In this conversation, Professor David Clark discusses his work using Cognitive Behaviour Therapy to treat Social Anxiety Disorder. He and Rachel talk about the Cognitive Behavioural model of Social Anxiety Disorder, considering the factors that contribute to maintaining this debilitating problem experienced by many people and the evidenced-based approaches to treating it. The conversation also delves into the economic impact of evidence-based psychological therapies and the importance of delivering high-quality, evidence-based care.
If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X, babcppodcasts on Instagram or email us at [email protected].
Useful links:
Papers:
David has published numerous papers in the field and a full list can be found here: https://bit.ly/3zjxcNy
The paper mentioned authored by Emma Warnock-Parkes is published in the Cognitive Behaviour Therapist and can be found here: https://bit.ly/3XzVsEq
Clark, D.M. (2018) Realising the mass public benefit of evidence-based psychological therapies: the IAPT program. https://pubmed.ncbi.nlm.nih.gov/29350997/
Clark et al (2023) More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder. https://www.cambridge.org/core/journals/psychological-medicine/article/more-than-doubling-the-clinical-benefit-of-each-hour-of-therapist-time-a-randomised-controlled-trial-of-internet-cognitive-therapy-for-social-anxiety-disorder/ED618AA69204AABD5C5691ABC454F5BE
Ehlers et al (2023) Therapist-assisted online psychological therapies differing in trauma focus for post-traumatic stress disorder (STOP-PTSD): a UK-based, single-blind, randomised controlled trial. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(23)00181-5/fulltext
OXCADAT:
A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/
Credits:
Music is Autmn Coffee by Bosnow from Uppbeat
Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee
License code: 3F32NRBYH67P5MIF
This podcast was edited and produced by Steph Curnow
Transcript:
Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients.
Today, we're talking about Social Anxiety Disorder, and we're really privileged to be joined by Professor David Clark, who's devoted his long and distinguished career to cognitive approaches to understanding and treating anxiety disorders, and also to disseminating these treatments so that help can be made available to as many people as possible.
In addition to his work in social anxiety, David's work has led to the development of effective NICE recommended cognitive therapy treatments for panic disorder and PTSD. David is well known for pioneering and tirelessly working to advise and steer the IAPT program in England, and he continues to work towards wider and wider dissemination of therapy through digitalisation and through his training, teaching, and political engagement worldwide.
Welcome to the podcast, David,
David: Oh, thank you for having me, Rachel. It's lovely to chat again as we've worked together so closely in the past. Lovely to see you.
Rachel: and there can be a few therapists working in the field of CBT and beyond who aren't aware of the enormous contribution you've made to social anxiety, but not everyone will know about your journey. So, it'd be great to hear about what got you interested in psychology, psychological disorders, and specifically social anxiety, both personally and professionally. And as a starting point, is it true that as a young man, your choice of study might've had rather more to do with the gender balance on the psychology program rather than the subject matter?
David: Well, that had an element to it. I think I've always been interested in mental health problems since I was a child, my mother was someone who people would come to when they were distressed, and she gave them obviously very supportive chats. But you often don't feel that just following your mother is the right way to go. And so I felt that maybe one could do better, and I was good at chemistry. So, I started really as an undergraduate as a chemist with the idea that we could develop some improved drug treatments for mental health. But I soon realised that drug treatments were quite limited and were likely to have pretty high relapse rates. I was also studying on a course where there were just four women in an intake of 200 first year students at Oxford, but I had bumped into a few members of the opposite gender at parties and one of them was wandering past chemistry one day and said, why don't you come down and have a cup of coffee in experimental psychology? where I found, it was a wonderful department, with lots of senior people just sitting down with the undergraduates talking through ideas over coffee, and of course, a much more even gender balance. So, I moved fairly quickly to the experimental psychology department.
Rachel: So there was a real motivation to help others right from the beginning, but maybe a small iota of self-interest there amongst that.
David: and an interest in social interactions of all sorts.
Rachel: And social anxiety then, what took you in that direction?
David: Well, the first sort of clinical problem we worked on is panic disorder, and that was at the time that we started working on it in the mid-1980s considered to be the most difficult to treat anxiety disorder. So, there's lots of research showing that those people with agoraphobia who also had panic attacks got least improvement from behaviour therapy. And similarly, those people with what we call generalized anxiety who had panic attacks also got least improvement. So it seemed a really good topic to work on. Of course, things worked out well for us in developing a cognitive model in the treatment. And I think nowadays people tend to think it's easiest to treat of all the anxiety disorders.
So in the sort of mid 90s, we started looking around for another problem and social anxiety is the most common anxiety disorder in the community. But what really fascinated us was that it is also the one with the lowest natural recovery rate. It starts in childhood for most people, and in the absence of treatment, it is often lifelong and it really interferes with your life. So it seems a really good challenge
Rachel: So an area where you could really make an impact in research and having had such success with the panic model and having such an elegant approach to that, that was really making a difference it felt like let's extend this, let's look where people are really suffering.
David: Yeah, and there was already a very respectable, psychological treatment. Group CBT was the dominant modality, the gold standard. But when you looked at the sort of outcomes in the best trials, it was rarely the case that you got more than 40 percent of people fully recovering from their social anxiety and that seems a real sadness for a condition that's so chronic and so common.
Rachel: And as you said, the largest, most widely prevalent problem in terms of anxiety disorders, but many of us can also identify with feelings of social awkwardness or shyness at some point in our life. But how does social anxiety develop then into a problem that impacts people more significantly as you've described? Who typically suffers from social anxiety and how does that come about?
David: Yeah, so you're obviously right. Many of us feel rather shy in some new social situations. And there are some events which pretty reliably make us anxious, like job interviews, particularly if you want the job. But that's sort of normal so we only think of people having an anxiety disorder if the anxiety is out of proportion to the situation. So it's not just in job interviews, for example, and it also really holds you back in life. You have a lot of avoidance and you can't do the things that you would like to. And so that's a real distinction between normal social anxiety and Social Anxiety Disorder really how much it interferes with your life.
Rachel: And I can reflect on my first job interview with you, David, and it gave me some insight, but also working with you subsequently gave me some insight into how those techniques that you have come across and developed have been, could be so helpful. So we have a bit of a challenge on this podcast, David. We love a good formulation in CBT, as you know, ideally with boxes and arrows and pictorial ways of describing things, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about how social anxiety develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids?
David: Well, the development is like most anxiety disorders. It's a mixture of genetic vulnerability, social learning, and adverse life events. That's not the interesting point from therapy. The interesting point from therapy is what keeps it going. And there's a really big puzzle because modern life is such that we all have to meet other people more or less every day. And at least when in adulthood, people with social anxiety, when they're meeting other people are not getting unambiguous negative feedback from them. So they seem to be having naturalistic exposure and we know that exposure therapy is a sound principle. So, the big puzzle for us as therapists is to work out why don't people benefit from naturalistic exposure? And being a cognitive therapist, I think the answer lies in getting into people's heads. And so, Adrian Wells and I interviewed a lot of people with social anxiety, tried to work out three things; what are they thinking? How does their thinking change what they pay attention to? And also how does it change the way they behave? And we found that if you can understand those three points and how the things interlock, then you can really understand why this is such a persistent problem.
Rachel: So it's something about thinking, about attention and about behaviour. Shall we start with the thoughts? what do they look like in social anxiety?
David: Well, the thoughts are often pretty self-evaluative. Thoughts like, I'm being boring, I'm being stupid, I look very anxious and of course, the idea that people have is that other people will be thinking similar things. It's almost like a projection of your own negative self-evaluation into other people's minds. And you're fearing you'll be rejected.
Rachel: Which sounds pretty scary…so what do people typically do when they have these kind of thoughts?
David: Well, the first thing is a shift in attention. Because people are worried about how they're coming across to other people, they focus a lot of their attention on how they think they appear. So, they may be talking to someone else but a lot of their attention is on themselves, thinking how am I coming across? And that shift to an internal focus of attention in itself is a problem, because if the conversation goes fine, the chances are you won't notice, because you're lost in your head. But when you get lost in your head, unfortunately, that gives you access to a lot of internal information, which people take as really good evidence for their worst fears, although actually it's not.
Rachel: How does that work in practice?
David: Well, the most common thought is that other people can see you're anxious and then they'll think badly of you because of that. So, of course, Adrian Wells and I asked lots of people, well, have people said to you, Golly! David, you looked really anxious when we were having a drink in the pub on Friday evening. And some patients say yes, someone has said that to me. But to our enormous surprise, most patients said, no one's ever said that. So of course, we then ask the obvious question, well if people haven't said that? Why do you think it? And the answer was always the same; I feel very anxious and therefore I really must look very anxious. That sounds logical but research shows it's a bad strategy. It's not that someone with social anxiety doesn't look at all tense, but the difference between how they think they look based on their feelings and how they really look is enormous and gets bigger the more anxious they feel. So, the more anxious you feel, the more you overestimate how anxious you look. So that's point one; people are using their feelings to decide how they appear.
Rachel: Over and above those anxious feelings, I know a lot of your work has focussed on other types of internal information that also play a role???
If you're worried about how people see you, you won't be surprised to hear that people with social anxiety often have images in which they see themselves from someone else's perspective. That would be great if those images were how they really look, but sadly they're not. The images are really their worst fears visualised. So if you're worried about sweating and your lips shaking, what you see is big globules of sweat on your forehead and a quivering lip. Whereas the reality would be nothing like that. But because the image is observed from outside, it has a ring of truth to it and people just assume it's true. We use the word image and that conjures up an idea that it's a bit like a sort of 4k video. It is for some people, but mostly what people say is it's an impression they have. It's not like there's a video playing in the back of their head all the time, but if you ask them to describe how they look, they can generate it very quickly and it'll be like that.
The other source of information is maybe a bit more difficult for people to understand, it's what we call your felt sense. So, someone might be in a group of people in a conversation. And they may be standing really close to them. But they have the feeling that they're very distant from them. It’s almost as though space grows and they feel there's that group of people and they're all together and I'm separate and apart and I don't fit in. And that felt sense of being separate and apart and not fitting in is further evidence that people think you're boring, uninteresting and it is really like space grows for these people. It’s simply a consequence of self-focused attention; if you're watching yourself all the time, it makes you feel distinct from everyone else. Whereas if you're not watching yourself all the time, you're lost in the conversation. You feel part of the group.
Rachel:So that’s two factors you’ve mentioned already – shifting attention onto yourself so you can’t really take in what’s actually happening in the social situation and at the same time getting access to misleading internal information that seems to confirm your fears…
Yeah, the third thing, which is really destructive, is changes in behaviour. And there, in all anxiety disorders, people do what we call safety behaviours; things you do in order to prevent the thing you're afraid of from happening. But if, as in social anxiety, your fears are unrealistic, the problem is that if you do the safety behaviour and nothing bad happens, you'll think that's just because I saved myself that time. It's because I did the safety behaviour. But if I was just myself, let people get to know me, then they would think badly of me. So doing the safety behaviours maintains your anxiety.
Rachel: It makes perfect sense that you wouldn’t want to run the risk of rejection or humiliation…What kind of safety behaviours do you tend to see in social anxiety?
