CBT for Social Anxiety Disorder: An Immigrant Case Study

Demographic Information and Identifying Problem

The client, a 38-year-old married male, recently contacted a faculty anxiety clinic seeking treatment. At the time he contacted the center, he self-reported experiencing social anxiety in different settings — for instance, when talking to strangers, speaking or writing in front of a group, and in hostile situations. He also reported that he often avoided these settings because of social anxiety. He specifically pointed out that writing in front of a group of people was one of the worst experiences he had to endure regularly, due to the nature of his work (Weiss, Singh, & Hope, 2011).

According to his self-reports, the client was born in Central America and immigrated to the United States when he was about 8 years old. He stated that he had experienced social anxiety since childhood, before moving to the United States. As a child, he had moved from a rural village where most people spoke an indigenous language to a city where the majority conversed in Spanish. At that point in his life, he began feeling anxious when interacting with others because he feared they would think less of him if they discovered he could not speak Spanish fluently.

He noted that from that point onward there remained a number of situations that caused him anxiety, and that as an adult he had turned to alcohol as a coping mechanism. On a more positive note, he reported that he had recently become sober and purchased a self-help book to assist with his social anxiety. He nonetheless felt that clinical therapy was the only way to completely eliminate his negative thought patterns (Weiss, Singh, & Hope, 2011).

Referral, Treatment Setting, and Diagnostic Evaluation

Referral to a specialist capable of handling the case was required, and it was agreed that the client should be sent to a mental health specialist. Different cases require different types of referral; at times it is best to refer a patient to a community mental health interdisciplinary team. Such teams are typically composed of professionals from various disciplines who collectively contribute to better patient outcomes. These professionals include social workers, occupational therapists, clinical psychologists, psychiatric nurses, and psychiatrists, among others. Normally, one individual from the team is appointed to conduct a re-evaluation of the condition. That specialist will typically inquire about previous interventions and their outcomes, identify risk or contributing factors, and assess the social support available to the patient. The specialist may then develop an individualized intervention plan addressing both symptoms and underlying causes, which may include pharmacological treatment, psychological intervention, or a combination of both (Generalized anxiety disorder in adults — Treatment, 2014).

A Caucasian-American woman with a doctorate in clinical psychology handled this case. She is a licensed clinical psychologist with expertise in treating various types of anxiety disorders and supervised the treatment process. The psychological intervention consisted of seventeen sessions concentrating on cognitive exposure, cognitive restructuring, and psycho-education, utilizing Hope and colleagues' (2000) Managing Social Anxiety: A Cognitive-Behavioral Approach manual. Each of the seventeen sessions was fifty minutes long, with one session per week. The Social Anxiety Session Change Index (SASCI) measures and corresponding treatment sessions were used to evaluate the client's progress (Weiss, Singh, & Hope, 2011).

The symptoms the client reported were consistent with those described under Social Anxiety Disorder (SAD) in the Anxiety Disorders Interview Schedule for DSM-IV, with no additional diagnoses. Problematic symptoms included experiencing anxiety when talking to strangers, speaking or writing in front of a group, when reprimanding others, or when being the center of attention. A clinician's severity assessment was conducted using the ADIS-IV, and the client received a severity rating of 5 out of a maximum of 8, indicating symptoms between moderate and severe. He also noted that his condition caused difficulties at work and in educational settings. One of the most problematic daily challenges was writing in front of others, which his job required. He noted that the condition also limited the types of employment he could pursue, as he was only comfortable in roles requiring minimal interaction with others. He had enrolled in a computer literacy program but did not complete it, fearing he might have to speak in front of the entire class if he needed clarification on an issue (Weiss, Singh, & Hope, 2011).

Assessment Measures

The BFNE is a twelve-item assessment tool that measures the degree to which an individual believes that others view them unfavorably — a characteristic considered central to social anxiety. Respondents rate the extent to which each item is characteristic of them. The BFNE demonstrates good reliability, and its scores correlate with measures of depression and loneliness. This measure was administered in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011).

The SIAS is a twenty-item measure of anxiety during social engagements. Respondents indicate, on a scale of 0 to 4, how characteristic each item is of them, with 0 meaning "not true" and 4 meaning "extremely true." Individuals with social anxiety have consistently scored higher on this scale than those without the condition, supporting its validity. The SIAS also demonstrates above-average internal consistency. This measure was administered in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011; Hope, Heimberg, & Turk, 2010).

The SPS is a twenty-item measure of anxiety when performing actions in the presence of others. As with the SIAS, respondents indicate on a scale of 0 to 4 how characteristic each item is of them. Total scores range from 0 to 80, and a score of 24 or above indicates social anxiety disorder. Research has demonstrated the scale's utility as a discriminator with strong divergent and convergent validity, as well as above-average internal consistency and test-retest reliability. This measure was administered in the 1st and 17th sessions (Weiss, Singh, & Hope, 2011).

The SASCI is a 4-item measure typically administered one week before each session. The client reports the extent to which they believe they have changed since treatment began across four dimensions: problems associated with SAD symptoms, feelings of shame or embarrassment in social situations, avoidance of social interactions, and general anxiety toward social engagement. Responses are recorded on a seven-point Likert-type scale, with 1 indicating negative change, 4 indicating no change, and 7 indicating significant positive change. Research has demonstrated that the SASCI has good sensitivity to change, discriminant validity, and internal consistency. The index was administered after every session except the fourth (Weiss, Singh, & Hope, 2011).

As part of the overall intervention, a Fear and Avoidance Hierarchy was collaboratively developed during session four. After generating a list of feared scenarios, the client was asked to rate both the degree of anxiety each scenario elicited and how frequently he avoided it. Anxiety severity was rated on a scale of 0 to 100, with 0 indicating no anxiety and 100 indicating extreme anxiety. Avoidance was similarly rated on a 0 to 100 scale, with 0 indicating no avoidance and 100 indicating total avoidance. Fear and avoidance ratings were obtained during the 4th and 17th sessions (Weiss, Singh, & Hope, 2011).

Cognitive restructuring sessions focused on identifying and modifying negative thought processes, with advanced sessions targeting core beliefs. All anxiety-exposure sessions were conducted in two formats: worksheet assignments and in-session role-playing (Weiss, Singh, & Hope, 2011).

The mental status assessment in this case constituted a structured evaluation of the client's cognitive and behavioral functioning. It encompassed assessments of higher cognitive abilities, mentality and insight, thought and perception, mood and affect, speech and motor activity, attentiveness, level of consciousness, and general appearance and behavior. Among these indicators, the most clinically relevant were constructional ability, memory, language, attentiveness, and abstract reasoning. Unlike other assessment forms, the mental status evaluation is a more structured and systematic approach. Because such evaluations can be threatening and require full client cooperation, it was determined that this evaluation should be conducted at the end of the examination process, when the client could be more at ease and some degree of rapport had been established. An effective clinician begins assessing informally during normal physical and history evaluations, noting the client's attitude, affect, attentiveness, behavior, and appearance, and then applies a structured framework to record these observations as clinically meaningful measures. When indications of serious psychiatric conditions are present — such as deviant thinking or behavior, neurological irregularities, or difficulties with daily activities — a formal evaluation of specific cognitive abilities should be conducted near the end of the assessment process. When the need for psychiatric evaluation has been established, the patient should be fully informed of the purpose and rationale of the evaluation to secure their cooperation and prevent resistance (Martin, n.d.).