is a high level of depression (Klosko et al., 1984)-yet, it is unlikely that future studies will confirm this predictor variable, as it is no longer valid in other anxiety disorders like agoraphobia (cf. Hand et al., 1986; Barlow, 1988). The present study investigated the long-term effectiveness of two different outpatient treatment modalities: (group) Personal Effectiveness Training (PET, Liberman et al., 1975) as one well known social skills training program and (individual IE, or group GE) exposure in viz)0 in patients with social phobia or with social skills deficits. Both treatment modalities include training in social competence as well as in coping with anxiety. Both patient-subgroups suffer from phobic anxiety and from deficits. Treatments and patients differ with regard to the relative importance of treatment ingredients and symptomatologies, according to their labels. METHOD Treatments The Personal Eflectiveness Training was conducted according to Liberman et al. (1975). This is a semi-structured training in social skills administered according to the specific needs of each patient. The groups (68 patients) were carried out twice a week with a total of 25 sessions of 1.5 hr each, over a period of 3 months. The total treatment time was 37.5 hr. The exposure in viva consisted of 4 sessions, once a week, over a period of 1 month. In the group condition (4-6 patients), duration of exposure in each session was 6 hr (additionally 2 hr of preand post-session discussion) and in the individual condition 2 hr (with additional 1 hr discussion). The last fifth session lasting 2 hr in GE and 1 hr in IE was used as a sum up discussion. The total treatment time was 34 hr in GE and 12 in IE. The treatment is to convey a general coping strategy for social situations by means of: (1) training in social perception and discrimination, (2) exposure to and management of anxiety provoking situations, (3) training of social skills, (4) training of ‘social intelligence’. This treatment, while containing a variety of standardized exposure situations, is also applied according to the needs of the individual patient (i.e. predominant phobia or social skills deficits). The therapists accompany the patients (or groups) throughout the in vivo sessions, encouraging self-responsibility in, and proper application of, confrontation with anxiety provoking situations, regarding motor as well as cognitive behaviour. In cases with social skills deficits, therapists are giving direct instructions-modeling, prompting or coaching the desired behaviours (similar to the office-based PET program). This exposure in vivo is described in detail in Wlazlo (1989).
Exposure in vim vs social skills &raining for social phobia
183
The selection criteria for the study were: (1) No history of psychosis, (2) social inhibition (phobia and/or deficits) as the main complaint and reason for seeking treatment, (3) no previous behaviour therapy for this complaint, (4) agreement to be taken off pre-existing psychotropic medication before the active part of treatment. According to DSM-III-R criteria, these patients can be diagnosed as social phobia and/or with avoidant personality disorder. The main complaints of the patients were: anxiety about negative evaluation caused either by negative cognitive anticipation or skills deficits; avoidance of social situations (speaking to strangers, making conversation, being under scrutiny, being assertive, etc.). Because of their suffering they appeared motivated to overcome their problems. From an initial sample of 167 patients with ‘social inhibition’ registered between 198 1 and 1986,20 patients refused treatment and 14 became dropouts. Thirty patients were omitted from this analysis because they showed severe comorbidity (agoraphobia, obsessions~ompulsions, depression, and other, with social inhibition mostly as the primary disorder). Of the remaining 103 (62%) patients, 78 had completed pre- and post-treatment ratings as well as t yr and/or a long-term follow-up. The follow-up duration ranged from I to 5.5 yr after treatment (X = 2.5 yr). Of the 78 patients, 29 had received PET, 17 IE and 32 GE (see Fig. 1); the patients were allocated to the treatment procedures by chance, according to their time of application for treatment; it could not be done at random because there was only one treatment Intoke
interview
N -167 I\’ INDIVIDUAL lxxPosURE
Behoviour onolysi 5 Refusals
b
GROUP lmo!xJRli
N=62
Theropy
Drop-outs
Other diognoses Therapy terminated and diagnosis s, inhibition
Patients with pre, post, lyr FU and/or long- term FU
Fig. I. Distribution of patients during the period under study.
184
ZYGMUNT WLAZLO Table
Age Sex
male female
Marital status
with partner without partner
I.
DescriDtive
data
PET
IE
GE
kz
31.03 14(17.9%) 15 (19.2%)
28.29 13(16.7%) 4(5.1%)
30.0 18 (23.1%) 14(17.9%)
30.01 45 (57.7%) 33 (42.3%)
17(21.8%)
9(11.5%)
I3 (16.7%)
39 (50.0%)
12(15.4%)
8 (10.3%)
I9 (24.4%)
39 (50.0%)
8.96
8.58
10.0
9.29 (yr)
3.96
4.47
4.25
4.19 (yr)
4.11
5.74
5.10 (Wl .,
Duration of illness Duration of treatment before BT Period between onset and first treatment PET = Personal
et al
5.0 Effectiveness
Training;
IE = individual
exposure:
GE = group exposure.
