treatment of severe social phobia: effects of guided

Journal of Consulting and Clinical Psychology Copyright 1988 by the American Psychological Association, Inc. 1988, Vol. 56, No. 2, 251-260 0022-006X/88/$00.75

Treatment of Severe Social Phobia: Effects of Guided Exposure With and Without Cognitive Restructuring

Richard P. Mattick University of New South Wales and

Clinical Research Unit for Anxiety Disorders St. Vincent's Hospital, Sydney, Australia

Lorna Peters University of New South Wales

Sydney, Australia

Fifty-one social phobics with severe scrutiny fears were randomly assigned to treatment in an experi- ment designed to assess the effectiveness of therapist-guided exposure and to determine the extent to which cognitive restructuring alone increases the effects of this exposure. Additionally, the ability of treatment-induced changes in locus of control, of irrational attitudes, and of within-session habituation to predict level of functioning at follow-up was assessed. Treatment integrity assessment showed compliance with instructions that was consistent with the respective treatments. The combined condition proved to be significantly more effective than guided exposure alone in endstate functioning, in increasing behavioral approach, and in decreasing self-rated avoidance. Regression analysis showed that treatment-induced changes in fear of negative evaluation (FNE), irrational beliefs, locus of control, and exposure-practice habituation were significantly predictive of endstate functioning at follow-up; the change in FNE accounted for virtually all the explained variance.

Although social phobia is a prevalent and disabling anxiety disorder (Myers et al., 1984), its nature and treatment have received relatively little attention. Exposure has been shown to be an effective therapy (Biran, Augusto, & Wilson, 1981; Emmel- kamp, Mersch, Vissia, & Van der Helm, 1985), but it does not always appear to bring about cognitive changes (Butler, Culling- ton, Munby, Amies, & Gelder, 1984; Emmelkamp et al., 1985), which are believed to be necessary for the fullest recovery (But- ler, 1985). Buffer et al. (1984) showed that the addition of an anxiety-management package produced cognitive changes beyond programmed (self-conducted) exposure and thereby argued that exposure alone may be an insufficient treatment for this disorder. However, the exposure condition used in their study may not have provided an adequate trial of exposure therapy.

Variations that appear to be simple in the administration of exposure therapy have been found to result in significant differences in effectiveness. Both Williams, Turner, and Peer (1985) and Williams, Dooseman, and Kleifield (1984) have

This report is based on a part of Richard P. Mattick's doctoral dissertation, which was conducted at the University of New South Wales, Syd- ney, Australia and was supervised by J. C. Clarke. The research was supported by an Australian Government Commonwealth Postgraduate Research Award.

We thank JaneUe Ah-Cann and Ron Rapee for acting as independent blind assessors, Louise Kahabka and Vera Thomson for secretarial work, Kevin Bird and Dusan Hadzi-Pavlovic for statistical advice, and Phoebe Holt and Elizabeth MurreU for commenting on parts of the manuscript. We also acknowledge the assistance of the behavioral test confederates and the helpful comments of the reviewers.

Correspondence concerning this article should be addressed to Richard P. Mattick, Clinical Research Unit for Anxiety Disorders, St. Vincent's Hospital, 299 Forbes Street, Darlinghurst, Sydney, New South Wales 2010, Australia.

shown that, for circumscribed phobias, exposure involving the active guidance of the therapist produced significantly better outcomes than graduated exposure where such direction was not provided, particularly when the therapist assisted the patient who was having difficulty progressing and provided steps to facilitate the generalization of success. Behavioral and cognitive changes may thus occur less readily in graduated exposure without therapist supervision of patients during actual exposure practice (cf. Buffer et al., 1984; Mathews, Gelder, & John- ston, 1981). Indeed, Gelder (1982) acknowledged that programmed practice, such as that used by Butler et al. (1984) in which the therapist did not accompany the patient but acted as an adviser, did " n o t . . . produce the cognitive changes which are required for complete recovery" (p. 93) and argued that an anxiety-management package is required to produce the best outcome.

In regard to our present knowledge of social phobia treatment, Marks (1985) noted that it has not yet been demonstrated exactly which ingredients of anxiety management enhanced the effects of exposure in the Butler et al. (1984) study: Their extensive package included relaxation training, distraction techniques, and rational restructuring. Hence, the current literature does not clearly show the extent to which cognitive restructuring alone augments the effects of therapist-assisted, guided exposure. Cognitive-restructuring procedures do appear to produce treatment effects in social phobia comparable to those of exposure treatment (Emmelkamp et al., 1985; Mattick, Peters, & Clarke, 1987) and may enhance the effects of exposure (Mat- tick, Peters, & Clarke, 1987). Thus, it seems timely and appro- priate to compare the changes brought about by therapist-assisted guided exposure with and without the use of cognitive therapy in a large-scale study.

Of at least equal importance are the mechanisms through which treatment exerts its effects. In social phobia, the fear of

251

252 RICHARD P. MATTICK AND LORNA PETERS

negative evaluation (FNE) by others appears to be a major defi- cit (Marks, 1969; Nichols, 1974) and, although this has not been demonstrated to date, the reduction o f this fear has been argued to be an important mediator o f long-term functioning (Butler, 1985). However, no study (that we know of) has assessed the importance of changes in FNE, in alterations of irrational attitudes, and in within-session habituation that have resulted from treatment. The present study was designed (a) to examine the extent to which treatment- induced changes in irrational attitudes are predictive o f long-term outcome and (b) to compare the relative efficacy of therapist-assisted guided exposure with and without cognitive restructuring.

