psychodynamic psychotherapy for social phobia

Psychodynamic psychotherapyfor social phobia:A treatment manual based onsupportive-expressive therapy

Falk Leichsenring, DScManfred Beutel, MDEric Leibing, Dsc

Social phobia is a very frequent mental disorder characterized by anearly onset, a chronic unremitting course, severe psychosocialimpairments and high socioeconomic costs. To date, no manual for thepsychodynamic treatment of social phobia exists. After a briefdescription of the disorder, a manual for a short-term psychodynamictreatment of social phobia is presented. The treatment is based onLuborsky's supportive-expressive (SE) therapy, which is complementedby treatment elements specific to social phobia. The treatment includesthe characteristic elements ofSE therapy, that is, setting goals, focus onthe Core Conflictual Relationship Theme (CCRT) associated with thepatient's symptoms, interpretive interventions to enhance insight into theCCRT, and supportive interventions, in particular fostering a helpingalliance. In order to tailor the treatment more specifically to socialphobia, treatment elements have been added, for example informing thepatient about the disorder and the treatment, a specific focus on shameand on unrealistic demands, and encouraging the patient to confrontanxiety-producing situations. More directive interventions are includedas well, such as specific prescriptions to stop persisting self-devaluations.The treatment manual is presently being used in a large-scalerandomized controlled multicenter study comparing short-termpsychodynamic psychotherapy and cognitive-behavioral therapy in the

We thank Dr. Lester Luborsky (University of Pennsylvania) and Dr. Karl Konig(Goettingen) for helpful comments.Dr. Leichsenring is Professor at the Glinic of Tiefenbrunn, Goettingen, Germany, andProfessor in the Department of Psychosomatics and Psychotherapy, University ofGoettingen, Germany. Dr. Beutel is Professor at the Glinic of Psychosomatics andPsychotherapy, University of Mainz, Germany. Dr. Leibing is Professor ofPsychosomatics and Psychotherapy, University of Goettingen, Germany.Correspondence may be sent to Prof. Dr. Falk Leichsenring, Department ofPsychosomatics and Psychotherapy, University of Goettingen, von—Siebold-Str. 5,37075 Goettingen, Germany: e-mail: [email protected] (Gopyright © 2007 TheMenninger Foundation)

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Psychodynamic psychotherapy for social phobia

treatment of social phobia. (Bulletin of the Menninger Clinic, 71[1],57-83)

The criteria for empirically supported treatments include the use oftreatment manuals (Chambless & HoUon, 1998). With regard to anxi-ety disorders, manuals for psychodynamic treatment have been devel-oped for generalized anxiety disorder (Crits-Christoph,Crits-Christoph, Wolf-Palacio, Fichter, &c Rudick, 1995; Leichsenring,Winkelbach & Leibing, 2005) and for panic disorder (Milrod et al.,2000; Wiborg & Dahl, 1996). For social phobia (or social anxiety dis-order), however, no manual for psychodynamic treatment has yet beenpublished.

With regard to the treatment of social phobia, cognitive-behavioraltherapy (CBT) and serotonin reuptake inhibitors (SSRIs) have yieldedbeneficial results (Zaider & Heimberg, 2003). However, the responserates—about 50%—are far from satisfactory (Davidson et aL, 2004;Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003; Zaider &Heimberg, 2003). Subgroups of patients with social phobia do not bene-fit sufficiently from CBT, that is, patients with generalized social phobia,comorbid depression, or comorbid avoidant personality disorder(Zaider & Heimberg, 2003). Furthermore, studies of long-term treat-ment effects are scant (Gould, Buckminster, Pollack, Otto, & Yat, 1997).As suggested by experts in the field, the insufficient response rates may beimproved by longer and more intensive treatments (Zaider & Heimberg2003, p. 80). In most of the available studies of CBT, treatment durationranged from 7 to 15 sessions. According to the data reported by Kopta,Howard, Lowry, & Beutler (1994, p. 1012), at least 25 sessions are re-quired to achieve clinically significant improvements in the majority ofpatients with chronic anxiety disorders. For these reasons, evidence re-garding the efficacy of psychodynamic psychotherapy in social phobia,including comparisons with other treatments, is urgently required. In thisarticle, a manual for a short-term psychodynamic treatment of socialphobia will be presented. The manual is based on supportive-expressive(SE) therapy (Luborsky, 1984), which is complemented by specific treat-ment elements relevant to social phobia. Thus, we do not present a newmodel of psychodynamic psychotherapy, but a specification ofpsychodynamic psychotherapy for social phobia that is based on SF ther-

1. The treatment manual is presently being used in a large-scale randomized controlledmulticenter study comparing short-term psychodynamic psychotherapy and GBT inthe treatment of social phobia. http://www.controlled-trials.com/ISRGTN53517394.The study is supported by a grant of the Bundesforschungsministerium [Federal Minis-try of Research, Berlin, Germany].

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apy. In the first part, general principles of SE therapy will be described. Inthe second part, therapeutic elements specific to the treatment of socialphobia will be presented.'

Supportive-Expressive Therapy

Supportive-expressive therapy was developed by Luborsky (1984) andis based on his work at the Menninger Foundation (Wallerstein, 1989;Wallerstein & Robbins, 1956). SE therapy can be carried out both as ashort-term (time-limited) and as a long-term (open-ended) treatment.Short-term treatments tend to be from 6 to 25 sessions. Long-termtreatments range from a few months to several years (Luborsky, 1984).Meanwhile, manual-guided adaptations of SE therapy for a variety ofspecific psychiatric disorders are available. These include depressivedisorders, generalized anxiety disorder (GAD), bulimia nervosa,avoidant personality disorder, obsessive-compulsive personality disor-der, and opiate and cocaine dependence (Barber, Morse, Krakauer,Chitams, Crits-Christoph, 1997; & Crits-Christoph et al., 1995; Gar-ner et al., 1993; Luborsky, Mark, et al., 1995; Luborsky, Woody, Hole,Velleco, 1995; Mark & Faude, 1995; Mark, Barber, &Grits-Christoph, 2003). The efficacy of SE therapy in specific psychiat-ric disorders was studied in several randomized controlled trials. Inthese studies, the following mental disorders were treated: opiate addic-tion (Woody, Luborsky, McLellan, & O'Brian,1990; 1995 Woody etal. 1983;), cocaine abuse (Grits-Ghristoph et al., 1999, 2001), bulimianervosa (Garner et al., 1993), GAD (Grits-Ghristoph et al., 2005;Leichsenring, Winkelbach &c Leibing, 2006), and personality disorders(Vinnars, Barber Noren, Gallop, & Weinryb, 2005). Furthermore,there have been two open (i.e. uncontrolled) trials of SE therapy in de-pressive disorders and in obsessive compulsive and avoidant personal-ity disorder (Barber et al., 1997; Diguer, Barber, &c Luborsky, 1993).Thus, SE therapy is among the empirically best supported models ofpsychodynamic psychotherapy (Leichsenring, 2005; Leichsenring andLeibing, in press).

