Ash Catton


PhD Candidate, Clinical Psychology Student

The Suitability of Clark & Wells Cognitive Model of Social Anxiety as a Basis for Treatment Among Adolescents


October 15, 2021

Social Anxiety Disorder (SAD) is characterised by an intense and disproportionate fear of social situations, where the individual fears negative evaluation such that the situations are either avoided or endured with much distress (American Psychiatric Association, 2013). While many models for SAD have been developed, the Cognitive Model (CM) developed by Clark and Wells (1995) places a heavy emphasis on formulating maintaining factors which makes it a suitable model as a basis for treatment. It outlines multiple interactions between cognitions (core beliefs, conditional beliefs about the social situation, and unconditional high normative expectations about social situations), the attribution of threat to a social situation, increases in self-focused attention including social awareness, and the role of safety behaviours and physiological sensations of anxiety in maintaining the perception of social threat. Treatment based off this model includes psychoeducation that socialises clients to their own formulation, exposure tasks and behavioural experiments, attention training for social situations, video feedback, and challenging cognitions (Clark et al., 2003). Early research on the model suggests that cognitive therapy derived from this model (CT) demonstrated superior effect sizes to pharmacological treatments alone, and the effect size increased with the addition of booster sessions that held at 12-month follow up (Clark et al., 2003). 

While SAD is often studied in adult populations, there are unique developmental considerations when conceptualising SAD among adolescent groups. For instance, symptoms tend to emerge in early adolescence and peak in middle to late adolescence (Merikangas et al., 2009; Van Oort et al., 2009). Developmentally, these are also periods marked by the development of public self-consciousness and a shift away from reliance on parental support to nurturance by peer relationships (Leigh & Clark, 2018). These factors are thus crucial in formulating SAD in adolescence, and intervening at a young age may prevent young people developing entrenched avoidance behaviour. The suitability of applying CM to adolescence was investigated in a systematic review by Leigh and Clark (2018) who presented literature relevant to each aspect of CM including cognitions, social self-consciousness, and safety behaviours alongside some developmental considerations unique to adolescence, particularly maintenance factors. 

Regarding cognitions, they found support for the notion that negative social cognitions specified in CM, may help maintain social anxiety among adolescents. For example, Hodson et al. (2008) used a questionnaire design among a moderately sized UK sample of 11-14 year olds and found those categorised as highly socially anxious (using the SPAI-C) scored higher on measures of negative social cognitions (e.g. “other people will think I am boring”) and post-event processing which gauges how often an individual ruminates over a social situation. Supporting this, a large German sample of adolescents also included a measure of social attitudes which measure core and intermediate beliefs (“I am weird”, “I must not show signs of weakness to others”) and found a large effect size between high and low socially anxious youth. Further, a study on Finnish adolescents suggests that negative cognitions may be more focused on the self in a social situation rather than oriented toward other people or the situation itself (Ranta et al., 2014). Taken together, these results support the notion that negative cognitions of the type specified in CM may occur among socially anxious adolescents. However, research on the presence of negative cognitions themselves are correlational and no causal link has been demonstrated. By contrast, the presence of post-hoc catastrophising of social situations (“post-mortem”) has been shown, and CT for adolescents may be more effective if focused on this. This is further supported by developmental considerations that, depending on the age of the client, may find the notion of cognitions too abstract to contemplate (Carr, 2015). This may be why developmental psychologists have emphasised behavioural experiments over normal cognitive restructuring in therapy, or where cognitive work may be more focused on belief disconfirmation (Carr, 2015). 

Leigh and Clark (2018) also found support for general self-focused attention among most studies they reviewed, concluding a medium effect size, yet again cautioned that all studies were correlational and the causal role of self-focused attention on heightening perceived threat and thus anxiety as specified in the model, could not be established. However, they found support for another aspect of self-focused attention, Negative Observer-Perspective Social Images which refers to a perception of the self through the lens of other people with a moderate effect, and that the anticipated observer image of an anxious person may be informed by the individuals own physiological sensations. In other words, there is support for the notion that socially anxious adolescents perceive themselves more negatively in other people’s eyes, and this effect is moderated by their own levels of physiological arousal. This suggests that attention training, per the CT framework, may be an effective treatment target. However, research on Attention Training  for social anxiety among youth using a dot probe task have been mixed with one study finding support in a small sample of two boys aged 8-9 (Cowart & Ollendick, 2011) but not among a larger sample of 58 adolescents using the same task (Ollendick et al., 2019). While this may suggest that the effectiveness of attention training for SAD among youth may hinge on developmental considerations, it remains that dot probe tasks do not feature in CT. Rather, attention training in CT includes focusing attention on the social situation itself and not self-monitoring (Clark et al., 2003). The effect of this task has not been researched. 

Lastly, Leigh and Clark (2018) concluded that a medium to large effect existed for the presence of safety behaviours among adolescents, but emphasise that no experimental designs have been conducted to conclude any causal role. For example, Hodson et al. (2008) found that the most socially anxious adolescents scored higher on the Social Behaviour Questionnaire which assesses safety behaviour such as rehearsal of performance in advance and avoiding eye contact, than those who scored moderately or low on the SPAI-C. While no definitive support exists for the role of safety behaviours on maintaining anxiety, their presence suggests they may be a viable treatment target. 