M e t h o d

Subjects

The sample contained 51 White patients (24 male) with a mean age of 37 years (see Table 1). Forty of 9 ! subjects met criteria after respond- ing to newspaper feature articles and to television and radio coverage that described social phobia and a university-based treatment clinic (without requesting volunteers), and 11 patients were referred from medical practitioners. Of the advertisement respondents that were not included, 19 did not attend the screening interview; 5 complained of only interpersonal anxiety (without the scrutiny fears that define social phobia); ! 1 revealed another disorder in more immediate need of treatment, such as alcohol abuse (1), psychotic disturbance (4), avoidant personality disorder (1), agoraphobia (4), or organic tremor (1); l0 did not report definite avoidance behavior and scored fewer than 4 points on the Marks and Mathews (1979) 0-8 rating of avoidance; and 6 were offered treatment but declined. All subjects met Diagnostic and Statisti- cal Manual of Mental Disorders ( DSM-III," American Psychiatric Asso- ciation, 1980) criteria for social phobia and reported extreme levels of fear and the avoidance of performing routine activities in the presence of others because they feared being scrutinized during such activities. Included were phobias of eating with others, drinking with others, writing or signing in front of others, walking down busy streets, or using public transport, all for the fear of scrutiny from others.l The majority of the sample was phobic in more than one of these situations (76%, drinking; 71%, eating; 71%, signing their name; 67%, writing in the presence of others; 27%, being in public places; 22%, using public lava- tories (all male); and 25%, other situations including talking, playing sports, or carrying out fine motor acts if others might be watching). All considered that their phobias were chronic and debilitating and that they interfered with their lives, and none complained of or displayed marked social skills deficits.

Experimental Design

A single-factor, two-group design was used. One treatment condition provided guided exposure (EXP), and the other provided a combination of guided exposure and cognitive restructuring (COMB). Subjects were allocated to groups on a random basis. Additionally, measures of locus of control, of FNE, and of irrational beliefs, although they are essentially dependent variables in the study of treatment efficacy, were included as independent variables within a separate stepwise, linear, multiple regression analysis to assess their relative contribution to long-term functioning.

Treatment

General aspects. Subjects were treated in groups (mean n = 5, range = 4-7) for 2 hr a week for 6 weeks. Two therapists who were experienced in the treatment of social phobia conducted treatment sessions.

One was a psychologist who was experienced in the behavioral treatment of phobias and had worked for over 3 years using the exposure and cognitive treatments of the current study. The second therapist was a senior-level undergraduate psychology student who had received clinical training and had gained experience in the use of the current techniques by treating more than 30 severe social phobics over a 6-month period. Hence, both therapists were practiced in the treatment procedures described later and were present at all treatment sessions, with the more experienced therapist leading and supervising all treatment sessions. Meetings were held at the end of each session to discuss and monitor the integrity of treatment implementation. The therapists identified no violations of treatment integrity, either by the contamination of the exposure-alone condition with cognitive procedures or by the subjects in that condition spontaneously discussing cognitive procedures. Addi- tionally, treatment-implementation integrity was assessed from behavioral diary data (cf. Vermilyea, Bariow, & O'Brien, 1984). The therapists, because they were also the experimenters, were aware of the issues being examined but viewed both treatment conditions as effective and attempted to convey equal expectancies of improvement to subjects. (Ratings of treatment credibility and integrity were taken to assess the presence of any differential treatment implementation or differential expectancies that might have affected treatment outcome.)

Guided exposure. The rationale emphasized the role of avoidance behavior in the etiology and maintenance of phobias and completely ignored the role of maladaptive thinking. From the first session, subjects were required to repeatedly enter and stay in feared situations until their desire to avoid them subsided. The situations selected for exposure were those that were deemed by subjects to be moderately difficult, which thus provided a graded approach. For example, subjects who were afraid of eating and drinking typically began by simply buying some- thing from a cafe without consuming it and ended by eating at a crowded table in a busy cafe. The therapists monitored progress initially by directing and leading subjects into increasingly difficult situations, often in small groups comprising subjects with similar fears. By the third session, direct assistance was being withdrawn and subjects were seeking out and entering situations either in groups with shared fears or alone. However, in all sessions, therapists checked on exposure practice, were fully accessible to subjects, interacted in an encouraging manner, and praised performance. This strategy was adopted to increase subjects' sense of self-control over the phobic behavior. For all subjects, a number of steps were used to assist exposure, including: (a) mastery of subtasks, (b) graduated time, (c) modelling, and (d) varying performance (cf. Williams et al., 1985). To enhance generalization, different and increasingly difficult situations were used across both treatment sessions and self-directed exposure homework assignments. On homework behavioral diary sheets, subjects recorded (a) situations used for exposure, (b) initial maximum anxiety (on a 0-100 scale), (c) minutes in the situation, (d) final anxiety (on a 0-100 scale), and (e) anxiety-related thoughts to get an unobtrusive measure of changes in cognitions. In each session, homework was reviewed, the rationale was repeated for 45 min, supervised practice occurred for 60 min, and problems and homework were discussed for 15 min. Subjects used at least two different situations for exposure within each treatment session.