mode offered at a time (PET between 1981-1983; Exposure between 1983-1986). The total group consisted of 45 (57.7%) male and 33 (42.3%) female patients with mean age of 30 yr. Fifty percent of all patients lived without spouse. The mean duration of illness was 9.29 yr, indicating that the mean age of onset was about 20 yr (see Table 1). Measures patients treatment) Outcome
with pre-. post, selected for study. All subsequent
anxiety, social
yr and/or were taken
assessment self-rating
(1.5-5.5
after
scales.
deficits
Social was measured the subscale the Fear Schedule (Hallam Hafner, 1978) of 10 presenting social which are on O-3 of severity. higher the the higher anxiety. BehazGoural against the anxiety was with a analog 99 scale (Hand Zaworka, 1981). scale is reverse formulation behavioural avoidance. lower the the greater level of avoidance. Interference social anxiety daily life was measured a visual 99 mm (Hand & 1981). The the score greater the with daily activities. Social and social were assessed UF-questionnaire (U-Fragebogen, de Muynck Ullrich, 1977), most commonly and extremely validated scale Germany. This consists on factors: ‘fear failures and ‘fear of of guilt’ ‘decency’. ‘ability making requests’, to refuse’, contact’, ‘ability for requests’ and to Especially three scales of social refuse’ behaviourally oriented. styles were with a questionnaire (IE-SV-F, & Hinsch, 1) consisting 8 scales internal vs and stable variable attributions successful and situations. Because social competence the attribution were used over time in the and for patients only the long-term a between comparison was only for follow-up ratings. neurotic complaints was measured the Depression scale (DS) & Koeller, which in studies correlates with the Wakefield-Depression-Inventory (Snaith al., 1971). higher the the higher depressive symptomatology. Obsessire-compulsiz:e-symptoms were with the Obsessive-Compulsive In(HOCI, Zaworka al., 1983). inventory consists 6 subscales: checking, (b) (c) cleaning (d) speaking, (e) ruminations to acting, harming
Exposure in viuo vs social skills training for social phobia
185
obsessions. In each subscale the score of 25 represents clinically relevant symptomatology; this cut off point was derived from a clinical sample of obsessive-compulsive patients. Other phobias were assessed with the Fear Survey Schedule (Hallam & Hafner, 1978) with subscales of agoraphobia, blood-injury-disease phobia and animal phobia. All items are rated on a O-3 scale of severity. Like for the social anxiety scale behavioural resistance against and interference through these phobias were assessed on visual analogue 99 mm scales. Psychosomatic complaints were measured with a german inventory (FBL-W. Fahrenberg, 1975) consisting of 5 subscales and a total score, the latter being in the analysis. Separation of primary social phobia and social skills deficits was done by clinical judgement of experienced therapists who partially had treated these patients. The retrospective assessment was based on the case records from the intake interview and the course of the treatment. Assessment of the extent of the social phobia and skills deficits was done by the same raters on two 99 mm visual analogue scales for social phobia and for social skills deficits (0 = no anxiety or no deficits; 99 = extreme anxiety or extreme deficits). Both procedures are described in detail in Wlazlo (1989). With those patients examined at the long-term follow-up, additionally a semistructured interview was carried out to assess: treatment impact on several areas of life (family, partnership, leisure activities, financial situation, work, social contacts, sexuality and psychological wellbeing); subjective treatment evaluation; actual life and health conditions (actual complaints, need for further treatment, medication). RESULTS General outcomes Since the ratings on all measures before treatment did not differ significantly between the three conditions, a repeated 2 factor analysis of variance (MANOVA) for each scale was used. The within group comparison was done with trend analyses and the between group comparison with 1 factor analyses (ONEWAY with Scheffe-test at the 5% level) at each point of measurement. Main complaints (social anxiety and skills deficits) All three treatment modalities led to a significant decrease of social anxiety (P -C0.001) over time. The least significant reduction of anxiety occurred in individual exposure (linear trend of the treatment-time interaction, P = 0.045). The analysis of the within-group changes showed that the reduction occurred mainly during the active treatment phase, with further reductions between 3 months- and 2.5 yr after treatment. Similar significant changes occurred on the aooidance scale (P < 0.001) and on the interference through the anxiety (P < 0.001) scale (see Fig. 2). For the two latter scales changes tended to be the largest in the group exposure, but numerical differences did not reach statistical significance. For the reasons mentioned, the examination of the changes over time on the social skills scales of the UF was only possible for the group exposure, which led to significant improvements on all behaviourally oriented scales: ‘fear of social contact’, ‘ability for making requests’, ‘inability to refuse’ (P < 0.001, for each subscale) (see Table 2). The between treatments comparison at follow-up did not show any differences on these scales. Since the three treatment conditions did not differ on any other scales at pre-treatment, it can tentatively be assumed that all treatments could lead to a similar acquisition of skills (especially assertiveness) during treatment as well as during the follow-up phase. Because of the lack of data at pre-treatment on these scales in PET and IE conditions, this assumption is speculative as yet. Attribution tendencies. Similarly for the social skills scales, repeated assessments of these cognitive variables were done only with the group exposure patients, who showed significant changes in the kind of attribution for successful and unsuccessful experiences (see Fig. 3). These patients enhanced the attributions for successful experiences to their own abilities (P -C0.001) and efforts (P = 0.032) and reduced the attribution to external variable factors like luck (P = 0.014) whereas the attribution of success to the difficulty of a situation remained unchanged; For unsuccessful experiences there was a reduction of the attribution to own inability (P < 0.001) and to the difficulty of a given situation (P = 0.017) and the attributions to unsufficient efforts and to bad luck remained unchanged.
