Psychodynamic psychotherapy for social phobia: A treatment manual based on supportive-expressive therapy

Falk Leichsenring, DSc Manfred Beutel, MD Eric Leibing, Dsc Social phobia is a very frequent mental disorder characterized by an early onset, a chronic unremitting course, severe psychosocial impairments and high socioeconomic costs. To date, no manual for the psychodynamic treatment of social phobia exists. After a brief description of the disorder, a manual for a short-term psychodynamic treatment of social phobia is presented. The treatment is based on Luborsky's supportive-expressive (SE) therapy, which is complemented by treatment elements specific to social phobia. The treatment includes the characteristic elements ofSE therapy, that is, setting goals, focus on the Core Conflictual Relationship Theme (CCRT) associated with the patient's symptoms, interpretive interventions to enhance insight into the CCRT, and supportive interventions, in particular fostering a helping alliance. In order to tailor the treatment more specifically to social phobia, treatment elements have been added, for example informing the patient about the disorder and the treatment, a specific focus on shame and on unrealistic demands, and encouraging the patient to confront anxiety-producing situations. More directive interventions are included as well, such as specific prescriptions to stop persisting self-devaluations. The treatment manual is presently being used in a large-scale randomized controlled multicenter study comparing short-term psychodynamic psychotherapy and cognitive-behavioral therapy in the

We thank Dr. Lester Luborsky (University of Pennsylvania) and Dr. Karl Konig (Goettingen) for helpful comments. Dr. Leichsenring is Professor at the Glinic of Tiefenbrunn, Goettingen, Germany, and Professor in the Department of Psychosomatics and Psychotherapy, University of Goettingen, Germany. Dr. Beutel is Professor at the Glinic of Psychosomatics and Psychotherapy, University of Mainz, Germany. Dr. Leibing is Professor of Psychosomatics and Psychotherapy, University of Goettingen, Germany. Correspondence may be sent to Prof. Dr. Falk Leichsenring, Department of Psychosomatics and Psychotherapy, University of Goettingen, vonSiebold-Str. 5, 37075 Goettingen, Germany: e-mail: fleichs@gwdg.de (Gopyright 2007 The Menninger Foundation)

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Psychodynamic psychotherapy for social phobia

treatment of social phobia. (Bulletin of the Menninger Clinic, 71[1], 57-83)

The criteria for empirically supported treatments include the use of treatment manuals (Chambless & HoUon, 1998). With regard to anxiety disorders, manuals for psychodynamic treatment have been developed for generalized anxiety disorder (Crits-Christoph, Crits-Christoph, Wolf-Palacio, Fichter, &c Rudick, 1995; Leichsenring, Winkelbach & Leibing, 2005) and for panic disorder (Milrod et al., 2000; Wiborg & Dahl, 1996). For social phobia (or social anxiety disorder), however, no manual for psychodynamic treatment has yet been published. With regard to the treatment of social phobia, cognitive-behavioral therapy (CBT) and serotonin reuptake inhibitors (SSRIs) have yielded beneficial results (Zaider & Heimberg, 2003). However, the response ratesabout 50%are far from satisfactory (Davidson et aL, 2004; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003; Zaider & Heimberg, 2003). Subgroups of patients with social phobia do not benefit sufficiently from CBT, that is, patients with generalized social phobia, comorbid depression, or comorbid avoidant personality disorder (Zaider & Heimberg, 2003). Furthermore, studies of long-term treatment effects are scant (Gould, Buckminster, Pollack, Otto, & Yat, 1997). As suggested by experts in the field, the insufficient response rates may be improved by longer and more intensive treatments (Zaider & Heimberg 2003, p. 80). In most of the available studies of CBT, treatment duration ranged from 7 to 15 sessions. According to the data reported by Kopta, Howard, Lowry, & Beutler (1994, p. 1012), at least 25 sessions are required to achieve clinically significant improvements in the majority of patients with chronic anxiety disorders. For these reasons, evidence regarding the efficacy of psychodynamic psychotherapy in social phobia, including comparisons with other treatments, is urgently required. In this article, a manual for a short-term psychodynamic treatment of social phobia will be presented. The manual is based on supportive-expressive (SE) therapy (Luborsky, 1984), which is complemented by specific treatment elements relevant to social phobia. Thus, we do not present a new model of psychodynamic psychotherapy, but a specification of psychodynamic psychotherapy for social phobia that is based on SF ther1. The treatment manual is presently being used in a large-scale randomized controlled multicenter study comparing short-term psychodynamic psychotherapy and GBT in the treatment of social phobia. http://www.controlled-trials.com/ISRGTN53517394. The study is supported by a grant of the Bundesforschungsministerium [Federal Ministry of Research, Berlin, Germany]. Vol. 71, No. 1 (Winter 2007) 57