Combined treatment. Exposure and cognitive restructuring were in- tegrated, and the rationale emphasized both avoidance behavior and the role of irrational thoughts in initiating and maintaining this behavior. Subjects were told that it was essential to address these factors together

~None of these patients were agoraphobic; agoraphobic patients avoid "public places, from which escape might be difficult or help not available, in case of sudden incapacitation" (American Psychiatric As- sociation, 1980, p. 227). Socially phobic patients may also (and often do) avoid public situations, but they fear the critical scrutiny of others and hold an associated fear of acting in a humiliating fashion.

TREATMENT OF SEVERE SOCIAL PHOBIA 2 5 3

by entering phobic situations and identifying, challenging, and altering their maladaptive beliefs and attitudes. The treatment followed the same format as the exposure treatment, except that subjects were required to use the cognitive techniques during exposure. The correct use of these procedures was monitored carefully both in treatment and from behavioral diary sheets.

The cognitive-restructuring component combined systematic rational restructuring (Goldfried & Goldfried, 1975) with elements of rational-emotive therapy (Ellis, 1962). It was suggested that (a) the con- cern about the opinions of others, (b) the feeling that others are watching, and (c) the belief that signs of anxiety are particularly visible and noticed by others are largely unfounded and are responsible for the anxiety experienced in phobic situations. Importance was placed on identifying all irrational thoughts and on making the thoughts more realistic and rational. Subjects were required to analyze thoughts before, during, and after phobic situations for two sources of irrationality: (a) the degree of likelihood that their interpretation of the situation was in fact realistic and (b) the ultimate implications of the way they had labeled the situation. Initially, the therapists played an active role in this process, but once the method was understood, subjects were encouraged to practice in pairs or on their own and were told that emotional reactions in social settings must now serve as a cue to start rational reevaluations. Patients were encouraged to assist each other in the analysis and modification of their irrational beliefs. At the first session, subjects were given a booklet explaining the rational-emotive approach (Young, 1974), which was discussed at the next session. At the third session, selected irrational assumptions from Ellis (1962) were incorporated into the practice sessions. Homework behavioral diary sheets were supplied on which subjects recorded (a) a description of the situation, (b) initial maximum anxiety, (c) irrational thoughts that occurred, (d) a rational reappraisal of the situation, (e) subsequent anxiety, and (f) the time spent in the situation (Goldfried & Goldfried, 1975). The structure of sessions was identical to that used for the exposure treatment.

M e a s u r e s

Behavioral Approach Test. Individually tailored, hierarchically or- dered lists of situations were constructed to represent the range of avoided activities, from moderately to extremely frightening (e.g., entering a cafeteria, buying food or coffee, and leaving with it through eating a full meal in a crowded restaurant with another person). The choice of hierarchy items followed the method of Biran, Augusto, and Wilson (1981). (Confederates were frequently used to provide a greater and more realistic threat.) A situation or activity was included only if the subject said she or he would avoid it if given a choice. Ratings on a 0- 100 subjective units of disturbance scale (SUDS) were used to order the items hierarchically. At the second pretreatment interview, before the Behavioral Approach Test (BAT), this order was rechecked. At each assessment, one item was selected for the test. This was done by starting at the bottom of the hierarchy, describing each item in turn, and asking the subject if the item could be attempted. This procedure was contin- ued until the subject refused a particular item because it was too distressing. Subjects then attempted to undertake the highest item that they felt could be achieved successfully. (The items listed below the item achieved were left untested and were assumed accomplishable because the list was arranged hierarchically and the subjects had stated that these items could be achieved.) The position in the hierarchy of the item sue- cessfully completed and a SUDS rating of the anxiety experienced when this item was undertaken were recorded. The SUDS rating was analyzed to assure that both groups made similar efforts on the BAT at the assessments. To provide an "unfamiliar threat" during the BAT assessment (of. Biran & Wilson, 1981) and thus to make it a more valid test, the actual physical locations used in the BAT were not used in the exposure treatment sessions. Additionally, to further ensure the validity of the

BAT data, successful completion of the BAT item chosen according to the instructions given (patient either did or did not complete the activity as described) was ascertained by an independent assessor. On the rare occasion that a subject failed an item, the previous item on the hierarchy was selected for testing. Pilot testing of the BAT indicated that the assessment of all items often was not practically possible.

Self-report measures. Self-report measures included the Social Pho- bia Scale (SPS) to assess anxiety in situations that are typically the focus of social phobia (test-retest correlation = 0.87, internal consistency = 0.93); the Fear Questionnaire (FQ; Marks and Mathews, 1979); 39 items from the Irrational Beliefs Test (IBT; Jones, 1969) that correspond to four irrational assumptions (demand for approval, high self-expecta- tion, irresponsibility, and anxious overconcern) and are rated on a 9- point scale; the Fear of Negative Evaluation Scale (FNES); the Social Avoidance and Distress Scale (SADS; Watson & Friend, 1969), which was used as a constant covariate in the analysis of between-groups differences only and is not reported as a dependent variable; and the Locus of Control of Behaviour Scale (LCBS; Craig, Franklin, & An- drews, 1984). 2 To assess whether treatment differences were related to expectations of improvement, subjects rated their perceptions (a) that treatment seemed logical; (b) that treatment would successfully elimi- nate fears; (c) that they could confidently recommend the treatment to others; and (d) that treatment would successfully reduce other fears (of. Borkovec & Nau, 1972). A 0-10 bipolar scale (0 = completely false, 5 = don't know, 10 = completely true) was used that differed slightly from that of Borkovec and Nau.

