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2014 13: 128 originally published online 23 September 2013Clinical Case StudiesCrystal C. McIndoo and Derek R. Hopko

DepressionCognitive-Behavioral Therapy for an Arab College Student With Social Phobia and

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Article

Cognitive-Behavioral Therapy for an Arab College Student With Social Phobia and Depression

Crystal C. McIndoo1 and Derek R. Hopko1

AbstractCoexistent social anxiety disorder (SAD) and major depression can be highly debilitating and cause significant interference with social, occupational, and educational functioning. Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for SAD and allows for flexibility in treating individuals of diverse cultural backgrounds. At present, treatment outcome research on the efficacy of CBT among Arab individuals with anxiety and mood disorders is highly limited. The current case study presents the implementation of a manualized CBT protocol for an Arab male with SAD and a secondary diagnosis of major depression. With attention to unique cultural influences on the development and maintenance of his symptom presentation, treatment consisted of 14 individual sessions, with outcome data yielding significant reductions in social anxiety, somatic anxiety, and depression at the posttreatment assessment. This case study demonstrates the potential efficacy of manualized CBT for SAD among Arab individuals and highlights the need for further systematic investigation using randomized controlled trials.

KeywordsArab culture, social phobia, cognitive-behavioral therapy

1 Theoretical and Research Basis for TreatmentBackground and Prevalence of Social Anxiety Disorder (SAD) and Depression

Anxiety and depressive disorders are common among college students, with prevalence rates ranging from 15% to 20% (American College Health Association, 2012; Eisenberg, Gollust, Golberstein, & Hefner, 2007; Gallagher, 2010). These conditions are often accompanied with substance abuse problems (Weitzman, 2004; Wu, Pilowsky, Schlenger, & Hasin, 2007) and are also associated with significant functional impairment, including less frequent engagement in social, physical, and educational behaviors (Hopko & Mullane, 2008); poorer academic perfor-mance and decreased retention (Gallagher, 2010; Pritchard & Wilson, 2003); and increased

1The University of Tennessee–Knoxville, USA

Corresponding Author:Derek R. Hopko, Department of Psychology, The University of Tennessee–Knoxville, 307 Austin Peay Building, Knoxville, TN 37996-0900, USA.Email: [email protected]

504132 CCS13210.1177/1534650113504132Clinical Case StudiesMcIndoo and Hopkoresearch-article2013

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vulnerability to interpersonal problems (American College Health Association, 2012; Barrera & Norton, 2009; Eisenberg et al., 2007).

SAD is characterized by a fear of social situations where an individual is exposed to possible social evaluation, fears behaving in an embarrassing or humiliating manner, and actively avoids social situations or endures them with extreme distress (American Psychiatric Association [APA], 2013). Recently updated SAD diagnostic criteria (APA, 2013) involve a shift from the patient having to recognize the social fear response as excessive or unreasonable to the clinician being more involved in this judgment. In addition, there is now the requirement that symptoms be pres-ent for a minimum of 6 months in adults. The lifetime prevalence rate for SAD is approximately 12% (Grant et al., 2005; Kessler, Chiu, Demler, & Walters, 2005), and epidemiological studies suggest SAD is one of the most common anxiety disorders (Ferrari et al., 2010; Kessler et al., 2005). Individuals with SAD often have coexistent psychological disorders, such as major depression or substance abuse (Kessler, 2003), and among younger adults with depression, SAD is the most commonly occurring comorbid anxiety disorder (Stein et al., 2001). SAD often has long-term negative effects on interpersonal, occupational, and educational functioning (Barrera & Norton, 2009; Heimberg, Stein, Hiripi, & Kessler, 2000). Individuals diagnosed with SAD and major depression report more distress and more intense suicidal ideation, more frequently attempt suicide, have a more prolonged clinical course, and have increased academic, social, and occu-pational dysfunction relative to individuals presenting with either condition alone (Bruce et al., 2005; Stein et al., 2001).

Cultural Context

Consistent with prevalence data collected in the United States, SAD is highly common among Arab college students (12%-13%) and is more prevalent among younger adults in the Arab culture (aged 18-34 years; Chaleby, 1987; Iancu et al., 2011). Among Arab individuals, SAD is diagnosed more often in those who are unmarried as well as those with higher education and occupational status (Chaleby, 1987; Iancu et al., 2011). The prevalence of SAD in Arab individuals as a function of gender has not revealed consistent differences, although there are more compelling data suggesting SAD in Arab cultures is more common in females (Iancu et al., 2011; Karam et al., 2006). Interestingly, Arab college students appear less likely to seek psychological treatment for SAD compared with other college students (Iancu et al., 2011; Karam et al., 2006; Levav et al., 2007). This finding suggests potential cultural barriers may be operative, such as mental health stigmas, financial barriers, limited access to health care, and decreased psychological awareness, factors that may prevent Arab individuals from receiving treatment for SAD (Iancu et al., 2011). It has also been found that (younger) adult Arab individuals with higher education are less willing to conform to societal norms, which may be related to increased risk for developing SAD (Chaleby, 1987; Iancu et al., 2011). Increased desire for individuation, social skill deficits, and reduced self-expression also may increase risk for SAD in Arabs (Iancu et al., 2011). As Arab culture is largely collectivist, Arabs also may feel more personal responsibility for political and social behaviors and out-comes, which also may increase stress and anxiety. Individual success and failure reflects on the entire family, so social evaluation is highly salient and may have significant negative repercussions, such as a decline or termination of parental support. Finally, Arab culture requires that people act according to rigid and disciplined moral codes and rituals (Iancu et al., 2011), which can increase the likelihood of responding to social situations with fear and anxi-ety, as there is little margin for error in terms of violating cultural boundaries. Indeed, people in the Arab culture can be outcast rapidly and permanently when social behaviors deviate from the norm to even a small degree.

