Comparison of the effectiveness of cognitive behavioral therapy and psychodrama on students with social anxiety

Authors
Mehdi Bakaeian 1
Mustafa Bolghan-abadi 1
Mohsen Asghari nekah 2
1 Department of psychology, Neyshabur Branch, Islamic Azad University, Neyshabur, Iran
2 Department of Education and Psychology, Ferdowsi university of Mashhad, Mashhad, Iran
Abstract
Introduction

Social anxiety is one of the most common anxiety disorders. There are various treatments for it. The aim of this study was to compare the effect of cognitive group behavioral intervention and psychodrama in reducing the symptoms of this disorder.

Materials and Methods

The research is a quasi-experimental study with pre-test and post-test with the control group. 445 students participated in this study. First, Connor's social phobia questionnaire and then clinical interviews selected 36 students who had the most social anxiety and then were randomly divided into three groups. For one group, group cognitive-behavioral therapy was performed in 12 sessions of 2 hours, and for the other group, were performed too. Finally, social anxiety was assessed in three groups and the results were compared.

Results

Most of them lacked the criteria for social anxiety (370students) and 15 patients (3.4%) showed severe symptoms of the disorder. Analysis of covariance showed that there was a significant difference between the mean post-test scores of intervention and control group(F=37.25 and p<0.001), this difference was also no significant between intervention groups (p >0/05).