Behavioral diary measures. The weekly values of(a) number of exposures to phobic stimuli, (b) total exposure time in minutes, (c) number of cognitive-restructuring exercises reported, (d) mean peak anxiety level, and (e) final anxiety level on contact with phobic situations were calculated from the behavioral diary sheets and coded. (A cognitive- restructuring exercise was defined as the disputing of an irrational belief as described in the treatment section.) To check the accuracy of this coding, a week's worth of data were randomly chosen and independently recoded. There was complete agreement on 89% of these codings. 3 For analysis, the data were blocked into 2-week time intervals (cf. Michel- son, Mavissakalian, Marchione, Dancu, & Greenwald, 1986). Addition- ally, as part of a separate study of cognitive changes in behavioral treatment of social phobia, 9 EXP subjects and 6 COMB subjects completed self-monitoring sheets (Mattick, Peters, Rapee, & Clarke, 1987). Be- cause there were no significant differences between these 15 subjects and those completing the self-monitoring as described previously on any of the dependent variables across all assessments (2 Treatments X 2 Types of Self-Monitoring X 3 Repeated-Measures ANOVAS), the data from these two sets of subjects were combined.

Composite measures of endstate functioning and improvement. Sub- jects' levels of endstate functioning were classified using three stringent a priori criteria (cf. Michelson, Mavissakalian, & Marchione, 1985). One point was given for each of the following at follow-up: (a) a target phobia avoidance rating of 2 or less; (b) a self-rating of severity of phobia of 2 or less; and (c) completion of 100% of the BAT with a SUDS (in vivo anxiety) rating (out of 100) of 30 or less. A score of 0 = low endstate functioning, 1 = moderate endstate functioning, 2 = high endstate functioning, and 3 = very high endstatefunctioning. The last classification

2 Further information on or copies of the measures used are available on request.

3 These codings were not binary. Rather, an overall value was calculated for each patient for each week on the five variables. The formula of agreement was the number of codings agreed upon divided by the total number of codings, expressed as a percentage. The percentage of perfect agreement for each of the five categories was 92, 80, 96, 92, and 96, respectively.

254 RICHARD E MATTICK AND LORNA PETERS

represents an excellent clinical outcome with only slight-to-negligible phobic symptomatology.

Finally, a composite measure of improvement was used to assign each subject to one of four levels of change based on (a) a decrease of 3 or more from pretreatment level on the target phobia avoidance rating; (b) a decrease of 3 or more from pretreatment level on the self-rating of severity; and (c) an increase in BAT performance of at least 50% beyond pretreatment levels of performance. This measure offered the advantage of assessing change independent of pretreatment differences in severity.

Procedure

At a screening interview, the diagnosis of social phobia was made by a psychologist who was experienced in DSM-III diagnoses of anxiety disorders and was then independently confirmed from a structured diagnostic interview (Robins, Helzer, Croughan, & Ratcliff, 1981). The BAT was conducted at a second interview prior to random assignment and again later by an independent assessor who was not involved in the study and was blind to group assignment. To maintain the integrity of the blind, subjects were cautioned against discussing aspects of the treatment with the independent assessor, and the assessors reported that for no subject were they aware of the treatment condition. To ensure that demand on the BAT was equal across the assessments (and assessors), patients were always requested to choose the most difficult item they were prepared to attempt. (The SUDS ratings also addressed the issue of differential demand affecting performance on the BAT.) Self-report measures were completed independently of therapists. Treatment credibility was assessed at the start of the third treatment session and was not revealed to therapists to avoid the possibility of influencing therapist behavior toward subjects (cf. Wilkins, 1973). Subjects were instructed to use the treatment procedures until follow-up. At the 3-month follow- up, subjects were offered additional treatment.

Resu l t s

Statistical Analysis

Multivariate analyses of variance (MANOVAS) were conducted at pretreatment, posttreatment, and follow-up. Between and within-group differences were examined using a MANOVA approach to repeated-measures data, and the effects of interest were examined by using univariate tests of specific contrasts (O'Brien & Kaiser, 1985), with the pretreatment level of the SADS used as a constant covariate. Specifically, two orthogonal and planned repeated-measures contrasts were used to compare data from before to after treatment, with after treatment defined as posttreatment and follow-up measures, averaged, and to compare posttreatment with follow-up to test for significant change across this period (Poor, 1973). A small number of subjects with some missing data were excluded from some analyses.