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Cognitive-Behavioral Theory of SAD

Based on cognitive-behavioral theory, SAD is the result of maladaptive cognitive processes that interfere with an individual’s ability to perform in social situations (Hope, Heimberg, & Turk, 2010; Hopko, McNeil, Zvolensky, & Eifert, 2002; Rapee & Heimberg, 1997). Specifically, indi-viduals with SAD are overly concerned with how others perceive them and often view others as overly critical and judgmental, with excessively high performance standards that are unachiev-able (Hope et al., 2010; Rapee & Heimberg, 1997). Individuals with SAD often believe they are socially inadequate and place great importance on other people’s perspectives and evaluations, which leads to increased self-focused attention and hypervigilance to indicators of social disap-proval (Rapee & Heimberg, 1997). According to cognitive-behavioral theory, a socially anxious individual creates an irrational mental representation of how others perceive his/her external appearance and behavior and simultaneously focuses attentional resources to this distorted men-tal representation and potential social threats, such as being evaluated negatively (Rapee & Heimberg, 1997). Somatic symptoms also frequently occur in response to situations that are social or evaluative (Rapee & Heimberg, 1997). Somatic symptoms are an important component of social anxiety because physiological responses such as difficulty breathing, blushing, shaking, stammering, and sweating can create a negative feedback loop in which the patient recognizes these symptoms, ruminates upon them, and thus may further increase the likelihood of social performance deficits and negative evaluation (Rapee & Heimberg, 1997). Individuals with SAD tend to overestimate the degree that other people perceive them as anxious, rate themselves as more anxious than observers, and judge their social behaviors more critically than observers (Norton & Hope, 2001; Rapee & Heimberg, 1997). Furthermore, they often see social situations as more competitive than nonanxious people and report feeling less adequate (Hope, Sigler, Penn, & Meier, 1998). Given distorted mental representations and biased expectations, socially anxious individuals overpredict the likelihood of negative social outcomes, which is accompa-nied by physical (e.g., sweating, racing heart, hot flashes), cognitive (e.g., fear of embarrassment and rejection), and behavioral (e.g., freezing, stuttering, and avoidance) symptoms of anxiety. SAD is thus a maladaptive cycle in which cognitive distortions and biases lead individuals to misinterpret social cues and facilitate beliefs that they will be negatively evaluated and consid-ered inadequate, creating increased anxiety in future social performance situations (Rapee & Heimberg, 1997).

Treatment Rationale

Psychological interventions for people with SAD include pharmacological treatment, social skills training, cognitive restructuring, relaxation training, in vivo and imaginal exposure, and interpersonal as well as psychodynamic therapy (Barlow, 2008). Treatment outcome research suggests cognitive-behavioral therapy (CBT) that includes a combination of exposure therapy and cognitive restructuring is highly effective in reducing SAD symptoms (Heimberg, 2002; Taylor, 1996). Preliminary data also suggest CBT may be effective for Arab individuals (Nassar-McMillan, Hakim-Larson, & Hakim-Larson, 2003). There are many advantages to using this treatment approach with individuals from collectivistic cultures. For example, CBT is action oriented, present-focused, emphasizes problem solving, and is highly structured and time-lim-ited, making the intervention compatible for individuals with a collectivistic background (Corey, 2008). In addition, the collaborative relationship between the therapist and client matches the values of a collectivistic culture, where individuals prefer therapist expertise, directedness, and an action-oriented approach (Corey, 2008). Furthermore, this approach focuses on an individu-al’s core belief system as a method of self-testing, and works from the client’s value system to integrate cultural variables into treatment. CBT should therefore be well suited for

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Arab individuals presenting with SAD. However, well-designed treatment outcome research evaluating the efficacy of CBT for Arab individuals with SAD is lacking. A recently developed manualized cognitive-behavioral treatment for SAD (Hope et al., 2010) directly addresses cul-tural issues and guides therapists to be aware of culturally specific interpersonal behaviors that may appear irrational to someone with a different cultural background. For example, in some cultures, assertive expression is limited by gender and casual conversation may not be acceptable given someone’s social status. Therapists are thus encouraged to be mindful of clients’ cultural values when developing exposure exercises and homework assignments. Given empirical sup-port for CBT and the cultural sensitivity of this approach, manualized CBT was used in the treat-ment of an Arab male presenting with SAD and secondary major depression (Hope et al., 2010).