Understanding of symptoms, conflicts, and transference in SE therapy:The Gore Gonflictual Relationship Theme (GGRT)

In psychodynamic psychotherapy, psychiatric symptoms are regardedas being determined by biological and psychological factors (Gabbard,2000; Luborsky, 1984, 1996, 2001; Miller, Taber, Gabbard, Hurley,2005). Luborsky (1996, 2001) assumes a general biopsychosocial pre-disposition that plays a role in the choice of the leading symptom. With

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regard to social phobia, the underlying neural processes are, as yet, littleunderstood (Kent &; Rauch, 2003). There is evidence of decreased ac-tivity in the cortical areas and a shift to increased activation of thephylogenetically older subcortical anxiety circuits during social stress(Kent &c Rauch, 2003; Tillfors et al., 2001; Veit et al., 2002). Further-more, serotonin transporter polymorphisms were reported to be relatedto amygdala excitability and symptom severity (Furmark et al., 2004).With regard to their psychological aspects, psychiatric symptoms areconceptualized in psychodynamic therapy as the consequence of unre-solved conflicts or impairments in ego-functions (for the concept ofego-functions see, for example, Bellak, Hurvich, & Gediman, 1973).

The psychodynamic concept of conflict was noted by Luborsky as a"Gore Gonflictual Relationship Theme" (GGRT, Luborsky, 1984,1990a, 1990b; see also Grits-Ghristoph, Gonnolly, & Shaffer, 1999;Grits-Ghristoph et al., 1988; Eckert, Luborsky, Barber, &Grits-Ghristoph,1990). A GGRT consists of three components: a wish{W: "I wish that person x . . . " ) , a response from the other {RO: "Butperson x will.. ."), and a response from the self (RS: "Thus, I will...").In this scheme, response from the self (RS) represents the patient'ssymptoms. For a patient with a social phobia, the GGRT may be de-scribed, for example, in the following way (Gabbard, 1992): "I wish tobe affirmed by others (W). However, the others will humiliate me (RO).I feel ashamed and get afraid of being together with others, so I have de-cided to avoid exposing myself {RS, symptoms of social phobia)."However, we do not assume that there is one specific CCR T that is com-mon to all patients with social phobia.

The heterogeneity of social phobia will be discussed below more indetail. The development of the symptoms of social phobia—and ofmental symptoms in general—is preceded by the perception of a dangerthat can be perceived as inside or outside of the person (Luborsky,1996, 2001). According to Luborsky (1996, 2001), usually both aretrue. The danger is perceived in connection with interpersonal relation-ships (e.g., "How will this beautiful woman react, if I approach her ?" or"How will the audience react to my talk?"). The perceived danger is as-sociated with an activation of the subject's GGRT, which is associatedwith feelings of fear and loss of control, hopelessness, helplessness, andfeeling blocked (Luborsky, 1996, p. 15; 2001, p. 1139). These psycho-logical phenomena are paralleled by physiological changes. If the feel-ings of fear and loss of control cannot be defended against or copedwith, social phobia can develop with its typical fears and avoidances.

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Focus of Treatment

In SE therapy, the therapist's task is to identify the GGRT on which thepatient's present symptoms are based. For that purpose, he or she inves-tigates relationship episodes that are included in the patient's narrativesabout interactions with other people told in the course of therapy(Luborsky, 1984, 1990a, 1990b); for example, "At my father's birth-day party, when I told him that I had successfully passed my exam, heonly said 'Your brother was faster, boy!' I felt terribly ashamed." Oncethe theme is identified, it will serve as the focus to which the therapistwill direct his or her and the patient's attention. The GGRT represents atransference potential, a scheme including central wishes, anticipatedreactions of others and from the self ("I wish that. . . , but the others will. . . So I will.. .") that will be reproduced repeatedly like a theme andvariations of a theme in spite of its self-hurtful nature (Luborsky,1984). Freud (1912/1958) referred to the transference potentials as re-lationship "stereotype plates." The emphasis that psychodynamicpsychotherapies put on the relational aspects of transference is a keytechnical difference from cognitive-behavioral therapies (Gutler,Goldyne, Markowitz, Devlin, & Glick, 2004).

Setting Goals

Setting goals is an important component of SE therapy: Goals bring thepatient to treatment, keep him or her in treatment, and provide orienta-tion and markers of progress or lack of it (Luborsky, 1984, pp. 62-63).Setting goals also modulates or brakes regression, which is particularlyimportant for suspicious patients and for those who are afraid of de-pendency (Luborsky, 1984). For short-term treatment, goals must befocal in nature (Grits-Ghristoph et al., 1995; Luborsky, 1984;). Thus,they should not include comprehensive changes in personality. Goalsshould be formulated in the patient's language. If a patient, in settinggoals, only refers to the symptoms of social phobia, it is important to ac-tively relate the symptoms to the GGRT. According to an example givenby Grits-Ghristoph et al. (1995, p. 53), this can be done by an interven-tion as follows: "Well, now you have given me a picture of your symp-toms but it would be helpful to me to know more about you, yourfamily, your relationships and your work." Or the therapist might say,for example: "We agree that it is an important goal of this treatment towork on your anxiety in giving lectures at the university. You also toldme that it is important for you to be appreciated by others. In order tohelp you with your social anxieties, I suggest we explore your feelingsand try to find out if your social anxieties at the university have some-



thing to do with that problem." In the next step, the therapist relates im-provements in symptoms with the associated changes in self-conceptand interpersonal relationships (Grits-Ghristoph et al., 1995). Goalsmay change during the course of treatment. For example, the patientmay feel safer or his or her resistance is reduced or has been workedthrough.