Pretreatment Characteristics of Subjects

Pretreatment subject characteristics are displayed in Table 1. There were no significant differences between groups in age, durat ion of phobia, sex distribution, marital status, or medica- t ion usage. 4 The overall ratio of men to women was roughly equal, consistent with previous observations (e.g., Marks, 1969; Mattick, Peters, & Clarke, 1987). To alleviate symptoms, 73% of the sample admitted that they had used medication (mainly benzodiazepines and, less frequently, beta-adrenergic blocking

Table 1 Summary of Subject Characteristics

Treatment condition

Exposure Combined Total Variable group group sample

Sample size N 26 25 51 Men (n) 10 14 24

Age M 39.4 34.2 36.7 SD 9.7 12.7 11.2

Duration M 17.5 14.1 15.8 SD 13.5 13.2 13.4

Marital status Married 13 12 25 Divorced 2 2 4 Single 11 11 22

Note. Combined group = exposure plus cognitive restructuring.

drugs) and 75% admitted that they had used alcohol, whereas 92% had previously received some form of t reatment with little or no reported change in symptomatology. Scores on the FQ target-phobia measure, the FQ social-avoidance measure, and the FNES (see Table 2) were comparable to those reported in other studies on social phobia (e.g., Biran, Augusto, & Wilson, 1981; Butler et al., 1984; Emmelkamp et al., 1985). Taken together, the long durat ion of the phobia, the stringent selection criteria on severity, the high rate of previous consultations and of anxiolytic drug and alcohol use, and the comparabili ty of pretreatment scores to other studies are evidence that the sample was clinically relevant. Prior to conducting the outcome analyses, a MANOVA was conducted between the two treatments on the pretreatment dependent variable scores. There was no significant difference detected between the groups (F < 1).

Four subjects from the COMB group and 3 from the EXP group were dropped from the analysis. Five subjects did not complete treatment, and 2 missed an assessment occasion. Rea- sons for not completing t reatment included personal problems unrelated to treatment, travel difficulties, physical illness, and

4 Subjects who were taking concurrent benzodiazepine medication in the EXP group (n = 10) and the COMB group (n = 6) were compared with those who were not (n = 13 and n = 15, respectively) on all of the dependent variables across assessments (2 X 2 x 3; Treatments X Levels of Medication x Repeated-Measures ANOVAS). Overall, those who were taking medication had significantly higher scores on the Social Phobia Scale, the Fear of Negative Evaluation Scale (FNE), the Irrational Be- liefs Test, the Fear Questionnaire (FQ) social-avoidance measure, and the FQ other-phobia measure, which suggests that they were more se- verely affected. Those patients who were taking medication showed significantly greater decreases in the FQ self-rated severity and general- anxiety/depression measures from before to after treatment, which suggests a facilitative therapeutic role for concurrent benzodiazepine medication, although at the same time medication patients showed fewer decreases in the FNES than the nonmedication patients across the same period. There were no significant interactions between medication and treatment conditions.

TREATMENT OF SEVERE SOCIAL PHOBIA 255

fear of becoming worse. One subject was excluded because only half the treatment sessions were attended. To test for pretreatment differences between completers and noncompleters, a MA- NOVA was conducted. No significant difference occurred ( F < 1).

Differences Between and Within Groups

The MANOVAS were conducted between the treatments at posttreatment and follow-up. The posttreatment MANOVA revealed no between-groups differences on the outcome variables (F < 1). The follow-up MANOVA revealed a significant between- group difference on these variables, F(10, 32) = 2.77, p < .05. Tests of planned contrasts were then conducted to examine and compare differences between treatments across assessments.

Credibility~expectations of therapy The groups did not differ significantly on these scores (EXP group mean = 32.91, SD = 5.05, and COMB group mean = 31.28, SD = 6.36). This result suggests that the treatments were presented to the subjects in an equally credible fashion by the therapists and that both groups held high and equal expectancies for improvement. Hence, credibility effects did not appear to be responsible for treatment-outcome differences, which allowed the data to be inter- preted unambiguously (cf. Kazdin & Wilcoxon, 1976).

Behavioral Approach Test. The results for this measure are presented in Table 2 and illustrated in Figure 1. An inspection of Figure 1 shows that between pretreatment and posttreatment, both groups showed a substantial increase in BAT performance. Analyses ofcovariance (ANCOVAS) for assessment occasion confirmed that there was a significant overall improvement from before to after treatment (see Table 2). However, interactions between assessments and treatment groups indicated that the COMB group showed a significantly greater increase in BAT performance than the EXP group from before to after treatment.

Subjective fear. The SUDS ratings were recorded during the BAT based on the BAT item completed. The ANOVAS indicated that there were no significant group effects, thus the BAT items undertaken by both groups were, on average, equally distressing and there was no differential effort on the BAT between groups. There was a significant overall decrease in SUDS ratings from posttreatment to follow-up, F(1, 42) = 4.50, p < .05; MS~ = 264.65, although again there were no significant Group • As- sessment interactions, which further demonstrated that between-groups differences in BAT performance could not be attributed to differential effort or willingness to undertake anxiety-provoking tasks.

Self-report measures. Figure 2 and Table 2 show changes in the self-report measures of treatment outcome. The ANCOVAS for assessment showed that there were powerful statistically significant repeated-measures effects on all dependent measures for treatment. Between-groups differences were apparent on the target-phobia avoidance rating only. An inspection of Figure 2 shows that the changes in self-rated avoidance of the target phobia paralleled those changes that occurred in BAT performance. Both groups improved on self-rated avoidance from pretreatment to posttreatment, with the COMB group showing further gains between posttreatment and follow-up and the EXP group showing slight losses. This Treatment • Repeated Measures in-

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teraction reached statistical significance. The FQ self-rating of phobic severity measure showed essentially the same result, although the differences failed to attain significance.