186
ZVGMUNr WLAZLO et a/.
The between group comparison on these scales at follow-up did not show any differences, leading to the tentative hypothesis that the three approaches may be equally effective in changing these cognitive variables. Other neurotic
complaints
All three treatments led to significant reductions on all scales for other neurotic symptoms over time (see Fig. 2). From a clinical point of view the most relevant were the reduction of depression (P < 0.001) and of obsessional ruminations prior to acting (P < 0.001). The clear decrease of the depressive mood occurred mainly during the treatment, but continued between 3 months- and 2.5 yr follow-up. The obsessional thoughts, which are very often in a functional connection with social inhibition (apprehension about possible consequences), decreased to a similar extent during treatment and FU period. Social
if
anxiety
MANOVA;
PRE
PC 0.001
POST
Behavioural 74 T
(FSS-S)
:
,
2.5 yr
3MON
Interference
(FSS-I
Resistance
1
MANOVA: P( 0.001 PRE
POST
3MON
Depression
1
( FSS-R
2.5 yr
(D-S)
20 v
64 T I
60 +
18
56
16
52 _^
14
4ci
44
12
40 36
10
32
8
28 24
PRE Ruminations 5r
MANOVA: PC 0.001
MANOVA: PC 0.001
before
POST
3rloN
Psychosomatic
acting
2.5 yr
complaints
(FBL-WI
(HOCC-E)
88 ” 84 1. , 1
PRE
MANOVA; P< 0.001
POST
: 3MON
, 2.5 yr
80 11 76 11
HANOVA:
72 11 68 . PRE
POST
PC 0.001
3rlON
I 2.5 yr
Fig. 2. Measures of social anxiety and other neurotic symptoms before and after treatment, at 3-month and at 2.5 yr follow-up. PET = Personal Effectiveness Training; IE = individual exposure; GE = group exposure. Behavioural resistance scale = reverse formulation of behavioural avoidance.
Exposure
D#erential
in ho
vs social skills training
for social phobia
187
outcomes
The sample was divided into two subgroups: 35 (47.3%) patients with primary high deficits (irrespective the extent of the phobia) and 39 (52.7%) patients with primary high phobia (irrespective the extent of the deficits). Thus, both subgroups included patients with high phobia and high deficits; in the group labelled ‘primary deficits’ they accounted for 67.6% and in the group Table
2. Means
and
standard
deviations
N Social Anxiety (FSS-S)
Behavioural Resistance (FSS-R)
Interference with daily life activities (FSS-I)
Depression (DS)
‘Ruminations before acting’ (HOCI-E)
‘Harming obsessions’ (HOCI-F)
Psychosomatic complaints (FBL-W)
Fear of social contact (FU-2)
PET
20
IE
I7
GE
26
PET
19
IE
I7
GE
23
PET
I9
IE
I6
GE
23
PET
I8
IE
I5
GE
24
PET
20
IE
I7
GE
27
PET
20
IE
I7
GE
27
PET
20
IE,
I7
GE
25
PET
20
IE
I7
GE
25
Ability for PET making demands (FU-3) IE
Inability to refuse (FU-4)
20 I7
GE
25
PET
20
IE
I7
GE
25
for the multivariate (MANOVA)
2-factor
analysis
of variance
Pre
Post
3Mon
R SD f SD ic SD
13.30 4.32 13.06 4.78 15.92 4.60
10.90 4.05 10.59 5.05 12.08 4.79
IO.10 4.92 II.53 5.71 II.46 4.67
8.50 5.05 9.82*** 5.43 9.50 5.28
ic SD ic SD P SD
41.63 24.02 37.29 29.65 39.09 25.22
55.00 22.93 58.00 30.71 57.13 26.49
54.47 26.50 47.23 29.37 64.70 22.61
59.58 25.90 58.82 30.38*** 70.22 20.64
f SD ic SD ic SD
55.47 21.34 55.00 31.94 57.91 24.49
35.84 23.83 38.31 31.37 35.91 26.01
37.58 24.32 39.31 28.14 27.09 20.81
29.05 23.94 39.62 34.17*** 25.35 25.96
X SD ic SD ic SD
16.89 8.57 14.53 9.31 18.17 8.93
12.89 9.92 II.40 9.49 II.12 8.03
12.50 12.06 10.67 8.00 Il.21 8.30
10.06 9.66 9.20 7.33*** 8.42 6.88
x SD ic SD ic SD
4.25 1.83 3.82 I.51 4.07 2.34
3.60 I .93 2.71 1.86 3.37 I .92
3.20 1.85 2.71 1.83 3.1 I I .97
2.10 1.37 2.29*” 1.65*‘* 2.22 I .22
ic SD ii SD ic SD
3.70 I .84 3.71 I .90 4.04 2.29
3.45 1.50 3.47 I .77 3.59 I.89
3.35 1.66 3.18 1.51 3.22 I .60
2.90 I.16 3.12 1.54” 2.70 1.03
ic SD ic SD ic SD
98.90 23.75 101.23 30.23 108.04 24.26
94.15 25.39 93.76 30.67 102.20 24.15
91.90 27.30 96.41 30.39 98.12 22.87
85.60 23.64 95.29 31.81*** 89.68 20.85
37.84 8.90
30.05 15.53 31.65**’ 15.92 31.12 12.33
37.84 8.1 I
39.60 6.01 41.18 9.70*** 40.28 9.25
ic SD ic SD ic SD ic SD ic SD ic SD ic SD R SD R SD
46.76 9.76
38.28 9.0 I -
30.16 9.32
36.76 10.84 -
32.92 7.45
-
28.04 8.55
25.32 9.53
FU (2.5 yr)
20.51, 9 41 23.29 8.91*** 22.28 II.00
PET = Personal Effectiveness Training; IE = individual exposure; GE = group exposure. Behavioural resistance scale = reverse formulation of behavioural avoidance. *I’ < 0.05: **p