Interventions of Supportive-Expressive Psychotherapy

Psychodynamic psychotherapies operate on a supportive-expressive(or supportive- interpretive) continuum (Gabbard, 2000; Gill, 1951;Luborsky, 1984; Wallerstein, 1989). For SE therapy, supportive andexpressive (or interpretive) interventions have been specified andoperationalized both by treatment manuals and by rating scales for ad-herence and competence (Barber &c Grits-Ghristoph, 1996; Luborsky,1984; Luborsky, Woody, McLellan, & Rosenzweig, 1982). Eor SEtherapy, the relation between supportive and expressive interventionscan be described in the following way (Luborsky, 1984): The more se-verely disturbed a patient is, or the more acute his or her problem is, themore supportive and the less expressive interventions are required andvice versa. Thus, a broad spectrum of mental disorders can be treatedwith SE therapy ranging from milder adjustment disorders or stress re-actions to severe personality disorders, such as borderline personalitydisorder or even psychotic conditions (Luborsky, 1984). Empiricalstudies have confirmed that the interventions specific to SE therapy sig-nificantly correlate with the outcome of SE therapy (Barber, Luborsky,& Grits-Ghristoph, 1996; Grits-Ghristoph, Gooper, &c Luborsky,1988; Luborsky, McGlellan, Woody, O'Brian, & Auerbach, 1985).These findings suggest that specific techniques of SE therapy as con-trasted to nonspecific factors account for a significant proportion of thevariance in outcome of SE therapy (Barber et al., 1996).

Supportive interventionsThe establishment of a helping alliance is regarded by Luborsky as thecentral aspect of supportive interventions. Two types of helping alli-ances are described: Type I refers to the experience that the therapist isproviding help and the patient is receiving help. Luborsky (1984, p. 82)has formulated several principles of type I supportive interventions; forexample, "Gonvey a sense of understanding and acceptance" or "Gon-vey, through words and manner, support for the patient's wish toachieve the goals" (e.g., "In the first session you set the goal to reduceyour social anxieties. Thus, it is important that you not avoid going tothat party"). Type II refers to the patient's experience of working to-

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gether in a team effort (Luborsky, 1984). Principles of type II support-ive interventions include, for example, encouraging a "we bond" (e.g.,"As we have found out in the last session, you . . .") or recognizing thepatient's growing ability to work on his or her problems in the sameway the therapist does (e.g., "This time you found out yourself whatmakes you so afraid of others. You did it in the same way that we did ithere"). Furthermore, the fact of achieving understanding (expressiveaspect) is assumed to also have a supportive value (Luborsky 1984, p.89).

Expressive interventionsExpressive interventions enhance the patient's cognitive and emotionalunderstanding of his or her present symptoms and of the underlyingCCRT (Luborsky, 1984). The CCRT is studied in present and past rela-tionships, including the "here and now" relationship with the therapist.Repeatedly working through the CCRT in different relationships is as-sumed to improve the patient's understanding and to help him or her indeveloping more adaptive behaviors. For expressive interventions,Luborsky (1984, pp. 121, 94-141) has formulated a number of princi-ples in his generic manual. For example, "The therapist's responseshould deal effectively with a facet of the main relationship problemand at times relate that to one of the symptoms (e.g., "We have seen thatyou are not only afraid of exposing yourself [Symptom, RS], but youalso like to be at the center of attention [Wish]. However, you are afraidthat other people will humiliate you [RO]."

Social Phobia

Social phobia (or social anxiety disorder) is characterized by an exces-sive irrational fear that others will scrutinize a person's actions in socialor performance situations (American Psychiatric Association, 1994).With regard to lifetime prevalence, social phobia is the most prevalentanxiety disorder (13.3%; Kessler et al., 1994). In comparison to allmental disorders, social phobia is exceeded in lifetime prevalence onlyby major depressive disorder and alcohol dependence (Kessler et al.,1994). In the generalized form of social phobia, almost all social situa-tions are anxiety-producing, whereas the isolated form is restricted tospecific social situations (American Psychiatric Association, 1994). So-cial phobia is characterized by an early onset, a chronic, unremittingcourse, high socioeconomic costs, and a marked impairment in func-tions and quality of life (Keller, 2003; Kessler, 2003). Furthermore, so-cial phobia has secondary effects on mental diseases (e.g., depression)and on help seeking (Keller, 2003). However, social phobia is both



underdiagnosed and undertreated (Kasper, 1998; Katzelnick & Greist,2001).

As a result of both phenomenological and psychodynamic factors, itis very likely that social phobia is not a homogeneous disorder. Sub-groups of patients with social phobia exist; for example, patients withisolated versus generalized social phobia, and patients with comorbiddepression, alcohol abuse, avoidant personality disorder, ormaladaptive interpersonal styles (Zaider & Heimberg, 2003).

Furthermore, from a psychodynamic point of view, social pho-bia—like other mental disorders—is modified by the respective under-lying psychodynamic factors, that is, by specific confhcts, modes ofpersonality functioning, and level of personality organization. SE ther-apy represents an approach that can be flexibly adapted to the individ-ual patient's needs; for example, with regard to the amount ofsupportive or interpretive interventions that are necessary. As men-tioned above, subgroups of patients with social phobia do not benefitsufficiently from CBT (Zaider & Heimberg, 2003). SE therapy specifi-cally adapted to social phobia can be expected to have great potential,particularly for treating refractory social phobia where personality is-sues are concerned. This applies especially to patients with comorbidavoidant personality disorder.

Psychodynamics of Social Phobia

Anxiety is a central concept of psychoanalytic and psychodynamic the-ory and therapy (Zerbe, 1990). Psychodynamic aspects of social phobiahave been discussed by several authors (e.g., Gabbard, 1992; Hoffman,1999, 2002, 2003; Joraschky, 1998; Konig, 1981). Some of these as-pects have been corroborated by empirical studies; however, further ev-idence supporting at least some of these aspects is required.Furthermore, some of these authors focused on specific aspects of thepsychodynamics of social phobia. However, as already mentionedabove, we do not assume that there is one aspect of the psychodynamicsthat is common to all patients with social phobia. The discussion of thepsychodynamics of social phobia will be presented for self psychologi-cal, object relational, ego-psychological, instinctual, andattachment-related aspects.