David: Well, if I was worried that you think what I'm saying is boring, I might engage in a couple of safety behaviours. I might have carefully prepared in advance this morning all the answers I was going to give to you in this podcast, which actually I haven't, but I might've done that, just to make sure I came across really good, better than I really am. And I also, as we're talking now, I might be memorising everything that we've already said and checking whether what I'm about to say makes sense, whether it's clever enough. And I probably go quiet every now and again because I think, oh, it's not clever enough, I'm not quite sure what to say. Those two safety behaviours might get me through this interview. But afterwards, I'd still think, Oh God, I'm going to be caught out. People are going to think I'm really boring. So my fear wouldn't change if I was someone with social anxiety.
But they have other consequences, which are really problematic. And one of them is it really interferes with the social interaction because if you're doing all this memorising, then the person you're talking to gets the impression you're not really interested in them. You're mind's somewhere else. Which it sort of is. And so the conversation doesn't flow so well, and the chances are the other person may not be so interested in talking to you again. They're picking up the cues from you that you don't seem to be interested, so why should they be interested? They don't want to be rude by pushing themselves on you too much. So this is a special situation, where unlike many other anxiety disorders, the safety behaviours actually make some of the things you're afraid of actually happen. They make people less friendly to you. At least, the sort of safety behaviours that we call the avoidant ones. So, in that example, I would be avoiding saying certain things because I thought you'd think I was stupid.
There's another set of safety behaviours which maintain your fears, but don't necessarily impact other people. And they're what we call the impression management safety behaviours. We see them a lot with actors but also some people who are in professional roles that are well practiced. They will have lots of stories to tell people. They'll go to a party and they'll run through their funny jokes and their funny stories. And everyone sees them as the life and soul of the party. But they're doing this to avoid really talking about themselves, and as soon as they run out of their jokes, they'll move on to someone else because they're terrified that you might discover what they worry, which is that you might think they're boring if you just get to know them, or stupid, or uninteresting. So people tend not to notice that someone with social anxiety has social anxiety if they use a lot of these impression management safety behaviours, but they're still very destructive for the person because they prevent them from discovering that if they just were themselves, people would accept them in any case.
Rachel: Brilliant. David, if there are any fears lurking here, you know, I can give you some immediate stooge feedback that there wasn't an iota of boring or stupid in any of that. Really, as we would expect, articulate description of the model. And in common with other cognitive therapy models that we have, there's definitely something about how people think, the unhelpful and inaccurate thinking they have. Also how, what they're attending to that's bringing about that thinking and what they do in response to that information, but some very specific and particular mechanisms in social anxiety that you've spoken about. And we describe CBT as an evidence-based approach to psychological problems, not only because the therapy is tested and trialled, as you've done many times with this model, but also because the assumptions on which the models are based emerge from cognitive and behavioural science and are tested experimentally. And that gives clinicians and patients alike a confidence in the approach we're taking. It's not just sort of psychobabble. It doesn't just sort of feel like it works, but actually we've tested it out. So how have you and your colleagues systematically tested the assumptions about their maintenance of social anxiety and the model you've just described?
David: I guess there's two things. Firstly, obviously, we've tested the treatment that's derived from it in lots of randomized control trials. Thankfully, people in other countries have expressed interest as well. So there are now about a dozen randomized control trials in the UK, in Norway, in Sweden, in Germany, in Japan and in China, and the treatment is being compared against lots of alternatives, exposure therapy, group CBT, psychodynamic therapy, interpersonal psychotherapy, medication, psychiatric treatment as usual. It has always beaten whatever it's compared with. So it has a very solid evidence base in terms of the treatment package.
For the mechanisms, what we've tended to do is try and bring them into the laboratory and manipulate the processes in the lab and see whether that influences people's social anxiety in the short term. And we've also done sort of mediation analyses where we've measured the key processes and then looked at whether in a clinical trial when cognitive therapy is more effective than an alternative treatment, is it at least partly due to its greater ability to change those mechanisms? And there's a lot of research that has worked out positively using both types of experimental approach. So, for example, there's a nice experiment by Colette Hirsch, where Colette got people with social anxiety to have a conversation with a stranger. And, during that conversation, unbeknownst to the stranger, the patient switched in their mind between their habitual negative observer perspective image of themselves, or a more realistic one based on video feedback, and what was the consequence of that mental switch turning on one of the key processes? Well firstly, not surprisingly, when you turn on the negative image, you feel much more anxious. You think you come across looking much more anxious. And that's, as the model would predict, partly a distortion because the other person actually views you more positively. But there's also partly a reality in it in the sense that the difference that when you're doing your negative image, the other person still does view you less positively than when you haven't got the negative image, even though in both cases you're putting yourself down. So how does this mental image that you have in your head unbeknownst to the other person sort of leak and change the other person's perception of yourself? Well, it turns out that is because when you turn on the negative mental image, you also turn on the avoidant safety behaviours and those are what influence the other person. So, you see in this neat little experiment, the whole system has a tight interlocking of mental images, safety behaviours, self-perception and other people's responses.
Rachel: That's a really elegant study, isn't it? And it mirrors what we see clinically. Often we're trying to get our heads around these models as therapists, but when you ask those questions of someone who's truly suffering from social anxiety, it's like a light bulb moment when they, they say, yeah, I absolutely, I have that image of myself and yes, it does feel like I'm distanced from the people around us. So, so we know that in the therapy sessions, but it's really good to know that there's this experimental evidence underpinning that we can be confident in. You've described really well the mechanisms, the model, and some of the evidence behind it. What does treatment built on this model look like then typically?
David: Yeah, so the treatment, as with our other treatments, really closely focuses on the maintenance product processes in the model. It's a very tight sort of intervention based on those. So, it starts where patients are at. They are using their feelings to decide how they appear to other people, and they're very self-focused as they do that. So, rather than just giving them a bit of psychoeducation, explaining the model to them, we like them to feel it. And so we start with a little experiment in the therapy session, where we often get them to talk briefly to someone they haven't met yet. Doing it twice, once while focusing on themselves, thinking about how they're coming across and doing their safety behaviours. And once while trying to get out of their head, just lost in the conversation, focused externally. And to their immense surprise, they find that when they don't focus on themselves and do their safety behaviours, which is, of course, what they're doing to manage their social anxiety, when they don't do that, they do the opposite, they feel less anxious, and they think they come across better. So this really hooks people in on the therapy because you've done something which makes them feel better. It's not just a chat. It's not just a bit of psychoeducation. You've demonstrated in a social interaction that we have a way of making you feel better. So that hooks people in on the therapy. And of course they can start now experimenting a bit with trying to focus externally and drop some of those safety behaviours. So they're already on a roll early in therapy. We then look at these really distorted images people have and help them discover that they are distorted and therefore misleading, and best avoided paying attention to.
Rachel: So you’ve already said people are pretty convinced by these images and they may well have had them for a long time – how do we convince them they are worth reconsidering?
David: Well, we don't do that by nice reassurance from the therapist, saying, actually, I know you were feeling very anxious when we were talking earlier on but you came across pretty well. Because patients may not believe that. They may think, well, you're a therapist, you're paid to be nice. But maybe that's not like the real world. So instead, we like patients to see things with their own eyes. And so we use video feedback, where we video some social interactions, we get them to predict how they think they will appear based on their feelings and set up things in a very structured way. And then we get them to compare their predictions with what they actually see on the video. And when set up carefully, this is a really good way of helping people discover their perceptions of themselves are excessively negative. So you're now on a roll, and people are inquisitive. They think, well, the evidence I've been using so far to decide how I'd come across isn't good evidence. So, let's find out how I really come across. And that's when you get into doing a lot of what we call the behavioural experiments, where you get people into social situations and get them to drop their safety behaviours. So they give the world a chance to get to know them, participating more in the interactions. And they're focusing externally so they can see how people respond. And that process helps them to discover that if they give the world a chance to get to know them, not hiding away or using all the impression management safety behaviours to hide themselves in a different way, then they are generally accepted. And that's an incredibly positive experience.
You're always wanting to test particular fearful predictions. And if they don't come true, you want to know, why is that? Is it because the person thinks they were lucky that time? Or because they did those safety behaviours? Or is it because they've truly learned that actually they will be accepted if they let people know them? So you're often refining these experiments whenever you repeat them. You don't just do the same thing twice, you refine it in a collaboration with the patient to find the most convincing evidence for them.
Rachel: So lots and lots of behavioural experiments to test out those fears…
David: And there's a last component to the treatment which, we developed over time, which is that although people are not getting really negative feedback from other people as adults, some people have had socially traumatic events in the past; they’ve been bullied or teased at school and things. And in some cases, those socially traumatic events do impinge on the present. They influence the sort of images people have of themselves. And sometimes also the feelings are very similar to the past event. Even if in the past event, they were physically attacked or bullied and in the present in the adults there's no possibility anyone's going to do that but there's a similar feeling of physical threat. When we get those touchstones, showing that the past is intruding on the present, in terms of the nature of the images and the feelings, then we also do some work that we take from our PTSD treatment to help break the link between those trauma memories and present perception. And that gives us an extra bow in our arrow, which we find, helps to further really give people full confidence.
Rachel: So it's really active therapy, isn't it, David? And I think right from that very first pivotal experiment that you spoke about, where people are manipulating their safety behaviours and their focus of attention through all this real world finding out how the world really works, how people really perceive us is very active on the part of the therapist. And some of these experiments can be tricky to learn when you're starting out, but so useful and they are, they're really the gift that keeps on giving throughout therapy as you build this dossier of evidence about how the world really works, how people really respond to you. And for that reason, I remember I never dared come to supervision without having done at least one behavioural experiment with a client or perhaps a bit of imagery rescripting as we, as we got towards the end of therapy. But you really see how people's view of themselves changes and what a wonderful gift to know that actually you can be in the world as you are, and that is acceptable and worth a lot of work.
David: Yeah, and, and of course, what you did in preparation for supervision was absolutely the right thing to do because the research supports what you did. So, I've mentioned that there are clinical trials in lots of different countries, and the treatment has always beaten the competitor, but sometimes it beats the competitor by miles, sometimes by not quite so much. And, in the not quite so much, which has been some of the German studies, when we've looked with the investigators at what happens in the treatment, we've found they're doing very few of the behavioural experiments and they're not scheduling time to do that. So there's quite a lot of evidence that the more of these behavioural experiments you do, the better the outcomes you get. But quite a lot of them involve leaving the office with the patient to do things. And that is quite a problem in NHS services where our diaries are scheduled in such a way that it may be quite difficult to do it. So this is a problem that we still need to crack in routine practice.
Rachel: And I, I hear that a lot from therapists working in talking therapies and in other NHS settings that you've spoken about that the idea of doing a 90-minute session seems like a mountain to climb. How do we fit that into our service organisation? Or how do we get stooges into a session? And we talk about stooges just bringing people who are naive to the therapeutic set up to what the particular issues of the individual are to have a conversation and give some feedback in. What would your message be to services around the value of that and, and how they might think about building that into their organisation?
David: Well, I think I'd say, the NHS mental health services exist not for the convenience of the managers, they exist in order to transform the lives of our patients, and the evidence is really clear that you get much better outcomes if you organise a face to face therapy to do these things. And it's also very clear that wherever you get a patient to at the end of therapy, the gains are really well maintained over the next five to ten years in the follow up studies So, you're really changing someone's life, if you effectively treat their social anxiety disorder. People are coming in for treatment on average in their late 20s, early 30s. Life expectancy is 80 something. So you will give someone a different life for the next 50 to 60 years. They will do so many more things with their life. They'll meet so many more people. They will really be an enormous asset to society. So why wouldn't we want to organise our clinical diaries to transform someone's life for the next 50 years?