Leichsenring et al. apy. In the first part, general principles of SE therapy will be described. In the second part, therapeutic elements specific to the treatment of social phobia will be presented.' Supportive-Expressive Therapy Supportive-expressive therapy was developed by Luborsky (1984) and is based on his work at the Menninger Foundation (Wallerstein, 1989; Wallerstein & Robbins, 1956). SE therapy can be carried out both as a short-term (time-limited) and as a long-term (open-ended) treatment. Short-term treatments tend to be from 6 to 25 sessions. Long-term treatments range from a few months to several years (Luborsky, 1984). Meanwhile, manual-guided adaptations of SE therapy for a variety of specific psychiatric disorders are available. These include depressive disorders, generalized anxiety disorder (GAD), bulimia nervosa, avoidant personality disorder, obsessive-compulsive personality disorder, and opiate and cocaine dependence (Barber, Morse, Krakauer, Chitams, Crits-Christoph, 1997; & Crits-Christoph et al., 1995; Garner et al., 1993; Luborsky, Mark, et al., 1995; Luborsky, Woody, Hole, Velleco, 1995; Mark & Faude, 1995; Mark, Barber, & Grits-Christoph, 2003). The efficacy of SE therapy in specific psychiatric disorders was studied in several randomized controlled trials. In these studies, the following mental disorders were treated: opiate addiction (Woody, Luborsky, McLellan, & O'Brian,1990; 1995 Woody et al. 1983;), cocaine abuse (Grits-Ghristoph et al., 1999, 2001), bulimia nervosa (Garner et al., 1993), GAD (Grits-Ghristoph et al., 2005; Leichsenring, Winkelbach &c Leibing, 2006), and personality disorders (Vinnars, Barber Noren, Gallop, & Weinryb, 2005). Furthermore, there have been two open (i.e. uncontrolled) trials of SE therapy in depressive disorders and in obsessive compulsive and avoidant personality disorder (Barber et al., 1997; Diguer, Barber, &c Luborsky, 1993). Thus, SE therapy is among the empirically best supported models of psychodynamic psychotherapy (Leichsenring, 2005; Leichsenring and Leibing, in press). Understanding of symptoms, conflicts, and transference in SE therapy: The Gore Gonflictual Relationship Theme (GGRT) In psychodynamic psychotherapy, psychiatric symptoms are regarded as being determined by biological and psychological factors (Gabbard, 2000; Luborsky, 1984, 1996, 2001; Miller, Taber, Gabbard, Hurley, 2005). Luborsky (1996, 2001) assumes a general biopsychosocial predisposition that plays a role in the choice of the leading symptom. With
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Psychodynamic psychotherapy for social phobia regard to social phobia, the underlying neural processes are, as yet, little understood (Kent &; Rauch, 2003). There is evidence of decreased activity in the cortical areas and a shift to increased activation of the phylogenetically older subcortical anxiety circuits during social stress (Kent &c Rauch, 2003; Tillfors et al., 2001; Veit et al., 2002). Furthermore, serotonin transporter polymorphisms were reported to be related to amygdala excitability and symptom severity (Furmark et al., 2004). With regard to their psychological aspects, psychiatric symptoms are conceptualized in psychodynamic therapy as the consequence of unresolved conflicts or impairments in ego-functions (for the concept of ego-functions see, for example, Bellak, Hurvich, & Gediman, 1973). The psychodynamic concept of conflict was noted by Luborsky as a "Gore Gonflictual Relationship Theme" (GGRT, Luborsky, 1984, 1990a, 1990b; see also Grits-Ghristoph, Gonnolly, & Shaffer, 1999; Grits-Ghristoph et al., 1988; Eckert, Luborsky, Barber, & Grits-Ghristoph,1990). A GGRT consists of three components: a wish {W: "I wish that person x . . . " ) , a response from the other {RO: "But person x will..."), and a response from the self (RS: "Thus, I will..."). In this scheme, response from the self (RS) represents the patient's symptoms. For a patient with a social phobia, the GGRT may be described, for example, in the following way (Gabbard, 1992): "I wish to be affirmed by others (W). However, the others will humiliate me (RO). I feel ashamed and get afraid of being together with others, so I have decided to avoid exposing myself {RS, symptoms of social phobia)." However, we do not assume that there is one specific CCR T that is common to all patients with social phobia. The heterogeneity of social phobia will be discussed below more in detail. The development of the symptoms of social phobiaand of mental symptoms in generalis preceded by the perception of a danger that can be perceived as inside or outside of the person (Luborsky, 1996, 2001). According to Luborsky (1996, 2001), usually both are true. The danger is perceived in connection with interpersonal relationships (e.g., "How will this beautiful woman react, if I approach her ?" or "How will the audience react to my talk?"). The perceived danger is associated with an activation of the subject's GGRT, which is associated with feelings of fear and loss of control, hopelessness, helplessness, and feeling blocked (Luborsky, 1996, p. 15; 2001, p. 1139). These psychological phenomena are paralleled by physiological changes. If the feelings of fear and loss of control cannot be defended against or coped with, social phobia can develop with its typical fears and avoidances.

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Leichsenring et al. Focus of Treatment In SE therapy, the therapist's task is to identify the GGRT on which the patient's present symptoms are based. For that purpose, he or she investigates relationship episodes that are included in the patient's narratives about interactions with other people told in the course of therapy (Luborsky, 1984, 1990a, 1990b); for example, "At my father's birthday party, when I told him that I had successfully passed my exam, he only said 'Your brother was faster, boy!' I felt terribly ashamed." Once the theme is identified, it will serve as the focus to which the therapist will direct his or her and the patient's attention. The GGRT represents a transference potential, a scheme including central wishes, anticipated reactions of others and from the self ("I wish that..., but the others will . . . So I will.. .") that will be reproduced repeatedly like a theme and variations of a theme in spite of its self-hurtful nature (Luborsky, 1984). Freud (1912/1958) referred to the transference potentials as relationship "stereotype plates." The emphasis that psychodynamic psychotherapies put on the relational aspects of transference is a key technical difference from cognitive-behavioral therapies (Gutler, Goldyne, Markowitz, Devlin, & Glick, 2004). Setting Goals Setting goals is an important component of SE therapy: Goals bring the patient to treatment, keep him or her in treatment, and provide orientation and markers of progress or lack of it (Luborsky, 1984, pp. 62-63). Setting goals also modulates or brakes regression, which is particularly important for suspicious patients and for those who are afraid of dependency (Luborsky, 1984). For short-term treatment, goals must be focal in nature (Grits-Ghristoph et al., 1995; Luborsky, 1984;). Thus, they should not include comprehensive changes in personality. Goals should be formulated in the patient's language. If a patient, in setting goals, only refers to the symptoms of social phobia, it is important to actively relate the symptoms to the GGRT. According to an example given by Grits-Ghristoph et al. (1995, p. 53), this can be done by an intervention as follows: "Well, now you have given me a picture of your symptoms but it would be helpful to me to know more about you, your family, your relationships and your work." Or the therapist might say, for example: "We agree that it is an important goal of this treatment to work on your anxiety in giving lectures at the university. You also told me that it is important for you to be appreciated by others. In order to help you with your social anxieties, I suggest we explore your feelings and try to find out if your social anxieties at the university have some60 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia thing to do with that problem." In the next step, the therapist relates improvements in symptoms with the associated changes in self-concept and interpersonal relationships (Grits-Ghristoph et al., 1995). Goals may change during the course of treatment. For example, the patient may feel safer or his or her resistance is reduced or has been worked through.
Interventions of Supportive-Expressive Psychotherapy

