Peter Trower

New theoretical conceptions of social anxiety and social phobia

Abstract In this theoretical paper, it is argued that social anxiety arises from the activation of an evolved mechanism for dealing with intra-species (conspecific) threat, a mechanism which has played a vital role in the evolution of social groups. A model is developed showing how this “agonic” mode of defense, working through the psychological systems of appraisal and coping, leads the socially anxious to perceive others as hostile dominants, to fear negative evaluation from them and to respond, at one level of the disorder, by appeasement and submissive behavior, and at a more severe level of the disorder, by more primitive actions such as escape or avoidance. A further theme put forward is that the socially anxious person appears unable to recruit another evolved mechanism for social relating called the “hedonic” mode, in which social groups are structured in terms of cooperation, equality, and mutual support. Some therapeutic implications of these concepts are explored.

A new scale (SES) to measure engagement with community mental health services

The need for a measure of engagement with Community Mental Health Services has been identified. This article reports on the development and preliminary psychometric evaluation of a scale, Service Engagement Scale (SES), to measure engagement with community mental health services. Five Community Psychiatric Nurses completed the SES for 66 clients receiving Assertive Outreach services with an ICD-10 diagnosis of schizophrenia. Test–retest reliability of the subscale items and scale total is in the good to excellent range. Validity is supported by good internal consistency and by the criterion group method. Although preliminary psychometric results are promising, further psychometric study is necessary to evaluate the scales factor structure. The SES appears to evaluate engagement with services, and may therefore be a useful tool to identify areas of concern with clients experiencing engagement difficulties.

The Treatment of Social Failure A Comparison of Anxiety-Reduction and Skills-Acquisition Procedures on Two Social Problems

The differential response of two forms of social failure-primary and secondary-to two forms of treatment—a skills-acquisition procedure and an anxiety-reduction technique-was studied. Twenty socially unskilled (primary) patients and 20 socially phobic (secondary) patients were given either systematic desensitization (SD) or social skills training (SST). The unskilled patients responded more to SST, as predicted, in that they reported significantly less difficulty in social situations, went out more, and improved on their personal behavioral deficits. The phobic patients responded equally well to both therapies. The success of SST in both kinds of problems is explained in terms of an unpredicted dual role, in that it reduced anxiety as well as facilitated behavior change. This is discussed in the light of current theories of anxiety reduction.

Improving psychological adjustment following a first episode of psychosis: A randomised controlled trial of cognitive therapy to reduce post psychotic trauma symptoms

There are few evaluated psychological interventions or theoretical approaches which are specifically aimed at reducing problems related to adjustment and adaptation following a first episode of psychosis. The present study tests the efficacy of a form of CBT (Cognitive Recovery Intervention; CRI) in reducing trauma, depression and low self esteem following a first episode of psychosis, in a single-blind randomised controlled trial. A total of 66 patients who had recently experienced a first episode of psychosis were randomly assigned to CRI or treatment as usual (TAU) and followed up at 6 and 12 months. People receiving CRI tended to have lower levels of post-intervention trauma symptoms and demonstrated greater improvement than those receiving TAU alone. This was especially the case at 6 months for those with high pre-treatment levels of trauma. There was, however, no advantage for the CRI group with regards to reduced depression or improved self esteem. In conclusion, CRI appears to be an effective intervention to help young people adapt to the traumatic aspects of a first episode of psychosis although further evaluation in a larger study is warranted.

Psychometric properties of the Hospital Anxiety and Depression Scale with a population of members of a depression self-help group.

This paper reports the psychometric properties of the Hospital Anxiety and Depression Scale when used with 341 members of a self-help group for people with depression. We report internal reliability and factor structure for the complete data set and factor structure for groups split by gender, previous hospitalization for depression and current use of medication for depression. In each instance the factor structure reflects the intended depression and anxiety subscales. We comment on the usefulness of the HADS in studies of cognitive processes in depression and anxiety.

A survey of social inadequacy among psychiatric outpatients.