Rachel: So we do it because it helps, but it sounds like there's also an economic argument there as well, that people aren't going to be coming back for more therapy. Then they're not going to be suffering on a long-term basis.
David: There's an enormous economic argument and I guess you see the data for this most clearly with the data sets we've now developed in the NHS Talking Therapies program, and copies of the program that are done in other countries like Norway. So, for example, recently, in a Norwegian study, they showed that people who were treated in their version of NHS Talking Therapies, randomized to that versus treatment in standard treatment and primary care, including access to psychologists and psychiatrists, by the way, they had much better clinical outcomes, about twice the recovery rate. But interestingly, from an economic point of view, if you then followed them up for three years post treatment, the people who had had the talking therapy service had a higher personal income than the people who didn't, who were treated in primary care. And that difference in income is so large that it's four times greater than the cost of the service. So this data and other data we have in the UK, and in Spain, led Jeremy Hunt to invest an extra £590 million in expanding the talking therapy services in the autumn statement. Because he was convinced that this is solid data; that evidence based psychological therapy, when organised well in coherent services, actually helps grow the economy. So that's what the Chancellor is interested in, of course. In the NHS, we're also interested in saving money. And there's lots of good evidence that if you can effectively treat people's anxiety and depression, then over the next few years, they have less physical healthcare costs. A really nice example of that is a data linkage study from UCL recently, where they looked at people who were successfully treated in a Talking Therapy service and followed them up for the next three years and found they had significantly less adverse cardiovascular events, including heart attacks and strokes. So, there's an enormous impact that you can achieve from well delivered psychological therapies that have a higher recovery rate. But it is all to do with getting people better. So if you look at the Norwegian data, the benefit to cost ratio in terms of the economy is 4 overall compared to treatment as usual in primary care. But for those people who recover, it's 10. And for those people who don't recover, it's 0. So we really need to focus on making sure we deliver our psychological therapies in a high quality evidence based way.
Rachel: So when done well, it works and it pays and to do this treatment in particular, it's not just about talking therapy, it's doing therapy. And we've talked about how the behavioural experiments getting out there, testing and are so critical. And you've talked about the evidence base generally with this kind of care, thinking about social anxiety specifically, what’s the efficacy of this treatment, effectiveness of this treatment? And is it both effective and efficacious in the real world? Does it treat people the same? Does it work for a diverse population? Where's our evidence at in terms of that right now?
David: Yeah, so if you look at the randomized controlled trials, and with, delivered by research therapists but with NHS Talking Therapies patients, you get about 70 percent of people fully recovering from their social anxiety and significantly more, in the high 80 percent showing reliable improvement. You don't at the moment get such high recovery rates in routine care in NHS Talking Therapy services. And we think that is for two reasons. One is because some patients, contrary to NICE guidance, are given low intensity interventions rather than this type of face-to-face therapy. The other reason seems to be that people get less sessions than you see in the trials. And the last reason, which is really interesting, is that often therapists are not using a measure of social anxiety each week to guide practice. So, the recommended measure in talking Therapy services is the SPIN, but quite a lot of people don't seem to use it. And we have very good evidence from an analysis from UCL that when therapists do use the SPIN to track progress in therapy, they get much higher recovery rates. And why is that? Well, when you look closely at the data, one reason is that people get much more like the expected dose of therapy. When people are using the SPIN, I guess because they're more sensitive, the GAD may have improved, but they can see with a spin, but a lot of the social fears are still there. So they carry on. So that's really good for patients. But, and this is really interesting, even if you statistically control for that, you find that every hour of therapy is more effective if you're using the right measure. So, it just seems to be a way of helping us as therapists really focus on what matters and keep that tight focus.
Rachel: and not just using measures for measure's sake. It sounds like using them very actively is an important ingredient in what you're talking about.
David: oh, incredibly, it's not for measure's sake, it's really to focus your therapy. The other really interesting development recently is, as we've developed an internet version of the treatment, which has all the key components in it, but most of the work is done by the patient accessing the program online but with support from a therapist. And we find in the clinical trials that you get as good results with only about a third as much therapist time compared to sort of expert delivery. We've also found recently, in some pilot studies, in six Talking Therapy services that we can actually train up routine therapists in Talking Therapy services to get the same high recovery rates with the internet treatment as research therapists. So over 60 percent recovery, full recovery, which is a lot better than we currently get in the routine treatments face to face in Talking Therapies. So why is this? Well, I think because the internet program always develops, always delivers the full treatment content, and it does get patients to do an enormous number of behavioural experiments. And it does this by lots of videos which illustrate people doing behavioural experiments for different fearful beliefs in the real world. And so, patients can look at the video and then try it out in action. And that seems to hook people in. If people would like to see some of those videos and also get them as tips for designing their own behavioural experiments, you can see them all in the social anxiety section of the oxcadatresources.com website. That's a free website that the clinic created for therapists, and it's got an enormous amount of material about how to deliver our social anxiety treatment and our PTSD and panic treatment. And it's currently being used by therapists in a hundred and seventy-five countries around the world. So, if you log in and it's free, then you'll be joining a worldwide community of psychological therapists. There are apparently 195 countries, so we've still got twenty to go.
Rachel: It really is a wonderful resource, and your team has always been so generous with their research and materials and support of good therapy out there in the real world. Every corner of the real world, it sounds like, or almost. And for those that maybe aren't so clear about the distinction between low intensity and high intensity ways of working, we've become very used to this kind of language, certainly within Talking Therapies services. How does your internet program differ from supported self-help that people might have at a low intensity level and how would you distinguish that?
David: Yeah, it's a very good question. So I think the sort of supported self-help, low intensity intervention that people get from for social anxiety is basically some psychoeducation about social anxiety and encouragement and exposure therapy. Neither of those are actually components of cognitive therapy for Social Anxiety Disorder but the internet treatment has all the components of the high intensity treatment. So it has almost no overlap with what's currently given as low intensity interventions. But the interesting thing of course is it does require a lot less therapist time because the patient is doing a lot of the work. So you, you could say in that way, it is a new type of low intensity intervention but it's not what has been offered so far in Talking Therapy services.
I should also say that although it was designed to be used by high intensity therapists, in our most recent research with Talking Therapy services, we find that PWPs can be trained to get just as good outcomes with it. But what the patient is doing is not the equivalent of reading a self-help book on social anxiety, psychoeducation and exposure therapy. It's got video feedback of your social performance, it's got lots of experiential exercises, it's got specialised modules for all the different social fears, it's got ways of working with your trauma memories. They're all there in the program. Patients spend a lot of time in it, although the therapist's time is modest, about six hours over the full course of treatment. On average, we found in our most recent study that patients were spending approximately 40 hours on the internet treatment, and much more time in behavioural experiments. So, it sucks people in, they're really interested in it, because they recognise themselves. They can see, the program seems to know what they think, they recognise their thoughts. The program seems to be good at spotting these very subtle safety behaviours they have, including all the things they're doing in their head, which people can't just see, but the program alerts them to them, and they recognise from the case examples, people just like them, but then it just gives them so much more guidance in how to test things out in action with all these video clips.
Rachel: That's fantastic. It sounds like it's brilliant as we've spoken about for dissemination, getting the treatment out there to more people, but also sounds like there's some really interesting workforce developments there with PWPs being able to deliver this, our highly skilled PWP colleagues, with the right training and support.
David: Yeah, just one other point to say about it in that one of the strengths of internet programs is that if you get the content right, the program will always deliver the correct content. It doesn't have a day off. and it also will deliver it anywhere in the world. So we've now done trials with the program in China and in Japan. And really interestingly, with almost no modification, the program gets just as good outcomes with Chinese and Japanese residents.
Rachel: So is this a step towards artificially intelligent therapists?
David: Well the program is written to rely on help from real therapists who are familiar with the program and understand it well. It's possible that in the future with some of these online programs, you might find that you're guided through the therapy program with an avatar but that's not where we're up to.
Rachel: So we're not discouraging people to take up therapy as a career just yet. There are secure jobs still in the system.
David: Oh, absolutely. I mean society's growing understanding that psychological therapies don't only transform people's lives and the lives of people's families, but also are good for the economy means that without doubt, throughout the world, society is investing more in these evidence-based therapies. Obviously, the Talking Therapies Program has expanded job opportunities for therapists enormously. We've got an extra 11,000 therapists there. I anticipate that something similar will happen in community mental health for people who have conditions other than anxiety and depression. And I'm working with governments in many other countries to expand access to evidence based psychological therapies.
Rachel: All that said, we are human, and therapy can be challenging at times. And you've been in this in this game, in this system of working with social anxiety for many, many years. In your extensive experience of both delivering the therapy yourself, teaching, supervising. Where do therapists get stuck with social anxiety?
David: Well, I think, that the first issue is not really quite understanding the transference issue or the relationships issues. So social anxiety has a rather special relationship problem. It’s because you as a therapist are a stranger. So, you're a phobic object when you start the therapy, in fact when you start your assessment. It's a bit like saying to a spider phobic, we've got a really wonderful therapy for you and by the way, your therapist is a tarantula. That would interfere with the therapist process quite a bit, wouldn't it? And exactly the same thing happens in social anxiety and if you're not aware of that, you'll fall into lots of traps because of you being a phobic object. So quite a lot of our training is making people aware of what those traps are so they don't get sidetracked by them. And so what classic examples, well, there's one that happens in the initial assessment interview. People with social anxiety are worried about other people seeing they're anxious so they often try and hide the fact that they feel anxious. So if you're, doing your assessment interview and you feel you're making good progress, you're getting lots of details about the problem, you're starting to develop the model, the chances are your patient won't look very impressed. Because they're trying to stay in control, they're trying to stay a bit distant, so they don't look too anxious. And, if you're not aware that that's a safety behaviour that they've turned on because you're a phobic object, and so you're not really seeing the real person. You might mistake that as them having a lack of interest in your therapy and what you're doing. There's a good chance that will trigger lots of negative thoughts in your own head about your own performance, which will distract you from the therapy. So, the relationship issues start even in that first interview, but they carry on throughout therapy. So, because people are very focused on their feelings, when you're asking them, what were their thoughts, they often don't seem to answer immediately. They just say, well, I felt very embarrassed. And they don't say anything much more. And they look uncomfortable. And what do we normally do when people look uncomfortable in therapy? We sort of lean forward in our chair, look them in the eyes as I'm doing with you now and try and be very warm and empathic. But when we do that to someone with social anxiety, it's spotlighting them. It's making them centre stage, and they hate it. And so they're likely to, their minds are likely to go completely blank and they'll feel uncomfortable. They may even have a panic. So we have to adjust our interpersonal behaviour. So we're still very friendly, but not in their face in the way that you might do with some other people who are distressed. There are other sort of things that can go wrong in the relationship, like believing the evidence of your own eyes, if you're a therapist. So say someone says, Oh, well, my worst fear is that I'll blush. And as they say that they start to go red. And you might think, Oh my God, their fears are realistic. It's really true. I don't know that I can do much about this. But you're in the wrong place, you're observing what you see in front of you. You need at that point to get into the patient's head and find out, well, what do they think they look like at that moment? And if you do that, you'll find they think they look enormously worse than that. So, you can be misled by the evidence of your own eyes. And there are quite a few of these other therapist-patient relationship issues that people need to understand.