2 Case Introduction

“Kamal” was a 26-year-old, unmarried Arab male who was self-referred for individual psycho-therapy at a university psychological clinic. He graduated from a southeastern university in 2009 with a Biochemistry degree and was pursuing medical school. He resided at home with his mother and two sisters. The therapist was a female doctoral student in clinical psychology super-vised by a licensed clinical psychologist specializing in anxiety and mood disorders.

3 Presenting Complaints

Kamal reported that he was experiencing anxiety and depressive symptoms and was seeking treatment for difficulties in social situations. He explained that he had attempted medical school twice and was unable to complete his degree due to social anxiety that inhibited interactions with patients, classmates, and professors. Kamal reported having trouble initiating relationships with other people and interacting in social situations. He stated that it was difficult to communicate with other people, including immediate family members. Depressive symptoms included depressed mood, anhedonia, suicidal thoughts, weight loss, feeling of worthlessness, insomnia, excessive inappropriate guilt, indecisiveness, fatigue, and irritability. He reported a significant family history of depression. He indicated that in February of 2010, he was prescribed an antide-pressant from his primary care physician, but discontinued the medication after 2 months due to side effects. He commenced psychotherapy 21 months later.

During social interactions, Kamal feared he would not be able to express himself adequately and worried that people would subsequently ridicule him. He explained that during his clinical rounds in the hospital, his professor informed him that he needed to take more initiative in engaging with patients. Kamal reported that he was too anxious to initiate conversation with patients and had trouble maintaining eye contact. He reported that he completed one semester of medical school in 2009 but discontinued after feeling overwhelmed by social difficulties. He then attempted to complete his degree 1 year later, at which time he completed approximately three quarters of the year before leaving. At the initiation of psychotherapy, he was enrolled and planning on attending a second medical school in 2.5 months. Kamal stated that he had a close friend who would also be attending and hoped that this social support would assist him in cop-ing with social difficulties.

Kamal stated that he was very sensitive to criticism and was easily offended. For example, he reported that he disliked discussing controversial topics due to fear of saying something humiliat-ing or offensive. He also reported fearing situations where physical contact might occur (e.g., “rough housing”), due to self-perceptions of physical weakness and inadequacy. Kamal stated that he found other people very critical and overly competitive. He also expressed difficulties being assertive and saying “no,” suggesting he would either avoid responding altogether or say “maybe” until the person stopped requesting or a deadline passed. Kamal also mentioned extreme

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fear of informal social events, such as parties, and almost exclusively avoided these events. He was very concerned that social interactions were required in medical school (e.g., study groups, working with patients, and talking with residents), unlike his undergraduate training. Kamal had good psychological insight in that he realized his social difficulties had interfered with his ability to succeed in medical school.

4 History

Kamal was born in Algeria in 1986 where he resided for 3 years, followed by his family moving to Texas. His parents are married, although his father had recently moved to Virginia for an occu-pational transition. He reported living with his mother and two sisters (aged 20 and 23 years, respectively) in the southeast, where he had resided for the past 7 years. His family was planning on selling their home and relocating to Virginia to establish residence with his father. According to Berry’s (2003) model of acculturation, Kamal’s level of acculturation would be considered an attitude of integration in which he was involved with and maintained his Arab culture, and at the same time participated and was invested in learning about American culture.

Kamal stated that he had done well during his undergraduate education and graduated with a high grade point average. He explained that there were limited social requirements to complete his degree in biochemistry. However, he reported long-standing problems with social relation-ships and feeling anxious and inadequate around other people. Kamal could not precisely identify when these symptoms started, but reported that his social anxiety became most problematic approximately 2 years ago when he attempted medical school. He also stated that he started to feel depressed and hopeless about the future at this time, especially pertaining to his future in the medical field. He equated failing in medical school to “failing in life.” His social anxiety symp-toms were perceived as primary to the development of major depression. His depression had started to interfere with his functioning whereby he had trouble getting out of bed, missed classes and appointments, lacked interest in tasks (including school assignments), lacked energy to engage in activities, and had difficulty making decisions.

Kamal reported that he did not drink alcohol or use other substances. He was not currently prescribed medication and had previously taken antidepressants for 2 months in 2010. He reported having suicidal thoughts (e.g., “I do not want to be here anymore”), but stated he had never seriously considered committing suicide. Kamal reported that he had not received any prior psychological treatment, had never been hospitalized, and had no known medical problems.

5 Assessment

Kamal presented as well groomed and attentive during the intake appointment and subsequent therapy sessions. His speech tone and volume were soft, and his speech rate was slow. He was oriented to person, place, and time. He appeared anxious and depressed during sessions as evi-denced by limited eye contact, trembling speech, tense posture, and stiff facial expression. Anxiety was also evidenced by his early arrival to sessions (20 to 30 min) and his abrupt depar-ture following sessions. Kamal’s affect was congruent with his mood. There was no indication of perceptual distortions. He reported suicidal ideation, but no intent or plan. Kamal exhibited nor-mal thought processes and was of above average intelligence. He had good insight into psycho-logical symptoms and engaged in sessions cooperatively and collaboratively.