Copyright
0005-7967190 $3.00 + 0.00 cl 1990 Pergamon Press plc
EXPOSURE IN VII/O VS SOCIAL SKILLS TRAINING FOR SOCIAL PHOBIA: LONG-TERM OUTCOME AND DIFFERENTIAL EFFECTS* ZYGMUNTWLAZLO,KARINSCHROEDER-HARTWIG, IVERHAND, GRAZYNAKAISERand NICOLEM~~NCHAU Behavior
Therapy
Outpatient
Unit, Psychiatric 2000 Hamburg
University Hospital 20, F.R.G.
(UKE).
Martinistr.
52.
(Received 6 September 1989) Summary-This study examined the long-term effectiveness of specific exposure in vice (individual IE or group GE) and of office-based social skills training (group SST) in two groups of patients with social inhibition (primary social skills deficits or primary social phobia). Seventy-eight outpatients were divided into these two subgroups according to clinical assessment. Twenty-seven patients received SST which consisted of 25 twice a week 90-min group sessions: 32 patients received GE and 17 IE. Exposure in civo consisted of 4 weekly (8-hr in the group condition included 2 hr discussion; 3 hr in the individual condition included 1 hr discussion) sessions. Self-rating-assessments were carried out at pre- and post-treatment, at 3 months- and 2.5 yr follow-up. The general results indicate that all three treatment modes led to clinically and statistically-significant improvements in the main problem area (social anxiety, skills deficits), in other neurotic complaints (depression, obsessions, psychosomatic complaints) and in attribution-style. Patients with the diagnosis of primary phobia seemed to get the same profit from either treatment and showed slightly better gains (in all treatment modalities) than patients with skills deficits at long-term follow-up. Within the subgroup with skills d&icits there was a tendency for superior outcome of group exposure. These results and recommendations for future research are discussed.
INTRODUCTION
The effectiveness of exposure in uitlo treatments for agoraphobics and for obsessive-compulsives is well established. Successful application of exposure seems to require (a) in vivo, (b) prolonged and uninterrupted until anxiety subsides, (c) repeated, (d) the stimuli should be functional, i.e. anxiety provoking. Intense emotional, cognitive and behavioural involvement during exposure seems to enhance positive outcome. Other methods like modeling, relaxation, self-instructions or other cognitive techniques did not add to the effectiveness of exposure (Barlow, 1988; Marks, 1987). In contrast to this advanced state of research on exposure for most phobias and OCD, few attempts have been published on exposure in Go for social phobia or social inhibition. To our knowledge, a first attempt in using exposure in rho for social phobia was described by Hand et al. (1974, ‘social spin-off of exposure treatment) in their group study with agoraphobics; they modified the exposure treatment for those of their agoraphobics who showed severe symptoms of social phobia in the agoraphobic situations. Specific exposure in vivo for social phobics was first described and investigated by Wlazlo (1983) and Butler et al. (1984; Butler, 1985). While the first study employed a specific therapist-guided individual exposure in vivo, the second was based on manual-guided self-exposure, similar to the Home Based Treatment for agoraphobics (Mathews et al., 1981). Most of the few other clinical studies in this area showed a superiority of exposure in viuo when compared with other methods or with waiting list groups (Alstr6m et al., 1984; Biran et al., 1981; Hayes & Marshall, 1984). Yet, major methodological problems limit their generalizability. On the other side, social skills training programmes (SST) for social skills deficits are very well established in behaviour therapy; their effectiveness has been shown in numerous studies with clinical samples (Damm-Baggen & Kraaimaat, 1986; Hall & Goldberg, 1977; Falloon et al., 1977; Liberman et al., 1986; &t et al., 1981; Stravynski et al., 1982; Trower et al., 1978), where SST was superior to placebo, systematic desensitisation or cognitive modification. *This paper is based upon a doctoral dissertation submitted to the University of Hamburg, F.R.G. Portions of the study were presented at the annual convention of the Association for Advancement of Behavior Therapy, New York, 1988.