SelfpsychologyA disturbed self-concept is regarded as a central component of socialphobia (Hoffmann, 2002, 2003). It is associated with disturbances inself-perception and self-esteem and unreahstic devaluations or ideal-izations of the self. Empirical studies have confirmed that patients with

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social phobia are characterized by low self-esteem and high levels ofself-<;riticism and shame (Gox, Fleet, & Stein, 2004; Hirsch, Glark,Mathews, &c Williams, 2003; Hirsch et al., 2004; Izgic, Akyuz, Dogan,& Kugu, 2004; Lutwak & Ferrari, 1997). Patients with social phobiaseem to lack appreciating ("mirroring") introjects as they were de-scribed by Kohut (1971). The process of "transmuting internalization"(Kohut, 1971) seems to have been impaired in a special way, for exam-ple, by an identification with the aggressor as discussed by Hoffmann(2001,2003).

Gompensatory, mostly unconscious, fantasies of grandiosity that areused to defend against unbearable feelings of inferiority make up an-other important aspect of the psychodynamics of social phobia. Thesefantasies comply with excessive demands, for example, to give a uniquefancy talk or performance (Hoffmann, 2002, 2003). In an empiricalstudy by de Jong (2002), discrepancies between self-reported and im-plicit self-esteem were reported. In an implicit test of self-esteem, highsocially anxious subjects showed a highly positive self-image, whereasthey displayed relatively low levels of self-esteem on self-reportmeasures.

Gabbard (1992) stressed shame experiences in social phobia (seealso Gilbert, 2001). According to Gabbard (1992), shame experiencesin social phobia result from the wish to be in the center of attention andreceive affirming responses from others and the (anticipated) responsefrom disapproving parental figures. In order to avoid these imaginedhumihations or embarrassments, patients with social phobia avoid situ-ations where they risk these responses from others. Joraschky (1998)stressed the importance of shame for the regulation of self-objectboundaries and discussed shame as a consequence of boundaryviolations.

For a subgroup of patients suffering from erythrophobia, Konig(1981) described an embarrassing family secret (e.g., the patient's fa-ther, a priest, collected pornographic material, or her mother sufferedfrom alcohol abuse, or a bankruptcy had to be concealed). The socialphobia patient identified with the family member of whom he or shewas ashamed. In other cases, the whole family was ashamed of a behav-ior that was disregarded by the surrounding social environment (e.g., inimmigrants). Relating these considerations to those of Gabbard (1992),the GGRT could be formulated as follows: "I wish to be affirmed byothers. However, the others will humiliate me because I act in a waythat will make them think that I am like my father/mother, who didthose things I feel ashamed of. Thus, I would feel ashamed if I exposedmyself to the scrutiny of others. This I can avoid by keeping away frompeople." In empirical studies, shame was significantly positively related



to the fear of negative evaluation by others and social avoidance and itwas significantly negatively related to recalled parental care (Lutwak &Ferrari, 1997). In another empirical study, de Jong (2002) reported dis-crepancies between self-reported and implicit self-esteem.Psychodynamic theory assumes that the tendency to devalue oneself isprojected onto others. A study by Andrews and Pollock (1989) con-firmed that patients with social phobia used projection and otherimmature defense mechanisms significantly more frequently thannormal controls.

Object relations theoryFrom an object-relational perspective, social phobia is regarded as theresult of the internalization of early interpersonal experiences (seeabove, "identification with the aggressor"). As a consequence, deval-ued self-representations are associated with devaluing object-represen-tations. Gilbert (1989, 2001) assumes a hyperactivity of thecompetitive mode as compared to the security-providing mode. Pa-tients with social anxieties tend to perceive others predominantly asdangerous and to overlook friendly signals (Gilbert, 1989, 2001).

Ego-psychologyIn a subgroup of social phobia patients who are characterized by struc-tural deficits in personality organization and ego-functions, theego-functions of affect perception and affect control can be impaired.Furthermore, the assumption that others look at them as devaluing asthey do themselves can point to an impaired self-object differentiation(e.g., Bellak et al., 1973).

Instinctual aspectsClassical instinctual conflicts may play a role in some patients witherythrophobia. The symptom represents both the defense against an in-stinctual wish (e.g., a sexual wish) as well as its partial satisfaction.Gabbard (1992) discussed the importance of aggression and guilt in so-cial phobia. He assumes that guilt feelings in patients with social phobiastem from the unconscious demand for complete attention associatedwith the wish to scare away or kill off rivals. These guilt feelings may beinterwoven with shame stemming from the feeling that one is not reallycapable of displacing the rival and is therefore fraudulent.

Attachment theoryAn insecure attachment was clinically reported for many patients withanxiety disorders (Bowlby, 1988) and specifically for patients with so-cial phobia (Vertue, 2003). An insecure attachment may lead to social

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anxieties and avoidance and may inhibit a curious approach to theworld. Gabbard (1992) stressed the importance of separation anxietyin social phobia, that is, the fear of being abandoned or losing the care-giver's love when moving toward autonomy. In order to avoid such cat-astrophic cutoffs, patients with social phobia avoid connecting withpeople in the outside world. Problems of attachment in social phobiawere empirically confirmed in a study by Eng, Heimberg, Hart,Schneider, and Liebowitz (2001).

As mentioned earlier, further empirical research is necessary to con-firm these psychodynamic factors in social phobia.

A short-term psychodynamic psychotherapy of social phobia basedon SE therapy

In the following, we shall present a short-term psychodynamic therapyof social phobia based on SE therapy. Up to five sessions are scheduledfor diagnostic assessment (including both phenomenological andpsychodynamic aspects) and treatment arrangements. The succeedingtherapy may take up to 25 sessions.

Diagnostic assessments, informing the patient, and makingtreatment arrangements (introductory sessions 1-5)

Diagnostic sessions. Before starting treatment, diagnostic assessmentsare made by the therapist both on a phenomenological (DSM) and apsychodynamic level (CCRT), including biographical data relevant forthe development of social phobia.

Socialization interview. In a preliminary socialization interview(Luborsky, 1984; Orne & Wender, 1968), just before the treatmentstarts, the therapist informs the patient about the treatment and the dis-order (see below, principle 1). This information encompasses a generaland a disorder-specific part.

