Psychological Reports, 2011, 108, 3, 955-962. © Psychological Reports 2011
Comparison of Group and Individual Cognitive-behavioral Therapy in Reducing Fear of Negative Evaluation1, 2 Ebrahim Rezaei Dogaheh, Parvaneh Mohammadkhani, and Behrooz Dolatshahi University of Social Welfare and Rehabilitation Sciences Tehran, Iran Summary.—Previous studies have established the efficacy of group and individual formats of cognitive-behavioral therapy in reducing fear of negative evaluation in social anxiety disorder, but the effectiveness of the group and individual therapies has not been widely assessed. This study was conducted to compare the effectiveness of cognitive-behavior group therapy to individual cognitive-behavioral therapy in social anxiety disorder. 28 patients were randomly allocated to two groups of 14. Each group participated in 12 weekly sessions. The final sample was 22 participants after drop-out. Pretest and posttest data were collected using the Brief Fear of Negative Evaluation Scale and the Beck Depression Inventory–II. Controlling for pretest fear of negative evaluation and depression, cognitive-behavioral group therapy was more effective than individual cognitive-behavioral therapy in reducing fear of negative evaluation, but the clinical significance and improvement rates of the two treatment formats were equivalent.
Social anxiety disorder (SAD) is recognized by “a marked or persistent fear of one or more social or performance situations” in which the person is exposed to unfamiliar people or to possible scrutiny by others (American Psychiatric Association, 2000). Fear of negative evaluation is the core concept of most cognitive-behavioral models for social anxiety. According to these models, social phobic individuals divide their attention between the internal representations of their social self (negative images and “felt sense”) and external cues that could be taken as a sign of negative evaluation by others (Heimberg, 1997). The lifetime prevalence of social anxiety disorder is estimated between 7 and 13% (Furmark, 2002). Untreated social anxiety has a tendency to become chronic and often cooccurs with other psychological disorders including major depressive disorder, generalized anxiety, and alcohol abuse (Stein, McQuaid, Laffaye, & McCahill, 1999). Chambless and Ollendick (2001) categorized cognitive-behavioral therapy (CBT) as well-established/effective and specific for treatment of social anxiety disorder. Cognitive-behavioral group therapy (CBGT) Address correspondence to Ebrahim Rezaei Dogaheh (
[email protected]). This study was funded by a grant from the Research and Technology Department of the University of Social Welfare and Rehabilitation Sciences.
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DOI 10.2466/02.21.PR0.108.3.955-962
ISSN 0033-2941
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E. R. dogaheh, et al.
has been suggested as the treatment of choice for social anxiety disorder (Heimberg, 2001). The positive effects of cognitive-behavior group therapy increase with time and most patients with social anxiety disorder report clinically significant change after intensive intervention (Barlow, 2001). In some of these studies, CBGT was compared with attention placebo control group (Heimberg, Salzman, Holt, & Blendell, 1993) and a placebo condition (Heimberg, Dodge, Hope, Kennedy, Zolo, & Becker 1990), showing that the effects of cognitive-behavior group therapy are robust on common therapeutic factors such as therapist attention (Heimberg, Liebowitz, Hope, Schneier, Welkowitz, et al., 1998). Meta-analyses (e.g., Taylor, 1999) confirm that cognitive-behavior group therapy has a statistically significant effect compared to control treatment conditions. Heimberg, et al. (1993) showed that the participants in cognitive-behavior group therapy retained therapeutic gains at five-year follow-up and remained less symptomatic than patients in a support-attention group. There is general agreement that existing cognitive-behavior group therapy treatments must be improved. Some patients cannot optimally benefit from cognitive-behavior group therapy. For example, Heimberg, et al. (1998; quoted in Stangier, Heidenreich, Peits, Lauterbach, & Clark, 2003) reported that about 60% of patients receiving cognitive-behavior group therapy responded, but based on more stringent criteria, only 38% of patients who completed the treatment could be considered improved. The second reason for alternative interventions is that logistics and preparation for cognitive-behavior group therapy are time consuming. Such difficulties result in dropout, risk of less attention to each patient’s problems and dysfunctional beliefs, and a probability of avoidance behavior due to particular group conditions (Clark, Ehlers, Haekmann, McManus, Fennell, Grey, et al., 2006). Regardless of these limitations, cognitive-behavior group therapy allows more easily simulated social situations during role-play and is potentially useful for social and vicarious learning (Stangier, et al., 2003). So far, studies comparing group and individual formats of CBT for social anxiety are limited. Lucas and Telch (1993; quoted in Heimberg, 2001) compared the effectiveness of group and individual CBT with an attention control group and concluded that the two formats gave the same therapeutic results, but the group protocol was more cost-effective. Other meta-analytic studies in which cognitive-behavior group therapy was compared with active therapy (e.g., Moreno Gil, Méndez Carrillo, & Sánchez Meca, 2001) confirmed the efficacy of cognitive-behavior group therapy (ES = 0.75 in the posttest and ES = 0.95 at follow-up) and the group versus individual formats showed no significant difference in treatment outcome. In contrast, Aderka (2009) found that individual was superior to group cognitive-behavior therapy. Thus, research on treatment format is still inconclusive. Thus, the main purpose of the present study was to
Reducing Fear of Negative Evaluation
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compare the effectiveness of these two formats in reducing fear of negative evaluation in a sample of Iranian patients. Method Participants The study samples comprised 28 participants among patients referred to health centers of the University of Social Welfare and Rehabilitation Sciences University (ages 18 to 35 years; M = 22.5, SD = 4.7). Inclusion criteria were holding at least a high school diploma and having the diagnosis of social anxiety disorder, according to DSM-IV–TR, as the main complaint. The exclusion criteria were psychotic disorder, substance abuse, and major depression disorder. The participants were randomly divided and allocated to two groups, namely CBGT (n = 12; 5 men, 7 women; M age = 23.0 yr., range 19–32) and ICBT (individual cognitive-behavioral therapy; n = 10; 4 men, 6 women; M age = 22.0 yr., range = 18–34), each group including 12 primary and 2 reserve individuals. Missing three sessions was assessed as a drop-out. By applying this criterion and after baseline assessment, six participants had dropped out before the completion of interventions. The final sample size was 22 (including 12 patients in cognitive-behavior group therapy and 10 patients in the ICBT group). The calculated power was 0.73, and applied power was 0.65. Measures Brief Fear of Negative Evaluation Scale (BFNE).—The Brief Fear of Negative Evaluation Scale (Leary, 1983) measures fear of negative evaluation, the core feature of social anxiety disorder. This scale is composed of 12 items and uses a 5-point format (1: Not at all characteristic of me to 5: Extremely characteristic of me). Eight items describe the presence of fear or worry and four remaining items focus on the absence of fear or worry. Confirmatory factor analysis indicated a two-factor solution to be appropriate (Weeks, Heimberg, Fresco, Trevor, Turk, Schneier, et al., 2005). Furthermore, the Brief Fear of Negative Evaluation Scale exhibited a positive and significant correlation with the Social Phobia Inventory (r = .43, p