Rachel: So you need to be very reflective as a therapist and taking that presumably also to supervision and thinking about how that's working its way out with your interactions in therapy.
David: Yeah and you'll also find them covered in the workshops and things. So on the OXCADAT Resources website, for example, there is a full day workshop of me showing how to do the cognitive therapy for social anxiety, and it does cover these interpersonal issues.
Rachel: And what about David when there is a grain or even more than a grain of truth in some of people's beliefs and I'm thinking here not about, for example, their blushing being very obvious. I'm thinking about groups that do face social prejudice. So, for example, people from global majority, people that face discrimination based and other protected characteristics. How do we adapt the therapy to this when there also is social anxiety in that picture.
David: Yeah, well, I mean, the first thing to say about all cognitive therapy is that you don't challenge facts. So, there are situations where people are subject to discrimination and bias and things like that. The therapy isn't going to challenge that. That's the truth. The therapy works on the sort of added meaning that people put on those things and the distortions, and also of course helps people to be more assertive in standing up to these things.
Rachel: and another issue that comes up, certainly I find in supervision is people thinking about either comorbidity or really entrenched negative views of the self that people might describe as, self-esteem problems or depression related problems.
David: Yeah, so this is a really good question, and I think, quite a lot of the thinking here has sadly, been sort of over influenced by the structure of Beck's original cognitive therapy for depression book where there the argument is that early on in therapy, you deal with behavioural changes and negative automatic thoughts, but you leave what is called assumptions or your basic beliefs about yourself until late in therapy. That is completely the wrong thing to do in social anxiety. Everyone with social anxiety has some fairly substantial negative self-perceptions, or what Chris Padesky would call core schemas, like, I'm unlikable, I'm weird, I'm different from other people and those are a lot of the action. And people can mistake them for low self-esteem, but there, there are a lot of the core of social anxiety and the treatment works incredibly well with them. As long as you bring them into play right from the beginning of therapy. So, if someone has a thought like, a belief like I'm unlikable, bring it into play in the early behavioural experiments, in the video feedback and all these other things. And when you bring it into play, then it changes very well. So, we would say there's quite a misunderstanding of the distinction between low self-esteem and social anxiety. There's a very nice paper by Emma Warnock-Parkes recently in Cognitive Behavioural Practice, which really outlines this point clearly and shows you how you make sure you bring these very negative self-concepts onto the table, right from the start.
Rachel: I really valued reading that paper recently and we'll make sure that's in the show notes along with the other great resources you've signposted us to, David.
David: I should however say, having made a bit of a criticism of the original Beck Cognitive Therapy for Depression, or at least the impact he's had outside of depression, that this autumn the second edition of Cognitive Therapy for Depression will be published just 45 years after the original and posthumously, of course, because Tim Beck recently died. But it's a very welcome update and I would certainly recommend people have a look at it.
Rachel: That's wonderful. It certainly has stood the test of time, hasn't it? But an update is probably overdue. And you've spoken David about some of the misperceptions therapists can have in therapy about the personal interpersonal interaction with their clients. And that sort of speaks to another issue that we talk a lot about on this podcast that CBT isn't just a process of clinically applying techniques and tools- we bring ourselves as therapists and all of our assumptions and life experience with us to therapy. So for example, when I was working in your team in London, I found myself doing some things that I might never have dreamt of doing deliberately otherwise in busy shops and cafes and train stations. I think I hopped across a train station platform at one point in London, and they've stuck with me for a very long time. Now I remember your story of spraying water under your arms, into your armpits and going into news agents and pointing at shelves and things like that, but it does speak to how we might be challenged ourselves. By this work as therapists might we have to challenge some of our own assumptions, our own excessively high standards of social behaviour or concerns about judgment, those kinds of things.
David: Yeah, I think one of the very nice things about cognitive therapy is it allows you to take many of your own beliefs as hypotheses, just like your patient’s beliefs, and can encourage us as therapists to test out in action some of the beliefs that make us a bit worried in some situations or a bit inhibited in some situations. And it's a really good thing for therapists to do themselves because it helps them understand the difficult journey that their patients are on. If you do something that you find challenging, it gives you a better insight into how hard it is for the patient. But it also helps you really internalise the whole treatment approach. And so maybe I could ask you for our listeners to tell us about maybe one or two of those things that you did that were challenging and what you learned as a therapist from doing them.
Rachel: So I think it's a truism that we're often drawn to bits of therapy where we have some personal investment or some sneaking kind of cognitive distortions of our own to test, aren't we? But certainly, I remember spending a lot of time in Camberwell where we worked at the time, in cafes, spilling drinks and dropping, in the days when we still used cash, dropping coins on the floor or going up to the nearest busy station in London and behaving slightly oddly on train platforms as people walk past without a care in the world, not looking at me for one second, because they were just on their way to their train and looking at their watches and getting on with their lives weren't they? So lots of things. I do feel slightly sorry for the cafe owner. So we'll go back someday and offer to clear up.
David: But would I be right in saying that you were genuinely surprised by the lack of people's interest in those things when you essentially broke some of your own personal rules about social behaviour.
Rachel: Absolutely, it's astounding really what, in a sense you can get away with. And I guess you often call these sorts of widening the bandwidth experiments, don't you? And we all have this internal sort of narrow highway. Or, or perhaps not highway, narrow path that we tread often in our lives. I think my teenage sons might not thank you for the fact that my bandwidth is quite as wide as it is David, that my social behaviour might gotten a bit out there, but you know, people expect strange things from psychologists, don't they?
David: Well, yeah, I think you can, never be fully admired as a, as a parent in these situations. And it's not uncommon for parents to occasionally embarrass their children.
Rachel: Not just me then. So what have you learned then from people you've worked with? I think we often do learn from our patients, don't we? Are there stories that stand out from your experience?
David: Well, I think in social anxiety, the main thing I've learned is that the person you meet at the start of therapy is not the real person. The person you meet at the start of therapy is hidden away behind these various safety behaviours. And if in the course of working with them, you can get them to drop these and let the world know them. Without exception, they're all really interesting people. And it's just so wonderful to see them be themselves and contribute to the world. And so that's the most fundamental thing I've learned. And I think this has been a change in the way we thought about therapy. So, in the sort of 1980s and 1990s in anxiety disorders, there's a lot of talk about anxiety management training. The idea that anxiety is something that we teach people's skills to manage. It was sort of relaxation training or distraction, coping techniques, social skills and things. And, the cognitive revolution has been to say. No, that's not what you do. You really focus on people's fearful beliefs and work with them to help them to discover that they're not realistic. These things aren't going to happen, or if they do happen, they're not as catastrophic as you think. And once you get that fundamental understanding, there isn't anything to manage. You don't need these techniques. And I think this, this does change the way we as therapists think about anxiety. It's not, this is an anxious person, we've got to teach them a few coping techniques. It's more, this is someone who is the victim of their fearful beliefs and we can, working with them, help free them from being the victim of those beliefs then they can have a very normal life.
Rachel: It's always really heartening at the end of therapy. We do a therapy blueprint, don't we, to summarise people's learning. And I don't think there's a feeling like it when you leave work at the end of the day, and someone has written on their therapy blueprint. It's okay to be who I am. I can be me. That's a good day at the office.
And David, you are sort of retired. You've retired from at least one of your roles, but that doesn't seem to be slowing you down or observably reducing your output and productivity. Can you tell us a little bit more about horizons for you, your research, the field, what's going on in social anxiety more broadly?
David: so I have retired from my university post at Oxford. when you get to a certain age, Oxford requires everyone to retire. We have a compulsory retirement age but that has sort of freed me up. I don't have the sort of teaching duties and administrative duties I had before, and I don't have to follow term times. So it's certainly given me more time to support the Talking Therapies program, and I hope also lobbying for an equivalent of that in community mental health, where at the moment, less than 2 percent of people seen in community mental health services get a course of psychological therapy. I mean, it's just appalling. So, I hope we can change that. And thankfully, around the world, our governments are getting interested in trying to make psychological therapies more widely available to the public. I think a lot of it from the politician's point of view is the economic argument that sucks them in. But of course, the economic benefits only occur if you do good therapy and you have good recovery rates. So, there's also an interest in designing your mental health services with that in mind and recording outcomes. So I find myself having the opportunity to support psychological therapists in many different countries as they strive to make psychological therapies more widely available for their public. In the last couple of months I've been, working in Iceland, in South Korea, in Nova Scotia, in Spain, in Norway, and Finland. Oh and Hong Kong.
Rachel: but we still need to hit those 20 countries that aren't yet on the OXCADAT website, David, that that's your target for the next 10 years. We're recording this podcast in the run up to general election. It will probably go out after that time so I should say that having given a plug for Jeremy Hunt today, that other chancellors may be available.
David: Well, I think, I think what I'd say about that is that, one of the great things about the Talking Therapies program is it was initially developed by the Labour administration. It was, cherished and further expanded by the coalition. And has been cherished and further expanded by the current administration with further investment from every Prime Minister other than perhaps the one who didn't have time in office to do that. So it's been a cross party thing. And why has it been a cross-party thing? I think it's largely been because of the extraordinary willingness that everyone in the program has to recording patient outcomes and allowing them to be reported. Because it means whatever government you have, of whatever political persuasion, they can see that patients get better with the psychological therapies. And so they can see it's worth investing. And that's really all down to the extraordinary work of people in these services and their willingness to be transparent about what they do. And it's very different, difficult for any politician of any political persuasion, not to support you when there is no doubt that you're doing a lot of good, a lot of people recovering and you're saving society a lot of money. And that's true for these Talking Therapy services. If we can get the rest of psychological interventions to also go for that sort of transparency, I'm sure we will find further support across the board.
Rachel: And it's also due in no small part, David, to your championing and your communication and your skills in delivering that message and telling those in power, who seem to come with, an open-door people want to invest in and are committed to this, this cause, but actually the cause needs championed as well. And that's what you've done so incredibly well.
David: But it would get nowhere without the wonderful workforce.
Rachel: And David. In CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, I'm going to ask you what the key messages you would like to leave folk with regarding this work with social anxiety,
David: Well, I think the key message I'd say is that this is a very treatable condition, which it's worth investing your time in because in the absence of treatment most people won't recover. But if we get it right, you completely change their lives, and this is one of the greatest gifts that we can have as psychological therapists, the chance to help someone change their life. For the very long term, there's very little relapse, people just are different for the next decades.
Rachel: which takes us really nicely full circle to your mum and the help that she gave people that inspired you into this work in the first place. David, thank you so much for spending this time with us. So grateful for your time, your wisdom, and also all your work in this area. And we hopefully will welcome you back at some later date to talk about some of the many other pieces of work that you've done, that we can learn from.
Thank you so much.
David: Well, thank you for having me on and it's lovely to be able to catch up with you again after all the work we've done together in the past.
Rachel: Thank you, David.
Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you.
Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.
View all episodes
By Rachel Handley for BABCPIn this conversation, Professor David Clark discusses his work using Cognitive Behaviour Therapy to treat Social Anxiety Disorder. He and Rachel talk about the Cognitive Behavioural model of Social Anxiety Disorder, considering the factors that contribute to maintaining this debilitating problem experienced by many people and the evidenced-based approaches to treating it. The conversation also delves into the economic impact of evidence-based psychological therapies and the importance of delivering high-quality, evidence-based care.
