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A case for integrating values clarification work into cognitive

behavioral therapy for social anxiety disorder

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DOI: 10.1037/a0039633

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A Case for Integrating Values Clarification Work Into Cognitive Behavioral Therapy for Social Anxiety Disorder

Robin Grumet and Marilyn Fitzpatrick McGill University

Social anxiety disorder (SAD) is a common and often debilitating psychological disorder. Cognitive behavioral therapy (CBT) has been found to be efficacious in treating SAD, however, barriers to successful treatment still remain. In particular, given the difficulty of engaging clients in anxiety-inducing exposure interventions, it is important to address issues of client motivation in treatment. The current article provides a rationale for incorporating values clarification work from an acceptance and commitment therapy perspective into CBT for SAD. More specifically, it proposes helping clients in CBT for SAD to clarify their values and commit to behaving in ways consistent with their values. The rationale is that values work could enhance treatment motivation and adherence by providing motivation to engage in the difficult work of exposure. Values work also contributes to a sense of meaning and purpose that can enhance positive well-being and quality of life. Finally, values work might be beneficial in maintaining gains following the termination of treatment. Suggestions for application strategies of incorporating values work in to CBT for SAD are provided, in addition to recommendations for research.

Keywords: cognitive behavioral therapy, social anxiety disorder, acceptance and com- mitment therapy, values clarification

Social anxiety disorder (SAD) is a debilitat- ing psychological disorder characterized by an intense fear of social situations, particularly those in which there is the possibility of scrutiny or negative evaluation from others (American Psychiatric Association, 2013). SAD is the third most common psychiatric disorder, with a life- time prevalence estimated at 13% in the Uni- ted States (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), and is associated with significant functional impairment in social, occupational, and other areas of functioning (American Psychiatric Association, 2013). SAD is also associated with a markedly reduced qual- ity of life (QOL; Hambrick, Turk, Heimberg, Schneier, & Liebowitz, 2003; Kessler, 2003; Stein & Kean, 2000), diminished positive affect

(Kashdan, 2007; Kashdan & McKnight, 2013), and fewer positive psychological experiences, such as curiosity (Kashdan, 2007; Weeks & Heimberg, 2012), as well as physical health problems (Sareen, Cox, Clara, & Asmundson, 2005) and suicidal ideation and attempts (Cougle, Keough, Riccardi, & Sachs-Ericsson, 2009). Given the prevalence of SAD and its debilitating impact, it is important to extend the impact of validated treatments to address SAD symptoms and to improve QOL and foster pos- itive functioning among sufferers.

CBT for SAD: The Need for Values

There is ample evidence that cognitive be- havioral therapy (CBT) is efficacious in treating SAD in both individual (Clark et al., 2003; Lincoln et al., 2003; Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003) and group formats (Heimberg & Becker, 2002; Hope, Heimberg, & Bruch, 1995; McEvoy, Nathan, Rapee, & Campbell, 2012; Mörtberg, Clark, & Bejerot, 2011). The fundamental aim of CBT for SAD is to modify the socially relevant dys- functional cognitions that maintain avoidance

Robin Grumet and Marilyn Fitzpatrick, Department of Educational and Counselling Psychology, McGill Univer- sity.

Correspondence concerning this article should be ad- dressed to Robin Grumet, Department of Educational and Counselling Psychology, McGill University, 3700 McTav- ish Street, Montreal, Quebec, H3A 1Y2. E-mail: robin [email protected]

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Journal of Psychotherapy Integration © 2016 American Psychological Association 2016, Vol. 26, No. 1, 11–21 1053-0479/16/$12.00 http://dx.doi.org/10.1037/a0039633

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behavior and the symptoms of the disorder (Hope, Burns, Hayes, Herbert, & Warner, 2010). This is achieved through two types of (related) interventions. First, cognitive restruc- turing is used to help clients identify, reexam- ine, and modify distorted cognitions (i.e., thoughts, core beliefs; Hope et al., 2010). Cli- ents then complete exposure tasks that put them in situations that they fear and would typically avoid (e.g., assigning a client homework to go to a party and initiate a conversation with a stranger) until they habituate to the feared stim- uli (Hope et al., 2010).

In addition to cognitive restructuring, expo- sure is also meant to restructure cognitions and disconfirm false and maladaptive beliefs by pro- viding an experience that is contrary to the distorted cognition (Heimberg, 2002). Exposure also improves SAD symptomatology through a behavioral route. Fear extinction occurs when the individual faces a feared situation with high anxiety; the anxiety is reduced over time until it ultimately abates (Heimberg, 2002). Emotional processing theory posits that extinction occurs through exposure when new incompatible learning takes place and replaces the old faulty association (Foa & Kozak, 1986; Foa & Mc- Nally, 1996). The individual habituates to the feared stimulus, producing a corrective learning experience (Foa & Kozak, 1986; Foa & Mc- Nally, 1996). The newer inhibitory learning model of extinction postulates that a new asso- ciation is developed while the original fear as- sociation remains intact (Craske et al., 2008; Craske, Treanor, Conway, Zbozinek, & Verv- liet, 2014). Both associations remain accessible, indicating that the original fear association can arise in some contexts. Working to enhance the retrieval of inhibitory learning is essential (Craske et al., 2008, 2014). From this perspec- tive, habituation per se is not the central focus, but rather the importance of distress tolerance is highlighted.