182
~~.~MUNTWLAZLO
et a/.
The main assumption in the literature is that anxiety reduction is the main mechanism of change for patients with social phobia and that skills acquisition is essential for patients with skills deficits. Nevertheless, till now no study has been published comparing a group exposure in viva approach with SST. In either of these subgroups, even worse, their diagnostic differentiation outside the behaviour therapy literature appears inadequate: in the DSM-III (APA, 1980) and DSM-IIIR(APA, 1987) patients with social skills deficits are rather diagnosed mainly on Axis II, as avoidant personality disorder indicating greater disturbance and unfavourable treatment response (Liebowitz, 1986; Liebowitz et al., 1985). an assumption without empirical support. Among the few clinical investigations examining differential treatment effects for these subgroups, &t et al. (1981) found that the effectiveness of applied relaxation (AR) vs SST depends on patients’ response patterns, i.e. physiological reactivity vs skills deficits. Trower et al. (1978) found better effects of SST for patients with social phobia, as well as with social skills deficits, compared to systematic desensitisation (SD). Although additional ‘neurotic’ symptoms are frequently reported in social phobia (Amies et al., 1983; Solyom et al.. 1986; Greenberg & Stravynski. 1985; McCann et al., 1987), little attention has been paid to treatment effects on these symptoms, except for an indirect reduction of depression (Alstrom et al., 1984; Butler et al., 1984; Trower et al., 1978; Stravynski et al.. 1982). There are only three long-term follow-up studies with at least a 1 yr follow-up (Alstrom et al., 1984; Biran et al., 1981; Falloon et al., 1977). Other studies reported 6 months (Butler et al., 1984; Marziller et al., 1976; Shaw, 1979; Stravynski et al., 1982; Trower et al., 1978). 3 months (Hall & Goldberg, 1977), or no follow-up (Emmelkamp et al.. 1985; bst et al., 1981). Differential success/failure analyses are missing. The only predictor of treatment failure so far identified is a high level of depression (Klosko et al., 1984)-yet, it is unlikely that future studies will confirm this predictor variable, as it is no longer valid in other anxiety disorders like agoraphobia (cf. Hand et al., 1986; Barlow, 1988). The present study investigated the long-term effectiveness of two different outpatient treatment modalities: (group) Personal Effectiveness Training (PET, Liberman et al., 1975) as one well known social skills training program and (individual IE, or group GE) exposure in viz)0 in patients with social phobia or with social skills deficits. Both treatment modalities include training in social competence as well as in coping with anxiety. Both patient-subgroups suffer from phobic anxiety and from deficits. Treatments and patients differ with regard to the relative importance of treatment ingredients and symptomatologies, according to their labels. METHOD Treatments The Personal Eflectiveness Training was conducted according to Liberman et al. (1975). This is a semi-structured training in social skills administered according to the specific needs of each patient. The groups (68 patients) were carried out twice a week with a total of 25 sessions of 1.5 hr each, over a period of 3 months. The total treatment time was 37.5 hr. The exposure in viva consisted of 4 sessions, once a week, over a period of 1 month. In the group condition (4-6 patients), duration of exposure in each session was 6 hr (additionally 2 hr of preand post-session discussion) and in the individual condition 2 hr (with additional 1 hr discussion). The last fifth session lasting 2 hr in GE and 1 hr in IE was used as a sum up discussion. The total treatment time was 34 hr in GE and 12 in IE. The treatment is to convey a general coping strategy for social situations by means of: (1) training in social perception and discrimination, (2) exposure to and management of anxiety provoking situations, (3) training of social skills, (4) training of ‘social intelligence’. This treatment, while containing a variety of standardized exposure situations, is also applied according to the needs of the individual patient (i.e. predominant phobia or social skills deficits). The therapists accompany the patients (or groups) throughout the in vivo sessions, encouraging self-responsibility in, and proper application of, confrontation with anxiety provoking situations, regarding motor as well as cognitive behaviour. In cases with social skills deficits, therapists are giving direct instructions-modeling, prompting or coaching the desired behaviours (similar to the office-based PET program). This exposure in vivo is described in detail in Wlazlo (1989).