If you liked this episode and want to hear more, please do subscribe wherever you get your podcasts. You can follow us at @BABCPpodcasts on X, babcppodcasts on Instagram or email us at [email protected].
Useful links:
Papers:
David has published numerous papers in the field and a full list can be found here: https://bit.ly/3zjxcNy
The paper mentioned authored by Emma Warnock-Parkes is published in the Cognitive Behaviour Therapist and can be found here: https://bit.ly/3XzVsEq
Clark, D.M. (2018) Realising the mass public benefit of evidence-based psychological therapies: the IAPT program. https://pubmed.ncbi.nlm.nih.gov/29350997/
Clark et al (2023) More than doubling the clinical benefit of each hour of therapist time: a randomised controlled trial of internet cognitive therapy for social anxiety disorder. https://www.cambridge.org/core/journals/psychological-medicine/article/more-than-doubling-the-clinical-benefit-of-each-hour-of-therapist-time-a-randomised-controlled-trial-of-internet-cognitive-therapy-for-social-anxiety-disorder/ED618AA69204AABD5C5691ABC454F5BE
Ehlers et al (2023) Therapist-assisted online psychological therapies differing in trauma focus for post-traumatic stress disorder (STOP-PTSD): a UK-based, single-blind, randomised controlled trial. https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(23)00181-5/fulltext
OXCADAT:
A wealth of useful videos and therapist resources for social anxiety, PTSD and panic disorder can be found here: https://oxcadatresources.com/
Credits:
Music is Autmn Coffee by Bosnow from Uppbeat
Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee
License code: 3F32NRBYH67P5MIF
This podcast was edited and produced by Steph Curnow
Transcript:
Rachel: Welcome to Let's Talk About CBT Practice Matters, the BABCP podcast for therapists using Cognitive Behavioural Therapy with me, Rachel Handley. Each episode, we talk to an expert in CBT who share insights that will help you understand and apply CBT better to help your patients.
Today, we're talking about Social Anxiety Disorder, and we're really privileged to be joined by Professor David Clark, who's devoted his long and distinguished career to cognitive approaches to understanding and treating anxiety disorders, and also to disseminating these treatments so that help can be made available to as many people as possible.
In addition to his work in social anxiety, David's work has led to the development of effective NICE recommended cognitive therapy treatments for panic disorder and PTSD. David is well known for pioneering and tirelessly working to advise and steer the IAPT program in England, and he continues to work towards wider and wider dissemination of therapy through digitalisation and through his training, teaching, and political engagement worldwide.
Welcome to the podcast, David,
David: Oh, thank you for having me, Rachel. It's lovely to chat again as we've worked together so closely in the past. Lovely to see you.
Rachel: and there can be a few therapists working in the field of CBT and beyond who aren't aware of the enormous contribution you've made to social anxiety, but not everyone will know about your journey. So, it'd be great to hear about what got you interested in psychology, psychological disorders, and specifically social anxiety, both personally and professionally. And as a starting point, is it true that as a young man, your choice of study might've had rather more to do with the gender balance on the psychology program rather than the subject matter?
David: Well, that had an element to it. I think I've always been interested in mental health problems since I was a child, my mother was someone who people would come to when they were distressed, and she gave them obviously very supportive chats. But you often don't feel that just following your mother is the right way to go. And so I felt that maybe one could do better, and I was good at chemistry. So, I started really as an undergraduate as a chemist with the idea that we could develop some improved drug treatments for mental health. But I soon realised that drug treatments were quite limited and were likely to have pretty high relapse rates. I was also studying on a course where there were just four women in an intake of 200 first year students at Oxford, but I had bumped into a few members of the opposite gender at parties and one of them was wandering past chemistry one day and said, why don't you come down and have a cup of coffee in experimental psychology? where I found, it was a wonderful department, with lots of senior people just sitting down with the undergraduates talking through ideas over coffee, and of course, a much more even gender balance. So, I moved fairly quickly to the experimental psychology department.
Rachel: So there was a real motivation to help others right from the beginning, but maybe a small iota of self-interest there amongst that.
David: and an interest in social interactions of all sorts.
Rachel: And social anxiety then, what took you in that direction?
David: Well, the first sort of clinical problem we worked on is panic disorder, and that was at the time that we started working on it in the mid-1980s considered to be the most difficult to treat anxiety disorder. So, there's lots of research showing that those people with agoraphobia who also had panic attacks got least improvement from behaviour therapy. And similarly, those people with what we call generalized anxiety who had panic attacks also got least improvement. So it seemed a really good topic to work on. Of course, things worked out well for us in developing a cognitive model in the treatment. And I think nowadays people tend to think it's easiest to treat of all the anxiety disorders.
So in the sort of mid 90s, we started looking around for another problem and social anxiety is the most common anxiety disorder in the community. But what really fascinated us was that it is also the one with the lowest natural recovery rate. It starts in childhood for most people, and in the absence of treatment, it is often lifelong and it really interferes with your life. So it seems a really good challenge
Rachel: So an area where you could really make an impact in research and having had such success with the panic model and having such an elegant approach to that, that was really making a difference it felt like let's extend this, let's look where people are really suffering.
David: Yeah, and there was already a very respectable, psychological treatment. Group CBT was the dominant modality, the gold standard. But when you looked at the sort of outcomes in the best trials, it was rarely the case that you got more than 40 percent of people fully recovering from their social anxiety and that seems a real sadness for a condition that's so chronic and so common.
Rachel: And as you said, the largest, most widely prevalent problem in terms of anxiety disorders, but many of us can also identify with feelings of social awkwardness or shyness at some point in our life. But how does social anxiety develop then into a problem that impacts people more significantly as you've described? Who typically suffers from social anxiety and how does that come about?
David: Yeah, so you're obviously right. Many of us feel rather shy in some new social situations. And there are some events which pretty reliably make us anxious, like job interviews, particularly if you want the job. But that's sort of normal so we only think of people having an anxiety disorder if the anxiety is out of proportion to the situation. So it's not just in job interviews, for example, and it also really holds you back in life. You have a lot of avoidance and you can't do the things that you would like to. And so that's a real distinction between normal social anxiety and Social Anxiety Disorder really how much it interferes with your life.
Rachel: And I can reflect on my first job interview with you, David, and it gave me some insight, but also working with you subsequently gave me some insight into how those techniques that you have come across and developed have been, could be so helpful. So we have a bit of a challenge on this podcast, David. We love a good formulation in CBT, as you know, ideally with boxes and arrows and pictorial ways of describing things, but this is an audio podcast. So here's the challenge. Can you give us a brief explanation about how social anxiety develops and is maintained without repetition, hesitation, deviation, boxes, arrows, or other visual aids?
David: Well, the development is like most anxiety disorders. It's a mixture of genetic vulnerability, social learning, and adverse life events. That's not the interesting point from therapy. The interesting point from therapy is what keeps it going. And there's a really big puzzle because modern life is such that we all have to meet other people more or less every day. And at least when in adulthood, people with social anxiety, when they're meeting other people are not getting unambiguous negative feedback from them. So they seem to be having naturalistic exposure and we know that exposure therapy is a sound principle. So, the big puzzle for us as therapists is to work out why don't people benefit from naturalistic exposure? And being a cognitive therapist, I think the answer lies in getting into people's heads. And so, Adrian Wells and I interviewed a lot of people with social anxiety, tried to work out three things; what are they thinking? How does their thinking change what they pay attention to? And also how does it change the way they behave? And we found that if you can understand those three points and how the things interlock, then you can really understand why this is such a persistent problem.
Rachel: So it's something about thinking, about attention and about behaviour. Shall we start with the thoughts? what do they look like in social anxiety?
David: Well, the thoughts are often pretty self-evaluative. Thoughts like, I'm being boring, I'm being stupid, I look very anxious and of course, the idea that people have is that other people will be thinking similar things. It's almost like a projection of your own negative self-evaluation into other people's minds. And you're fearing you'll be rejected.
Rachel: Which sounds pretty scary…so what do people typically do when they have these kind of thoughts?
David: Well, the first thing is a shift in attention. Because people are worried about how they're coming across to other people, they focus a lot of their attention on how they think they appear. So, they may be talking to someone else but a lot of their attention is on themselves, thinking how am I coming across? And that shift to an internal focus of attention in itself is a problem, because if the conversation goes fine, the chances are you won't notice, because you're lost in your head. But when you get lost in your head, unfortunately, that gives you access to a lot of internal information, which people take as really good evidence for their worst fears, although actually it's not.
Rachel: How does that work in practice?
David: Well, the most common thought is that other people can see you're anxious and then they'll think badly of you because of that. So, of course, Adrian Wells and I asked lots of people, well, have people said to you, Golly! David, you looked really anxious when we were having a drink in the pub on Friday evening. And some patients say yes, someone has said that to me. But to our enormous surprise, most patients said, no one's ever said that. So of course, we then ask the obvious question, well if people haven't said that? Why do you think it? And the answer was always the same; I feel very anxious and therefore I really must look very anxious. That sounds logical but research shows it's a bad strategy. It's not that someone with social anxiety doesn't look at all tense, but the difference between how they think they look based on their feelings and how they really look is enormous and gets bigger the more anxious they feel. So, the more anxious you feel, the more you overestimate how anxious you look. So that's point one; people are using their feelings to decide how they appear.
Rachel: Over and above those anxious feelings, I know a lot of your work has focussed on other types of internal information that also play a role???
If you're worried about how people see you, you won't be surprised to hear that people with social anxiety often have images in which they see themselves from someone else's perspective. That would be great if those images were how they really look, but sadly they're not. The images are really their worst fears visualised. So if you're worried about sweating and your lips shaking, what you see is big globules of sweat on your forehead and a quivering lip. Whereas the reality would be nothing like that. But because the image is observed from outside, it has a ring of truth to it and people just assume it's true. We use the word image and that conjures up an idea that it's a bit like a sort of 4k video. It is for some people, but mostly what people say is it's an impression they have. It's not like there's a video playing in the back of their head all the time, but if you ask them to describe how they look, they can generate it very quickly and it'll be like that.
The other source of information is maybe a bit more difficult for people to understand, it's what we call your felt sense. So, someone might be in a group of people in a conversation. And they may be standing really close to them. But they have the feeling that they're very distant from them. It’s almost as though space grows and they feel there's that group of people and they're all together and I'm separate and apart and I don't fit in. And that felt sense of being separate and apart and not fitting in is further evidence that people think you're boring, uninteresting and it is really like space grows for these people. It’s simply a consequence of self-focused attention; if you're watching yourself all the time, it makes you feel distinct from everyone else. Whereas if you're not watching yourself all the time, you're lost in the conversation. You feel part of the group.
Rachel:So that’s two factors you’ve mentioned already – shifting attention onto yourself so you can’t really take in what’s actually happening in the social situation and at the same time getting access to misleading internal information that seems to confirm your fears…
Yeah, the third thing, which is really destructive, is changes in behaviour. And there, in all anxiety disorders, people do what we call safety behaviours; things you do in order to prevent the thing you're afraid of from happening. But if, as in social anxiety, your fears are unrealistic, the problem is that if you do the safety behaviour and nothing bad happens, you'll think that's just because I saved myself that time. It's because I did the safety behaviour. But if I was just myself, let people get to know me, then they would think badly of me. So doing the safety behaviours maintains your anxiety.
Rachel: It makes perfect sense that you wouldn’t want to run the risk of rejection or humiliation…What kind of safety behaviours do you tend to see in social anxiety?
