I chose to research the Cognitive Behavioral Therapy (CBT) approach developed by Beck. This decision was not easy since I appreciated the focal points of each cognitive therapy. However, my impression is that it is particularly essential to learn CBT due to the great variety of applications and large modern evidence base supporting this approach. Furthermore, CBT shares characteristics and integrates techniques from all the other cognitive therapies (Beck, 2011). I opine this makes CBT highly customizable to the client. CBT treatment is based on an individualized, ever-evolving conceptualization and a focus on cognitive change (Beck, 2011). It is necessary to consistently collaborate with the client, especially to develop conceptualization and form goals. The therapist and client can problem solve together to reach consensus in therapy. Although, eventually the client will be given more freedom to practice skills by becoming increasingly active and independent in therapy. This will help the client continue to apply CBT concepts once therapy is terminated. CBT aims to be time limited and is highly structured; planning, review, collect data (e.g., mood check), discuss pertinent problems to solve, teach skills, summarize, homework, and feedback (Beck, 2011). Each session is structured to meet specific goals. Sometimes therapy does delve into the past, however, CBT is mostly concerned with present issues (Beck, 2011). I understand the CBT therapist to only delve into the past when it is a pertinent part of client conceptualization or if the client is highly interested in making those connections and requires attention to the past to move forward. The basic assumption when using CBT is that a certain pattern of dysfunctional thinking underlies each disorder (Beck, 2011). I find CBT conceptualization and treatment to be very sensible and thorough.
Theoretical Foundation
The theoretical foundation of CBT is quite straightforward. Beck (1963) asserted that usually unpleasant thoughts precede unpleasant affect. Furthermore he stated, these thoughts had systematic errors (i.e., “cognitive distortions”) like arbitrary inference, selective abstraction, overgeneralization, exaggeration, and exact labeling. The cognitive model can be used to understand that interpretations of a situation, based on beliefs and expressed through automatic thoughts, lead to emotional, behavioral, and physiological consequences (Beck, 2011). For example, someone may be turned down to a date and think, “no one loves me,” and decide to give up dating. However, upon examining the truth in the statement an individual may realize their family loves them. Furthermore, I think it is important to keep in mind the behavior (i.e., withdrawal or avoidance) also reinforces negative thoughts and beliefs. It is also of import that triggering events can have some complexity and are unique to the individual, for example, having trouble concentrating can trigger negative automatic thoughts, or images, which lead to nervousness and other negative thoughts. Changing thinking, especially core beliefs, to be more realistic and adaptive helps alleviate symptoms and increase functioning (Beck, 2011). Thus, a client that believes they are unlovable will have symptoms (i.e., consequences of beliefs), such as depression, reduced when their negative beliefs are diminished.
Brief History
CBT was developed, much like other therapies, when a psychology practitioner found a gap or limitation in their treatment(s). On psychotherapy.net (n.d.) Aaron Beck explained that he created cognitive therapy from findings through his studies that suggested depressed people perceive events more negatively than others. He stated depression was likely an evolutionary protection to conserve energy during times with perceived little resources. Basically, Beck identified patterns of thinking common to depression that also were explanatory of depression. He likely also noticed that his clients required assistance addressing these thoughts. Dr. Beck helped patients identify and address maladaptive thinking with success and then went on to teach others and finally developed the first manual in 1979 (Beck, 2011). Since then CBT has been widely practiced. CBT grew from Beck’s original studies and model on depression to be a treatment well-suited for a diverse population with a wide range of disorders and concerns (Beck, 2011). It is possible that CBT became popular primarily due to the ability to directly address issues in a short period of time.
Automatic Thoughts
Automatic thoughts are one of the main driving forces in symptomatology using the CBT approach. Individuals can have many automatic thoughts throughout the day (Beck, 2011). For example, automatic thoughts may be present while writing a final paper. According to Beck (2011), healthy individuals may do a reality check when aware of their thoughts. However, he explained most people are unaware of thoughts and more aware of feelings; CBT therapists use guided discovery to help clients identify thinking. Furthermore, some automatic thoughts are valid and others are irrational or unhelpful (Beck, 2011). For example, “I made a mistake” may be valid while “I am a total failure” is not. The thought “I am a failure” could lead an individual to procrastinate and possibly fail. In this way these thoughts are pervasive daily obstacles that lead to vicious circles. CBT helps by addressing automatic thoughts first and then beliefs (Beck, 2011). Automatic thoughts are separate concepts in CBT than beliefs.