Exposure in vim vs social skills &raining for social phobia
183
The selection criteria for the study were: (1) No history of psychosis, (2) social inhibition (phobia and/or deficits) as the main complaint and reason for seeking treatment, (3) no previous behaviour therapy for this complaint, (4) agreement to be taken off pre-existing psychotropic medication before the active part of treatment. According to DSM-III-R criteria, these patients can be diagnosed as social phobia and/or with avoidant personality disorder. The main complaints of the patients were: anxiety about negative evaluation caused either by negative cognitive anticipation or skills deficits; avoidance of social situations (speaking to strangers, making conversation, being under scrutiny, being assertive, etc.). Because of their suffering they appeared motivated to overcome their problems. From an initial sample of 167 patients with ‘social inhibition’ registered between 198 1 and 1986,20 patients refused treatment and 14 became dropouts. Thirty patients were omitted from this analysis because they showed severe comorbidity (agoraphobia, obsessions~ompulsions, depression, and other, with social inhibition mostly as the primary disorder). Of the remaining 103 (62%) patients, 78 had completed pre- and post-treatment ratings as well as t yr and/or a long-term follow-up. The follow-up duration ranged from I to 5.5 yr after treatment (X = 2.5 yr). Of the 78 patients, 29 had received PET, 17 IE and 32 GE (see Fig. 1); the patients were allocated to the treatment procedures by chance, according to their time of application for treatment; it could not be done at random because there was only one treatment Intoke
interview
N -167 I\’ INDIVIDUAL lxxPosURE
Behoviour onolysi 5 Refusals
b
GROUP lmo!xJRli
N=62
Theropy
Drop-outs
Other diognoses Therapy terminated and diagnosis s, inhibition
Patients with pre, post, lyr FU and/or long- term FU
Fig. I. Distribution of patients during the period under study.
184
ZYGMUNT WLAZLO Table
Age Sex
male female
Marital status
with partner without partner
I.
DescriDtive
data
PET
IE
GE
kz
31.03 14(17.9%) 15 (19.2%)
28.29 13(16.7%) 4(5.1%)
30.0 18 (23.1%) 14(17.9%)
30.01 45 (57.7%) 33 (42.3%)
17(21.8%)
9(11.5%)
I3 (16.7%)
39 (50.0%)
12(15.4%)
8 (10.3%)
I9 (24.4%)
39 (50.0%)
8.96
8.58
10.0
9.29 (yr)
3.96
4.47
4.25
4.19 (yr)
4.11
5.74
5.10 (Wl .,
Duration of illness Duration of treatment before BT Period between onset and first treatment PET = Personal
et al
5.0 Effectiveness
Training;
IE = individual
exposure:
GE = group exposure.
mode offered at a time (PET between 1981-1983; Exposure between 1983-1986). The total group consisted of 45 (57.7%) male and 33 (42.3%) female patients with mean age of 30 yr. Fifty percent of all patients lived without spouse. The mean duration of illness was 9.29 yr, indicating that the mean age of onset was about 20 yr (see Table 1). Measures patients treatment) Outcome
with pre-. post, selected for study. All subsequent
anxiety, social
yr and/or were taken
assessment self-rating
(1.5-5.5
after
scales.
