The Case for Single-Disorder Protocols: Social Anxiety Disorder

Social anxiety disorder is a complex condition characterized by a persistent fear of social or performance situations where one might be judged or scrutinized by others. This anxiety can provoke panic attacks and lead to significant avoidance behaviors, disrupting daily life and social interactions.

I recently attended a workshop led by Professor David M. Clark, a prominent figure in the field of clinical psychology and a pioneer in devising effective psychological treatments. Professor Clark, alongside Adrian Wells, developed a groundbreaking model for social anxiety that is now considered the gold-standard for understanding this disorder. The model not only sheds light on the dynamics of social anxiety but also emphasizes the necessity of an idiosyncratic formulation for each client.

The workshop presented the Clark and Wells model of social anxiety and illustrated the key treatment procedures that have been developed from the model. They include: self-focused attention and safety behaviors experiential exercise, video-feedback, externally-focused attention training, behavioral experiments, and procedures (discrimination training and memory re-scripting) for addressing early traumatic experiences that influence patients’ current behavior in social situations.

Below, I will outline the key takeaways and insights I gained from the workshop, explore the intricacies of the Clark and Wells model, attempt to further my understanding of its applications, and discuss why specific disorder protocols may be more beneficial than broad-spectrum treatments in certain cases.

Understanding Social Anxiety Disorder

Social anxiety disorder, often abbreviated as SAD, is more than just shyness or garden-variety fear of public speaking (which is one of the most common fear in the world, often ranked as more anxiety provoking than the thought of dying).

Social anxiety disorder is a diagnosable mental health condition typified by marked and persistent fear of at least one social or performance situation. It is characterized by intense fear of being scrutinized or negatively evaluated by others, which can provoke anxiety and potentially panic attacks. The social phobic recognizes that this fear is excessive, yet it leads to avoidance behavior or intense distress during social interactions (American Psychiatric Association, 2022).

Symptoms and Diagnosis

Individuals with social anxiety typically experience:

• Intense fear of social interactions where they might be judged.
• Worry about embarrassing or humiliating themselves.
• Fear that others will notice their anxiety, which may manifest as blushing, trembling, or sweating.

This fear or anxiety is disproportionate to the actual threat posed by the social situation and leads to significant distress or impairment in social, occupational, or other important areas of functioning. For diagnosis, these feelings must be persistent, generally lasting six months or more.

Impact on Daily Life

The implications of social anxiety in daily life are vast:

• • Avoidance: Many people with social anxiety tend to avoid social situations altogether, which can lead to isolation and hinder relationships, educational opportunities, and career progression.
  • Distress in Unavoidable Situations: When avoidance is not possible, such as in mandatory work meetings or presentations, individuals may experience intense distress and anxiety, impacting their performance and overall well-being.

Social anxiety is more than a personal struggle; it is a pervasive disorder that can significantly interfere with one’s ability to function in various spheres of life.

The Clark and Wells (1995) Model Explained

The Clark and Wells (1995) model of social anxiety has revolutionized the understanding and treatment of social anxiety disorder. This model posits that social anxiety is primarily maintained through a cycle of self-focused attention and employment of safety behaviors.

Key Components of the Model

Self-Focused Attention: Social anxiety is fueled by an excessive self-focus during social interactions. This self-focus leads individuals to monitor themselves closely, critically evaluating their behavior and appearance in real-time. Such heightened self-awareness distorts their perception of social interactions, often leading to negative conclusions about how they are perceived by others.

What’s interesting about self-focused attention is that it can skew our perception of ourselves and the world. It often induces unpleasant feelings or negative emotions within us. This is particularly intriguing when examined through an electroencephalography (EEG). For instance, when individuals are instructed to think about themselves during an EEG, the recorded brain waves match those typically associated with negative emotions. This suggests that self-focused attention can lead to negative emotions, demonstrating a correlation between self-thought and feeling bad from a brain wave perspective.

Safety Behaviors: Safety behaviors are actions or tactics employed by individuals to protect themselves from perceived threats or negative evaluations. Examples include:

• • Wearing makeup to cover signs of blushing.
  • Holding something firmly in one’s hands to prevent shaking from being noticed.
  • Rehearsing conversations to avoid silent moments or perceived awkwardness.
  • Preparing topics of interest to bring up in conversations.

While these behaviors might reduce anxiety in the short term, they paradoxically maintain and even amplify anxiety over time by preventing the individual from experiencing the situation without the safety net these behaviors provide.

The issue with safety behaviors is that they hinder learning. For instance, when an individual with social phobia prepares for everyday social situations (e.g., by strategically reading the newspaper to find conversation topics), they never discover that the social interaction could go well even without this preparation.

Another issue with safety behaviors is that they can inadvertently cause the very thing the individual fears. For instance, someone who fears being negatively evaluated by others due to visible sweat stains might wear an extra layer of clothing to conceal their sweat. Ironically, this can make them hotter and more likely to sweat.

The Model’s Application in Therapy

In therapeutic settings, the Clark and Wells model is utilized to help individuals recognize and eventually reduce their reliance on safety behaviors. Therapy encourages turning attention outward rather than inward, engaging fully with the social environment. This approach helps to break the cycle of anxiety by challenging the beliefs that underpin safety behaviors and by exposing individuals to their feared situations in a controlled manner.

Professor Clark noted that individuals with social phobia often appear distant and disinterested when they present to treatment. However, this demeanor does not necessarily reflect their actual feelings or intentions. Instead, it’s a result of self-focused attention and the performance of safety behaviors. Clark pointed out that when clinicians first meet a patient with social anxiety disorder for the first time, they’re essentially meeting the patient’s safety behaviors, not the true individual.