Conclusion

Both methods are effective in reducing social anxiety. Also, the results showed that the two therapeutic interventions in reducing social anxiety in students are not superior to each other.
Keywords
cognitive behavioral therapy
Group therapy
Psychodrama
Social anxiety
Students
1. Batler G. Overcoming Social Anxiety and Shyness,2nd Edition:A self-help guide using cognitive behavioural techniques. London: Robinson. 2016,95-99
2. Kessler R. C., Petukhova M., Sampson N. A., Zaslavsky A. M., & Wittchen H. U.Twelve month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. IJMPR, 2016, 21(3), 169-184
3. Menezes G. B. D., Coutinho E. S. F., Fontenelle L. F., Vigne P., Figueira I., Versiani, M. Second-generation antidepressants in social anxiety disorder: meta-analysis of controlled clinical trials. Psychopharmacology, 2011, 215(1), 11-14.
4. Kaplan Sadock. Benjamin James. and Sadock Virginia Alcott. Synopsis of Psychiatry, Behavioral Sciences/ Clinical Psychiatry. TranslationRezaeiFarzin.Tehran:PublisherArjmand.2019(Persian).
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing.2013,671-73.
6. Hedman E, Ström P, Stünkel A, Mörtberg E. Shame and guilt in social anxiety disorder: Effects of cognitive behavior therapy and association with social anxiety and depressive symptoms. Plos one. 2013.;8(4):e61713..https://doi.org/10.1371/journal.pone.0061713
7. Karlsen B.S., Clench-Aas J., Roy B.V.,Raanaas, R.K. Relationships between social anxiety and mentalhealth problems in early adolescents from differentsocioeconomic groups: results from acrosssectional health survey in Norway. J PsycholAbnorm Child; . 2014,3: 120-6.
8. Mercede N. Relationship of Quality of Life and Achievement Motivation with UnderaduatedStudent’s Anxiety. J Depression Anxiety; 2012, 1(1):1–4
9. Dyrbye L.N.,Thomas, M.R.,Huntington, J.L.,Lawson, K.L.,Novotny, P.J.,Sloan, J.A.,etal. Personal life events and medical student burnout:a multicenter study.Acad Med; . 2006,81(4):374–84.
10. Leta S. Depression Rates among College Students on the Rise. The Daily California. 2001;3(2):189-92.
11. Labbafinejad Y, Bossaghzade A. Assessment of anxiety prevalence and its contributing factors in female medical students of Tehran University of Medical Sciences in 2010-2011. ioh. 2012; 9 (3) :32-38. [Persian]
12. Momeni M, Zeyghami R, Moradi M, Taherpour M, Sarichloo ME. Prevalence and factors associated with social phobia in ursing and midwifery students. Journal of health and care. 2015 Jun 10;17(2):137-45. [Persian].
13. Salina M., Ng C.G., Gill J.S., Chin J.M. Social anxiety problem among medical students in university Malaya medical center (UMMC) – A crosssectional study. Malaysian J Psychiatry; 2008, 17(2): 17-22.
14. Strahan E.Y. The effects of social anxiety and social skills on academic performance. Pers Individ Dif; 2003,34(2):347–66.
15. Aderka IM, McLean CP, Huppert JD, Davidson JR, Foa EB. Fear, avoidance and physiological symptoms during cognitive-behavioral therapy for social anxiety disorder.J BRAT. 2013 1;51(7):352-8.
16. Goldin PR, Lee I, Ziv M, Jazaieri H, Heimberg RG, Gross JJ. Trajectories of change in emotion regulation and social anxiety during cognitive-behavioral therapy for social anxiety disorder J BRAT 2014 ,1;56:7-15.
17. Shannon J. The shyness and social anxiety workbook for teens: CBT and act skills to help you build social confidence. New York: New Harbinger Publications; 2012,119-22
18. Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. JCP. 2008 Apr;69(4):621.
19. Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, Pilling S. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry. 2014 Oct 1;1(5):368-76.
20. Heimberg RG, Becker RE. Cognitive-behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. Guilford Press; 2002 Jul 3.
21. Clark DM, Ehlers A, Hackmann A, McManus F, Fennell M, Grey N, Waddington L, Wild J. Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. JCCP.2006 Jun;74(3):568.
22. McEvoy PM, Nathan P, Rapee RM, Campbell BN. Cognitive behavioural group therapy for social phobia: Evidence of transportability to community clinics. J BRAT. 2012 Apr 1;50(4):258-65.