In the general part of information, the therapist explains what he orshe will do (e.g., "I will listen to you and help you with your social pho-bia") and what the patient is expected to do (e.g., "You may talk abouteverything you are concerned with"). Furthermore, arrangementsabout the treatment are made, including duration of treatment and fre-quency of sessions, appointment times, payment, and handling ofmissed sessions and of premature termination. First, achievable goalsare set (see above), and the therapist communicates realistic hope thatthe goals can be achieved. Therapist and patient agree to review whathas been accomplished with regard to the goals set before treatment at



the half-way point (session 13). Therapy will be carried on only untilthe predefined goals have been reached. This may be the case in lessthan 30 (25+5) sessions. These arrangements will help to establish agood working alliance that is additionally fostered by the therapistshowing his or her interest toward the patient and by empathicunderstanding (Luborsky, 1984).

In the disorder-specific part of information, the patient is cognitivelyprepared for the psychodynamic treatment of his or her social phobia.The therapist informs the patient about the pathological nature of his orher symptoms, about the necessity of treatment, about the treatmentprocedures, and about possible problems and outcome of the treat-ment. Here the patient is informed that for the treatment to be success-ful, he or she must be exposed step by step to the feared situations (theself-exposure procedure and its integration into the psychodynamictreatment will be described below more in detail). Thus, the patient isgiven a rationale allowing for a first orientation. It is essential to explainthe importance of graduated self exposure to the feared situations. Withregard to the expressive-supportive dimension, preparing the patientcognitively to the treatment has a supportive effect.

Phenomenological, biographical, and psychodynamic assessmentand treatment arrangements, including informing the patient, may takeup to five sessions. The subsequent treatment may take another 25sessions.

Phases of treatmentAnalogous to the description of SE therapy for GAD byCrits-Christoph et al. (1995), the 25-session treatment of social phobiacan be described in four phases.

Early phase (treatment sessions 1-8). In the early phase of treatment,the therapist's primary task is to establish a good therapeutic alliance(Crits-Christoph et al., 1995; Hoffmann, 2002, 2003). For this pur-pose, he or she uses the supportive interventions described above(Luborsky, 1984). The patient chooses a topic he or she would like totalk about, referring to the symptoms of social phobia or another prob-lem. The therapist encourages the patient to talk about his or her rela-tionships with other people. The therapist works on identifying theCCRT and tries to relate the symptoms of social phobia to theunderlying CCRT.

Middle phase (treatment sessions 9-16). In order to intensify the treat-ment processes, the frequency of sessions is increased to two weekly ses-sions in the middle phase of the treatment. In this phase, the CCRT is

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refined. The therapist relates the CCRT to different interpersonal rela-tionships. He or she shows how the CCRT has occurred again andagain in the patient's life, and also in the relationship to the therapist("working through"). In the middle phase, traumatic experiences maycome to light (Crits-Christoph et al., 1995). However, traumatic expe-riences are not a specific focus of SE therapy. The therapist and the pa-tient examine how traumatic experiences have influenced the CCRT.For example, the wish for protection (W) could have been frustrated bythe fact that a patient's parents did not help her deal with abuse by anuncle. What would have been the patient's wish regarding the traumaticexperience (e.g., to express her fear or anger, or to be taken seriously)?As described by Crits-Christoph et al. (1995), SE therapy examinesboth the CCRT patterns according to Luborsky (1984) andposttraumatic stress reactions and maladaptive coping and defensivestyles according to Horowitz (1976). For GAD, Borkovec (1994) as-sumes that the patient's persistent worrying has a defensive function,which is the avoidance of confrontation with even more stress (i.e.,traumatic experiences). In a similar manner, the persistent anticipatingfears of patients with social phobia may have a defensive function(Hoffmann, 2002, 2003). They often serve as a defense against bothsexual wishes and real relationships ("Nobody wants a woman like me.. . "; "Men only want sex. . .") . Here, phobic avoidance serves a defen-sive purpose that may, at least in part, explain its persistence. This hy-pothesis should be seriously considered, especially if the phobicavoidance refers to contacts with the other sex. Anxiety-provoking andrepressed aspects of mental life keep having effects, both consciouslyand unconsciously, and are manifested in repetitive maladaptive rela-tionship patterns. These relationship patterns are cyclic, that is, theywork as self-fulfilling prophecies ("Someone who is that clumsy in so-cial contact with other people has no chance in a society where you al-ways have to be "hip"). The self guided symptom exposure (see above)is introduced in this phase and is constantly used. In session 13 (orsometime between sessions 13 and 15), therapist and patient explicitlyreview what has been accomplished with regard to the predefined goals.If the goals have been reached, the treatment may take less than 25sessions.

Termination phase (treatment sessions 17-22). In SE therapy, termi-nation of therapy is regarded as particularly important (Luborsky,1984). It is recommended that therapists, for example, remind the pa-tient when termination will take place or mark treatment phases (ar-rival at a goal) so they can serve as milestones. During the terminationphase, the symptoms often recur as the CCRT is activated by both the



anticipated loss of the therapist and by the anticipation that the wishesinherent in the CCRT (e.g., security, guidance, closeness, care, accep-tance, appreciation) will not be fulfilled (Luborsky, 1984). The thera-pist interprets the resurgence of the phobic symptoms and relates themto the CCRT. In his generic manual, Luborsky (1984) formulated sev-eral principles with regard to termination (for details, see Luborsky,1984, pp. 142-158). We recommend discussing termination issues nolater than session 18 of 25. Because understanding the CCRT is a cen-tral goal of treatment, we follow Crits-Christoph et al. (1995) in rec-ommending that therapists summarize what has been learned about theCCRT and its relation to social phobia during the termination phase.

Booster sessions (treatment sessions 23, 24, and 25) . The sessions 23,24, and 25 will be carried out as booster sessions in 2-week intervals.We have already used booster sessions in our previous treatment studyof GAD (Leichsenring etal., 2006). Our experiences are consistent withthose reported by Crits-Christoph et al. (1995): The positive effects ofthe booster sessions outweigh any potential interference with the work-ing through of termination. For this reason, we recommend the use ofbooster sessions in the treatment of social phobia. The therapist uses thebooster sessions to monitor and support the patient s improvementswith regard to social phobia. Furthermore, the therapist's task is to en-courage and support the patient's own activities in working on his orher problems, including his or her self-exposure (internalization of thetherapist). The therapist relates relapse to the CCRT and to the loss ofthe therapist. If serious relapse occurs, the patient is referred for anothertreatment.