David: Well, if I was worried that you think what I'm saying is boring, I might engage in a couple of safety behaviours. I might have carefully prepared in advance this morning all the answers I was going to give to you in this podcast, which actually I haven't, but I might've done that, just to make sure I came across really good, better than I really am. And I also, as we're talking now, I might be memorising everything that we've already said and checking whether what I'm about to say makes sense, whether it's clever enough. And I probably go quiet every now and again because I think, oh, it's not clever enough, I'm not quite sure what to say. Those two safety behaviours might get me through this interview. But afterwards, I'd still think, Oh God, I'm going to be caught out. People are going to think I'm really boring. So my fear wouldn't change if I was someone with social anxiety.
But they have other consequences, which are really problematic. And one of them is it really interferes with the social interaction because if you're doing all this memorising, then the person you're talking to gets the impression you're not really interested in them. You're mind's somewhere else. Which it sort of is. And so the conversation doesn't flow so well, and the chances are the other person may not be so interested in talking to you again. They're picking up the cues from you that you don't seem to be interested, so why should they be interested? They don't want to be rude by pushing themselves on you too much. So this is a special situation, where unlike many other anxiety disorders, the safety behaviours actually make some of the things you're afraid of actually happen. They make people less friendly to you. At least, the sort of safety behaviours that we call the avoidant ones. So, in that example, I would be avoiding saying certain things because I thought you'd think I was stupid.
There's another set of safety behaviours which maintain your fears, but don't necessarily impact other people. And they're what we call the impression management safety behaviours. We see them a lot with actors but also some people who are in professional roles that are well practiced. They will have lots of stories to tell people. They'll go to a party and they'll run through their funny jokes and their funny stories. And everyone sees them as the life and soul of the party. But they're doing this to avoid really talking about themselves, and as soon as they run out of their jokes, they'll move on to someone else because they're terrified that you might discover what they worry, which is that you might think they're boring if you just get to know them, or stupid, or uninteresting. So people tend not to notice that someone with social anxiety has social anxiety if they use a lot of these impression management safety behaviours, but they're still very destructive for the person because they prevent them from discovering that if they just were themselves, people would accept them in any case.
Rachel: Brilliant. David, if there are any fears lurking here, you know, I can give you some immediate stooge feedback that there wasn't an iota of boring or stupid in any of that. Really, as we would expect, articulate description of the model. And in common with other cognitive therapy models that we have, there's definitely something about how people think, the unhelpful and inaccurate thinking they have. Also how, what they're attending to that's bringing about that thinking and what they do in response to that information, but some very specific and particular mechanisms in social anxiety that you've spoken about. And we describe CBT as an evidence-based approach to psychological problems, not only because the therapy is tested and trialled, as you've done many times with this model, but also because the assumptions on which the models are based emerge from cognitive and behavioural science and are tested experimentally. And that gives clinicians and patients alike a confidence in the approach we're taking. It's not just sort of psychobabble. It doesn't just sort of feel like it works, but actually we've tested it out. So how have you and your colleagues systematically tested the assumptions about their maintenance of social anxiety and the model you've just described?
David: I guess there's two things. Firstly, obviously, we've tested the treatment that's derived from it in lots of randomized control trials. Thankfully, people in other countries have expressed interest as well. So there are now about a dozen randomized control trials in the UK, in Norway, in Sweden, in Germany, in Japan and in China, and the treatment is being compared against lots of alternatives, exposure therapy, group CBT, psychodynamic therapy, interpersonal psychotherapy, medication, psychiatric treatment as usual. It has always beaten whatever it's compared with. So it has a very solid evidence base in terms of the treatment package.
For the mechanisms, what we've tended to do is try and bring them into the laboratory and manipulate the processes in the lab and see whether that influences people's social anxiety in the short term. And we've also done sort of mediation analyses where we've measured the key processes and then looked at whether in a clinical trial when cognitive therapy is more effective than an alternative treatment, is it at least partly due to its greater ability to change those mechanisms? And there's a lot of research that has worked out positively using both types of experimental approach. So, for example, there's a nice experiment by Colette Hirsch, where Colette got people with social anxiety to have a conversation with a stranger. And, during that conversation, unbeknownst to the stranger, the patient switched in their mind between their habitual negative observer perspective image of themselves, or a more realistic one based on video feedback, and what was the consequence of that mental switch turning on one of the key processes? Well firstly, not surprisingly, when you turn on the negative image, you feel much more anxious. You think you come across looking much more anxious. And that's, as the model would predict, partly a distortion because the other person actually views you more positively. But there's also partly a reality in it in the sense that the difference that when you're doing your negative image, the other person still does view you less positively than when you haven't got the negative image, even though in both cases you're putting yourself down. So how does this mental image that you have in your head unbeknownst to the other person sort of leak and change the other person's perception of yourself? Well, it turns out that is because when you turn on the negative mental image, you also turn on the avoidant safety behaviours and those are what influence the other person. So, you see in this neat little experiment, the whole system has a tight interlocking of mental images, safety behaviours, self-perception and other people's responses.
Rachel: That's a really elegant study, isn't it? And it mirrors what we see clinically. Often we're trying to get our heads around these models as therapists, but when you ask those questions of someone who's truly suffering from social anxiety, it's like a light bulb moment when they, they say, yeah, I absolutely, I have that image of myself and yes, it does feel like I'm distanced from the people around us. So, so we know that in the therapy sessions, but it's really good to know that there's this experimental evidence underpinning that we can be confident in. You've described really well the mechanisms, the model, and some of the evidence behind it. What does treatment built on this model look like then typically?
David: Yeah, so the treatment, as with our other treatments, really closely focuses on the maintenance product processes in the model. It's a very tight sort of intervention based on those. So, it starts where patients are at. They are using their feelings to decide how they appear to other people, and they're very self-focused as they do that. So, rather than just giving them a bit of psychoeducation, explaining the model to them, we like them to feel it. And so we start with a little experiment in the therapy session, where we often get them to talk briefly to someone they haven't met yet. Doing it twice, once while focusing on themselves, thinking about how they're coming across and doing their safety behaviours. And once while trying to get out of their head, just lost in the conversation, focused externally. And to their immense surprise, they find that when they don't focus on themselves and do their safety behaviours, which is, of course, what they're doing to manage their social anxiety, when they don't do that, they do the opposite, they feel less anxious, and they think they come across better. So this really hooks people in on the therapy because you've done something which makes them feel better. It's not just a chat. It's not just a bit of psychoeducation. You've demonstrated in a social interaction that we have a way of making you feel better. So that hooks people in on the therapy. And of course they can start now experimenting a bit with trying to focus externally and drop some of those safety behaviours. So they're already on a roll early in therapy. We then look at these really distorted images people have and help them discover that they are distorted and therefore misleading, and best avoided paying attention to.
Rachel: So you’ve already said people are pretty convinced by these images and they may well have had them for a long time – how do we convince them they are worth reconsidering?
David: Well, we don't do that by nice reassurance from the therapist, saying, actually, I know you were feeling very anxious when we were talking earlier on but you came across pretty well. Because patients may not believe that. They may think, well, you're a therapist, you're paid to be nice. But maybe that's not like the real world. So instead, we like patients to see things with their own eyes. And so we use video feedback, where we video some social interactions, we get them to predict how they think they will appear based on their feelings and set up things in a very structured way. And then we get them to compare their predictions with what they actually see on the video. And when set up carefully, this is a really good way of helping people discover their perceptions of themselves are excessively negative. So you're now on a roll, and people are inquisitive. They think, well, the evidence I've been using so far to decide how I'd come across isn't good evidence. So, let's find out how I really come across. And that's when you get into doing a lot of what we call the behavioural experiments, where you get people into social situations and get them to drop their safety behaviours. So they give the world a chance to get to know them, participating more in the interactions. And they're focusing externally so they can see how people respond. And that process helps them to discover that if they give the world a chance to get to know them, not hiding away or using all the impression management safety behaviours to hide themselves in a different way, then they are generally accepted. And that's an incredibly positive experience.
You're always wanting to test particular fearful predictions. And if they don't come true, you want to know, why is that? Is it because the person thinks they were lucky that time? Or because they did those safety behaviours? Or is it because they've truly learned that actually they will be accepted if they let people know them? So you're often refining these experiments whenever you repeat them. You don't just do the same thing twice, you refine it in a collaboration with the patient to find the most convincing evidence for them.
Rachel: So lots and lots of behavioural experiments to test out those fears…
David: And there's a last component to the treatment which, we developed over time, which is that although people are not getting really negative feedback from other people as adults, some people have had socially traumatic events in the past; they’ve been bullied or teased at school and things. And in some cases, those socially traumatic events do impinge on the present. They influence the sort of images people have of themselves. And sometimes also the feelings are very similar to the past event. Even if in the past event, they were physically attacked or bullied and in the present in the adults there's no possibility anyone's going to do that but there's a similar feeling of physical threat. When we get those touchstones, showing that the past is intruding on the present, in terms of the nature of the images and the feelings, then we also do some work that we take from our PTSD treatment to help break the link between those trauma memories and present perception. And that gives us an extra bow in our arrow, which we find, helps to further really give people full confidence.
Rachel: So it's really active therapy, isn't it, David? And I think right from that very first pivotal experiment that you spoke about, where people are manipulating their safety behaviours and their focus of attention through all this real world finding out how the world really works, how people really perceive us is very active on the part of the therapist. And some of these experiments can be tricky to learn when you're starting out, but so useful and they are, they're really the gift that keeps on giving throughout therapy as you build this dossier of evidence about how the world really works, how people really respond to you. And for that reason, I remember I never dared come to supervision without having done at least one behavioural experiment with a client or perhaps a bit of imagery rescripting as we, as we got towards the end of therapy. But you really see how people's view of themselves changes and what a wonderful gift to know that actually you can be in the world as you are, and that is acceptable and worth a lot of work.
David: Yeah, and, and of course, what you did in preparation for supervision was absolutely the right thing to do because the research supports what you did. So, I've mentioned that there are clinical trials in lots of different countries, and the treatment has always beaten the competitor, but sometimes it beats the competitor by miles, sometimes by not quite so much. And, in the not quite so much, which has been some of the German studies, when we've looked with the investigators at what happens in the treatment, we've found they're doing very few of the behavioural experiments and they're not scheduling time to do that. So there's quite a lot of evidence that the more of these behavioural experiments you do, the better the outcomes you get. But quite a lot of them involve leaving the office with the patient to do things. And that is quite a problem in NHS services where our diaries are scheduled in such a way that it may be quite difficult to do it. So this is a problem that we still need to crack in routine practice.
Rachel: And I, I hear that a lot from therapists working in talking therapies and in other NHS settings that you've spoken about that the idea of doing a 90-minute session seems like a mountain to climb. How do we fit that into our service organisation? Or how do we get stooges into a session? And we talk about stooges just bringing people who are naive to the therapeutic set up to what the particular issues of the individual are to have a conversation and give some feedback in. What would your message be to services around the value of that and, and how they might think about building that into their organisation?
David: Well, I think I'd say, the NHS mental health services exist not for the convenience of the managers, they exist in order to transform the lives of our patients, and the evidence is really clear that you get much better outcomes if you organise a face to face therapy to do these things. And it's also very clear that wherever you get a patient to at the end of therapy, the gains are really well maintained over the next five to ten years in the follow up studies So, you're really changing someone's life, if you effectively treat their social anxiety disorder. People are coming in for treatment on average in their late 20s, early 30s. Life expectancy is 80 something. So you will give someone a different life for the next 50 to 60 years. They will do so many more things with their life. They'll meet so many more people. They will really be an enormous asset to society. So why wouldn't we want to organise our clinical diaries to transform someone's life for the next 50 years?