Kamal was administered The Anxiety Disorder Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994), which is a semistructured interview that assesses for anxiety and depressive disorders. This assessment revealed concurrent diagnoses of SAD and major depressive disorder. His multiaxial diagnosis was as follows:

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Kamal completed several self-report assessment measures prior to and during therapy.

Beck Anxiety Inventory (BAI)

The BAI (Beck & Steer, 1993) is a 21-item questionnaire that measures somatic symptoms of anxiety, with higher scores indicating increased anxiety (range = 0-63). Sample items include “unable to relax” and “heart pounding.” Good psychometric properties have been demonstrated among college, medical, and psychiatric samples (Antony, Orsillo, & Roemer, 2001).

Beck Depression Inventory–II (BDI-II)

The BDI-II (Beck, Steer, & Brown, 1996) is a self-report measure of depression severity over the past 2 weeks and includes 21 items rated on a 4-point Likert-type scale (range = 0-63). Higher scores suggest increased depression severity. Sample items include degree of “sadness” and “loss of pleasure.” The scale has excellent psychometric properties among depressed younger adults (Nezu, Ronan, Meadows, & McClure, 2000).

Social Anxiety Session Change Index (SASCI)

The SASCI (Hayes, Miller, Hope, Heimberg, & Juster, 2008) is a self-report measure of social anxiety, including somatic, cognitive, and behavioral (avoidance) symptoms, as well as level of interference in work, school, or social activities. Four items are rated on a 7-point Likert-type scale (range = 4-28). Questions are answered by comparing feelings in the present relative with how the person felt before treatment (1 = much less than the start of treatment, 4 = not different from the start of treatment, 7 = much more than the start of treatment). Sample items include, “How anxious do you currently become in anticipation of or when in social/performance situa-tions?” and “How concerned are you about doing or saying something embarrassing or humiliat-ing in front of others, or that others might think badly of you for what you do or say?” Lower scores suggest decreased social anxiety since the commencement of psychotherapy. A score of 16 suggests no change has occurred since beginning treatment, scores of 4 to 15 suggest improve-ment, and scores of 17 to 28 suggest deterioration (Hayes et al., 2008). This scale has good inter-nal consistency (Hayes et al., 2008).

6 Case Conceptualization

The case formulation was based on a cognitive-behavioral model of SAD, theorizing that social anxiety is associated with predisposed vulnerabilities to be anxious and that individuals view social situations through cognitive distortions and misrepresentations of the perspectives of observers (Rapee & Heimberg, 1997). From an early age, Kamal reported that he was an anxious

Statistical Manual of Mental Disorders (Diagnostic and Statistical Manual of Mental Disorders; 4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000).

Axis I 300.23 Social Anxiety Disorder 296.23 Major Depressive Disorder, Single EpisodeAxis II V71.09 No DiagnosisAxis III None, by self-reportAxis IV Academic Problems, Social Support ProblemsAxis V Global Assessment of Functioning (GAF) = 65

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134 Clinical Case Studies 13(2)

child who would cling to his mother and sisters when frightened or in unfamiliar situations. Kamal reported that he was the only person in his immediate family who seemed anxious and shy around other people. He mentioned that his mother and sisters were very assertive and domineer-ing. It is possible that growing up with females who had strong personalities may have contrib-uted to feelings of insecurity and inadequacy for Kamal, especially given that in Arab culture males are expected to be more assertive and self-confident (Iancu et al., 2011). Kamal reported that from a young age he felt awkward communicating with other people and that his family would tease him about his shyness and lack of assertiveness. Such experiences likely contributed to Kamal’s belief that he was undesirable, unattractive, boring, and had nothing to offer during social events. In addition, Kamal talked about his family (especially his father) as having high expectations of him and never being satisfied with Kamal’s performance. The high demands of Kamal’s father and cultural standards for males likely contributed to the development of mal-adaptive cognitions related to social situations and feeling inadequate. He maintained core beliefs that had themes of helplessness and unrelenting standards, such as feeling inferior, like a failure, inadequate and undeserving of success, and that he did not possess the skills and abilities of other people. Rapee and Heimberg (1997) postulated that socially anxious individuals believe others are highly critical and place great importance on others’ views, which increases awareness and sensitivity to social disapproval. Kamal stated that he did not want to offend anyone, so he avoided sharing his opinions on controversial topics. He also believed that when he had offered his perspective on a debatable topic, other people were often offended based on the way they looked at him. Kamal equated voicing his opinion with the outcome of being rejected and unwanted, and believed his comments would not be valuable given other’s high standards and expectations. These strong beliefs strengthened his self-perceptions of being unworthy and unlik-able, resulting in intense fears of being rejected or abandoned, as well as intensifying his fears that he would never have meaningful friendships. As mentioned earlier, in Arab culture, there is a significant emphasis on appropriate social behaviors that reflect upon the entire family. Kamal talked about how he felt pressure to succeed in medical school, not only for himself but also for his family. It is highly likely that Kamal’s Arab culture and family dynamics strongly influenced the development of excessive self-focused attention and expectations of negative evaluations in social interactions.