Specific elements for the treatment of social phobia using SE therapyIn the following, specific elements of a short-term psychodynamic ther-apy that were found to be particularly useful in the treatment of socialphobia will be described. Here, we specifically refer to principles thatHoffmann (1999, 2002,2003) derived from the presently existing psy-choanalytic concepts of social phobia. We use these principles to adaptthe treatment specifically to social phobia. In general, it is important forthe therapist to adopt a more active stance than in classical psychoana-lytic therapy. This refers to actively establishing a helping alliance, iden-tifying the CCRT, formulating the treatment focus and treatment goals,treating the social phobic avoidance behaviors, and dealing withduration and termination aspects (see below).

Principle 1: Extensively inform the patient at the beginning of the treat-ment about his or her disorder, including the primary symptoms. In the

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socialization interview (see above), the patient will be cognitively pre-pared by informing him or her about the pathological nature of thesymptoms, about the necessity of treatment, and about procedures,problems, and possible outcomes of therapy. By being informed at thebeginning of treatment, the patient is given a rationale that allows for afirst orientation. With regard to the supportive-expressive dimension,cognitive preparation has a supportive effect insofar as the patient is ad-dressed as an adult counterpart (Hoffmann, 2002, 2003). This princi-ple is implicitly included in Luborsky's conception of SE therapy.

Principle 2: Establish a secure positive therapeutic alliance. In SE ther-apy, the helping alliance is regarded as an important supportive treat-ment element. Because insecure attachment seems to play an importantrole in many patients with in social phobia (Eng et al., 2001; Hoffmann,2002,2003; Vertue, 2003), the establishment of a secure therapeutic al-liance is of particular and specific importance. This is true for severalreasons. It provides a new alternative ("corrective emotional") experi-ence that allows the patient to experience a secure attachment. Further-more, a "secure base" (Bowlby, 1988) allows the patient to confront hisor her fears, both in a psychological and a behavioral manner. Thus, thefeeling of security allows the patient to try out new behaviors; for exam-ple to find out what happens when he or she does not avoid a feared so-cial situation. However, as Fonagy and Target (2005) have recentlypointed out, a secure attachment not only provides a secure base, butalso serves as a major organizer of early brain development. Secure at-tachment and mentalization seem to serve as a "buffer against break-downs in affective regulation during times of stress" (Fonagy SiC Target,2005, p. 339). Thus, Fonagy and Target (2005) see mentalization as be-ing linked both to Bion's (1962) containment concept and toWinnicott's (1960/1965) concept of "good enough mothering." A se-cure attachment can be expected to help the patient to improve his orher affective regulation during social stress. Furthermore, another linkexists to Kohut's (1971) concept of mirroring and transmuting internal-ization and to Konig's (1981, 1997, p. 94) concept of an internalized(impulse) "directing" object that is usually impaired in phobic patients.It can be assumed that the internalization of a security providing and es-teeming object contributes to improving the patient's self-etseem

2. Referring to the available evidence for the role of attachment and mentalization inmental disorders, Bateman and Fonagy (2003) have recently developed an attach-ment-based treatment program for borderline personality disorder that has proved tobe efficacious (Bateman &C Fonagy, 1999, 2001).

70 Bulletin ofthe Menninger Clinic


regulation and impulse control. Thus, establishing a secure positivetherapeutic relationship has several important implications.^

Principle 3: Focus on the affect of shame and point out its central role insocial phobia early in treatment (even during the diagnostic interviews).This "affective preparation" aims to make the central role of shame forthe maintenance of the symptoms of social phobia permanently con-scious. Hoffmann (2002, 2003) differentiates between two types ofshame:

• Conscious (open) shame. This predominates in the generalizedform of social phobia. Its verbalization by the therapist leads to re-lief in the patient. Example: "Listening to you, I get the impressionthat you are terribly ashamed of your alleged failure, even of your-self in general. This is certainly very painful."

• Unconscious (covered) shame. This is prevalent in the specificform of social phobia. Its verbalization by the therapist may leadto resistance and rationalizing defense.

With regard to shame experiences, the expected humiliation by othersconstitutes the RO-component of the CCRT. The RS-component ismade up of the shame and fear of being humiliated or embarrassed. Intreating social phobia, the therapist focuses on the different aspects ofthe fear of humiliation or embarrassment and sometimes relates it toother components of the underlying CCRT. Because shame is a highlysocial affect, the fear of humiliation (Gedo, 199f) can be expected to berepeated in the therapeutic transference-countertransference constella-tion. By focusing on these aspects of transference andcountertransference in the therapeutic relationship, the therapist candirectly work through the maintaining conditions of social phobia. Thepatient's transference allows for an in vivo repetition of the develop-mental conditions that once led to the social phobia and the inhibitionof social behavior (Gabbard, 1992). Thus, self-exposure also takesplace in the patient-therapist relation, which is different from exposurein CBT. Focusing on shame and the associated components of theCCRT has an expressive effect.

Principle 4: Confront patients with the unrealistic demands they makeon themselves. Patients with social phobia usually tend to make exces-sive demands on themselves and their own (social) performance. Withthese demands, the anticipatory fears and the psychophysiologicalarousal increase considerably. Uncovering and working through such

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excessive expectations usually leads to a surprising relief. According toHoffmann (2002, 2003), two steps are required:

• First, the therapist confronts the patient with his or her excessivedemands and makes them conscious. For example: "Is it possiblethat you make excessive demands on yourself?" or "Did you al-ways expect that much of yourself?" or, referring to past relation-ships: "Who expected you to be perfect in the past?"

• Second, if (but only if) the patient realizes his or her excessive de-mands on himself or herself, the therapist can refer to the patient'sprojection onto others. Fxample: "Maybe we can understand yourfear of others' expectations in that it is you who ascribes them toothers. Mostly, others do not have a particular interest in someoneelse" or "It is not that easy to differentiate between the expecta-tions of others and one's own expectations. Has it ever occurred toyou that it is you who ascribes your own expectations to otherpeople?"

The excessive expectations will also be projected onto the therapist.Sometimes, even beginning in the first session, a transference trap maydevelop that is specific to these patients. They tend to test if the therapistfulfills the excessive demands that the patients make on themselves.Dealing with such expectations in a relaxed and humorous way, includ-ing openly admitting that the therapist is not perfect, allows the patientsto become aware that they permanently expect too much of themselvesearly in treatment.