Intermediate and Core Beliefs
Beliefs are the foundation to thoughts and actions. Beliefs can be about the self, future, and the world, which is called the cognitive triad (DeRubeis et al., 2010).There are two types of beliefs pertinent to CBT conceptualization: core beliefs and intermediate beliefs. These beliefs are exceedingly emotionally charged and personal. Core beliefs underlie intermediate beliefs and automatic thoughts. According to Beck (2011) core beliefs are global, rigid, and overgeneralized. He described intermediate beliefs as rules, attitudes, and assumptions. For example, an assumption can be, “If I quit dating I won’t feel as bad.” The core belief of a client with the former assumption may be, “I am unlovable.” The typical schema of depressed clients has themes of low self-esteem, self-blame, overwhelming responsibilities, and desires to escape (Beck, 1963). Examples of core beliefs are: “I am incapable,” “everything is my fault,” “I am powerless,” and “I am unimportant.” Situations that trigger these beliefs will likely result in maladaptive coping. Core beliefs are more difficult to uncover than automatic (i.e., surface level) thoughts.
Guided Discovery and Behavioral Experiments
Guided discovery and behavioral experiments, I opine, are integral to CBT. These interventions address the main goal in therapy: cognitive change. Guided discovery begins as a series of questions used to unveil upsetting cognitions and gain distance; then, evaluate validity and decatastrophize fears (Beck, 2011). An example of a question is, “what other explanations for the situation are there?” These questions open up alternative options and create more flexible thinking. On the other hand, behavioral experiments are used to directly test a client’s thinking (Beck, 2011). In this way the client can have ‘concrete’ proof that some cognitions are invalid. According to Beck (2011), testing negative predictions in therapy can have a more significant impact than simply discussing validity of thoughts. For example, a client may think that the mere sight of a spider will be too much to handle. This prediction can be tested safely in therapy by viewing an image of a spider in a book or online. A client may think that others are disgusted by scars and a survey can be done to test this thought. Guided discovery and behavioral experiments can do a lot to diminish negative and irrational beliefs.
Other interventions
There are many other CBT interventions that can further help clients overcome their limiting thoughts. Throughout therapy the therapist will focus on strengths and positives with the goal of helping clients feel better by the end of each session (Beck, 2011). Focusing on positives will increase the clients’ self-esteem and assist in positive change and likely decrease drop-out risk. The therapeutic alliance is also essential and can be seen as an intervention in itself. Beck (2011) stated a good alliance can help the client feel likeable, less alone, more optimistic, and with a greater sense of self-efficacy. Another vital early intervention is activity scheduling (i.e., behavioral activation) (Beck, 2011). It can be especially helpful to schedule easier activities first and ensure that negative thoughts that may arise during these activities are addressed. Behavioral activation and problem-solving can be paired to create a meaningful life for the client. Weighing advantages and disadvantages, as part of problem-solving, can be helpful to clients in many ways. “[CBT includes] problem solving, making decisions, refocusing, relaxation and mindfulness, coping cards, graded task assignments, exposure, role play, the “pie” technique, self-comparisons, and credit lists” (Beck, 2011, p. 256). Refocusing is interesting, it is beneficial when someone may need to simply accept their thoughts in the moment to complete an important task. Splitting a task into more manageable steps is also helpful. Imagining and distancing can be used to reduce distress and widen perspective (Beck, 2011). Jumping into the future, by asking “what happens next,” with an image can create distance. One of the greatest benefits of CBT is the option to be creative with these interventions which can be optimized for the clients needs.
Application of CBT for Asians with Social Anxiety Disorder
The population I selected to discuss is people of Asian descent with Social Anxiety Disorder (SAD). According to the American Psychiatric Association (2013), the criteria for social anxiety disorder is fear of social situations or embarrassment provoked almost always by certain social situations which leads to avoidance. Furthermore, they stated the fear is out of proportion to real danger, fear persists for more than six months, and there is significant distress. I thought that the Asian culture would be interesting to research since social norms are quite different from Western social norms. For one, Asian culture is collectivistic compared to the Western individualistic culture. Respect for one another is highly valued for Asians (Hays, 2009). This is especially true concerning respect for elders. In the United States people value respect, however, I view the respect in Asian and collectivistic cultures to be more external and obvious. For example, certain Asian cultures expect external shows of respect for greetings. It is also noteworthy that reciting strengths could be seen as immodest to Asians (Hays, 2009). These factors could have some effect on the presentation of social anxiety. However, Asian Americans have been found to endorse anxiety symptoms less than other groups (Marques et al., 2011). It is possible that Asians are less likely to admit they need help and seek it. I think CBT would be a good approach for individuals of Asian descent with SAD.