7 Course of Treatment and Assessment of Progress

Based on this case conceptualization, Kamal was treated using a manualized intervention for SAD, Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach (Hope et al., 2010). The manual recommends that treatment consist of 16 one-hour sessions that are carried out over 16 to 20 weeks. Given the client’s time restraints in which he was returning to medical school in 2.5 months, treatment was adjusted accordingly. Over the course of 11 weeks, Kamal completed 14 one-hour sessions. The treatment protocol consisted of five components: psychoeducation, cognitive restructuring that included identifying and challenging automatic thoughts, exposure with continued cognitive restructuring, advanced cognitive restructuring, and termination. The treatment required Kamal to use a workbook that guided him through information on the etiology and symptoms of social anxiety, out-of-session exposure exercises, and other homework assignments.

Kamal attended the initial intake appointment in which background information, presenting problems, and other relevant mental health history was obtained. It was also important for the clinician to assess his cultural background and its relation to his presenting problems. However, given that Kamal was at the integration level of acculturation and was active in both Arab and American culture, few modifications to the treatment approach were required (Berry, 2003). During the first two treatment sessions, rapport was built, cultural factors were discussed, and the

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ADIS-IV was administered to formulate diagnoses and a treatment plan. Kamal met diagnostic criteria for SAD and major depressive disorder and it was decided that CBT would be a good match for his presenting problems. Kamal purchased the social anxiety workbook and was asked to read the first chapter before beginning treatment. At the beginning of the first treatment ses-sion, he completed the SASCI, BAI, and BDI-II. These measures were completed at the begin-ning of subsequent sessions to monitor treatment progress.

Psychoeducation

As recommended in the treatment manual, psychoeducation was provided over the first four ses-sions, and readings and assignments were competed between sessions. The psychoeducation segment of treatment was covered in Chapters 1 through 4 of the workbook. Throughout treat-ment, the therapist took on an active role, focused on the present, and provided structured ses-sions to accommodate a client with a collectivistic background. In addition, the therapist practiced cultural awareness by being open to Kamal’s Arab culture and discussing it with him frequently. The client and therapist addressed traditional cultural values, such as Arab etiquette (e.g., “adab” or well mannered children), social and familial expectations, gender roles, and stigma related to mental health services. Within the first four sessions, Kamal was provided information about the course of treatment; the definition and examples of SAD; how social anxiety manifests in terms of physical, cognitive, and behavioral symptoms; and how to rate anxiety using the Subjective Units of Discomfort Scale (SUDS), and a fear and avoidance hierarchy was created (Table 1). Kamal’s fear and avoidance hierarchy included activities he believed would produce a high level of anxiety based on past experiences. The most difficult situation rated in terms of avoidance and

Table 1. Fear and Avoidance Hierarchy.

Subjective Units of Distress Scale (0-100) Avoidance (0-100)

#1 most difficult situation: Going to parties where I barely know anyone

100 95

#2 most difficult situation: situations involving physical contact, even playful physical contact

95 100

#3 most difficult situation: Talking with very critical people

90 75

#4 most difficult situation: Talking to people who bring up controversial topics

90 75

#5 most difficult situation: Being in a highly competitive environment

80 50

#6 most difficult situation: Saying “no” to someone

75 50

#7 most difficult situation: Talking with men and women in an informal setting

70 75

#8 most difficult situation: Standing and talking in large group

70 25

#9 most difficult situation: Being an authority figure

60 25

#10 most difficult situation: Talking to an authority figure

55 30

#11 most difficult situation: Sharing an opinion 40 50#12 most difficult situation: Giving or receiving a

compliment25 15

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anxiety elicitation was “going to parties where I barely know anyone.” The next highest rated activity was “situations involving physical contact, even playful physical contact.” Additional situations on Kamal’s hierarchy were

talking with very critical people, talking to people who raised controversial topics, being in highly competitive environments, saying no to someone, talking with men and women in an informal setting, standing and talking in a large group, being an authority figure, talking with an authority figure, sharing an opinion, and giving or receiving a compliment.

Kamal’s hierarchy was created while being mindful of his cultural background. For example, Kamal was asked on several occasions how his SAD was expressed within his cultural context. Kamal reported that being assertive was hard for him and that culturally it was more acceptable to talk to same-sex individuals. Mindfulness of his cultural values related to gender role expectations therefore resulted in specific exposure interactions occurring much more frequently with males relative to females. Also, Kamal reported that his anxiety about talking to an authority figure was related to his culture because he was taught to fear people in authority out of respect for their rank. The therapist provided acceptance and practiced awareness of the cultural value toward authority and Arab etiquette of adab. This issue was discussed in great detail and the therapist took more time in session to explore the topic and Kamal was able to process the relation between his cultural value and avoidance of authority. Kamal was able to find a balance in communicating with authority figures without feeling like he was being disrespectful. Kamal was very coopera-tive and active during sessions and compliant in completing homework assignments. Kamal conveyed that he understood how he experienced social anxiety with physical (e.g., tense, but-terflies in my stomach, and sweating), cognitive (e.g., “others are evaluating me,” “I will look stupid”), and behavioral (e.g., avoidance) symptoms.