Principle 5: Encourage the patient to actively confront rather than avoidthe anxiety-producing situation. Encourage him or her to study this situ-ation exactly. This principle is consistent with Freud's (1919/1955)recommendations for the treatment of phobia. Freud regarded confron-tation with the anxiety-producing situation as a sine qua non in thetreatment of phobias. Crits-Cristoph et al. (1995) have integrated thisprinciple into the SE treatment manual for GAD. In social phobia, con-frontation with the anxiety-producing situation is of particular impor-tance, and patients with social phobia usually react with resistanceagainst exposure. However, the patient's experiences during self-expo-sure are important for treatment success because they question theCCRT and allow for its change. Self-exposure may be introduced, forexample, in the following way: "In order to reach your treatment goals,it is necessary for you to confront your anxieties in specific situations.However, it is important that you don't jump into the situations likejumping into cold water, plugging your nose, and closing your eyes, but



that you study the situation minutely, including your behavior and oth-ers' responses. When you have done so, we can examine what you havelearned through this in the next session." Another intervention couldbe, for example, as follows: "Although such a step requires you to becourageous, it is not a test of courage. It is necessary for you to explore,step by step, the situations you have systematically avoided until now.However, it is you who takes the steps and who decides what you cantolerate."

In the socialization interview, when the rationale of the SE therapy ispresented, the patient is informed that a self-guided symptom exposureis included in the treatment to help the patient with his or her social anx-ieties. However, the exposure itself should not begin before the middlephase of the treatment. Details of the exposure and its stepwise progres-sion are planned in the sessions preceding exposure. In general, the pa-tient should not widen the extent of exposure too quickly; slowprogression is superior to a stormy approach. In this phase of treat-ment, controlled progression to exposure is important ("What do youbelieve to be capable of doing as a next step?"). Thus, the therapist'stask, in this phase, consists of advising the patient to find the best pro-gression speed (e.g., "I really understand that you wish to go on quickly,but I think it is advantageous to stick to the amount of exposure we hadplanned. Often less is more". Or: "I really can understand your reluc-tance to exposure after all these years of avoidance, but I am convincedthat your chance for change is greater if you really undertake the painfulsteps we had planned"). Caveat: Neither the therapist nor the patientshould force or protract the tempo. Self-exposure should not be intro-duced before a secure positive relationship has been established (see be-low). Encouraging the patient to confront the anxiety-producingsituation is a supportive intervention, but its effect—insight into theCCRT and modification of its components—is expressive.

Self-exposure in psychodynamic psychotherapy is characterized bysome differences as compared to CBT. One of them was already men-tioned above: (1) Feelings of shame and anxiety also develop in the ther-apeutic relationship. They are therapeutically used and workedthrough with regard to the underlying CCRT; (2) furthermore, the ex-periences of the patient during self-exposure outside the therapeutic set-ting are related to the CCRT; and (3) contrary to CBT, the therapistdoes not accompany the patient during self-exposure outside the thera-peutic setting. In this respect, CBT is much more supportive anddirective.

Principle 6: Explore and discuss the use of psychotropic substances andmedication to reduce anxiety. Many patients with social phobia use

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psychotropic substances or medication to reduce their social anxieties(e.g., alcohol, marijuana, benzodiazepines, or beta blockers). Studies inthe treatment of panic disorder (Subic-Wrana, Mancher, 8c Beutel,2006) have shown that the misuse of psychotropic substances can ham-per emotional experiences that are essential for psychotherapeuticprogress. For this reason, this kind of avoidance behavior should becarefully explored and discussed at the beginning of treatment.

Principle 7: Do not forget that many people with social anxieties havereal impairments with regard to their social skills due to the length oftheir disorder. As mentioned above, supportive interventions are ofparticular importance. Hoffmann (2002, 2003) stressed that it is im-portant for the patient to establish an "inner dialogue" that encouragesthe patient. This inner dialogue should be activated, especially beforeexposures, and can include literally addressing oneself. If possible, ad-dressing oneself should be done audibly. It is preferable that the patientaddresses himself or herself, but as a second choice, the inner dialoguemay be carried out (virtually) with the therapist. The following state-ment may serve as an example for addressing oneself: "Peter, there isabsolutely no doubt that you prepared this speech as well as the lastone, and that you are able to give your speech as spontaneously as thelast one. Stop thinking about others' alleged opinions of you." The in-ner dialogue with the therapist can be prepared, for example, in the fol-lowing way: "Do you think it would be easier for you to stand up toyour fear, if you were to take me with you in your breast pocket so thatwe could confront your fear together? For many people, such an ideacan be very helpful." The following communication of a patient withhimself may serve as an example for an established inner dialogue withthe therapist: "You (therapist) conveyed to me that it is only mymisperception of others' opinion that makes me panic. Now I will findout!"

Helping the patient to establish an inner (encouraging) dialogue fos-ters the internalization of an appreciating (Kohut, 1971) or directing(Konig, 1981, 1997, p. 94) object.

Principle 8: Be aware of your countertransference and be sure to respectthe patient. Only if you respect the patient can you help him/her to revisehis/her distorted self image. As stressed by Luborsky (1984), respectingthe patient is an important component of supportiveness. In patientswith social phobia, whose central problem is a lack of self-respect (andwho project this disdain onto others), respecting the patient is of para-mount importance. For these patients, it is crucial that the therapist con-veys his/her respect to the patient (Hoffmann, 2002, 2003). Respecting



the patient's view of having a 'fundamental deficit' (i.e. to be damaged,insufficient, no good or in deficit), which is a characteristic for many pa-tients with social phobia, can hardly be overestimated (see below"prescriptions").

Other interventions that are particularly usefulfor the treatment of social phobia

According to Hoffmann (2002,2003), several other principles of inter-vention are particularly useful for the treatment of social phobia. Threeof these principles are prescriptions, the stage paradigm, and humor.

PrescriptionsMany patients with social phobia tend to persistently devalue them-selves. It is the therapist's task to recognize and work through these ten-dencies and to show the patient that it these mechanisms that contributeto the maintenance of social phobia. The specific means of self-devalua-tion may provide important information about the underlying CCRT,for example, about its wish or reaction of the object component. It is im-portant for progress in social phobia that the therapist does not allowthe patient to devalue himself or herself persistently during the sessions.Dealing with the disturbed self-image requires both empathic under-standing and persistent and tactful correcrion. Hoffmann (2002,2003)recommended correcting the distorted self-image persistently withoutfurther comment. Example:

Patient: Someone who performs like you can be sure that others areinterested in you. But when people look at me, they think at once:"'What does this stupid handicapped guy want here?"