Psychodynamic psychotherapies operate on a supportive-expressive (or supportive- interpretive) continuum (Gabbard, 2000; Gill, 1951; Luborsky, 1984; Wallerstein, 1989). For SE therapy, supportive and expressive (or interpretive) interventions have been specified and operationalized both by treatment manuals and by rating scales for adherence and competence (Barber &c Grits-Ghristoph, 1996; Luborsky, 1984; Luborsky, Woody, McLellan, & Rosenzweig, 1982). Eor SE therapy, the relation between supportive and expressive interventions can be described in the following way (Luborsky, 1984): The more severely disturbed a patient is, or the more acute his or her problem is, the more supportive and the less expressive interventions are required and vice versa. Thus, a broad spectrum of mental disorders can be treated with SE therapy ranging from milder adjustment disorders or stress reactions to severe personality disorders, such as borderline personality disorder or even psychotic conditions (Luborsky, 1984). Empirical studies have confirmed that the interventions specific to SE therapy significantly correlate with the outcome of SE therapy (Barber, Luborsky, & Grits-Ghristoph, 1996; Grits-Ghristoph, Gooper, &c Luborsky, 1988; Luborsky, McGlellan, Woody, O'Brian, & Auerbach, 1985). These findings suggest that specific techniques of SE therapy as contrasted to nonspecific factors account for a significant proportion of the variance in outcome of SE therapy (Barber et al., 1996). Supportive interventions The establishment of a helping alliance is regarded by Luborsky as the central aspect of supportive interventions. Two types of helping alliances are described: Type I refers to the experience that the therapist is providing help and the patient is receiving help. Luborsky (1984, p. 82) has formulated several principles of type I supportive interventions; for example, "Gonvey a sense of understanding and acceptance" or "Gonvey, through words and manner, support for the patient's wish to achieve the goals" (e.g., "In the first session you set the goal to reduce your social anxieties. Thus, it is important that you not avoid going to that party"). Type II refers to the patient's experience of working toVol. 71, No. 1 (Winter 2007) 61

Leichsenring et al. gether in a team effort (Luborsky, 1984). Principles of type II supportive interventions include, for example, encouraging a "we bond" (e.g., "As we have found out in the last session, you ...") or recognizing the patient's growing ability to work on his or her problems in the same way the therapist does (e.g., "This time you found out yourself what makes you so afraid of others. You did it in the same way that we did it here"). Furthermore, the fact of achieving understanding (expressive aspect) is assumed to also have a supportive value (Luborsky 1984, p.
89).

Expressive interventions Expressive interventions enhance the patient's cognitive and emotional understanding of his or her present symptoms and of the underlying CCRT (Luborsky, 1984). The CCRT is studied in present and past relationships, including the "here and now" relationship with the therapist. Repeatedly working through the CCRT in different relationships is assumed to improve the patient's understanding and to help him or her in developing more adaptive behaviors. For expressive interventions, Luborsky (1984, pp. 121, 94-141) has formulated a number of principles in his generic manual. For example, "The therapist's response should deal effectively with a facet of the main relationship problem and at times relate that to one of the symptoms (e.g., "We have seen that you are not only afraid of exposing yourself [Symptom, RS], but you also like to be at the center of attention [Wish]. However, you are afraid that other people will humiliate you [RO]."
Social Phobia

Social phobia (or social anxiety disorder) is characterized by an excessive irrational fear that others will scrutinize a person's actions in social or performance situations (American Psychiatric Association, 1994). With regard to lifetime prevalence, social phobia is the most prevalent anxiety disorder (13.3%; Kessler et al., 1994). In comparison to all mental disorders, social phobia is exceeded in lifetime prevalence only by major depressive disorder and alcohol dependence (Kessler et al., 1994). In the generalized form of social phobia, almost all social situations are anxiety-producing, whereas the isolated form is restricted to specific social situations (American Psychiatric Association, 1994). Social phobia is characterized by an early onset, a chronic, unremitting course, high socioeconomic costs, and a marked impairment in functions and quality of life (Keller, 2003; Kessler, 2003). Furthermore, social phobia has secondary effects on mental diseases (e.g., depression) and on help seeking (Keller, 2003). However, social phobia is both
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Psychodynamic psychotherapy for social phobia underdiagnosed and undertreated (Kasper, 1998; Katzelnick & Greist, 2001). As a result of both phenomenological and psychodynamic factors, it is very likely that social phobia is not a homogeneous disorder. Subgroups of patients with social phobia exist; for example, patients with isolated versus generalized social phobia, and patients with comorbid depression, alcohol abuse, avoidant personality disorder, or maladaptive interpersonal styles (Zaider & Heimberg, 2003). Furthermore, from a psychodynamic point of view, social phobialike other mental disordersis modified by the respective underlying psychodynamic factors, that is, by specific confhcts, modes of personality functioning, and level of personality organization. SE therapy represents an approach that can be flexibly adapted to the individual patient's needs; for example, with regard to the amount of supportive or interpretive interventions that are necessary. As mentioned above, subgroups of patients with social phobia do not benefit sufficiently from CBT (Zaider & Heimberg, 2003). SE therapy specifically adapted to social phobia can be expected to have great potential, particularly for treating refractory social phobia where personality issues are concerned. This applies especially to patients with comorbid avoidant personality disorder.
Psychodynamics of Social Phobia