Cognitive Restructuring

The next phase of treatment involved cognitive restructuring, a topic covered over two sessions. Kamal engaged in identifying automatic thoughts and providing specific examples of thinking errors, problematic thoughts, and irrational responses. He was taught to perceive his thoughts about social interactions as hypotheses and to examine them logically. Also, he learned to chal-lenge his irrational automatic thoughts and replace them with more realistic, productive, and rational responses. For instance, Kamal gave a compliment to someone (situation), identified his automatic thought as “she thinks I am boring and the compliment was generic”, recognized the thinking error as “mind reading” and “an unproductive and unhelpful thought”, challenged the thought with disputing questions, and produced the rational response of “I have never been told I am boring and there is a low chance I am boring.” Throughout these sessions, Kamal was moti-vated and completed all assignments as required.

Exposure and Cognitive Restructuring

The third component of treatment began in Session 7 and involved exposure with cognitive restructuring. Kamal’s fear and avoidance hierarchy was used to guide exposure exercises that occurred both within and between treatment sessions. The exposures followed the treatment pro-tocol and included picking a situation collaboratively, writing down automatic thoughts associ-ated with the situation, identifying emotions linked with automatic thoughts, identifying thinking errors, challenging automatic thoughts, creating rational responses, making behavioral goals, then carrying out the exposure exercise, rating anxiety using SUDS, using rational responses throughout the exposure, and discussing exposure and outcomes. Kamal completed a number of

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in-session and between-session exposures with success, as evidenced by reduction in SUDS rat-ings and decreased avoidance. Examples of in-session exposures included giving and receiving a compliment, discussing a controversial topic and giving his opinion, and having a 10- to 15-min conversation with a stranger in a small group, which was arranged by the therapist. The in-session exposures were largely successful, with Kamal reporting less anxiety as the exposure continued and increased use of rational responses. Kamal completed a number of between-session exposure exercises, such as conversing with men and women in an informal setting for an hour, talking with an authority figure, giving a compliment to his friend and sister, saying “no” to someone, debating a controversial topic, giving his opinion at a party, and attending a religious service and talking to people in attendance. Kamal reported that exposures outside of session were successful and felt he obtained his goals. He also stated he was able to apply cognitive restructuring strate-gies during exposures to reduce anxiety in social situations. He reported that in most situations he found it easier than expected to complete exposure.

Advanced Cognitive Restructuring

The fourth stage of treatment began in the 10th session and involved advanced cognitive restruc-turing, a topic covered over two sessions. The main focus of this treatment component was to assist Kamal in identifying patterns of primary automatic thoughts to identify core beliefs. Automatic thoughts are driven by underlying core beliefs about the self, others, the world, and the future. At first, Kamal and the therapist worked together to identify dysfunctional core beliefs by examining automatic thoughts recorded in session, and then the client was assigned home-work to further examine automatic thoughts in real life social situations and discover core mal-adaptive beliefs. Kamal’s main core beliefs were identified as “I’m incompetent”, “I’m defective, I don’t measure up”, and “I’m unlikable.” Outside of session, Kamal completed the worksheet “peeling your onion—discovering and challenging your core beliefs,” which was then reviewed in session. Kamal was focused in sessions and dedicated to working through his social anxiety. He continued to engage in exposures outside of session and completed all assignments as recommended.

Termination

The last stage of treatment was the termination session, which entailed reviewing what Kamal had learned about identifying automatic thoughts, identifying thinking errors, using disputing questions to challenge automatic thoughts, generating rational responses, eliminating avoidance, giving up safety behaviors, reviewing treatment progress, and learning to maintain treatment gains. Kamal reported high satisfaction with treatment and learned many skills to combat his social anxiety and confront social situations he used to avoid. He stated feeling confident about attending social events, talking to people, and doing tasks he would avoid in the past because these situations produced overwhelming anxiety (e.g., going to the dentist or shopping). Self-report measures and his verbal report indicated that his social anxiety and depressive symptoms decreased. Kamal and the therapist also processed how he felt about the treatment and termina-tion. Kamal was moving out of the area, so he was provided with a list of cognitive-behavioral therapists located close to his new home. He agreed to contact the therapist or one of the referrals if his social anxiety resurfaced and was interfering with life functioning.