Rachel: So we do it because it helps, but it sounds like there's also an economic argument there as well, that people aren't going to be coming back for more therapy. Then they're not going to be suffering on a long-term basis.
David: There's an enormous economic argument and I guess you see the data for this most clearly with the data sets we've now developed in the NHS Talking Therapies program, and copies of the program that are done in other countries like Norway. So, for example, recently, in a Norwegian study, they showed that people who were treated in their version of NHS Talking Therapies, randomized to that versus treatment in standard treatment and primary care, including access to psychologists and psychiatrists, by the way, they had much better clinical outcomes, about twice the recovery rate. But interestingly, from an economic point of view, if you then followed them up for three years post treatment, the people who had had the talking therapy service had a higher personal income than the people who didn't, who were treated in primary care. And that difference in income is so large that it's four times greater than the cost of the service. So this data and other data we have in the UK, and in Spain, led Jeremy Hunt to invest an extra £590 million in expanding the talking therapy services in the autumn statement. Because he was convinced that this is solid data; that evidence based psychological therapy, when organised well in coherent services, actually helps grow the economy. So that's what the Chancellor is interested in, of course. In the NHS, we're also interested in saving money. And there's lots of good evidence that if you can effectively treat people's anxiety and depression, then over the next few years, they have less physical healthcare costs. A really nice example of that is a data linkage study from UCL recently, where they looked at people who were successfully treated in a Talking Therapy service and followed them up for the next three years and found they had significantly less adverse cardiovascular events, including heart attacks and strokes. So, there's an enormous impact that you can achieve from well delivered psychological therapies that have a higher recovery rate. But it is all to do with getting people better. So if you look at the Norwegian data, the benefit to cost ratio in terms of the economy is 4 overall compared to treatment as usual in primary care. But for those people who recover, it's 10. And for those people who don't recover, it's 0. So we really need to focus on making sure we deliver our psychological therapies in a high quality evidence based way.
Rachel: So when done well, it works and it pays and to do this treatment in particular, it's not just about talking therapy, it's doing therapy. And we've talked about how the behavioural experiments getting out there, testing and are so critical. And you've talked about the evidence base generally with this kind of care, thinking about social anxiety specifically, what’s the efficacy of this treatment, effectiveness of this treatment? And is it both effective and efficacious in the real world? Does it treat people the same? Does it work for a diverse population? Where's our evidence at in terms of that right now?
David: Yeah, so if you look at the randomized controlled trials, and with, delivered by research therapists but with NHS Talking Therapies patients, you get about 70 percent of people fully recovering from their social anxiety and significantly more, in the high 80 percent showing reliable improvement. You don't at the moment get such high recovery rates in routine care in NHS Talking Therapy services. And we think that is for two reasons. One is because some patients, contrary to NICE guidance, are given low intensity interventions rather than this type of face-to-face therapy. The other reason seems to be that people get less sessions than you see in the trials. And the last reason, which is really interesting, is that often therapists are not using a measure of social anxiety each week to guide practice. So, the recommended measure in talking Therapy services is the SPIN, but quite a lot of people don't seem to use it. And we have very good evidence from an analysis from UCL that when therapists do use the SPIN to track progress in therapy, they get much higher recovery rates. And why is that? Well, when you look closely at the data, one reason is that people get much more like the expected dose of therapy. When people are using the SPIN, I guess because they're more sensitive, the GAD may have improved, but they can see with a spin, but a lot of the social fears are still there. So they carry on. So that's really good for patients. But, and this is really interesting, even if you statistically control for that, you find that every hour of therapy is more effective if you're using the right measure. So, it just seems to be a way of helping us as therapists really focus on what matters and keep that tight focus.
Rachel: and not just using measures for measure's sake. It sounds like using them very actively is an important ingredient in what you're talking about.
David: oh, incredibly, it's not for measure's sake, it's really to focus your therapy. The other really interesting development recently is, as we've developed an internet version of the treatment, which has all the key components in it, but most of the work is done by the patient accessing the program online but with support from a therapist. And we find in the clinical trials that you get as good results with only about a third as much therapist time compared to sort of expert delivery. We've also found recently, in some pilot studies, in six Talking Therapy services that we can actually train up routine therapists in Talking Therapy services to get the same high recovery rates with the internet treatment as research therapists. So over 60 percent recovery, full recovery, which is a lot better than we currently get in the routine treatments face to face in Talking Therapies. So why is this? Well, I think because the internet program always develops, always delivers the full treatment content, and it does get patients to do an enormous number of behavioural experiments. And it does this by lots of videos which illustrate people doing behavioural experiments for different fearful beliefs in the real world. And so, patients can look at the video and then try it out in action. And that seems to hook people in. If people would like to see some of those videos and also get them as tips for designing their own behavioural experiments, you can see them all in the social anxiety section of the oxcadatresources.com website. That's a free website that the clinic created for therapists, and it's got an enormous amount of material about how to deliver our social anxiety treatment and our PTSD and panic treatment. And it's currently being used by therapists in a hundred and seventy-five countries around the world. So, if you log in and it's free, then you'll be joining a worldwide community of psychological therapists. There are apparently 195 countries, so we've still got twenty to go.
Rachel: It really is a wonderful resource, and your team has always been so generous with their research and materials and support of good therapy out there in the real world. Every corner of the real world, it sounds like, or almost. And for those that maybe aren't so clear about the distinction between low intensity and high intensity ways of working, we've become very used to this kind of language, certainly within Talking Therapies services. How does your internet program differ from supported self-help that people might have at a low intensity level and how would you distinguish that?
David: Yeah, it's a very good question. So I think the sort of supported self-help, low intensity intervention that people get from for social anxiety is basically some psychoeducation about social anxiety and encouragement and exposure therapy. Neither of those are actually components of cognitive therapy for Social Anxiety Disorder but the internet treatment has all the components of the high intensity treatment. So it has almost no overlap with what's currently given as low intensity interventions. But the interesting thing of course is it does require a lot less therapist time because the patient is doing a lot of the work. So you, you could say in that way, it is a new type of low intensity intervention but it's not what has been offered so far in Talking Therapy services.
I should also say that although it was designed to be used by high intensity therapists, in our most recent research with Talking Therapy services, we find that PWPs can be trained to get just as good outcomes with it. But what the patient is doing is not the equivalent of reading a self-help book on social anxiety, psychoeducation and exposure therapy. It's got video feedback of your social performance, it's got lots of experiential exercises, it's got specialised modules for all the different social fears, it's got ways of working with your trauma memories. They're all there in the program. Patients spend a lot of time in it, although the therapist's time is modest, about six hours over the full course of treatment. On average, we found in our most recent study that patients were spending approximately 40 hours on the internet treatment, and much more time in behavioural experiments. So, it sucks people in, they're really interested in it, because they recognise themselves. They can see, the program seems to know what they think, they recognise their thoughts. The program seems to be good at spotting these very subtle safety behaviours they have, including all the things they're doing in their head, which people can't just see, but the program alerts them to them, and they recognise from the case examples, people just like them, but then it just gives them so much more guidance in how to test things out in action with all these video clips.
Rachel: That's fantastic. It sounds like it's brilliant as we've spoken about for dissemination, getting the treatment out there to more people, but also sounds like there's some really interesting workforce developments there with PWPs being able to deliver this, our highly skilled PWP colleagues, with the right training and support.
David: Yeah, just one other point to say about it in that one of the strengths of internet programs is that if you get the content right, the program will always deliver the correct content. It doesn't have a day off. and it also will deliver it anywhere in the world. So we've now done trials with the program in China and in Japan. And really interestingly, with almost no modification, the program gets just as good outcomes with Chinese and Japanese residents.
Rachel: So is this a step towards artificially intelligent therapists?
David: Well the program is written to rely on help from real therapists who are familiar with the program and understand it well. It's possible that in the future with some of these online programs, you might find that you're guided through the therapy program with an avatar but that's not where we're up to.
Rachel: So we're not discouraging people to take up therapy as a career just yet. There are secure jobs still in the system.
David: Oh, absolutely. I mean society's growing understanding that psychological therapies don't only transform people's lives and the lives of people's families, but also are good for the economy means that without doubt, throughout the world, society is investing more in these evidence-based therapies. Obviously, the Talking Therapies Program has expanded job opportunities for therapists enormously. We've got an extra 11,000 therapists there. I anticipate that something similar will happen in community mental health for people who have conditions other than anxiety and depression. And I'm working with governments in many other countries to expand access to evidence based psychological therapies.
Rachel: All that said, we are human, and therapy can be challenging at times. And you've been in this in this game, in this system of working with social anxiety for many, many years. In your extensive experience of both delivering the therapy yourself, teaching, supervising. Where do therapists get stuck with social anxiety?
David: Well, I think, that the first issue is not really quite understanding the transference issue or the relationships issues. So social anxiety has a rather special relationship problem. It’s because you as a therapist are a stranger. So, you're a phobic object when you start the therapy, in fact when you start your assessment. It's a bit like saying to a spider phobic, we've got a really wonderful therapy for you and by the way, your therapist is a tarantula. That would interfere with the therapist process quite a bit, wouldn't it? And exactly the same thing happens in social anxiety and if you're not aware of that, you'll fall into lots of traps because of you being a phobic object. So quite a lot of our training is making people aware of what those traps are so they don't get sidetracked by them. And so what classic examples, well, there's one that happens in the initial assessment interview. People with social anxiety are worried about other people seeing they're anxious so they often try and hide the fact that they feel anxious. So if you're, doing your assessment interview and you feel you're making good progress, you're getting lots of details about the problem, you're starting to develop the model, the chances are your patient won't look very impressed. Because they're trying to stay in control, they're trying to stay a bit distant, so they don't look too anxious. And, if you're not aware that that's a safety behaviour that they've turned on because you're a phobic object, and so you're not really seeing the real person. You might mistake that as them having a lack of interest in your therapy and what you're doing. There's a good chance that will trigger lots of negative thoughts in your own head about your own performance, which will distract you from the therapy. So, the relationship issues start even in that first interview, but they carry on throughout therapy. So, because people are very focused on their feelings, when you're asking them, what were their thoughts, they often don't seem to answer immediately. They just say, well, I felt very embarrassed. And they don't say anything much more. And they look uncomfortable. And what do we normally do when people look uncomfortable in therapy? We sort of lean forward in our chair, look them in the eyes as I'm doing with you now and try and be very warm and empathic. But when we do that to someone with social anxiety, it's spotlighting them. It's making them centre stage, and they hate it. And so they're likely to, their minds are likely to go completely blank and they'll feel uncomfortable. They may even have a panic. So we have to adjust our interpersonal behaviour. So we're still very friendly, but not in their face in the way that you might do with some other people who are distressed. There are other sort of things that can go wrong in the relationship, like believing the evidence of your own eyes, if you're a therapist. So say someone says, Oh, well, my worst fear is that I'll blush. And as they say that they start to go red. And you might think, Oh my God, their fears are realistic. It's really true. I don't know that I can do much about this. But you're in the wrong place, you're observing what you see in front of you. You need at that point to get into the patient's head and find out, well, what do they think they look like at that moment? And if you do that, you'll find they think they look enormously worse than that. So, you can be misled by the evidence of your own eyes. And there are quite a few of these other therapist-patient relationship issues that people need to understand.