Anxiety is a central concept of psychoanalytic and psychodynamic theory and therapy (Zerbe, 1990). Psychodynamic aspects of social phobia have been discussed by several authors (e.g., Gabbard, 1992; Hoffman, 1999, 2002, 2003; Joraschky, 1998; Konig, 1981). Some of these aspects have been corroborated by empirical studies; however, further evidence supporting at least some of these aspects is required. Furthermore, some of these authors focused on specific aspects of the psychodynamics of social phobia. However, as already mentioned above, we do not assume that there is one aspect of the psychodynamics that is common to all patients with social phobia. The discussion of the psychodynamics of social phobia will be presented for self psychological, object relational, ego-psychological, instinctual, and attachment-related aspects. Selfpsychology A disturbed self-concept is regarded as a central component of social phobia (Hoffmann, 2002, 2003). It is associated with disturbances in self-perception and self-esteem and unreahstic devaluations or idealizations of the self. Empirical studies have confirmed that patients with
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Leichsenring et al. social phobia are characterized by low self-esteem and high levels of self-<;riticism and shame (Gox, Fleet, & Stein, 2004; Hirsch, Glark, Mathews, &c Williams, 2003; Hirsch et al., 2004; Izgic, Akyuz, Dogan, & Kugu, 2004; Lutwak & Ferrari, 1997). Patients with social phobia seem to lack appreciating ("mirroring") introjects as they were described by Kohut (1971). The process of "transmuting internalization" (Kohut, 1971) seems to have been impaired in a special way, for example, by an identification with the aggressor as discussed by Hoffmann (2001,2003). Gompensatory, mostly unconscious, fantasies of grandiosity that are used to defend against unbearable feelings of inferiority make up another important aspect of the psychodynamics of social phobia. These fantasies comply with excessive demands, for example, to give a unique fancy talk or performance (Hoffmann, 2002, 2003). In an empirical study by de Jong (2002), discrepancies between self-reported and implicit self-esteem were reported. In an implicit test of self-esteem, high socially anxious subjects showed a highly positive self-image, whereas they displayed relatively low levels of self-esteem on self-report measures. Gabbard (1992) stressed shame experiences in social phobia (see also Gilbert, 2001). According to Gabbard (1992), shame experiences in social phobia result from the wish to be in the center of attention and receive affirming responses from others and the (anticipated) response from disapproving parental figures. In order to avoid these imagined humihations or embarrassments, patients with social phobia avoid situations where they risk these responses from others. Joraschky (1998) stressed the importance of shame for the regulation of self-object boundaries and discussed shame as a consequence of boundary violations. For a subgroup of patients suffering from erythrophobia, Konig (1981) described an embarrassing family secret (e.g., the patient's father, a priest, collected pornographic material, or her mother suffered from alcohol abuse, or a bankruptcy had to be concealed). The social phobia patient identified with the family member of whom he or she was ashamed. In other cases, the whole family was ashamed of a behavior that was disregarded by the surrounding social environment (e.g., in immigrants). Relating these considerations to those of Gabbard (1992), the GGRT could be formulated as follows: "I wish to be affirmed by others. However, the others will humiliate me because I act in a way that will make them think that I am like my father/mother, who did those things I feel ashamed of. Thus, I would feel ashamed if I exposed myself to the scrutiny of others. This I can avoid by keeping away from people." In empirical studies, shame was significantly positively related 64 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia to the fear of negative evaluation by others and social avoidance and it was significantly negatively related to recalled parental care (Lutwak & Ferrari, 1997). In another empirical study, de Jong (2002) reported discrepancies between self-reported and implicit self-esteem. Psychodynamic theory assumes that the tendency to devalue oneself is projected onto others. A study by Andrews and Pollock (1989) confirmed that patients with social phobia used projection and other immature defense mechanisms significantly more frequently than normal controls. Object relations theory From an object-relational perspective, social phobia is regarded as the result of the internalization of early interpersonal experiences (see above, "identification with the aggressor"). As a consequence, devalued self-representations are associated with devaluing object-representations. Gilbert (1989, 2001) assumes a hyperactivity of the competitive mode as compared to the security-providing mode. Patients with social anxieties tend to perceive others predominantly as dangerous and to overlook friendly signals (Gilbert, 1989, 2001). Ego-psychology In a subgroup of social phobia patients who are characterized by structural deficits in personality organization and ego-functions, the ego-functions of affect perception and affect control can be impaired. Furthermore, the assumption that others look at them as devaluing as they do themselves can point to an impaired self-object differentiation (e.g., Bellak et al., 1973). Instinctual aspects Classical instinctual conflicts may play a role in some patients with erythrophobia. The symptom represents both the defense against an instinctual wish (e.g., a sexual wish) as well as its partial satisfaction. Gabbard (1992) discussed the importance of aggression and guilt in social phobia. He assumes that guilt feelings in patients with social phobia stem from the unconscious demand for complete attention associated with the wish to scare away or kill off rivals. These guilt feelings may be interwoven with shame stemming from the feeling that one is not really capable of displacing the rival and is therefore fraudulent. Attachment theory An insecure attachment was clinically reported for many patients with anxiety disorders (Bowlby, 1988) and specifically for patients with social phobia (Vertue, 2003). An insecure attachment may lead to social
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Leichsenring et al. anxieties and avoidance and may inhibit a curious approach to the world. Gabbard (1992) stressed the importance of separation anxiety in social phobia, that is, the fear of being abandoned or losing the caregiver's love when moving toward autonomy. In order to avoid such catastrophic cutoffs, patients with social phobia avoid connecting with people in the outside world. Problems of attachment in social phobia were empirically confirmed in a study by Eng, Heimberg, Hart, Schneider, and Liebowitz (2001). As mentioned earlier, further empirical research is necessary to confirm these psychodynamic factors in social phobia. A short-term psychodynamic psychotherapy of social phobia based on SE therapy In the following, we shall present a short-term psychodynamic therapy of social phobia based on SE therapy. Up to five sessions are scheduled for diagnostic assessment (including both phenomenological and psychodynamic aspects) and treatment arrangements. The succeeding therapy may take up to 25 sessions. Diagnostic assessments, informing the patient, and making treatment arrangements (introductory sessions 1-5) Diagnostic sessions. Before starting treatment, diagnostic assessments are made by the therapist both on a phenomenological (DSM) and a psychodynamic level (CCRT), including biographical data relevant for the development of social phobia. Socialization interview. In a preliminary socialization interview (Luborsky, 1984; Orne & Wender, 1968), just before the treatment starts, the therapist informs the patient about the treatment and the disorder (see below, principle 1). This information encompasses a general and a disorder-specific part. In the general part of information, the therapist explains what he or she will do (e.g., "I will listen to you and help you with your social phobia") and what the patient is expected to do (e.g., "You may talk about everything you are concerned with"). Furthermore, arrangements about the treatment are made, including duration of treatment and frequency of sessions, appointment times, payment, and handling of missed sessions and of premature termination. First, achievable goals are set (see above), and the therapist communicates realistic hope that the goals can be achieved. Therapist and patient agree to review what has been accomplished with regard to the goals set before treatment at 66 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia the half-way point (session 13). Therapy