An investigation into the extent and nature of social inadequacy among outpatients diagnosed as neuroses and personality disorders was undertaken on patients aged 18-49 attending one clinic over a six-month period. A feature of this survey was that each patient took part in a standard social interaction test, and their performance was assessed by two psychologists. A relatively high proportion of patients, one in six on the most conservative estimate, and probably over one in four, were judged by psychologists and psychiatrists to be socially inadequate, and the results showed a clear pattern of behavioural, social and personality factors associated with these judgements. Implications for assessment and treatment are discussed.

The balance of power in therapeutic interactions with individuals who have intellectual disabilities

OBJECTIVES Establishing a collaborative relationship is a cornerstone of cognitive behavioural therapy (CBT). Increasingly CBT is being offered to people with intellectual disabilities who may have problems with receptive and expressive communication, and a history of disadvantage or discrimination in their relationships with those in positions of power. Consequently, they may have difficulty establishing a collaborative interaction with their therapist. This paper uses a novel method of interactional analysis to examine if collaboration increases as therapy progresses. DESIGN AND METHODS Fifteen participants with borderline to mild intellectual disabilities and significant problems of depression, anxiety and anger were recruited from specialist clinical services to participate in this study. Verbatim transcripts of therapy sessions 4 and 9 were coded using an initiative-response method of analysing power distribution in dialogue, to investigate collaboration at the level of therapeutic interaction. RESULTS The initiative-response scores indicated that power was relatively equally distributed between clients and therapists. On this measure there was no significant increase in collaboration as therapy progressed, as the dialogues were relatively equal from session 4. Analyses of the pattern of interaction showed that whilst the therapists asked most questions, the clients contributed to the flow of the analysis and played an active part in dialogues. CONCLUSIONS The implications of these findings are discussed, along with the possible uses of such interactional analyses in identifying barriers to communication and ways of establishing effective therapeutic dialogue.

Measuring Negative Person Evaluations: The Evaluative Beliefs Scale

We report the development and a preliminaryanalysis of the Evaluative Beliefs Scale (EBS). The EBSmeasures negative person evaluations, a key class ofbeliefs within cognitive psychotherapy and thought to be closely linked to emotional disturbance.Three hundred ninety-four members of a UK-basedself-help group called Depressives Anonymous completedthe EBS and the Hospital Anxiety and Depression Scale (HADS). The EBS was found to have good internalreliability, a clear factor structure and concurrentvalidity when compared with the HADS. We believe the EBSmight have utility for clinical research and practice, not only as an assessment and outcomemeasure but also for testing hypotheses aboutconnections between cognitions and emotions.

Social Anxiety, Evolution, and Self-Presentation

An old but radical idea in social psychology is that the “person” is not a passive product—of environmental conditioning or genetic abnormality or biochemical factors or unconscious psychic phenomena—but is an active creation of the individual him- or herself (Gergen, 1984). Any approach to understanding and studying social anxiety has to take a position on this issue, since it has a major influence on subsequent model building, research, and therapeutic developments. Clinical psychology and psychiatry have traditionally favored one or other versions of the former paradigm, that people are products of various forces, be it internal or external. However, variants of the latter idea (that people are agents of their own creation [Trower, 1984, 1987]) is now well established in social psychology and becoming an emergent paradigm in the clinical field. For example Heimberg, Dodge, & Becker (1987) list five models of social phobia, all of which are arguably of the latter rather than the former school. Following Goffman’s seminal dramaturgical model (Goffman, 1959), the explicit or implicit theme in these types of models is that individuals are the architects of their own self-presentations, are motivated to present themselves favorably, and social anxiety is a fear of negative evaluation of the self that is likely to follow from predicted failures in self-presentation performances.

The Person in Recovery From Acute and Severe Psychosis: The Role of Dependency, Self-Criticism, and Efficacy

The role of 3 personality dimensions (i.e., dependency, self-criticism, and efficacy) in recovery from an acute and severe psychosis was examined. Conceptualizing psychosis as involving difficulties in establishing psychological boundaries, the authors hypothesized that dependency has a greater disruptive effect on recovery than self-criticism. Results of a reanalysis of longitudinal data (N = 76) of people with schizophrenia spectrum disorders during recovery from acute psychosis were consistent with this hypothesis: Dependency predicted depressive and negative symptoms, and, under low efficacy, perceived loss of independence and insight into the presence of the illness. These findings elucidate the central role of interpersonal relatedness as a foundation for self-definition in recovery from psychosis.