Therapist: You know that you are neither stupid nor handicapped.

Patient: I am surely handicapped and the others can see it. People areright, I am a nothing and everybody can see it at once.

Therapist: May I make a suggestion? We have already talked aboutthe word "handicapped." I do not share your view, as I have alreadysaid. You should not devaluate yourself during the sessions in thisway any more. Could we agree on this? Here is a place were nobodymay devaluate you—/ don't do this and please don't do it yourselfCan you accept this? That I provide a "nondevaluation" space foryou?

Prescriptions aiming to protect the patient against himself or herself arehelpful for successful treatment of self-esteem problems. In short-term

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psychotherapy they may be indispensable. Hoffmann's patients oftenreported, after termination of therapy, that changes in their self-esteemhad begun to develop when they were "prohibited" from devalueingthemselves during the sessions. To stress it again: In each phase of thetreatment, it is essential for the patient to feel that a prescription aims atrespecting the patient and to protect the patient from himself or herself.

Stage paradigmAs another confronting intervention, Hoffmann (2002, 2003) de-scribed the "stage paradigm": The patient is asked to imagine his or herexperience as a scene on a stage. This intervention is very useful in help-ing patients to distance themselves from their own experience. This de-velops reflective functioning (Fonagy, f 998; Fonagy 8c Target, 2005)with regard to their social fears. Referring to the therapeutic situation,Sterba (1934) described this capacity as a therapeutic splitting of theego into an "experiencing" and an "observing" part. The stage para-digm may be introduced in the following way (Hoffmann, 2002,2003):

I would like to make a suggestion. Imagine the episode you have justtold me about as a performance on a stage. You are sitting comfort-ably in the audience and you are observing yourself talking with theshop assistant. Do you have the picture in your mind? You see your-self permanently looking to the ground, speaking very softly, not say-ing what you are really looking for—just as you told me. What doyou think about the shop assistant? What do you think aboutyourself as a customer?

HumorHumor may have a very relaxing effect in persistent self-esteem prob-lems. Much is gained if the patient is able to laugh for the first timeabout his or her unrealistic social fears, thus achieving a distance fromhimself or herself. For the use of humor, tactful timing is required andthe patient's vulnerability must be kept in mind. A secure positive rela-tionship is required as well. Hoffmann (2002,2003) gave the followingexample for the use of humor in asking a patient who used the stage par-adigm: "What are they playing? A tragedy, a comedy or even slap-stick?" Kohut (1966) described the development of the capacity forhumor as a transformation of narcissism.

Concluding remarks

The psychodynamic manual for the treatment of social phobia pre-sented here is based on the principles of SE therapy (Luborsky, 1984).



The treatment has been specifically adapted to social phobia with refer-ence to contributions from Gabbard (1992), Fonagy (1998),Crits-Christoph et al. (1995), Konig (1981, 1997), and Hoffmann(1999,2002,2003). In particular, the treatment principles suggested byHoffmann (1999, 2002, 2003) were integrated into the manual. Insome instances, the treatment may be more directive than usual SE ther-apy. This especially applies to the prescripdons described above. How-ever, to encourage the patient to actively confront, rather than avoid,the anxiety-producing situation is consistent with Freud's (1919/1955)recommendations for the treatment of phobia. For the treatment ofcompulsions, Freud (1919/1955) made similar recommendations.

For psychodynamically trained therapists, it is possible to use thismanual and its principles adequately after a relatively short training pe-riod. For the treatment of GAD with SE therapy, Crits-Christoph et al.(1995) recommend at least four training cases, which is consistent withthe experiences we have had in our own treatment study of SE therapyof GAD. For the assessment of adherence and competence in SE ther-apy, a rating scale is available (Penn Adherence and Competence Scalefor Supportive-Expressive Therapy, PACS-SE; Barber &cCrits-Christoph, 1996; Luborsky, 1984). For the treatment of socialphobia, the authors of this manual adapted the scale by adding disor-der-specific items. Crits-Christoph et al. (1995) suggested a tentativecriterion of 4 or more on the 1-7 scale of the PACS-SE as a cutoff scorefor acceptable competence.

Although the psychodynamic treatment presented here includessome behavioral elements (e.g., self-exposure or prescriptions), it dif-fers from CBT treatment models for social phobia. In contrast, for ex-ample, to the approach of Clark and Wells (1995), the psychodynamictreatment does not include specific therapeutic elements that character-ize the Clark and Wells approach (e.g., role play or training to systemat-ically change the focus of attention and safety behavior, video feedbackto change distorted self-imagery, cognitive restructuring of dysfunc-tional beliefs, modification of problematic anticipatory or posteventprocessing).

On the other hand, the psychodynamic treatment presented hereuses active ingredients that are not included in CBT approaches: It in-cludes the characteristic elements of SE therapy, that is, setting goals,focus on the CCRT associated with the patient's symptoms, interpre-tive interventions to enhance insight into the CCRT, and supportive in-terventions, in particular fostering a helping alliance. Furthermore,additional treatment elements are applied in order to tailor the treat-ment more specifically to social phobia; for example, a specific focus on

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distorted self-imagery, on shame and on unrealistic demands, or onspecific transference-countertransference patterns.

The treatment is conceptualized as a short-term treatment of 25 ses-sions (plus 5 introductory sessions). It is of note that the manual hasbeen developed specifically for patients with the primary diagnosis ofsocial phobia. Comorbid mental disorders may be present, but theymust not be the primary diagnosis. Although even severe mental disor-ders (e.g., borderline personality disorders) can be treated with SE ther-apy (Luborsky, 1984), the treatment presented here is conceptualizedas a short-term treatment that may not be appropriate for patients withsevere comorbid personality disorders (e.g., narcissistic or borderlinepersonality disorder). For the latter patients, modifications that wouldput a greater focus on supportive treatment elements are required(Luborsky, 1984).

Clinical experiences have shown that many patients with social pho-bia benefit from the treatment principles described here. Establishmentof psychodynamic treatment as an evidence-based procedure for abroad range of psychiatric disorders is hampered by the lack of suitabletreatment manuals. We have set out to fill the gap for a frequent and de-bilitating disorder traditionally neglected by psychoanalysis. We there-fore hope that dissemination of the treatment outlined will stimulateboth clinical and research efforts in the future.

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