SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 1 The Role of Therapeutic Alliance and Emotional Expressiveness on the Association Between Attachment Style and Treatment Outcomes

Cognitive-behavioral therapy (CBT) is a common treatment for social anxiety disorder, a prevalent anxiety disorder characterized by a persistent fear and avoidance of social situations (Heimberg, 2002). Although most patients emerge from CBT treatment with reduced anxiety and better functioning, not all individuals experience clinically significant improvement. Due to the interpersonal nature of this disorder, it may be useful to examine this problem through the lens of attachment theory. The present study will examine how individual differences in attachment security predict treatment outcomes in a clinical sample of individuals being treated for social anxiety disorder. It will also investigate the role of the therapeutic alliance, or bond a patient forms with their therapist, as a potential mechanism for the relationship between attachment and treatment outcomes. Finally, emotion regulation strategies are intricately tied to one’s attachment style and to the formation of close relationships. Thus, the present study will examine whether emotional expressiveness moderates the relationship between attachment style and therapeutic alliance. Implications will be discussed. SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 3 The Role of Therapeutic Alliance and Emotional Expressiveness on the Association Between Attachment Style and Treatment Outcomes Interacting with other people is a normal and essential part of our daily lives. As social beings, we have a powerful urge to belong and feel attached to others in close relationships (Bowlby, 1969; Baumesiter & Leary, 1995). In many ways, these interpersonal relationships contribute to our psychological well-being, physical health, and quality of life (Baumeister & Leary, 1995). These relationships shape not only our habitual social behavior, but also our sense of self and others (Alden, Mellings, Ryder, 2001). People have good reason, then, to be concerned with how others perceive them. Feeling anxious about social situations, arising from concerns about being evaluated and perceived by others, is termed social anxiety (Leary & Kowalski, 1997). Social anxiety does not always reach clinical levels but rather exists on a continuum from low to extreme degrees of concern over social evaluation (Rapee & Heimberg, 1997). For this reason, many people confuse shyness, or the regular experience of moderate levels of social anxiety, with social anxiety disorder (SAD), a diagnosable condition. Despite shared somatic, cognitive, and behavioral symptoms, shyness is considered a normal personality trait because it does not typically generate a high level of impairment and distress (Carducci, 1999). Indeed, those with SAD report a significantly greater number of social fears, avoidance of social situations, negative thoughts, and somatic symptoms in comparison with their shy counterparts (Heiser, Turner, Beidel, Roberson-Nay, 2009). This daily, debilitating distress experienced by affected individuals inspires researchers to identify the most efficacious treatments for the disorder, and to clarify which factors may influence treatment success. This is the primary goal of the present study. SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 4 Social Anxiety Disorder The Diagnostic and Statistical Manual of Mental Disorders (DSM) characterizes SAD as having an intense fear of negative evaluation from others in social and/or performance situations (American Psychiatric Association, 2000). SAD is classified as the most common anxiety disorder (Stein & Stein, 2008), with an estimated lifetime prevalence of approximately 12% (Kessler, Burglund, Demler, Jin, Merikangas, Walters, 2005). SAD most commonly begins during early childhood (Schneier, Johnson, Hornig, Liebowitz, & Weissman, 1992) and typically follows a debilitating and unremitting course into adolescence and adulthood (Chartier, Hazan, & Stein, 1998). The consequences of SAD are numerous and impair many aspects of an affected individual’s life. Due to the interpersonal nature of the disorder, the clear majority of individuals with SAD report that their career, academic, and general social functioning have been seriously impaired by their fears (Turner, Beidel, Dancu, & Keys, 1986). Compared to other psychiatric disorders such as panic disorder with agoraphobia and generalized anxiety disorder, those with SAD are much less likely to marry (Sanderson, Di Nardo, Rapee, & Barlow, 1990). They also tend to have fewer friends and fewer romantic relationships compared to the general population (Schneier et al., 1992). The symptoms of social anxiety have been shown to be associated with low life satisfaction, even after controlling for the level of disability engendered by these symptoms (Hambrick, Turk, Heimberg, Schneier, & Liebowitz, 2003). Finally, 70-80% of those with SAD also meet criteria for an additional condition, and often SAD precedes