will be carried on only until the predefined goals have been reached. This may be the case in less than 30 (25+5) sessions. These arrangements will help to establish a good working alliance that is additionally fostered by the therapist showing his or her interest toward the patient and by empathic understanding (Luborsky, 1984). In the disorder-specific part of information, the patient is cognitively prepared for the psychodynamic treatment of his or her social phobia. The therapist informs the patient about the pathological nature of his or her symptoms, about the necessity of treatment, about the treatment procedures, and about possible problems and outcome of the treatment. Here the patient is informed that for the treatment to be successful, he or she must be exposed step by step to the feared situations (the self-exposure procedure and its integration into the psychodynamic treatment will be described below more in detail). Thus, the patient is given a rationale allowing for a first orientation. It is essential to explain the importance of graduated self exposure to the feared situations. With regard to the expressive-supportive dimension, preparing the patient cognitively to the treatment has a supportive effect. Phenomenological, biographical, and psychodynamic assessment and treatment arrangements, including informing the patient, may take up to five sessions. The subsequent treatment may take another 25 sessions. Phases of treatment Analogous to the description of SE therapy for GAD by Crits-Christoph et al. (1995), the 25-session treatment of social phobia can be described in four phases. Early phase (treatment sessions 1-8). In the early phase of treatment, the therapist's primary task is to establish a good therapeutic alliance (Crits-Christoph et al., 1995; Hoffmann, 2002, 2003). For this purpose, he or she uses the supportive interventions described above (Luborsky, 1984). The patient chooses a topic he or she would like to talk about, referring to the symptoms of social phobia or another problem. The therapist encourages the patient to talk about his or her relationships with other people. The therapist works on identifying the CCRT and tries to relate the symptoms of social phobia to the underlying CCRT. Middle phase (treatment sessions 9-16). In order to intensify the treatment processes, the frequency of sessions is increased to two weekly sessions in the middle phase of the treatment. In this phase, the CCRT is
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Leichsenring et al. refined. The therapist relates the CCRT to different interpersonal relationships. He or she shows how the CCRT has occurred again and again in the patient's life, and also in the relationship to the therapist ("working through"). In the middle phase, traumatic experiences may come to light (Crits-Christoph et al., 1995). However, traumatic experiences are not a specific focus of SE therapy. The therapist and the patient examine how traumatic experiences have influenced the CCRT. For example, the wish for protection (W) could have been frustrated by the fact that a patient's parents did not help her deal with abuse by an uncle. What would have been the patient's wish regarding the traumatic experience (e.g., to express her fear or anger, or to be taken seriously)? As described by Crits-Christoph et al. (1995), SE therapy examines both the CCRT patterns according to Luborsky (1984) and posttraumatic stress reactions and maladaptive coping and defensive styles according to Horowitz (1976). For GAD, Borkovec (1994) assumes that the patient's persistent worrying has a defensive function, which is the avoidance of confrontation with even more stress (i.e., traumatic experiences). In a similar manner, the persistent anticipating fears of patients with social phobia may have a defensive function (Hoffmann, 2002, 2003). They often serve as a defense against both sexual wishes and real relationships ("Nobody wants a woman like me. .. "; "Men only want s e x . . . " ) . Here, phobic avoidance serves a defensive purpose that may, at least in part, explain its persistence. This hypothesis should be seriously considered, especially if the phobic avoidance refers to contacts with the other sex. Anxiety-provoking and repressed aspects of mental life keep having effects, both consciously and unconsciously, and are manifested in repetitive maladaptive relationship patterns. These relationship patterns are cyclic, that is, they work as self-fulfilling prophecies ("Someone who is that clumsy in social contact with other people has no chance in a society where you always have to be "hip"). The self guided symptom exposure (see above) is introduced in this phase and is constantly used. In session 13 (or sometime between sessions 13 and 15), therapist and patient explicitly review what has been accomplished with regard to the predefined goals. If the goals have been reached, the treatment may take less than 25 sessions. Termination phase (treatment sessions 17-22). In SE therapy, termination of therapy is regarded as particularly important (Luborsky, 1984). It is recommended that therapists, for example, remind the patient when termination will take place or mark treatment phases (arrival at a goal) so they can serve as milestones. During the termination phase, the symptoms often recur as the CCRT is activated by both the 68 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia anticipated loss of the therapist and by the anticipation that the wishes inherent in the CCRT (e.g., security, guidance, closeness, care, acceptance, appreciation) will not be fulfilled (Luborsky, 1984). The therapist interprets the resurgence of the phobic symptoms and relates them to the CCRT. In his generic manual, Luborsky (1984) formulated several principles with regard to termination (for details, see Luborsky, 1984, pp. 142-158). We recommend discussing termination issues no later than session 18 of 25. Because understanding the CCRT is a central goal of treatment, we follow Crits-Christoph et al. (1995) in recommending that therapists summarize what has been learned about the CCRT and its relation to social phobia during the termination phase. Booster sessions (treatment sessions 23, 24, and 25) . The sessions 23, 24, and 25 will be carried out as booster sessions in 2-week intervals. We have already used booster sessions in our previous treatment study of GAD (Leichsenring etal., 2006). Our experiences are consistent with those reported by Crits-Christoph et al. (1995): The positive effects of the booster sessions outweigh any potential interference with the working through of termination. For this reason, we recommend the use of booster sessions in the treatment of social phobia. The therapist uses the booster sessions to monitor and support the patient s improvements with regard to social phobia. Furthermore, the therapist's task is to encourage and support the patient's own activities in working on his or her problems, including his or her self-exposure (internalization of the therapist). The therapist relates relapse to the CCRT and to the loss of the therapist. If serious relapse occurs, the patient is referred for another treatment. Specific elements for the treatment of social phobia using SE therapy In the following, specific elements of a short-term psychodynamic therapy that were found to be particularly useful in the treatment of social phobia will be described. Here, we specifically refer to principles that Hoffmann (1999, 2002,2003) derived from the presently existing psychoanalytic concepts of social phobia. We use these principles to adapt the treatment specifically to social phobia. In general, it is important for the therapist to adopt a more active stance than in classical psychoanalytic therapy. This refers to actively establishing a helping alliance, identifying the CCRT, formulating the treatment focus and treatment goals, treating the social phobic avoidance behaviors, and dealing with duration and termination aspects (see below). Principle 1: Extensively inform the patient at the beginning of the treatment about his or her disorder, including the primary symptoms. In the
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Leichsenring et al. socialization interview (see above), the patient will be cognitively prepared by informing him or her about the pathological nature of the symptoms, about the necessity of treatment, and about procedures, problems, and possible outcomes of therapy. By being informed at the beginning of treatment, the patient is given a rationale that allows for a first orientation. With regard to the supportive-expressive dimension, cognitive preparation has a supportive effect insofar as the patient is addressed as an adult counterpart (Hoffmann, 2002, 2003). This principle is implicitly included in Luborsky's conception of SE therapy.
Principle 2: Establish a secure positive therapeutic alliance. In SE ther-