These data, taken together, show marked clinical improvements across all assessment domains (including behavioral and self-report measures of phobic avoidance and anxiety, attitudinal measures, and measures of general functioning), with the COMB group manifesting an advantage in actual and self-reported avoidance behavior.

Clinical significance. The significance of clinical improvement was examined (a) descriptively, (b) by comparing final levels of treatment-outcome variables with those of other studies, (c) by considering composite endstate functioning and improvement measures, and (d) by considering requests for further treatment. The descriptive data showed that 48% (n = 1 I) of the EXP group were still reporting definite avoidance of the target phobia (a rating of more than 3 on the target phobia measure) at follow-up compared with 14% (n = 3) of the COMB group. This difference was significant (• = 5.69, p < .05). Consistent with the self-reports, an examination of BAT performance showed that 81% (n = 17) of the COMB group were able to complete at least 80% of the BAT items, whereas 17% of the EXP group reached this arbitrary criterion. This difference was also significant (• = 17.78, p < .05). When the more stringent criterion of being able to complete 100% of the BAT items was used, 52% (n = 11) of the COMB group met this level of performance at follow-up, whereas 17% (n = 4) of the EXP

256 RICHARD E MATTICK AND LORNA PETERS

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group achieved 100% performance. This difference was also significant (x2(1) = 9.13, p < .05).

The degree of the changes occurring in the social phobia avoidance measures, in the measure of other phobic avoidance, and in general anxiety and depression was of a similar magni- tude to the results of other research using exposure-based treatments (Butler et al., 1984). However, on the Fear of Negative Evaluation Scale, the EXP group showed substantial changes that varied from Butler et al. (1984), possibly because of proce- dural differences within the exposure treatment used.

Endstate functioning and improvement. The levels of endstate functioning and improvement at follow-up were compared. There was a significant difference between treatment conditions in endstate functioning: for low endstate functioning, COMB = 19% (n = 4) and EXP = 57% (n = 13); for moderate endstate functioning, COMB = 43% (n = 9) and EXP = 13% (n = 3); for high endstate functioning, COMB = 19% (n = 4) and EXP = 17% (n = 4); and for very high endstate functioning, COMB = 19% (n = 4) and EXP = 13% (n = 3), x2(3) = 7.83, p < .05. Similarly, there was a significant difference between the COMB and EXP conditions in the overall composite measure of improvement: for low improvement, COMB = 5% (n -- l) and EXP = 13% (n = 3); for moderate improvement, COMB = 0% (n = 0) and EXP = 30% (n = 7); for high improvement, COMB = 38% (n = 8) and EXP = 26% (n = 6); and for very high improvement, COMB = 57% (n = 12) and EXP = 30% ( n = 7), X2(3) = 9.53,p < .05.

Further treatment. Consistent with the group trends on the

dependent variables, at the follow-up, 24% (n = 5) of the COMB group stated that they felt they needed additional treatment, whereas 47% (n = 11) of the EXP group asked for further treatment. This difference was not significant according to chi- square analysis.

Integrity of Treatment Implementation

Reported treatment compliance. Table 3 shows the average weekly amount of exposure to phobic stimuli in number of exposures, total time spent in contact with phobic stimuli, and number of cognitive restructuring exercises undertaken and recorded during the 6 weeks of treatment. (Because it was felt that compliance would be very low, subjects were not requested to self-monitor activities during the follow-up period.) As required, both exposure groups engaged in active and repeated contact with phobic situations. To test for differences between groups in practice across treatment, univariate Group X Trend analyses (linear and quadratic; Hays, 1981) were conducted across the three 2-week self-monitoring periods. The only significant interaction was a linear trend for the COMB condition to increase the number of cognitive restructuring exercises undertaken over the treatment period relative to the EXP condition, F(1, 42) = 5.70, p < .05, MS~ = 1.80; thus, for the sake of brevity, only the group main effects and the overall means are reported. There was no significant difference between the two conditions in total weekly exposure time, although they did differ in total number of situations used for exposure each week, F(1,42) = 4.44, p < .05, MSE = 18.24, with the EXP condition doing more than the COMB condition.

Important, however, was the lack of a significant difference between the groups in the average amount of time spent per exposure to phobic situation: It did not appear that the exposure treatment received by the COMB group was quantitatively greater than that for the EXP group. If anything, the EXP subjects appear to have engaged in more frequent practice. The COMB group practiced the cognitive restructuring exercises as required, reporting rational reevaluations of disturbing thoughts, whereas virtually no such deliberate changes in think-

Table 3 Mean Weekly Number of Exposures, Total and Average Exposure Times, and Number of Cognitive Restructuring Exercises Reported

EXP COMB

Variable M SD M SD

Weekly no. exposures to phobic stimuli 10.8 5.0 8.0 3.1

Total weekly exposure time (min) 267.6 174.4 270.1 140.0

Average duration of each exposure (min) 25.6 12.8 37.7 14.2

No. CR exercises 0.1 0.2 5.7 2.6

Note. EXP = guided exposure; COMB = guided exposure combined with cognitive restructuring; CR = cognitive restructuring.


ing pattern were recorded by the EXP subjects on self-monitoring sheets, F(1, 42) = 97.61,p < .05, MSE = 3.60.