23. Butler AC, Chapman JE, Forman EM, Beck AT. The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clinical psychology review. 2006 Jan 1;26(1):17-31.
24. Feske U, Chambless DL. Cognitive behavioral versus exposure only treatment for social phobia: A meta-analysis. Behavior therapy. 1995 Sep 1;26(4):695-720.
25. Hofmann S. G.Advances in the research of social anxiety and its disorder anxiety. Anxiety,Stress,&Coping,2010, 23(3), 239-242.
26. Hofmann SG, Bögels SM. Recent advances in the treatment of social phobia: Introduction to the special issue. J. Cogn. Psychother. 2006 Apr 1;20(1):3.
27. Hofmann SG, Loh R. The Tridimensional Personality Questionnaire: changes during psychological treatment of social phobia. J. Psychiatr. Res. 2006 Apr 1;40(3):214-20.
28. Norton PJ, Price EC. A meta-analytic review of adult cognitive-behavioral treatment outcome across the anxiety disorders. J Nerv Ment Dis; 2007 195: 521–31
29. Rapee RM, Gaston JE, Abbott MJ. Testing the efficacy of theoretically derived improvements in the treatment of social phobia.. J Consul Clin Psychol 2009 Apr;77(2):317–27.
30. Otto MW, Pollack MH, Gould RA, Worthington III JJ, McArdle ET, Rosenbaum JF, Heimberg RG. A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia.. J Anxiety Disord 2000 Jul 1;14(4):345-58
31. Davidson JR, Foa EB, Huppert JD, Keefe FJ, Franklin ME, Compton JS, Zhao N, Connor KM, Lynch TR, Gadde KM. Fluoxetine, comprehensive cognitive behavioral therapy, and placeboin generalized social phobia. Arch Gen Psychiatry. 2004 Oct 1;61(10):1005-13
32. Pourrezaian M. The Clinical Evaluation of Psychodrama’s Effectiveness in Treatment of Social Anxiety: A Case Study. CPSJ. 2016Volume 6, Issue 24, Autumn, Pages 29-46. 10.22054/JCPS.2016.6513. [Persian]
33. Dehnavi S, Zadeh Mohammadi A, Hashemi S F, Bajelan M. Effectiveness of Psychodrama based on Unity-oriented Therapeutic Approach on Resilience of Patients with Multiple Sclerosis. Shefaye Khatam 2018, 6(3): 10-18. DOI: 10.29252. [Persian]
34. Holmes, Paul. The inner world outside (object relations theory and psychodrama). 2nd edition.London and New York, Routledge.2015,222
35. Corey G. Theory and practice of group counseling. 9th edition .Boston: Cengage Learning.2015,219
36. Enelow, S.(2015). Method acting and its discontentents: on American psychodrama. Illinois: Northwestern University Press.2015,113.
37. Moreno Z. T., Blomkvist, Leif Dag, Rutzel, T.Psychodrama, surplus reality and the art of healing.. United Kingdom, Taylor & Francis. Routledge; 1st edition 2000.111-13
38. Chesner A.One- toOnePsychodramaPsychotherapy.ApplicationsandTechnique.London.Routledge.2019,46-9
39. Weber, A. M.,& Haen, C. Clinical applications of drama therapy in child andadolescent treatment. New York: Brunner-Routledge.2005,61.
40. Dadsetan P. Anari A. Saleh Sedghpour B.Social Anxiety Disorders and Drama-Therapy.J of Iranian psychologists.2007.115-23. [Persian]
41. Mousavi H, Haghayegh SA. Efficacy of Psychodrama on Social Anxiety, Self-esteem and Psychological Well-being of University Students that met Diagnosis of Social Anxiety Disorder. Knowledge & Research in Applied Psychology. 2019,Vol 20. No. 3. PP: 22-30 Doi:10.30486/jsrp.2019.565164.1284. [Persian]
42. Wiltink J , Kliem S, Michal M,& Eetal. Mini - social phobia inventory (mini-SPIN): psychometric properties and population based norms of the German version. 2017.Wiltink et al. BMC Psychiatry .17:377 DOI 10.1186/s12888-017-1545-2
43. Connor KM, Davidson JR, Churchill LE, Sherwood A, Weisler RH, FOA E. Psychometric properties of the social phobia inventory (SPIN). The British Journal of Psychiatry. 2000 Apr 1; 176(4): 379-86
44. Hassanvand Amouzadeh M. The standardization of social phobia inventory (spin) in nonclinical iranian samples. Urmia medical journal. 2015 Apr 15; 26(1): 17-30. [Persian].
45. Bieling p j, Mccabe R E,Antony M M.Cognitive–Behavioral Therapy in Groups. translated by Khodayari M, Abedini Y.University of Tehran Press.2010, 269-304
46. Fathi T. Psychodrama Prevention and treatment of psychosocial diseases. Tehran:Nahid publisher.2020.38-52. [Persian]
47. Fedoroff IC, Taylor S. Psychological and pharmacological treatments of social phobia: a meta-analysis. JCP. 2001 Jun 1;21(3):311-24.