Overall Cognitive Social Anxiety Conceptualization
There has been an extensive variety of research into the cognitions that drive social anxiety, however, there is still room to research other cognitive factors relevant to SAD. Data has supported cognitive models of SAD especially concerning biased information processing (Nishikawa et al., 2017). SAD is similar to the conceptualization of depression concerning biased information processing. According to Musa et al. (2002), people with social phobia show an attentional bias toward social-threat words. Cognitive models of social anxiety disorder historically emphasized fear of negative evaluation and embarrassment; those with SAD believe the world is inherently critical and they are inadequate or unlikeable (Nishikawa et al., 2017). This fear is thought to cause extreme discomfort in social settings. Those with SAD tend to believe they are boring, a failure, and overall socially defective. Cognitive conceptualizations of SAD also emphasize perfectionism, self-criticism, approval, and dependency (Nishikawa et al., 2017). Gregory et al. (2018) found that the reduction of maladaptive beliefs relating to self and others’ evaluations predicted reductions of social anxiety symptom severity. Overall fear of negative evaluation(s) seems to be the most central component of SAD.
Comparison of Cognitive Models on Social Anxiety
The cognitive models are similar, however, each model offers a unique explanatory aspect of social anxiety. According to Wong et al. (2014) the Clark and Well’s cognitive model of SAD features a core conceptualization that individuals with SAD have a strong desire to make a favorable impression yet are insecure about their ability to do so. They explained that those with SAD likely predict failure and catastrophic consequences like loss of status and value. For example, someone with SAD may believe even slight inappropriate social behavior will result in shunning and harsh criticism. Wong et al. (2014) described another model, by Rapee and Heimberg, based on the idea that social threat is perceived on a continuum and those with SAD are at the high end of that continuum. Thus, individuals with SAD are more likely to perceive social mistakes and consequences to be severe. When comparing both models there was agreement that those with SAD give excessive attention to threat cues, have maladaptive avoidance, and dysfunctional cognitions about self, standards, and expectations (Wong et al., 2014). A more recent cognitive-behavioral model of SAD was developed by Hofmann (2007), he added to past models that those with SAD have difficulty planning and implementing goal attainment. He underscored in the model high perceived social standards, poorly defined social goals, heightened self-focused attention, negative self-perception, high estimated social cost, low perceived emotional control, perceived poor social skills, avoidance, and rumination. Wong et al. (2014) also described two other models, Moscovitch’s model that focuses on feared self-appraisals that highlight flaws (“will have nothing to say, hands will shake, I am ugly, I am stupud”); Stopa’s model which emphasizes that negative self-representations are too easily retrievable for those with SAD. Moscovitch’s model was especially interesting, those with SAD may experience more distress when a core feared self-appraisal is triggered. I opine all of these models offer helpful and valid conceptualizations of SAD.
Cognitive Therapy and Asians
CBT models have been devised to effectively address those of Asian descent. Early cultural adaptation models emphasized therapist match (ethnicity and language) and incorporated elements of the clients’ beliefs and worldviews (Hall et al., 2019). Clients may feel more at ease with a therapist that has a similar background; clients may believe they will only be understood by someone of their culture. However, a therapist of similar background may not always be available. Either way, it is essential to adapt therapy to the client to avoid early dropout. Asian Americans underutilize mental health services and have higher rates of premature termination (Hall et al., 2019). To properly serve this community a therapist must know what types of adaptations are most effective. An early cultural model added to the list of possible adaptations: metaphors, concepts, and goals among other factors (Hall et al., 2019). I would also add symbolism (e.g., the coy fish, lotus, cherry blossom) to the list of cultural adaptations. According to Hall et al. (2019), Asian Americans may especially appreciate cultural credibility, gift-giving, and immediate attention to somatic problems. A book recommendation could be seen as a gift. Hall et al. also discussed how Asian Americans incorporate family and community into their self identity; they may require interventions that maintain or create group harmony. For example, to ensure group harmony an Asian client may not respond well to interventions that will upset his or her family. Encouraging clients to neglect family obligations may not be the best approach, instead, making the clients’ family obligations more manageable would be more helpful. Addressing indirect communication and eliciting feedback that may be suppressed is also beneficial when working with an Asian individual (Hall et al., 2019). Psychologists must be mindful of these factors and integrate adaptations to ensure therapy is relevant and clients remain engaged.
