2020: The most challenging and exciting time to be a CBT therapist

David Clark started developing remotely delivered treatment for social anxiety disorder over 15 years ago. When I joined the team he told me the biggest challenges and most exciting innovations in CBT were yet to come in adapting to remote working. At the time I was sceptical. Now I wonder if he had some sort of time machine, and if so, why he didn’t also advise me to purchase Zoom shares. Thankfully, our group found that all of the core interventions of cognitive therapy for social anxiety can be delivered remotely. Our latest paper outlines how. Here are a few of the headlines:

• You are a phobic object, even at a distance

You might be the warmest, least threatening therapist around, but to somebody with social anxiety, meeting you is like a spider phobic having therapy with a tarantula. Pretty terrifying, even from a distance. Remember to normalize this and do what you can in early sessions to reduce the intensity of therapy (e.g. use share screen to build formulation).

• Are you looking at yourself too much?

People with social anxiety are habitually self-focused and even more so when they can see their own video during a conference call, so encourage patients to hide this during remote sessions. Attention training practice helps patients become more externally focused and can be easily done remotely. Our paper describes how, with links to attention training videos to use in remote sessions and share with patients for homework practice.

• Experiment! Experiment! Experiment!

Patients who do more behavioural experiments to test their specific beliefs in therapy get better outcomes. In face-to-face treatment we do experiments together, in and out of the therapy office, and more for homework.  So how do we replicate this active work when remote?  Our paper gives ideas and clinical examples for testing a range of fears. This might include doing experiments by:

1. Adding in other people to video conference calls
2. Patients leaving their home with the therapist guiding them on the phone
3. Patients making a phone call experiment live during a video conference session
4. Using virtual audiences

Carrying out experiments remotely can be challenging, but the blocks can be overcome with collaborative creativity.  

• Seeing is believing

Patients viewing video of themselves carrying out experiments is a powerful way to update distorted self-images. Our paper describes practical ways to do this remotely.  Have you ever watched video of yourself? If so, you will know how challenging it can be to switch off your inner critic. So always prepare patients to watch video objectively, as if they are watching a stranger (see also Warnock-Parkes et al., 2017 for more videofeedback tips).

Final thoughts

Like any CBT, remotely delivered therapy takes creativity and hard work, but can be highly effective when done well.  The wonderful thing about treating social anxiety is that by the end of treatment you discover the true person hiding underneath the mask of their safety behaviours. There is no greater gift than helping someone discover they are acceptable as they are.  Thankfully we can effectively do that at any social distance. You can find all cognitive therapy resources, therapy role-play videos and more at: www.oxcadatresources.com

From Richard Thwaites, the Editor-in-Chief of tCBT: Why I chose this article.

During the COVID-19 pandemic, many services (including my own) have moved partly, or wholly, to remote working with a number of associated challenges as we start to adapt our skills for a different therapy delivery method and working in less familiar ways!. This paper provides a fantastic ‘how to’ guide that has been invaluable over the last few months and will be highly applicable in the future during remote treatments for social anxiety and training and supervision around this.  It is fantastic that Dr Warnock-Parkes and colleagues have distilled their learning of the last ten years down into such a clinically useful paper (and so fast).