48. Clark DM, Ehlers A, McManus F, Hackmann A, Fennell M, Campell H, Flower T, Davenport C, Louis B. Cognitive therapy vs. fluoxetine plus self exposure in the treatment of generalized social phobia (social anxiety disorder): a randomized placebo controlled trial. JCCP. 2003;71(6):1058-67.
49. Rodebaugh TL, Holaway RM, Heimberg RG. The treatment of social anxiety disorder. Clin. Psychol. Rev.. 2004 Nov 1;24(7):883-908.
50. Melyani M, Shairi M R, Ghaedi Gh, Bakhtirari M, Tavali A .The effectiveness of cognitive-behavioral group therapy based on Heimberg`s model on the decrease of social anxiety symptoms. IJPCP, Vol. 15, No. 1, 2009, 42-49. [Persian]
51. Abedi Paricha H, Sadeghi E, Shalani B, Sadeghi S.The Effectiveness of Group Cognitive-Behavioral Intervention on The Reduction of Social Phobia in Male Students..2016). J TBCP.Vol. 9 (No. 41), pp.57-66. [Persian]
52. Rezayi F, Amiri M, Taheri E.Effectiveness of cognitive-behavioral group therapy on reducing social anxiety and negative cognitive evaluation among hard of hearing young girls. Quarterly of Counseling Culture and Psychotherapy. Allameh Tabataba’i University.2018, Vol. 8, No. 32.133-160. [Persian]
53. Leichsenring F, Salzer S, Beutel ME, Herpertz S, Hiller W, Hoyer J, Huesing J, Joraschky P, Nolting B, Poehlmann K, Ritter V. Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. AJP 2013 Jul;170(7):759-67. doi.org/10.1176/appi.ajp.2013.12081125
54. Calamaras MR, Tully EC, Tone EB, Price M, Anderson PL. Evaluating changes in judgmental biases as mechanisms of cognitive-behavioral therapy for social anxiety disorder. J BRAT . 2015 Aug 1;71:139-49.
55. Ramak N, Jangi P, Sangani A. The Effect of Cognitive Behavioral Techniques Training on Reducing Social Phobia in Nursing Students. Journal of Health and Care. 2019 Sep 10;21(3):223-32. [Persian]
56. Fogarty C, Hevey D, McCarthy O. Effectiveness of cognitive behavioural group therapy for social anxiety disorder: long-term benefits and aftercare. J BCP. 2019 Sep;47(5):501-13..doi:10.1017/S1352465819000079
57. Akinsola EF, Udoka PA. Parental influence on social anxiety in children and adolescents: Its assessment and management using psychodrama. JPsychology. 2013 Mar 28;4(03):246.
58. Phillips Sheesley A, Pfeffer M, Barish B. Comedic improv therapy for the treatment of social anxiety disorder. J Creativ Ment Health. 2016 Apr 2;11(2):157-69.
59. Aoyi L. Study on Intervention in Undergraduates’ Social Communication Anxiety with Drama Therapy. Journal of simulation. 2016 Apr;4(2):31.
60. Felsman P, Seifert CM, Himle JA. The use of improvisational theater training to reduce social anxiety in adolescents. The Arts in Psychotherapy. 2019 Apr 1;63:111-7. doi.org/10.1016/j.aip.2018.12.001
61. Bögels SM, Wijts P, Oort FJ, Sallaerts SJ. Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorder: an efficacy and partial effectiveness trial. Depression and Anxiety. 2014 May;31(5):363-73.
62. Gabbard, Glen O. Long-term psychodynamic psychotherapy: A basic text. American Psychiatric Pub., 2010.
63. Situmorang DD, Mulawarman M, Wibowo ME. Comparison of the Effectiveness of CBT Group Counseling with Passive vs Active Music Therapy to Reduce Millennials Academic Anxiety. International Journal of Psychology and Educational Studies. 2018;5(3):51-62.
64. Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, Pilling S. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry. 2014 Oct 1;1(5):368-76.
65. Wilson J. An introduction to psychodrama for CBT practitioners. J NZCCP. 2009;19(2):4-8.
66. Abeditehrani H, Dijk C, Toghchi MS, Arntz A. Integrating Cognitive Behavioral Group Therapy and Psychodrama for Social Anxiety Disorder: An Intervention Description and an Uncontrolled Pilot Trial.J CPE. 2020 Mar 31;2(1):1-21.doi.org/10.32872/cpe.v2i1.2693. [Persian]
67. Hamamci, Z. The Effect of Integrating Psychodrama and Cognitive Behavioral Therapy on Reducing Cognitive Distortions in Interpersonal Relationships. Journal of GPP & Sociometry,2002 55(1), 3–14. https://doi.org/10.3200/JGPP.55.1.3-14.
68. Treadwell T, Dartnell D. Cognitive Behavioral Psychodrama Group Therapy. Int J group psychoth . 2017 Jan 27;67(sup1):S182-93. https://doi.org/10.1080/00207284.2016.1218285.