Anxiety levels during exposure practice. Initial and final anxiety levels recorded on behavioral diary sheets within exposure practice were also blocked into three 2-week time intervals, and univariate tests of specific contrasts for linear and quadratic trends (Hays, 1981) were conducted on the change from peak to final anxiety level to assess differential habituation patterns between treatment conditions, both across and within exposure-practice sessions. There was a significant linear trend for both peak and final anxiety levels to decrease across the three 2-week treatment blocks, F(1, 42) = 4.64, p < .05, MSE = 189.14. The quadratic trend was nonsignificant. Similarly, within each exposure-practice session recorded on behavioral diary sheets, there was a strong and significant decrease in anxiety level, F(1, 42) = 106.35,p < .05, MSE = 49.64. These data, taken together, indicate that the exposure treatments did decrease anxiety both between (i.e., across) and within exposure- practice sessions. In within-session habituation, the COMB group showed a significantly higher overall anxiety level (averag- ing across initial and final anxiety levels, mean initial anxiety = 49.0, SD = 19.7; mean final anxiety = 28.8, SD = 15.4; F(I, 42) = 5.95,p < .05, MSE = 427.71). However, the COMB group enjoyed a significantly greater decline in anxiety level within exposure-practice sessions than did the EXP group (mean initial anxiety = 33.5, SD = 11.6; mean final anxiety = 22.8, SD = 13.0; F(1, 42) = 9.87,p < .05, MSE = 49.64).

Analysis of Postulated Mediators of Long-term Functioning

A planned, multiple, linear, stepwise regression was conducted using the stringent composite measure of endstate functioning as the independent variable and entering the pre- to posttreatment changes in the FNES, the IBT, and the LCBS scores as well as the averaged within-exposure-practice change in anxiety level (habituation) as predictors. The rationale for conducting this analysis was to delineate the relation of treatment-induced changes in these three possible mediating attitudinal variables and the within-exposure habituation with the absolute level of endstate functioning. The regression per- formed was significant, F(4, 35) = 2.73, p < .05, with R = 0.49 and R 2 = 0.24 for the change in the FNES, IBT, and LCBS and the within-exposure habituation level. In this analysis, the change in FNE was entered into the equation first, and it accounted for the vast majority of the explained variance (20%), with the change in the IBT and LCBS and the within-exposure habituation level accounting for virtually no additional variance once the effect of the FNE change was eliminated (i.e., held constant). This result supports the importance of decreasing concerns about the opinions of others to maximize the effects of exposure treatments for social phobia.

Finally, the low-moderate endstate subjects were compared with the high-very-high endstate subjects on the predictor variables used in the regression analysis. (Prior to treatment, these two groups did not significantly differ on any of these variables.) After treatment, the analyses revealed significant differences between groups on each of the three variables at both posttreatment occasions. The subjects classified as high-very-high end-

state functioning (n = 15) had lower FNES scores: posttest, t(42) = 2.77, p < .01; follow-up, t(42) = 2.76, p < .01; lower IBT scores: posttest, t(42) = 2.70, p < .01; follow-up, t(42) = 2.87, p < .01; and lower LCBS scores: posttest, t(41) = 3.13, p < .005; follow-up, t(41) = 3.67, p < .001, than the low-moderate endstate subjects (n = 29).

Discussion

Large-scale comparative-outcome research examining therapist-assisted guided exposure with and without a cognitive restructuring procedure (aimed to alter irrational, aberrant beliefs and attitudes) for social-phobia scrutiny fears has not previously been conducted. This study used established, validated, and reliable measurement instruments to reveal powerful, statistically significant repeated-measures effects across assessments, which indicated that these treatments are capable of producing substantial and lasting changes in severe and chronic social phobia. From before to after treatment, subjects in both conditions achieved significant changes in independently assessed avoidance behavior, in self-ratings of phobic avoidance and severity, in attitudinal measures, and in anxiety/depression measures. Between posttreatment and follow-up, the majority of these variables showed significant gains beyond the posttreatment level. The final levels of dependent measures were similar to those achieved in other treatment-outcome studies on social phobia (e.g., Butler et al., 1984); thus, treatment implementation was etficacious to other studies.

Analyses for between-groups differences showed that the condition in which guided exposure was combined with cognitive restructuring (COMB) yielded greater effects on actual behavior and on self-rated avoidance of the target phobic situation than guided exposure alone (EXP). These treatments also differed on the stringent composite measures of improvement and endstate functioning at follow-up; in both cases, relatively few COMB subjects (n = 4) were categorized with low (i.e., poor) endstate functioning, and only 1 subject was classified with only low-moderate improvement. The EXP condition produced 13 subjects categorized with low endstate functioning and 10 with low-moderate improvement. These results were reflected in the number of subjects requesting extra treatment at follow-up, although differences on this variable did not reach significance.