apy, the helping alliance is regarded as an important supportive treatment element. Because insecure attachment seems to play an important role in many patients with in social phobia (Eng et al., 2001; Hoffmann, 2002,2003; Vertue, 2003), the establishment of a secure therapeutic alliance is of particular and specific importance. This is true for several reasons. It provides a new alternative ("corrective emotional") experience that allows the patient to experience a secure attachment. Furthermore, a "secure base" (Bowlby, 1988) allows the patient to confront his or her fears, both in a psychological and a behavioral manner. Thus, the feeling of security allows the patient to try out new behaviors; for example to find out what happens when he or she does not avoid a feared social situation. However, as Fonagy and Target (2005) have recently pointed out, a secure attachment not only provides a secure base, but also serves as a major organizer of early brain development. Secure attachment and mentalization seem to serve as a "buffer against breakdowns in affective regulation during times of stress" (Fonagy SiC Target, 2005, p. 339). Thus, Fonagy and Target (2005) see mentalization as being linked both to Bion's (1962) containment concept and to Winnicott's (1960/1965) concept of "good enough mothering." A secure attachment can be expected to help the patient to improve his or her affective regulation during social stress. Furthermore, another link exists to Kohut's (1971) concept of mirroring and transmuting internalization and to Konig's (1981, 1997, p. 94) concept of an internalized (impulse) "directing" object that is usually impaired in phobic patients. It can be assumed that the internalization of a security providing and esteeming object contributes to improving the patient's self-etseem