Treatment Outcome Analyses

To assess clinically significant symptom changes in anxiety and depression, pretreatment and posttreatment scores were analyzed by comparing Kamal’s scores with both the general and

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clinical population (Jacobson & Truax, 1991). Clinically significant change is indicated when an individual’s posttreatment score is closer to the general population’s mean than the clinical population’s mean. Jacobson and Truax (1991) provided the following equation to determine clinically significant change, c = (µ1 + µ2) / 2, such that the clinical population mean (µ1) is added to the general population mean (µ2) and then divided by 2. The c score has to be greater than the individual’s posttreatment score to indicate that clinically significant change has occurred. Further analyses determine statistically significant change, such as the reliable change index (RCI; Jacobson & Truax, 1991) in which the client’s pre and posttreatment scores are compared with those of a reference group, with the RCI needing to exceed the z score for the 97th percentile (1.96) to indicate statistically significant change (p < .05). Kamal com-pleted three self-report measures to assess treatment outcomes for somatic symptoms of anxi-ety (BAI), depressive symptoms (BDI-II), and social anxiety symptoms (SASCI). Clinically significant change and reliable change indices were computed for scores on the BAI and BDI-II, but there were no data available for nonclinical samples on the SASCI. Therefore, the SASCI was used to measure change from the beginning of treatment, which is the designed intent of this scale.

BAI

Clinical significance. Normative data for the BAI was collected from 350 college students (M = 13.41, SD = 8.96; Osman, Kopper, Barrios, Osman, & Wade, 1997). Mean scores from a subsample (n = 37; M = 15.8, SD = 16.9) of college students with a primary diagnosis of SAD were selected for comparison from a full data set of an adult clinical sample (n = 193) under-going treatment for anxiety at a college clinic (Leyfer, Ruberg, & Woodruff-Borden, 2006). Kamal’s pretreatment BAI score (30) suggested severe anxiety symptoms and his posttreat-ment score (5) suggested mild anxiety. Results demonstrate clinically significant change in somatic symptoms of anxiety, as Kamal’s posttreatment score (BAI = 5) was under the thresh-old (c = 14.61).

Statistical significance. To assess statistically significant change, the RCI was calculated (Jacobson & Truax, 1991). An outpatient sample of adults (n = 21; age 18-60) diagnosed with SAD was used for comparison (pretreatment M = 19, SD = 8.60; posttreatment M = 3.19, SD = 3.93; Clark et al., 2006). Kamal’s BAI outcome data compared with this sample revealed reliable change in anxiety symptoms (RCI = −6.50 < −1.96, p < .05). Second, a sample of university students (n = 30; age 18-19) was used for comparison (pretreatment M = 13.4, SD = 8.9; posttreatment M = 5.90, SD = 5.90; Gawrysiak, Nicholas, & Hopko, 2009). Kamal’s pre- to posttreatment score compared with this sample also demonstrated reliable change in anxiety (RCI = −6.28 < −1.96, p < .05). Kamal’s data indicated clinically and statistically significant decreases in anxiety symp-toms over the course of treatment (Figure 1).

BDI-II

Clinical significance. Based on a study of 127 university students seeking treatment at an outpa-tient facility, normative data for the BDI-II were collected across four groups (nondepressed, M = 7.65, SD = 5.9; mildly depressed, M = 19.14, SD = 5.7; moderately depressed, M = 27.44, SD = 10.0; and severely depressed, M = 32.96, SD = 12.0; Spitzer, Williams, Gibbon, & First, 1990). Kamal’s pretreatment BDI-II score was 46 (severe depression) and his posttreatment score was 9 (minimal depression). Results demonstrate clinically significant change in depres-sive symptoms, since Kamal’s posttreatment score (BDI-II = 9) was under the threshold (c = 20.31).

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Statistical significance. To determine statistically significant change, the RCI was calculated (Jacobson & Truax, 1991). Treatment outcome data from a study of 30 moderately depressed college students receiving CBT was used for comparison (pretreatment M = 20.40, SD = 5.6; posttreatment M = 11.40, SD = 3.75; Gawrysiak et al., 2009). Kamal’s pre to posttreatment score relative to this sample demonstrated reliable change in depression (RCI = −14.77 < −1.96, p < .05). In addition, CBT treatment outcome data on a community sample of adults (n = 159; age 18-60 years) with major depressive disorder was used for comparison (pretreatment M = 32.01, SD = 7.48, n = 159; posttreatment M = 10.44, SD = 9.61, n = 113; Dimidjian et al., 2006). Kamal’s pre to posttreatment score compared with this sample also demonstrated reliable change in depression (RCI = −11.06 < −1.96, p< .05). In sum, Kamal’s data indicated clinically and sta-tistically significant decreases in depressive symptoms over the course of treatment (Figure 2).

SASCI

The SASCI was used to measure changes in social anxiety symptoms since commencing psycho-therapy. Hayes and colleagues (2008) outlined SASCI score interpretation as follows: A score of 16 suggests no change in social anxiety symptoms, scores of 4 to 15 suggest improvement in social anxiety symptoms, and scores of 17 to 28 suggest deterioration in social anxiety symptoms. Kamal’s pretreatment SASCI score was 16 and his posttreatment score was 9, suggesting improvement in social anxiety symptoms. Kamal reported markedly less social anxiety symptoms over the course of treatment (Figure 3). Specifically, he reported significant reductions in anticipatory anxiety (score 4 to 2), avoidance (score 4 to 2), and interference in school and social activities (Score 4 to 2).