These between-groups differences occurred in the present study despite the finding that subjects in both conditions rated the treatments as equally credible and complied with instructions consistently. Both groups received equivalent therapist contact, equivalent exposure, and had equivalent high expectancies for improvement. On behavioral diary sheets, subjects in the COMB condition reported deliberate reevaluations of aberrant cognitions to a significantly greater degree than those in the EXP condition, who reported virtually no such deliberate practice. (It may be that these data were simply an index of the instructions regarding the completion of the diary sheets, and additional independent ratings of session content may be useful in ensuring treatment integrity; cf. Michelson et al., 1986.) Sub- jects in both groups received an equal amount of real-life exposure to phobic situations and showed significant declines in anxiety both within and between exposure-practice sessions, al-


though those in the COMB condition showed significantly greater decreases in within-session anxiety levels. Overall, these data are consistent with our previous research on the cognitive and behavioral treatment of social phobia, thus suggesting an advantage for an intervention combining exposure with a cognitive procedure in the treatment of social phobia (cf. Mattick, Peters, & Clarke, 1987).

Moreover, in accord with a substantial body of clinical obser- vation and opinion, within-treatment change in aberrant attitudes about the importance of the opinions of others (Butler, 1985; Marks, 1969; Nichols, 1974) was significantly predictive of long-term endstate functioning. Butler (1985) most recently suggested that decreasing the socially phobic patients' concerns over the opinions of others is essential for effective treatment and asserted that if "this thought pattern does not change then the patient is likely to continue to ask for help" (p. 655). Our results provide the first empirical evidence to support this sug- gestion. The inability of change in within-session anxiety levels, on the IBT, and on the LCBS to account for a large amount of the explained variance and, thereby, to predict long-term phobic behavior suggests that change in these variables is less cen- tral than change in FNE for social phobia. Arguably, the locus of control measure used in this study was not sufficiently related to the behavior in question to predict endstate phobic functioning. However, this measure has been found predictive of both relapse and outcome for other problems (Craig & Andrews, 1985). More generally, because the construct of locus of control is distinct from that of self-eflicacy, self-efficacy assessment may produce different results (cf. Bandura, 1977). It remains to be demonstrated that changes in perceived self-efficacy are significantly predictive of long-term functioning in social phobia. Future studies of social phobia might include both global self- efficacy measures and self-efficacy measures specific to the behavior in question to further resolve these issues.

Finally, a number of comments are warranted regarding this study and the overall findings, as these may help to direct future research. First, although the COMB condition resulted in the best outcome in phobic functioning relative to the EXP condition, the two groups did not show differences in attitudinal measures, particularly on the FNES, even though the change in FNE best predicted long-term absolute level of functioning. Al- though these findings might seem contradictory, to consider cognitive restructuring as only a procedure for altering aberrant cognitions may prove too narrow a view; it is also well-recog- nized as an anxiety-management procedure. Cognitive-restructuring procedures attempt to reduce faulty thinking by teach- ing patients a systematic procedure to identify and counter such thoughts. Without specifically being trained in such procedures, patients may also show improvements in the cognitive- behavioral aspects of their disorder through exposure to corrective information (cf. Foa & Kozak, 1986) yet may not be highly skilled or proficient in using techniques to manage or dispel anxiety as it arises. The current EXP subjects who did not have such a procedure at their disposal may have been less likely to undertake difficult tasks and, hence, may have been more likely to experience and rate their phobic avoidance and severity as high. Additionally, using cognitive restructuring to manage anxiety may allow greater within-exposure decreases in SUDS level, as found for the current COMB group, and this may also

account for treatment-outcome differences (although this variable did not predict outcome beyond changes in FNE). Support for this interpretation comes from research on agoraphobia by Michelson et al. (1986), who found that decreases in exposure- session SUDS were associated with high endstate functioning. These authors argued that anxiety-management procedures appear to mediate the reduction of in vivo anxiety and, thereby, overall improvement.

Second, the variables used in the regression in this study accounted for only a small proportion of variance, suggesting that other factors are important in altering severe social phobia. Third, the treatment did not yield high-very-high endstate functioning for the majority of patients; thus, additional procedures may prove important in ameliorating this condition. And finally, although self-directed exposure and cognitive restructuring were an integral and important part of therapy, therapist contact of 2 hr per week for 6 weeks may have provided an inad- equate trial of the two treatment modalities, and a longer duration of treatment may yield a more decisive comparison of their relative efficacy.

The present findings have implications for optimizing the treatment of social phobia. They suggest that therapist-assisted and guided exposure is an effective treatment procedure that is apparently capable of producing marked and substantial behavioral and cognitive changes. However, greater effects on the phobia are produced through the addition of a cognitive-restructuring procedure. Although change in concerns over the opinions of others appears important, cognitive restructuring can exert effects on the phobia beyond this change. Future research might attempt to disentangle the general anxiolytic effect of such cognitive procedures from their specific role in altering aberrant beliefs and might also investigate, among other factors (e.g., self-efficacy), the role of other anxiety-management procedures in facilitating the reduction of within-exposure-session anxiety levels, examining the extent to which this reduction is an important mediator of overall functioning.

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Received February 9, 1987 Revision received June 18, 1987

Accepted July 2, 1987 �9

treatment of severe social phobia: effects of guided

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