2. Referring to the available evidence for the role of attachment and mentalization in mental disorders, Bateman and Fonagy (2003) have recently developed an attachment-based treatment program for borderline personality disorder that has proved to be efficacious (Bateman &C Fonagy, 1999, 2001). 70 Bulletin ofthe Menninger Clinic

Psychodynamic psychotherapy for social phobia regulation and impulse control. Thus, establishing a secure positive therapeutic relationship has several important implications.^ Principle 3: Focus on the affect of shame and point out its central role in social phobia early in treatment (even during the diagnostic interviews). This "affective preparation" aims to make the central role of shame for the maintenance of the symptoms of social phobia permanently conscious. Hoffmann (2002, 2003) differentiates between two types of shame: Conscious (open) shame. This predominates in the generalized form of social phobia. Its verbalization by the therapist leads to relief in the patient. Example: "Listening to you, I get the impression that you are terribly ashamed of your alleged failure, even of yourself in general. This is certainly very painful." Unconscious (covered) shame. This is prevalent in the specific form of social phobia. Its verbalization by the therapist may lead to resistance and rationalizing defense. With regard to shame experiences, the expected humiliation by others constitutes the RO-component of the CCRT. The RS-component is made up of the shame and fear of being humiliated or embarrassed. In treating social phobia, the therapist focuses on the different aspects of the fear of humiliation or embarrassment and sometimes relates it to other components of the underlying CCRT. Because shame is a highly social affect, the fear of humiliation (Gedo, 199f) can be expected to be repeated in the therapeutic transference-countertransference constellation. By focusing on these aspects of transference and countertransference in the therapeutic relationship, the therapist can directly work through the maintaining conditions of social phobia. The patient's transference allows for an in vivo repetition of the developmental conditions that once led to the social phobia and the inhibition of social behavior (Gabbard, 1992). Thus, self-exposure also takes place in the patient-therapist relation, which is different from exposure in CBT. Focusing on shame and the associated components of the CCRT has an expressive effect. Principle 4: Confront patients with the unrealistic demands they make on themselves. Patients with social phobia usually tend to make excessive demands on themselves and their own (social) performance. With these demands, the anticipatory fears and the psychophysiological arousal increase considerably. Uncovering and working through such
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Leichsenring et al. excessive expectations usually leads to a surprising relief. According to Hoffmann (2002, 2003), two steps are required: First, the therapist confronts the patient with his or her excessive demands and makes them conscious. For example: "Is it possible that you make excessive demands on yourself?" or "Did you always expect that much of yourself?" or, referring to past relationships: "Who expected you to be perfect in the past?" Second, if (but only if) the patient realizes his or her excessive demands on himself or herself, the therapist can refer to the patient's projection onto others. Fxample: "Maybe we can understand your fear of others' expectations in that it is you who ascribes them to others. Mostly, others do not have a particular interest in someone else" or "It is not that easy to differentiate between the expectations of others and one's own expectations. Has it ever occurred to you that it is you who ascribes your own expectations to other people?" The excessive expectations will also be projected onto the therapist. Sometimes, even beginning in the first session, a transference trap may develop that is specific to these patients. They tend to test if the therapist fulfills the excessive demands that the patients make on themselves. Dealing with such expectations in a relaxed and humorous way, including openly admitting that the therapist is not perfect, allows the patients to become aware that they permanently expect too much of themselves early in treatment. Principle 5: Encourage the patient to actively confront rather than avoid the anxiety-producing situation. Encourage him or her to study this situation exactly. This principle is consistent with Freud's (1919/1955) recommendations for the treatment of phobia. Freud regarded confrontation with the anxiety-producing situation as a sine qua non in the treatment of phobias. Crits-Cristoph et al. (1995) have integrated this principle into the SE treatment manual for GAD. In social phobia, confrontation with the anxiety-producing situation is of particular importance, and patients with social phobia usually react with resistance against exposure. However, the patient's experiences during self-exposure are important for treatment success because they question the CCRT and allow for its change. Self-exposure may be introduced, for example, in the following way: "In order to reach your treatment goals, it is necessary for you to confront your anxieties in specific situations. However, it is important that you don't jump into the situations like jumping into cold water, plugging your nose, and closing your eyes, but 72 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia that you study the situation minutely, including your behavior and others' responses. When you have done so, we can examine what you have learned through this in the next session." Another intervention could be, for example, as follows: "Although such a step requires you to be courageous, it is not a test of courage. It is necessary for you to explore, step by step, the situations you have systematically avoided until now. However, it is you who takes the steps and who decides what you can tolerate." In the socialization interview, when the rationale of the SE therapy is presented, the patient is informed that a self-guided symptom exposure is included in the treatment to help the patient with his or her social anxieties. However, the exposure itself should not begin before the middle phase of the treatment. Details of the exposure and its stepwise progression are planned in the sessions preceding exposure. In general, the patient should not widen the extent of exposure too quickly; slow progression is superior to a stormy approach. In this phase of treatment, controlled progression to exposure is important ("What do you believe to be capable of doing as a next step?"). Thus, the therapist's task, in this phase, consists of advising the patient to find the best progression speed (e.g., "I really understand that you wish to go on quickly, but I think it is advantageous to stick to the amount of exposure we had planned. Often less is more". Or: "I really can understand your reluctance to exposure after all these years of avoidance, but I am convinced that your chance for change is greater if you really undertake the painful steps we had planned"). Caveat: Neither the therapist nor the patient should force or protract the tempo. Self-exposure should not be introduced before a secure positive relationship has been established (see below). Encouraging the patient to confront the anxiety-producing situation is a supportive intervention, but its effectinsight into the CCRT and modification of its componentsis expressive. Self-exposure in psychodynamic psychotherapy is characterized by some differences as compared to CBT. One of them was already mentioned above: (1) Feelings of shame and anxiety also develop in the therapeutic relationship. They are therapeutically used and worked through with regard to the underlying CCRT; (2) furthermore, the experiences of the patient during self-exposure outside the therapeutic setting are related to the CCRT; and (3) contrary to CBT, the therapist does not accompany the patient during self-exposure outside the therapeutic setting. In this respect, CBT is much more supportive and directive. Principle 6: Explore and discuss the use of psychotropic substances and medication to reduce anxiety. Many patients with social phobia use
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Leichsenring et al. psychotropic substances or medication to reduce their social anxieties (e.g., alcohol, marijuana, benzodiazepines, or beta blockers). Studies in the treatment of panic disorder (Subic-Wrana, Mancher, 8c Beutel, 2006) have shown that the misuse of psychotropic substances can hamper emotional experiences that are essential for psychotherapeutic progress. For this reason, this kind of avoidance behavior should be carefully explored and discussed at the beginning of treatment. Principle 7: Do not forget that many people with social anxieties have real impairments with regard to their social skills due to the length of their disorder. As mentioned above, supportive interventions are of particular importance. Hoffmann (2002, 2003) stressed that it is important for the patient to establish an "inner dialogue" that encourages the patient. This inner dialogue should be activated, especially before exposures, and can include literally addressing oneself. If possible, addressing oneself should be done audibly. It is preferable that the patient addresses himself or herself, but as a second choice, the inner dialogue may be carried out (virtually) with the therapist. The following statement may serve as an example for addressing oneself: "Peter, there is absolutely no doubt that you prepared this speech as well as the last one, and that you are able to give your speech as spontaneously as the last one. Stop thinking about others' alleged opinions of you." The inner dialogue with the therapist can be prepared, for example, in the following way: "Do you think it would be easier for you to stand up to your fear, if you were to take me with you in your breast pocket so that we could confront your fear together? For many people, such an idea can be very helpful." The following communication of a patient with himself may serve as an example for an established inner dialogue with the therapist: "You (therapist) conveyed to me that it is only my misperception of others' opinion that makes me panic. Now I will find out!" Helping the patient to establish an inner (encouraging) dialogue fosters the internalization of an appreciating (Kohut, 1971) or directing (Konig, 1981, 1997, p. 94) object. Principle 8: Be aware of your countertransference and be sure to respect the patient. Only if you respect the patient can you help him/her to revise his/her distorted self image. As stressed by Luborsky (1984), respecting the patient is an important component of supportiveness. In patients with social phobia, whose central problem is a lack of self-respect (and who project this disdain onto others), respecting the patient is of paramount importance. For these patients, it is crucial that the therapist conveys his/her respect to the patient (Hoffmann, 2002, 2003). Respecting 74 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia the patient's view of having a 'fundamental deficit' (i.e. to be damaged, insufficient, no good or in deficit), which is a characteristic for many patients with social phobia, can hardly be overestimated (see below "prescriptions").
Other interventions that are particularly useful for the treatment of social phobia