Cognitive Therapy for Asians with SAD
In addition to cultural adaptations specific to Asians in general there are important considerations for Asians with SAD. In East Asian culture the principal cognitive concern for those with SAD is disruption of social harmony (Marques et al., 2011). Taijin-kyofusho (TKS) is similar to SAD and is closely related to social harmony. TKS is a cultural syndrome in East Asia where those affected are preoccupied with offending others through bodily characteristics, however, this has been extended to include fears that anxiety itself would cause discomfort to others (Nishikawa et al., 2017). Those with TKS fear offending others by blushing, staring, smell, and facial expression (Marques et al., 2011). This conceptualization differs from some cognitive models that focus on inward reflection and personal consequences. Breaking social rules in a collectivist culture may be met with harsh criticism and even shunning. Thus, the fear of greater consequences may be more defensible in this community. Furthermore, collectivist cultures have more social rules; it is possible that this causes a hyper-awareness of social behaviors. According to Lau and Sündermann (2019) harsh discipline, dependent social standards, and culture of shaming affect social anxiety among Asians. More research is needed; nonetheless, psychologists should collaborate with clients to gain insight on how culture may be contributing to the disorder.
Research
The efficacy of CBT has been widely supported in research. Some studies suggest that CBT is a better intervention than pharmacology. Mayo-Wilson et al. (2014) conducted a systematic review and network meta-analysis and found that individual CBT is the best intervention for initial treatment of social anxiety disorder. They compared CBT to pharmacological and other therapies such as psychodynamic, interpersonal, mindfulness, and supportive therapy. Interestingly, they did not find that combining CBT and pharmacological interventions (which we both efficacious alone) increased efficacy. These findings show that CBT can be used along and is the preferable option for treating SAD. Davidson et al. (2004) compared fluoxetine, comprehensive cognitive behavioral group therapy, and placebo; they found that active treatments were significantly better than placebo effects. However, the effect sizes of treatments were moderate with cognitive behavioral group therapy and placebo used together having the highest effect size. Furthermore, fluoxetine generated a faster response, although it was associated with adverse somatic effects. Pharmacological treatments are beneficial. However, there is less risk using CBT.
Those of Asian descent seem to respond best to certain stimuli and CBT can engage them accordingly, evidence of the efficacy of the treatment. According to Hall et al. (2019), findings indicate that the efficacy of treatment for Asian Americans depends somewhat on ethnic match and relevant content (e.g., academics). In their study they found that Asian American’s consider the ability of the therapist to relate essential (ehtnic match), however, they may rather talk to someone outside of the community to avoid being embarrassed or ashamed. This confirms that the flexibility inherent in using CBT is beneficial for this population. The therapist can adapt therapy to ensure it is relevant to the client. Furthermore, the therapist does not have to be an ethnic match to provide understanding. It is essential that the therapist collaborate with the client and be culturally competent. According to Nishikawa et al. (2017), those with social anxiety disorder (SAD) worry about causing discomfort to others and found evidence to confirm this. They also found that cognitive behavioural group therapy significantly reduced these worries. Asian’s may be especially sensitive to the discomfort of others. A CBT practitioner has the means to adapt therapy to this population’s needs.
Lastly, the research does support CBT specifically for those of Asian descent. Lau and Sundermann (2019) described a case study for a 25-year-old Chinese female; after 21 weeks symptoms went from severe to non-clinical. They stated behavioral experiments, schema formation (origins) and insights, and imagery rescripting were key interventions. They paid special attention to reworking her internalized cultural beliefs on filial piety to reduce shame. CBT was adapted to address cultural concerns and proved effective. Chen et al. (2007) conducted a study on Japanese people with SAD using CBT. They found that CBT was as efficacious among Japanese clients as Western clients. Their group CBT program reduced symptoms measured by 20 to 30%. Interestingly they found no substantial differences between those with SAD and TKS. Thus, SAD and TKS are similar enough that CBT is effective for both, transcending cultural divides. CBT can be used with confidence for Asians with SAD.
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