the onset of the comorbid condition (Schneier et al., 1992). The most common comorbid conditions include agoraphobia, or fear of crowded and public places, major depression, and substance abuse SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 5 (Schneier et al., 1992). These associations increase the risk for suicidal behavior and further impair one’s ability to live a meaningful life (Schneier et al., 1992). Models of SAD Rapee and Heimberg’s (1997) cognitive behavioral model of SAD examines the many processes that contribute to the genesis and maintenance of the disorder. The model begins as the individual is confronted with a perceived audience, which serves as the primary threat stimulus that inspires anxiety. From there, attentional resources are allocated to focus on a mental representation of the self as seen by the audience. This image is subject to distortion and focuses on the aspects of the self that may influence negative evaluation. Information from long-term memory relating to one’s typical appearance further influences this mental representation and the representation changes on a momentary basis, depending on cues received from the audience. Unfortunately, those with SAD will focus more on threat eliciting stimuli, such as noticing others frowning or appearing uninterested, and once noticed, they will have difficulty disengaging from them. Once this inherently negative mental representation of the self is made, it is compared to the appraisal of the audience’s expected standard, which is higher for those with higher social anxiety. The final piece of the model is the behavioral, cognitive, and physical symptoms of anxiety, which may include safety behaviors or escape from the situation altogether, beliefs that one is incompetent or unlovable, or physical manifestations of anxiety such as perspiration and heart palpitations. This cognitive model provides valuable information for how the socially anxious individual processes information and interacts with the world. Newer interpersonal models build on the cognitive one while adding a focus on the interpersonal dynamics at play and how they reinforce the underlying cognitive schema. Individuals with clinical levels of social anxiety tend SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 6 to avoid social situations and/or partake in safety behaviors meant to prevent feared outcomes and conceal information about one’s self (Alden & Taylor, 2009). These safety behaviors include: avoiding eye contact, moving slowly, and talking less (Wells, Clark, Salkovskis, Ludgate, Hackmann, Gelder, 1995). Such behaviors prevent people with SAD from experiencing an unambiguous disconfirmation of their unrealistic beliefs about feared catastrophes (Wells et al., 1995). Though socially anxious individuals believe they are protecting themselves with these behaviors, employing them has serious interpersonal consequences. In first encounters, socially anxious and phobic individuals are liked less by their conversational partners and are perceived as less sympathetic and less easy to talk to than are non-anxious individuals (Alden & Wallace, 1995). Due to the importance of reciprocation and disclosure in close relationships (Altman & Taylor, 1973), the adoption of safety behaviors may serve as an explanation as to why they are liked less. For those with SAD, interpersonal problems are maintained by a self-perpetuating cycle of events (Alden & Taylor, 2004); breaking this cycle is the goal of treatment. Treatment of SAD Though the fundamental principles of various treatments for SAD differ, they are united by a common goal: to reduce the suffering individual’s experience with this disorder. The most well-researched psychosocial treatments for SAD are cognitive-behavioral therapies (CBTs) (Heimberg, 2002). Rodebaugh, Holoway, and Heimberg (2004) propose that all forms of CBT appear likely to provide some benefit for adults. The central premise of CBT treatments is that most psychological disturbances are rooted in distorted or dysfunctional thinking, which influence the patient’s mood and behavior (Beck, 1995). Thus, intervening at the cognitive level will be most effective. SOCIAL ANXIETY DISORDER AND TREATMENT OUTCOMES 7 One of the major components of CBT is cognitive restructuring, or the process by which one identifies and disputes irrational or maladaptive thoughts known as cognitive distortions (Beck, 1964). In the context of social anxiety, this process targets not only the content of the patients’ maladaptive beliefs about the likelihood and cost of negative evaluation by others, but also the information-processing errors that maintain these beliefs (Leahy et al., 2011). These errors include automatic thoughts, or the very quick assessments people make of their situation, such as, “my mind will go blank.”. Related to these distorted automatic thoughts are maladaptive assumptions about social situations, such as, “If I’m not perfect, they’ll reject me,” or, “I must get everyone’s approval,” (Leahy et al., 2011). When combined with core beliefs such as “I’m n