According to Hoffmann (2002,2003), several other principles of intervention are particularly useful for the treatment of social phobia. Three of these principles are prescriptions, the stage paradigm, and humor. Prescriptions Many patients with social phobia tend to persistently devalue themselves. It is the therapist's task to recognize and work through these tendencies and to show the patient that it these mechanisms that contribute to the maintenance of social phobia. The specific means of self-devaluation may provide important information about the underlying CCRT, for example, about its wish or reaction of the object component. It is important for progress in social phobia that the therapist does not allow the patient to devalue himself or herself persistently during the sessions. Dealing with the disturbed self-image requires both empathic understanding and persistent and tactful correcrion. Hoffmann (2002,2003) recommended correcting the distorted self-image persistently without further comment. Example: Patient: Someone who performs like you can be sure that others are interested in you. But when people look at me, they think at once: "'What does this stupid handicapped guy want here?" Therapist: You know that you are neither stupid nor handicapped. Patient: I am surely handicapped and the others can see it. People are right, I am a nothing and everybody can see it at once. Therapist: May I make a suggestion? We have already talked about the word "handicapped." I do not share your view, as I have already said. You should not devaluate yourself during the sessions in this way any more. Could we agree on this? Here is a place were nobody may devaluate you/ don't do this and please don't do it yourself Can you accept this? That I provide a "nondevaluation" space for you? Prescriptions aiming to protect the patient against himself or herself are helpful for successful treatment of self-esteem problems. In short-term
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Leichsenring et al. psychotherapy they may be indispensable. Hoffmann's patients often reported, after termination of therapy, that changes in their self-esteem had begun to develop when they were "prohibited" from devalueing themselves during the sessions. To stress it again: In each phase of the treatment, it is essential for the patient to feel that a prescription aims at respecting the patient and to protect the patient from himself or herself. Stage paradigm As another confronting intervention, Hoffmann (2002, 2003) described the "stage paradigm": The patient is asked to imagine his or her experience as a scene on a stage. This intervention is very useful in helping patients to distance themselves from their own experience. This develops reflective functioning (Fonagy, f 998; Fonagy 8c Target, 2005) with regard to their social fears. Referring to the therapeutic situation, Sterba (1934) described this capacity as a therapeutic splitting of the ego into an "experiencing" and an "observing" part. The stage paradigm may be introduced in the following way (Hoffmann, 2002,2003): I would like to make a suggestion. Imagine the episode you have just told me about as a performance on a stage. You are sitting comfortably in the audience and you are observing yourself talking with the shop assistant. Do you have the picture in your mind? You see yourself permanently looking to the ground, speaking very softly, not saying what you are really looking forjust as you told me. What do you think about the shop assistant? What do you think about yourself as a customer? Humor Humor may have a very relaxing effect in persistent self-esteem problems. Much is gained if the patient is able to laugh for the first time about his or her unrealistic social fears, thus achieving a distance from himself or herself. For the use of humor, tactful timing is required and the patient's vulnerability must be kept in mind. A secure positive relationship is required as well. Hoffmann (2002,2003) gave the following example for the use of humor in asking a patient who used the stage paradigm: "What are they playing? A tragedy, a comedy or even slapstick?" Kohut (1966) described the development of the capacity for humor as a transformation of narcissism.
Concluding remarks

The psychodynamic manual for the treatment of social phobia presented here is based on the principles of SE therapy (Luborsky, 1984).
76 Bulletin of the Menninger Clinic

Psychodynamic psychotherapy for social phobia The treatment has been specifically adapted to social phobia with reference to contributions from Gabbard (1992), Fonagy (1998), Crits-Christoph et al. (1995), Konig (1981, 1997), and Hoffmann (1999,2002,2003). In particular, the treatment principles suggested by Hoffmann (1999, 2002, 2003) were integrated into the manual. In some instances, the treatment may be more directive than usual SE therapy. This especially applies to the prescripdons described above. However, to encourage the patient to actively confront, rather than avoid, the anxiety-producing situation is consistent with Freud's (1919/1955) recommendations for the treatment of phobia. For the treatment of compulsions, Freud (1919/1955) made similar recommendations. For psychodynamically trained therapists, it is possible to use this manual and its principles adequately after a relatively short training period. For the treatment of GAD with SE therapy, Crits-Christoph et al. (1995) recommend at least four training cases, which is consistent with the experiences we have had in our own treatment study of SE therapy of GAD. For the assessment of adherence and competence in SE therapy, a rating scale is available (Penn Adherence and Competence Scale for Supportive-Expressive Therapy, PACS-SE; Barber &c Crits-Christoph, 1996; Luborsky, 1984). For the treatment of social phobia, the authors of this manual adapted the scale by adding disorder-specific items. Crits-Christoph et al. (1995) suggested a tentative criterion of 4 or more on the 1-7 scale of the PACS-SE as a cutoff score for acceptable competence. Although the psychodynamic treatment presented here includes some behavioral elements (e.g., self-exposure or prescriptions), it differs from CBT treatment models for social phobia. In contrast, for example, to the approach of Clark and Wells (1995), the psychodynamic treatment does not include specific therapeutic elements that characterize the Clark and Wells approach (e.g., role play or training to systematically change the focus of attention and safety behavior, video feedback to change distorted self-imagery, cognitive restructuring of dysfunctional beliefs, modification of problematic anticipatory or postevent processing). On the other hand, the psychodynamic treatment presented here uses active ingredients that are not included in CBT approaches: It includes the characteristic elements of SE therapy, that is, setting goals, focus on the CCRT associated with the patient's symptoms, interpretive interventions to enhance insight into the CCRT, and supportive interventions, in particular fostering a helping alliance. Furthermore, additional treatment elements are applied in order to tailor the treatment more specifically to social phobia; for example, a specific focus on

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Leichsenring et al. distorted self-imagery, on shame and on unrealistic demands, or on specific transference-countertransference patterns. The treatment is conceptualized as a short-term treatment of 25 sessions (plus 5 introductory sessions). It is of note that the manual has been developed specifically for patients with the primary diagnosis of social phobia. Comorbid mental disorders may be present, but they must not be the primary diagnosis. Although even severe mental disorders (e.g., borderline personality disorders) can be treated with SE therapy (Luborsky, 1984), the treatment presented here is conceptualized as a short-term treatment that may not be appropriate for patients with severe comorbid personality disorders (e.g., narcissistic or borderline personality disorder). For the latter patients, modifications that would put a greater focus on supportive treatment elements are required (Luborsky, 1984). Clinical experiences have shown that many patients with social phobia benefit from the treatment principles described here. Establishment of psychodynamic treatment as an evidence-based procedure for a broad range of psychiatric disorders is hampered by the lack of suitable treatment manuals. We have set out to fill the gap for a frequent and debilitating disorder traditionally neglected by psychoanalysis. We therefore hope that dissemination of the treatment outlined will stimulate both clinical and research efforts in the future.

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