deficits
Social was measured the subscale the Fear Schedule (Hallam Hafner, 1978) of 10 presenting social which are on O-3 of severity. higher the the higher anxiety. BehazGoural against the anxiety was with a analog 99 scale (Hand Zaworka, 1981). scale is reverse formulation behavioural avoidance. lower the the greater level of avoidance. Interference social anxiety daily life was measured a visual 99 mm (Hand & 1981). The the score greater the with daily activities. Social and social were assessed UF-questionnaire (U-Fragebogen, de Muynck Ullrich, 1977), most commonly and extremely validated scale Germany. This consists on factors: ‘fear failures and ‘fear of of guilt’ ‘decency’. ‘ability making requests’, to refuse’, contact’, ‘ability for requests’ and to Especially three scales of social refuse’ behaviourally oriented. styles were with a questionnaire (IE-SV-F, & Hinsch, 1) consisting 8 scales internal vs and stable variable attributions successful and situations. Because social competence the attribution were used over time in the and for patients only the long-term a between comparison was only for follow-up ratings. neurotic complaints was measured the Depression scale (DS) & Koeller, which in studies correlates with the Wakefield-Depression-Inventory (Snaith al., 1971). higher the the higher depressive symptomatology. Obsessire-compulsiz:e-symptoms were with the Obsessive-Compulsive In(HOCI, Zaworka al., 1983). inventory consists 6 subscales: checking, (b) (c) cleaning (d) speaking, (e) ruminations to acting, harming
Exposure in viuo vs social skills training for social phobia
185
obsessions. In each subscale the score of 25 represents clinically relevant symptomatology; this cut off point was derived from a clinical sample of obsessive-compulsive patients. Other phobias were assessed with the Fear Survey Schedule (Hallam & Hafner, 1978) with subscales of agoraphobia, blood-injury-disease phobia and animal phobia. All items are rated on a O-3 scale of severity. Like for the social anxiety scale behavioural resistance against and interference through these phobias were assessed on visual analogue 99 mm scales. Psychosomatic complaints were measured with a german inventory (FBL-W. Fahrenberg, 1975) consisting of 5 subscales and a total score, the latter being in the analysis. Separation of primary social phobia and social skills deficits was done by clinical judgement of experienced therapists who partially had treated these patients. The retrospective assessment was based on the case records from the intake interview and the course of the treatment. Assessment of the extent of the social phobia and skills deficits was done by the same raters on two 99 mm visual analogue scales for social phobia and for social skills deficits (0 = no anxiety or no deficits; 99 = extreme anxiety or extreme deficits). Both procedures are described in detail in Wlazlo (1989). With those patients examined at the long-term follow-up, additionally a semistructured interview was carried out to assess: treatment impact on several areas of life (family, partnership, leisure activities, financial situation, work, social contacts, sexuality and psychological wellbeing); subjective treatment evaluation; actual life and health conditions (actual complaints, need for further treatment, medication). RESULTS General outcomes Since the ratings on all measures before treatment did not differ significantly between the three conditions, a repeated 2 factor analysis of variance (MANOVA) for each scale was used. The within group comparison was done with trend analyses and the between group comparison with 1 factor analyses (ONEWAY with Scheffe-test at the 5% level) at each point of measurement. Main complaints (social anxiety and skills deficits) All three treatment modalities led to a significant decrease of social anxiety (P -C0.001) over time. The least significant reduction of anxiety occurred in individual exposure (linear trend of the treatment-time interaction, P = 0.045). The analysis of the within-group changes showed that the reduction occurred mainly during the active treatment phase, with further reductions between 3 months- and 2.5 yr after treatment. Similar significant changes occurred on the aooidance scale (P < 0.001) and on the interference through the anxiety (P < 0.001) scale (see Fig. 2). For the two latter scales changes tended to be the largest in the group exposure, but numerical differences did not reach statistical significance. For the reasons mentioned, the examination of the changes over time on the social skills scales of the UF was only possible for the group exposure, which led to significant improvements on all behaviourally oriented scales: ‘fear of social contact’, ‘ability for making requests’, ‘inability to refuse’ (P < 0.001, for each subscale) (see Table 2). The between treatments comparison at follow-up did not show any differences on these scales. Since the three treatment conditions did not differ on any other scales at pre-treatment, it can tentatively be assumed that all treatments could lead to a similar acquisition of skills (especially assertiveness) during treatment as well as during the follow-up phase. Because of the lack of data at pre-treatment on these scales in PET and IE conditions, this assumption is speculative as yet. Attribution tendencies. Similarly for the social skills scales, repeated assessments of these cognitive variables were done only with the group exposure patients, who showed significant changes in the kind of attribution for successful and unsuccessful experiences (see Fig. 3). These patients enhanced the attributions for successful experiences to their own abilities (P -C0.001) and efforts (P = 0.032) and reduced the attribution to external variable factors like luck (P = 0.014) whereas the attribution of success to the difficulty of a situation remained unchanged; For unsuccessful experiences there was a reduction of the attribution to own inability (P < 0.001) and to the difficulty of a given situation (P = 0.017) and the attributions to unsufficient efforts and to bad luck remained unchanged.
186
ZVGMUNr WLAZLO et a/.
The between group comparison on these scales at follow-up did not show any differences, leading to the tentative hypothesis that the three approaches may be equally effective in changing these cognitive variables. Other neurotic
complaints
All three treatments led to significant reductions on all scales for other neurotic symptoms over time (see Fig. 2). From a clinical point of view the most relevant were the reduction of depression (P < 0.001) and of obsessional ruminations prior to acting (P < 0.001). The clear decrease of the depressive mood occurred mainly during the treatment, but continued between 3 months- and 2.5 yr follow-up. The obsessional thoughts, which are very often in a functional connection with social inhibition (apprehension about possible consequences), decreased to a similar extent during treatment and FU period. Social
if
anxiety
MANOVA;
PRE
PC 0.001
POST
Behavioural 74 T
(FSS-S)
:
,
2.5 yr
3MON
Interference
(FSS-I
Resistance
1
MANOVA: P( 0.001 PRE
POST
3MON
Depression
1
( FSS-R
2.5 yr
(D-S)
20 v
64 T I
60 +
18
56
16
52 _^
14
4ci
44
12
40 36
10
32
8
28 24
PRE Ruminations 5r
MANOVA: PC 0.001
MANOVA: PC 0.001
before
POST
3rloN
Psychosomatic
acting
2.5 yr
complaints
(FBL-WI
(HOCC-E)
88 ” 84 1. , 1
PRE
MANOVA; P< 0.001
POST
: 3MON
, 2.5 yr
80 11 76 11
HANOVA:
72 11 68 . PRE
POST
PC 0.001
3rlON
I 2.5 yr
Fig. 2. Measures of social anxiety and other neurotic symptoms before and after treatment, at 3-month and at 2.5 yr follow-up. PET = Personal Effectiveness Training; IE = individual exposure; GE = group exposure. Behavioural resistance scale = reverse formulation of behavioural avoidance.