Rachel: So you need to be very reflective as a therapist and taking that presumably also to supervision and thinking about how that's working its way out with your interactions in therapy.
David: Yeah and you'll also find them covered in the workshops and things. So on the OXCADAT Resources website, for example, there is a full day workshop of me showing how to do the cognitive therapy for social anxiety, and it does cover these interpersonal issues.
Rachel: And what about David when there is a grain or even more than a grain of truth in some of people's beliefs and I'm thinking here not about, for example, their blushing being very obvious. I'm thinking about groups that do face social prejudice. So, for example, people from global majority, people that face discrimination based and other protected characteristics. How do we adapt the therapy to this when there also is social anxiety in that picture.
David: Yeah, well, I mean, the first thing to say about all cognitive therapy is that you don't challenge facts. So, there are situations where people are subject to discrimination and bias and things like that. The therapy isn't going to challenge that. That's the truth. The therapy works on the sort of added meaning that people put on those things and the distortions, and also of course helps people to be more assertive in standing up to these things.
Rachel: and another issue that comes up, certainly I find in supervision is people thinking about either comorbidity or really entrenched negative views of the self that people might describe as, self-esteem problems or depression related problems.
David: Yeah, so this is a really good question, and I think, quite a lot of the thinking here has sadly, been sort of over influenced by the structure of Beck's original cognitive therapy for depression book where there the argument is that early on in therapy, you deal with behavioural changes and negative automatic thoughts, but you leave what is called assumptions or your basic beliefs about yourself until late in therapy. That is completely the wrong thing to do in social anxiety. Everyone with social anxiety has some fairly substantial negative self-perceptions, or what Chris Padesky would call core schemas, like, I'm unlikable, I'm weird, I'm different from other people and those are a lot of the action. And people can mistake them for low self-esteem, but there, there are a lot of the core of social anxiety and the treatment works incredibly well with them. As long as you bring them into play right from the beginning of therapy. So, if someone has a thought like, a belief like I'm unlikable, bring it into play in the early behavioural experiments, in the video feedback and all these other things. And when you bring it into play, then it changes very well. So, we would say there's quite a misunderstanding of the distinction between low self-esteem and social anxiety. There's a very nice paper by Emma Warnock-Parkes recently in Cognitive Behavioural Practice, which really outlines this point clearly and shows you how you make sure you bring these very negative self-concepts onto the table, right from the start.
Rachel: I really valued reading that paper recently and we'll make sure that's in the show notes along with the other great resources you've signposted us to, David.
David: I should however say, having made a bit of a criticism of the original Beck Cognitive Therapy for Depression, or at least the impact he's had outside of depression, that this autumn the second edition of Cognitive Therapy for Depression will be published just 45 years after the original and posthumously, of course, because Tim Beck recently died. But it's a very welcome update and I would certainly recommend people have a look at it.
Rachel: That's wonderful. It certainly has stood the test of time, hasn't it? But an update is probably overdue. And you've spoken David about some of the misperceptions therapists can have in therapy about the personal interpersonal interaction with their clients. And that sort of speaks to another issue that we talk a lot about on this podcast that CBT isn't just a process of clinically applying techniques and tools- we bring ourselves as therapists and all of our assumptions and life experience with us to therapy. So for example, when I was working in your team in London, I found myself doing some things that I might never have dreamt of doing deliberately otherwise in busy shops and cafes and train stations. I think I hopped across a train station platform at one point in London, and they've stuck with me for a very long time. Now I remember your story of spraying water under your arms, into your armpits and going into news agents and pointing at shelves and things like that, but it does speak to how we might be challenged ourselves. By this work as therapists might we have to challenge some of our own assumptions, our own excessively high standards of social behaviour or concerns about judgment, those kinds of things.
David: Yeah, I think one of the very nice things about cognitive therapy is it allows you to take many of your own beliefs as hypotheses, just like your patient’s beliefs, and can encourage us as therapists to test out in action some of the beliefs that make us a bit worried in some situations or a bit inhibited in some situations. And it's a really good thing for therapists to do themselves because it helps them understand the difficult journey that their patients are on. If you do something that you find challenging, it gives you a better insight into how hard it is for the patient. But it also helps you really internalise the whole treatment approach. And so maybe I could ask you for our listeners to tell us about maybe one or two of those things that you did that were challenging and what you learned as a therapist from doing them.
Rachel: So I think it's a truism that we're often drawn to bits of therapy where we have some personal investment or some sneaking kind of cognitive distortions of our own to test, aren't we? But certainly, I remember spending a lot of time in Camberwell where we worked at the time, in cafes, spilling drinks and dropping, in the days when we still used cash, dropping coins on the floor or going up to the nearest busy station in London and behaving slightly oddly on train platforms as people walk past without a care in the world, not looking at me for one second, because they were just on their way to their train and looking at their watches and getting on with their lives weren't they? So lots of things. I do feel slightly sorry for the cafe owner. So we'll go back someday and offer to clear up.
David: But would I be right in saying that you were genuinely surprised by the lack of people's interest in those things when you essentially broke some of your own personal rules about social behaviour.
Rachel: Absolutely, it's astounding really what, in a sense you can get away with. And I guess you often call these sorts of widening the bandwidth experiments, don't you? And we all have this internal sort of narrow highway. Or, or perhaps not highway, narrow path that we tread often in our lives. I think my teenage sons might not thank you for the fact that my bandwidth is quite as wide as it is David, that my social behaviour might gotten a bit out there, but you know, people expect strange things from psychologists, don't they?
David: Well, yeah, I think you can, never be fully admired as a, as a parent in these situations. And it's not uncommon for parents to occasionally embarrass their children.
Rachel: Not just me then. So what have you learned then from people you've worked with? I think we often do learn from our patients, don't we? Are there stories that stand out from your experience?
David: Well, I think in social anxiety, the main thing I've learned is that the person you meet at the start of therapy is not the real person. The person you meet at the start of therapy is hidden away behind these various safety behaviours. And if in the course of working with them, you can get them to drop these and let the world know them. Without exception, they're all really interesting people. And it's just so wonderful to see them be themselves and contribute to the world. And so that's the most fundamental thing I've learned. And I think this has been a change in the way we thought about therapy. So, in the sort of 1980s and 1990s in anxiety disorders, there's a lot of talk about anxiety management training. The idea that anxiety is something that we teach people's skills to manage. It was sort of relaxation training or distraction, coping techniques, social skills and things. And, the cognitive revolution has been to say. No, that's not what you do. You really focus on people's fearful beliefs and work with them to help them to discover that they're not realistic. These things aren't going to happen, or if they do happen, they're not as catastrophic as you think. And once you get that fundamental understanding, there isn't anything to manage. You don't need these techniques. And I think this, this does change the way we as therapists think about anxiety. It's not, this is an anxious person, we've got to teach them a few coping techniques. It's more, this is someone who is the victim of their fearful beliefs and we can, working with them, help free them from being the victim of those beliefs then they can have a very normal life.
Rachel: It's always really heartening at the end of therapy. We do a therapy blueprint, don't we, to summarise people's learning. And I don't think there's a feeling like it when you leave work at the end of the day, and someone has written on their therapy blueprint. It's okay to be who I am. I can be me. That's a good day at the office.
And David, you are sort of retired. You've retired from at least one of your roles, but that doesn't seem to be slowing you down or observably reducing your output and productivity. Can you tell us a little bit more about horizons for you, your research, the field, what's going on in social anxiety more broadly?
David: so I have retired from my university post at Oxford. when you get to a certain age, Oxford requires everyone to retire. We have a compulsory retirement age but that has sort of freed me up. I don't have the sort of teaching duties and administrative duties I had before, and I don't have to follow term times. So it's certainly given me more time to support the Talking Therapies program, and I hope also lobbying for an equivalent of that in community mental health, where at the moment, less than 2 percent of people seen in community mental health services get a course of psychological therapy. I mean, it's just appalling. So, I hope we can change that. And thankfully, around the world, our governments are getting interested in trying to make psychological therapies more widely available to the public. I think a lot of it from the politician's point of view is the economic argument that sucks them in. But of course, the economic benefits only occur if you do good therapy and you have good recovery rates. So, there's also an interest in designing your mental health services with that in mind and recording outcomes. So I find myself having the opportunity to support psychological therapists in many different countries as they strive to make psychological therapies more widely available for their public. In the last couple of months I've been, working in Iceland, in South Korea, in Nova Scotia, in Spain, in Norway, and Finland. Oh and Hong Kong.
Rachel: but we still need to hit those 20 countries that aren't yet on the OXCADAT website, David, that that's your target for the next 10 years. We're recording this podcast in the run up to general election. It will probably go out after that time so I should say that having given a plug for Jeremy Hunt today, that other chancellors may be available.
David: Well, I think, I think what I'd say about that is that, one of the great things about the Talking Therapies program is it was initially developed by the Labour administration. It was, cherished and further expanded by the coalition. And has been cherished and further expanded by the current administration with further investment from every Prime Minister other than perhaps the one who didn't have time in office to do that. So it's been a cross party thing. And why has it been a cross-party thing? I think it's largely been because of the extraordinary willingness that everyone in the program has to recording patient outcomes and allowing them to be reported. Because it means whatever government you have, of whatever political persuasion, they can see that patients get better with the psychological therapies. And so they can see it's worth investing. And that's really all down to the extraordinary work of people in these services and their willingness to be transparent about what they do. And it's very different, difficult for any politician of any political persuasion, not to support you when there is no doubt that you're doing a lot of good, a lot of people recovering and you're saving society a lot of money. And that's true for these Talking Therapy services. If we can get the rest of psychological interventions to also go for that sort of transparency, I'm sure we will find further support across the board.
Rachel: And it's also due in no small part, David, to your championing and your communication and your skills in delivering that message and telling those in power, who seem to come with, an open-door people want to invest in and are committed to this, this cause, but actually the cause needs championed as well. And that's what you've done so incredibly well.
David: But it would get nowhere without the wonderful workforce.
Rachel: And David. In CBT, we like to summarise and think about what we're taking away from each session. So in time honoured fashion, I'm going to ask you what the key messages you would like to leave folk with regarding this work with social anxiety,
David: Well, I think the key message I'd say is that this is a very treatable condition, which it's worth investing your time in because in the absence of treatment most people won't recover. But if we get it right, you completely change their lives, and this is one of the greatest gifts that we can have as psychological therapists, the chance to help someone change their life. For the very long term, there's very little relapse, people just are different for the next decades.
Rachel: which takes us really nicely full circle to your mum and the help that she gave people that inspired you into this work in the first place. David, thank you so much for spending this time with us. So grateful for your time, your wisdom, and also all your work in this area. And we hopefully will welcome you back at some later date to talk about some of the many other pieces of work that you've done, that we can learn from.
Thank you so much.
David: Well, thank you for having me on and it's lovely to be able to catch up with you again after all the work we've done together in the past.
Rachel: Thank you, David.
Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you.
Please email the Let's Talk About CBT team at [email protected]. That's [email protected]. Please rate, review and subscribe to the podcast by clicking subscribe wherever you get your podcasts so that new episodes are automatically delivered to your library and do please share the podcast with your therapist friends and colleagues.