Treating social phobia in children through group narrative therapy

This study explored the effectiveness of group narrative therapy in treating the symptoms of social phobia among boys. Twenty-four boys, aged 10–11 with a confirmed diagnosis of social phobia were randomly assigned to receive treatment (N = 12) or placed on a waiting list (N = 12) considered as a control group. The treatment group received fourteen 90-min sessions of narrative therapy twice a week. Results showed significant differences in the symptom scores for the intervention and waiting list groups. Assessment by parents and teachers showed that the group narrative therapy had a significant effect on reducing symptoms of social phobia among participants in the treatment group both at home and school settings one week after completion of treatment and sustained after thirty days. © 2013 Elsevier Ltd. All rights reserved. Treating social phobia in children through group narrative therapy Social phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur (American Psychiatric Association, 2004). Childhood social phobia is pervasive and can cause serious functional impairment and distress. Research has shown that children with social phobia have a high level of general emotional over-responsiveness, social inhibition, dysphoria, loneliness, general fearfulness, poor social skills, maladaptive behaviors, and educational problems (Beidel, Turner, & Morris, 1999). Children and adolescents with social phobia have a pessimistic outlook and a distrustful interpretation of social situations. They have a tendency to interpret positive social events in a discounting way and to show more negative emotional reactions to positive events (Vassilopoulos & Banerjee, 2008). Other studies have found that they show lower thresholds for threat perceptions and higher levels of negative feelings and thoughts than non-anxious children (Muris, Merckelbach, & Damsma, 2000). People with social phobia believe that others are inherently critical of them and for this reason they have a desire to positively impress others. However, at the same time, they feel dissatisfied and insecure. They frequently perceive threats that may include negative evaluation by others in social situations ∗ Corresponding author at: H2-10-2, Menara Polo, JLN 2/76E, Desa Pandan, 55100 Kuala Lumpur, Malaysia. Tel.: +60 3 9202 20474. E-mail address: [email protected] (M. Yoosefi Looyeh). (Fairbrother, 2002; Rapee & Heimberg, 1997). According to the cognitive behavioral approach, people with social phobia have a negative anticipatory processing which involves a series of negative thoughts prior to encountering a social situation. This process affects the individual’s mental representation of themselves, others and events (Clark & Wells, 1995). Among psychological approaches for treatment of social phobia, behavioral (Beidel, Turner, & Morris, 2000) and cognitive-behavioral therapies (McEvoya, 2007) have the most empirical support. Meta-analytic reviews indicate no treatment is well established for phobic and anxiety disorders in children and adolescents (Silverman, Pina, & Viswesvaran, 2008). As Fogler, Tompson, Steketee, and Hofmann (2007) have pointed out, despite the effectiveness of cognitive behavior therapy in social phobia, patients frequently drop out of treatment and some do not show improvements. Further empirical studies are needed to assess and promote different approaches of treatments for children and adolescents with social phobia (Aderka, 2009). This article presents how group narrative therapy can be employed in the treatment of social phobia in children. Research indicates that socially anxious children respond to ambiguous social narratives and scenarios with negative cognitions and lower estimation of their competency to deal with threat (Bögels & Zigterman, 2000). Warren, Emde and Sroufe (2000) suggest that narratives of children with social phobia about themselves and others represent their negative expectations which may be a leading factor or a mechanism for the development and maintenance of social phobia. Narrative approaches postulate that reality is not directly recognizable and that people live on the basis of meaning they attribute 0197-4556/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.aip.2013.11.005 M. Yoosefi Looyeh et al. / The Arts in Psychotherapy 41 (2014) 16–20 17 to their experiences of the world around them. Cultures shape people’s perceptions of reality or narratives through their experiences and social interactions across time. People attempt to make sense of their lives by integrating their experiences into a sequence and relating them to available cultural discourses and thereby creating a coherent sense of self. It is assumed that we live “in” and “through” our stories (Hill, 2011; Richert, 2006). Narratives reflect people’s identities and how they live their lives. Some narratives have positive influences, while others have negative ones on the way people behave and manage themselves. Narratives that disempower and limit an individual’s options for managing problems contribute to the development and maintenance of psychological dysfunction (Richert, 2006). A fundamental technique of narrative therapy is the process of externalizing through which therapists attempt to create a space between clients and problems and help them to view problems from multiple perspectives and develop self-empowering narratives (White, 2007; White & Epston, 1990). The newly constructed narratives form the basis for more effective solutions to problems (Freedman & Combs, 1996). The externalization process provides an effective tool for children to better understand their dominant problem-saturated narratives, develop new narratives, internalize personal agency and learn to deal with problems differently than they have in the past. Externalizing problems allow children to not think of themselves as the problem and focus on their relationship with the problem. By mapping the influence of the problem children are encouraged to explore the problem’s impact on their behaviors and emotions and its consequences in their dayto-day living (Carr, 1998; White & Epston, 1990). White (2007) has reformulated and clarified the process of externalizing, technically known as the scaffolding conversation map, and how it should be applied to achieve expected therapeutic outcomes. The scaffolding map includes (1) naming and characterizing the problem or initiatives; (2) exploring relations between problems/initiatives and consequences; (3) evaluating the consequences and exploring the thinking behind the evaluation and its relationship with life experiences; (4) drawing out expertise in self-management; and finally (5) expanding intentions into plans for action. Ramey, Tarulli, Frijters, and Fisher (2009) analyzed the sequential process of externalizing with children and adolescents by using video recordings of narrative therapy sessions. The results supported White’s scaffolding map of the sequential process of narrative therapy. A considerable amount of literature on the effectiveness of narrative interventions for children and adolescents has been published. These include treatment of adolescents with Asperger’s Disorder (Cashin, 2008), treating children who have experienced sexual abuse (McKenzie, 2005), and the improvement of personal narrative skills in children with severe communication disorders (Soto, Solomon-Rice, & Caputo, 2009). More recently, Kozlowska and Khan (2011) conducted a study using narrative therapy accompanied with cognitive-behavioral intervention to improve the emotional functioning and management of pain in children and adolescents with unexplained chronic pain. Waters (2011) used integrated narrative therapy and behavioral interventions to help families with attention seeking children. Yoosefi Looyeh and Matin (2006) employed a group narrative intervention for twenty 11-year-old children with learning disabilities. Results indicated children in the intervention group showed significant improvements in coping strategies. Sheibani, Yoosefi Looyeh, and Delavar (2007) examined the effectiveness of narrative therapy for a small group of 10–11 year old girls with depression. Children who received narrative therapy showed a significant reduction in symptoms of depression as reported by parents and teachers. Kamali and Yoosefi Looyeh (2013) explored the effectiveness of group narrative therapy for improving the school behavior of a small sample of 9–11 year old girls with Attention-Deficit/Hyperactivity Disorder (ADHD). Results showed that narrative therapy had a significant effect on reducing ADHD symptoms as reported by teachers (Yoosefi Looyeh, Kamali, & Shafieian, 2012). The current pilot study attempted to extend the literature in this field. The purpose was to explore the effectiveness of group narrative therapy among a small sample of 10–11 year old boys.