Regarding the efficacy of CT among adolescents, there is an unfortunate dearth of research in this area. An early study on a group of German youth aged 8-14 investigated the effect of treatment informed by CM, however their treatment differed markedly from the standard CT program, as it featured several psychoeducation sessions before individual treatment and formulation began and featured 20 sessions including parent-only sessions (Melfsen et al., 2011). Despite this, they found a significant difference in remission rates of SAD between youth in treatment and wait-list control with medium to large effect sizes across all measures used. Following this, a study on Norwegian youth with SAD that compared group therapy that integrated elements of two other prominent interventions, SET-C and Coping Cat for Adolescents, with individualised CT across 12 sessions found individuals treated with CT had significantly greater reductions in symptoms; 72.7% for CT, and 53.3% for group treatment (Ingul et al., 2014). Supporting this, a study of five adolescents aged 11-17 years diagnosed with SAD and using CT with 14 individual sessions found all participants achieved remission by the end of treatment (Leigh & Clark, 2018). 

Thus, it is evident that CM is a suitable model for formulating the maintenance of social anxiety among adolescents, despite their unique developmental considerations. There is much correlational support for the presence of negative cognitions, self-focused attention, and safety behaviours. Not only does the model appear applicable to this group, but CT based on this model has proven effective at reducing symptoms to the point of remission. In highlighting psychological mechanisms underpinning the maintenance of social anxiety, CM allows for treatment targets to be clearly identified and tracked as treatment progresses, as well as allowing for individual formulations that can understood by the client. In sum, CM can inform treatment for SAD among adolescents if treatment is tailored with developmental considerations in mind. 

References 
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders : DSM-5 (5th ed.). American Psychiatric Association. 
Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T., Davenport, C., & Louis, B. (2003). Cognitive Therapy Versus Fluoxetine in Generalized Social Phobia: A Randomized Placebo-Controlled Trial. Journal of consulting and clinical psychology, 71(6), 1058-1067. https://doi.org/10.1037/0022-006X.71.6.1058 
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Social phobia: Diagnosis, assessment, and treatment. (pp. 69-93). The Guilford Press. 
Cowart, M. J. W., & Ollendick, T. H. (2011). Attention training in socially anxious children: A multiple baseline design analysis. Journal of anxiety disorders, 25(7), 972-977. https://doi.org/10.1016/j.janxdis.2011.06.005 
Hodson, K. J., McManus, F. V., Clark, D. M., & Doll, H. (2008). Can Clark and Wells' (1995) Cognitive Model of Social Phobia be Applied to Young People? Behavioural and cognitive psychotherapy, 36(4), 449-461. https://doi.org/10.1017/S1352465808004487 
Ingul, J. M., Aune, T., & Nordahl, H. M. (2014). A Randomized Controlled Trial of Individual Cognitive Therapy, Group Cognitive Behaviour Therapy and Attentional Placebo for Adolescent Social Phobia. Psychotherapy and psychosomatics, 83(1), 54-61. https://doi.org/10.1159/000354672 
Leigh, E., & Clark, D. M. (2018). Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995). Clinical child and family psychology review, 21(3), 388-414. https://doi.org/10.1007/s10567-018-0258-5 
Melfsen, S., Kühnemund, M., Schwieger, J., Warnke, A., Stadler, C., Poustka, F., & Stangier, U. (2011). Cognitive behavioral therapy of socially phobic children focusing on cognition: A randomised wait-list control study. Child and adolescent psychiatry and mental health, 5(1), 5-5. https://doi.org/10.1186/1753-2000-5-5 
Merikangas, K. R., Nakamura, E. F., & Kessler, R. C. (2009). Epidemiology of mental disorders in children and adolescents. Dialogues in clinical neuroscience, 11(1), 7-20. https://doi.org/10.31887/DCNS.2009.11.1/krmerikangas 
Ollendick, T. H., White, S. W., Richey, J., Kim-Spoon, J., Ryan, S. M., Wieckowski, A. T., Coffman, M. C., Elias, R., Strege, M. V., Capriola-Hall, N. N., & Smith, M. (2019). Attention Bias Modification Treatment for Adolescents With Social Anxiety Disorder. Behavior therapy, 50(1), 126-139. https://doi.org/10.1016/j.beth.2018.04.002 
Ranta, K., Tuomisto, M. T., Kaltiala-Heino, R., Rantanen, P., & Marttunen, M. (2014). Cognition, Imagery and Coping among Adolescents with Social Anxiety and Phobia: Testing the Clark and Wells Model in the Population. Clinical psychology and psychotherapy, 21(3), 252-263. https://doi.org/10.1002/cpp.1833 
Van Oort, F. V. A., Greaves-Lord, K., Verhulst, F. C., Ormel, J., & Huizink, A. C. (2009). The developmental course of anxiety symptoms during adolescence: the TRAILS study. Journal of Child Psychology and Psychiatry, 50(10), 1209-1217. https://doi.org/https://doi.org/10.1111/j.1469-7610.2009.02092.x