8 Complicating Factors

There were a few complicating factors in treating Kamal with CBT. First, he had limited time to complete the treatment (2.5 months) because he was moving to another state to begin medical

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Figure 1. Beck Anxiety Inventory scores during treatment.Note. Measures were not administered until after week 2 once diagnoses and a treatment plan were formulated.*indicates data missing during week.

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school. This issue was addressed by arranging a biweekly meeting. Another conceivable compli-cating factor was that he was diagnosed with major depressive disorder, which theoretically could have hindered treatment progress. However, this factor did not appear to interfere with his ability

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to attend sessions, complete assignments, or affect any other aspect of psychotherapy. Indeed, the transdiagnostic effects of directly treating his SAD were observable in terms of clinically signifi-cant reductions in depression at post-treatment. This finding could largely be attributable to increased (social) environmental rewards associated with the extinction of social anxiety, which would theoretically attenuate depression (Lewinsohn, 1974). It should also be noted that Kamal cancelled two sessions due to transportation issues, although these missed appointments did not negatively impact treatment progress. As Kamal was not taking prescription medications (e.g., antidepressants or antianxiety) during treatment, this further limited complications in interpreting treatment efficacy, as favorable outcomes can be more directly attributable to CBT. Throughout therapy, Kamal was highly motivated and displayed a strong desire to learn skills to manage his social anxiety.

9 Access and Barriers to Care

On a couple of occasions, Kamal had transportation issues. He shared a family car with one of his siblings and had to work around her schedule. There were two instances when their schedules overlapped, causing him to miss two sessions. He had no problems with financial resources as he was treated at a psychological clinic that provided services on a sliding fee scale based on the client’s income.

10 Follow-Up

No follow-up appointments were scheduled due to Kamal moving to another state. Unfortunately, his phone number had changed, so he was unreachable at his new location. As with any clinical trial examining psychotherapy treatment efficacy, follow-up data is critical to assess maintenance of gains. The absence of follow-up data is thus a significant limitation to this case study.

11 Treatment Implications of the Case

This case study described a course of manualized CBT for an Arab male with SAD and lends further evidence for the effectiveness of CBT for SAD among ethnic minority groups. In addi-tion, this case study demonstrates some evidence that depressive symptoms can be alleviated when SAD is effectively treated. Barlow, Allen, and Choate (2004) proposed that CBT may be effective in treating comorbid anxiety and depressive disorders by targeting avoidance behavior proposed as a pathognomonic feature of both disorders. Further research should examine this idea as well as the transdiagnostic effects of treating other anxiety disorders, such as posttrau-matic stress disorder, generalized anxiety disorder, and specific phobia that may be comorbid with depression among ethnic minorities. Given the prevalence of comorbid anxiety and depres-sion and limited treatment outcome research on Arab individuals with these disorders, the present support for manualized cognitive-behavioral treatment is provocative and encouraging. This case study also provides empirical evidence that manualized cognitive-behavioral treatment is adapt-able to time-limits and cultural dynamics. Further research should be conducted with other minority populations to assess generalizability of the current findings, especially given the need for more culturally tailored treatments.

12 Recommendations to Clinicians and Students

A significant proportion of Arab individuals with anxiety and depression do not seek psychologi-cal treatment (Iancu et al., 2011; Karam et al., 2006; Levav et al., 2007). CBT has been effective

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for various anxiety disorders and depression (Cuijpers, Van Straten, & Warmerdam, 2007; Hollon & Ponniah, 2010). Although highly limited in breadth, available research suggests cognitive-behavioral treatment may be effective among Arab individuals (Nassar-McMillan et al., 2003). This case study provides further support for this notion. Findings suggest that clinicians should consider using Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach (Hope et al., 2010) to treat SAD when working with minority clients who are similar to this client and bring insight, intelligence, and motivation to psychotherapy, so long as cultural awareness is integrated into the treatment plan. It is also important for future studies to examine the efficacy of this manual with larger samples of minority clients before any strong recommendations can be made. These findings suggest this treatment manual may be recommended for clients who are experiencing social anxiety and depressive symptoms, with SAD as the principal diagnosis. In addition, the manualized treatment was effective despite limited therapist experience with the manual, but in conjunction with weekly supervision from a clinical psychologist specializing in anxiety and mood disorders and a motivated and determined client, its implementation was highly effective.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies

Crystal C. McIndoo, MS, is a doctoral graduate student in clinical psychology at the University of Tennessee. Her research and clinical interests include utilizing behavioral, cognitive, and mindfulness approaches in the treatment of mood and anxiety disorders, and co-comorbid health conditions.

Derek R. Hopko, PhD, is an Associate Professor of clinical psychology at the University of Tennessee and director of the Knoxville Psychological Assessment Laboratory (KPAL). His research program focuses on health psychology and emotional disorders, with primary interests in treatment outcome research on the efficacy of behavioral interventions to treat clinical depression, addressing co-existent medical conditions (i.e., cancer) that may be involved in the etiology and maintenance of depressive syndromes.

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