Integrative systemic and family therapy for social anxiety disorder: Manual and practice in a pilot randomized controlled trial (SOPHO-CBT/ST)

Abstract

Social anxiety disorders (SAD) are among the most prevalent mental disorders (lifetime prevalence: 7-12%), with high impact on the life of an affected social system and its individual social system members. We developed a manualized disorder-specific integrative systemic and family therapy (ISFT) for SAD, and evaluated its feasibility in a pilot randomized controlled trial (RCT). The ISFT is inspired by Helm Stierlin's concept of related individuation developed during the early 1980s, which has since continued to be refined. It integrates solution-focused language, social network diagnostics, and genogram work, as well as resource- and problem orientation for both case conceptualization and therapy planning. Post-Milan symptom prescription to fluidize the presented symptoms is one of the core interventions in the ISFT. Theoretically, the IFST is grounded in radical constructivism and "Cybern-Ethics," multi-directional partiality, and a both/and attitude toward a disorder-specific vs. non-disorder-specific therapy approach. SAD is understood from the viewpoint of social systems theory, especially in adaptation to a socio-psycho-biological explanatory model of social anxiety. In a prospective multicenter, assessor-blind pilot RCT, we included 38 clients with SAD (ICD F40.1; Liebowitz Social Anxiety Scale, LSAS-SR > 30): 18 patients participated in the ISFT, and 20 patients in Cognitive Behavioral Therapy (CBT; age: M = 36 years, SD = 14). Within-group, simple-effect intention-to-treat analyses showed significant reduction in social anxiety (LSAS-SR; ISFT: d = 1.67; CBT: d = 1.04), while intention-to-treat mixed-design ANOVA demonstrated the advantage of ISFT (d = 0.81). Per-protocol analyses supported these results. The remission rate based on blind diagnosticians' ratings was good to satisfactory (Structured Clinical Interview, SCID; 78% in ST, 45% in CBT, p = 0.083); this has yet to be verified in a subsequent confirmatory RCT. The article will present the ISFT rationale and manual, including a special focus on multi-person settings, and the central findings from our pilot RCT.

Keywords: cognitive-behavioral therapy; feasibility; integrative systemic and family therapy (ISFT); manual; multi-person; pilot; randomized controlled trial; social anxiety.

Figure 1

Socio-psycho-biological explanatory model adapted to social anxiety (Luhmann, 2017; Hunger et al., 2018; Schweitzer et al., 2020). S, Social system (verbal and non-verbal communication and interaction); P, Psychological system (thoughts, emotions); and B, Biological system (corporeal parameters).

Figure 2

Therapy systems: (A) Dyadic therapy system, including a reflecting team; (B) Multi-person therapy system, including a reflecting team (Hunger, 2021).

Figure 3

Support and anxiety social network (Schweitzer et al., 2020; Hunger, 2021).

Figure 4

Rationale of symptom prescription (Hunger, 2021).