Exposure
D#erential
in ho
vs social skills training
for social phobia
187
outcomes
The sample was divided into two subgroups: 35 (47.3%) patients with primary high deficits (irrespective the extent of the phobia) and 39 (52.7%) patients with primary high phobia (irrespective the extent of the deficits). Thus, both subgroups included patients with high phobia and high deficits; in the group labelled ‘primary deficits’ they accounted for 67.6% and in the group Table
2. Means
and
standard
deviations
N Social Anxiety (FSS-S)
Behavioural Resistance (FSS-R)
Interference with daily life activities (FSS-I)
Depression (DS)
‘Ruminations before acting’ (HOCI-E)
‘Harming obsessions’ (HOCI-F)
Psychosomatic complaints (FBL-W)
Fear of social contact (FU-2)
PET
20
IE
I7
GE
26
PET
19
IE
I7
GE
23
PET
I9
IE
I6
GE
23
PET
I8
IE
I5
GE
24
PET
20
IE
I7
GE
27
PET
20
IE
I7
GE
27
PET
20
IE,
I7
GE
25
PET
20
IE
I7
GE
25
Ability for PET making demands (FU-3) IE
Inability to refuse (FU-4)
20 I7
GE
25
PET
20
IE
I7
GE
25
for the multivariate (MANOVA)
2-factor
analysis
of variance
Pre
Post
3Mon
R SD f SD ic SD
13.30 4.32 13.06 4.78 15.92 4.60
10.90 4.05 10.59 5.05 12.08 4.79
IO.10 4.92 II.53 5.71 II.46 4.67
8.50 5.05 9.82*** 5.43 9.50 5.28
ic SD ic SD P SD
41.63 24.02 37.29 29.65 39.09 25.22
55.00 22.93 58.00 30.71 57.13 26.49
54.47 26.50 47.23 29.37 64.70 22.61
59.58 25.90 58.82 30.38*** 70.22 20.64
f SD ic SD ic SD
55.47 21.34 55.00 31.94 57.91 24.49
35.84 23.83 38.31 31.37 35.91 26.01
37.58 24.32 39.31 28.14 27.09 20.81
29.05 23.94 39.62 34.17*** 25.35 25.96
X SD ic SD ic SD
16.89 8.57 14.53 9.31 18.17 8.93
12.89 9.92 II.40 9.49 II.12 8.03
12.50 12.06 10.67 8.00 Il.21 8.30
10.06 9.66 9.20 7.33*** 8.42 6.88
x SD ic SD ic SD
4.25 1.83 3.82 I.51 4.07 2.34
3.60 I .93 2.71 1.86 3.37 I .92
3.20 1.85 2.71 1.83 3.1 I I .97
2.10 1.37 2.29*” 1.65*‘* 2.22 I .22
ic SD ii SD ic SD
3.70 I .84 3.71 I .90 4.04 2.29
3.45 1.50 3.47 I .77 3.59 I.89
3.35 1.66 3.18 1.51 3.22 I .60
2.90 I.16 3.12 1.54” 2.70 1.03
ic SD ic SD ic SD
98.90 23.75 101.23 30.23 108.04 24.26
94.15 25.39 93.76 30.67 102.20 24.15
91.90 27.30 96.41 30.39 98.12 22.87
85.60 23.64 95.29 31.81*** 89.68 20.85
37.84 8.90
30.05 15.53 31.65**’ 15.92 31.12 12.33
37.84 8.1 I
39.60 6.01 41.18 9.70*** 40.28 9.25
ic SD ic SD ic SD ic SD ic SD ic SD ic SD R SD R SD
46.76 9.76
38.28 9.0 I -
30.16 9.32
36.76 10.84 -
32.92 7.45
-
28.04 8.55
25.32 9.53
FU (2.5 yr)
20.51, 9 41 23.29 8.91*** 22.28 II.00
PET = Personal Effectiveness Training; IE = individual exposure; GE = group exposure. Behavioural resistance scale = reverse formulation of behavioural avoidance. *I’ < 0.05: **p