Why Focus on Specific Disorders?

The case for a single-disorder protocol for social anxiety, as opposed to employing a transdiagnostic intervention like the Unified Protocol I recently posted about can be summed up with one phrase: specificity.

Single-disorder protocols are designed to address the unique characteristics and symptoms of a specific disorder. This targeted approach allows therapists to:

• Develop deep expertise in the disorder’s dynamics.
• Tailor interventions to directly combat the core symptoms and maintenance mechanisms, such as the self-focused attention and safety behaviors identified in the Clark and Wells model.

Furthermore, focusing on one disorder at a time can enhance treatment efficacy by:

• • Allowing for more precise adjustments of therapy techniques to the individual’s specific needs.
  • Increasing the intensity and focus of therapy sessions, which can lead to quicker and more robust improvements.

Comparison with Transdiagnostic Approaches and Practical Application

While transdiagnostic treatment protocols, targeting commonalities across various disorders, have their benefits, they may not always target disorder-specific mechanisms as deeply and could potentially overlook key aspects of a disorder like social anxiety. Transdiagnostic approaches often aim for breadth, potentially sacrificing the depth required for conditions with complex interpersonal dynamics and deeply ingrained behavioral patterns.

The Clark and Wells model is an exemplary case of a single-disorder protocol that provides a structured framework for understanding and treating social anxiety. By focusing on specific behavioral and cognitive patterns, therapists can more effectively disrupt the maintenance cycle of social anxiety and achieve lasting change. The Clark and Wells’ model enables more personalized therapy tailored to each client’s specific symptoms. While transdiagnostic treatment protocols effectively address core psychopathology inherent in many psychiatric disorders, particularly internalizing disorders, the Clark and Wells’ approach offers additional benefits. It begins with experiential learning, identifies each client’s unique safety behaviors, encourages outward attention (as opposed to the self-focused attention characteristic of social anxiety), and employs numerous behavioral experiments. These experiments aim to assess whether the social phobic’s feared outcome is both warranted and as severe as they anticipate.

Reflections from the Workshop

Attending the workshop led by Professor Clark was an enlightening experience that offered deep insights into both the complexities of social anxiety and its effective management through the Clark and Wells model. My key takeaways are:

Idiosyncratic Formulations: One of the most significant insights was the importance of adapting therapy to the individual. This tailored approach helps in addressing the specific manifestations of social anxiety in each client, enhancing the effectiveness of the interventions. I have been fascinated by transdiagnostic protocols for some time now, but Clark’s workshop sparked an interest in single-disorder protocols which I look forward to continue to pursue further!

Importance of Safety Behaviors: Understanding the role and impact of safety behaviors in maintaining social anxiety was particularly enlightening. The workshop emphasized how identifying and gradually reducing these behaviors is crucial in the treatment process, and while doing so, furthered my understanding of safety behaviors in general and social anxiety safety behaviors specifically. This all boils down to: If you feel inclined to perform a safety behavior, then do the opposite of that safety behavior!  

Real-World Examples: Professor Clark shared numerous case studies and real-world examples that illustrated how the model is applied and the positive outcomes it can achieve, making the theoretical knowledge gained from the workshop much more tangible and applicable.

Advice for Comorbid Presentations: When a patient presents to treatment with comorbid pathologies, it can prove difficult to select which one to tackle first. Professor Clark recommended that one should strive to probe for which symptomatology has the strongest affect; the stronger the affect, the greater the cognitive distortion.

Inspiration for Practice: The knowledge and strategies learned have inspired new ideas in me for approaches to treating social anxiety in the future. The emphasis on experiential learning and its rationale, along withe the practical tips shared by Professor Clark will undoubtedly enhance my therapeutic competence going forward. For instance, one of the components derived from the Clark and Wells model is the use of imagery rescripting. Imagery rescripting has most commonly been used for PTSD, although it has some resemblance to Jeffrey Young’s Schema Therapy. It is used in social anxiety treatment when a mental image from childhood (often related to an event that sparked the onset of social anxiety; cf. kindling hypothesis for depression) causes significant distress and the idiosyncratic case formulation dictates that rescripting the event associated with that image may be beneficial for the patient.

Conclusion

The workshop on Cognitive Therapy for Social Anxiety Disorder was not only an educational journey into the depths of one of the most effective models for treating social anxiety but also a testament to the power of specialized, single-disorder protocols. The Clark and Wells model stands out as a beacon of tailored treatment, emphasizing the critical role of understanding and modifying self-focused attention and safety behaviors.

This model illustrates the importance of addressing specific symptoms and mechanisms within a disorder, offering a clear, structured approach that can lead to substantial improvements in the lives of those affected by social anxiety. The practical techniques and insights gained from this workshop underscore the value of such focused interventions, which are designed to challenge and change the dysfunctional patterns that maintain social anxiety.

As we continue to advance in our understanding and treatment of mental health disorders, the principles highlighted in the Clark and Wells model serve as a valuable guide for both researchers and practitioners. They are tried and tested, an exemplary reminder of the importance of simplicity in theoretical formulations, and serves as a personal reminder for me that while broad-spectrum treatments have their place, the precision of disorder-specific protocols can often provide the most direct path to recovery.

It was an honor to meet and learn from Professor Clark. It was an experience tha enriched my perspective of cognitive therapy and will undoubtedly shape my future practices in mental health care. As a fan of his work, having the opportunity to run my models of understanding of anxiety by him was invaluable. I even shamelessly got my picture taken with him!

Click here to learn more about cognitive therapy for social anxiety disorder on the OxCADAT website!

References

American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). American Psychiatric Association Publishing. https://doi.org/10.1176/appi.books.9780890425787

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). The Guilford Press.