Exposure interventions have received an abundance of empirical attention, as they are considered powerful and efficacious interven- tions (Dalrymple & Herbert, 2007). Though re- sults have been mixed, there is some evidence to suggest that exposure treatments are at least as effective as full CBT treatments that include both cognitive restructuring and exposure (Feske & Chambless, 1995; Gould, Buckmin- ster, Pollack, Otto, & Massachusetts, 1997;

Hope et al., 1995). For instance, there is re- search to support the efficacy of exposure inter- ventions (used independently) in producing cognitive changes similar to the effect produced by cognitive restructuring techniques on their own (Newman, Hofmann, Trabert, Roth, & Taylor, 1994).

Despite the well-documented effectiveness of CBT for SAD, it is not always successful. Some clients do not make a full recovery or improve at all; they even occasionally deteriorate (McAleavey, Castonguay, & Goldfried, 2014). Additionally, of those individuals that do re- spond to treatment, many still experience resid- ual symptoms (Dalrymple & Herbert, 2007).

Furthermore, a number of clients (10% to 20%) also terminate treatment prematurely (Es- kildsen, Hougaard, & Rosenberg, 2010). Even more concerning, when dropout rates are in- cluded, 40% to 50% of individuals with SAD show little or no improvement following CBT treatment (Eskildsen et al., 2010); clearly, this group needs something else. Exposure interven- tions, in particular, have been associated with an increased risk for dropout (McAleavey et al., 2014). In addition, clients sometimes do not adhere to treatment protocols and neglect to do homework. Furthermore, though some evidence indicates an improvement in QOL following participation in CBT for SAD, findings suggest that treated individuals still do not achieve the same levels of QOL as nonclinical populations (Dalrymple & Herbert, 2007). Thus, barriers to successfully treating this population using CBT still remain.

McAleavey and colleagues (2014) investi- gated clinician’s perceptions of barriers to treat- ment in CBT for SAD and found a myriad of issues that interfere with treatment and contrib- ute to less optimal outcomes. For instance, cli- ent motivation was a prominent barrier; 60.5% of clinicians reported that they believed that when client motivation was minimal at the out- set of treatment, CBT would be less successful, and that CBT would be more successful if mo- tivation improved. Relative to client motivation, 57.2% of clinicians were concerned about pre- mature termination and found that motivation decreased as patients attributed gains to medi- cations (26.1%), as improvement occurred (16.3%), or as an understanding of social phobia developed (9.1%). Notably, 55.4% of practitio- ners reported clients not working independently

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between sessions as a barrier. Relatedly, 27.5% also endorsed fear of exposure and associated emotional reactions as a barrier to successful treatment. Taken together, these findings indi- cate that clinicians saw client motivation and commitment to the therapeutic tasks as impor- tant obstacles to progress. In addition to thera- pists’ perspectives on client motivation, client self-reports have been related to outcomes in the treatment of anxiety disorders (de Haan et al., 1997; Keijsers, Hoogduin, & Schaap, 1994a, 1994b). However, findings in studies using self- report to assess motivation have been mixed. This inconsistency has been attributed to mea- surement issues with self-report (Lombardi, Button, & Westra, 2014). In a recent study using observational coding, Lombardi et al. (2014) found that client motivational language early in therapy was a strong predictor of treat- ment outcome in CBT for generalized anxiety disorder (GAD).

Given the perceived importance of motiva- tion to treatment outcome in the context of CBT for SAD, McAleavey et al. (2014) suggest that clinicians might find it helpful to complement their CBT for SAD treatment plan using other techniques to foster client motivation. As an example, they discuss motivational interview- ing (MI) to uncover clients’ intrinsic motivation to change. MI is predicated on the notion that in order to effectively foster readiness and com- mitment to change, the motivation for change should not be imposed from the outside (e.g., the therapist), but rather should be elicited from within the client (Hettema, Steele, & Miller, 2005). Given that personal values are an inher- ently motivational, direct human behavior (Bardi & Schwartz, 2003), and are intrinsic to the individual (Plumb, Stewart, Dahl, & Lund- gren, 2009), integrating values clarification work into CBT for SAD could enhance motiva- tion for SAD treatment.

Another strong argument for including values work in CBT treatment of SAD is to foster positive psychological functioning and augment QOL. Research indicates that values-behavior congruence (i.e., acting in a manner consistent with personal values) is associated with several wellness outcomes, including increased life sat- isfaction (Lundgren, Dahl, & Hayes, 2008) and QOL (Michelson, Lee, Orsillo, & Roemer, 2011). Relative to anxiety disorders, Michelson et al. (2011) found that values– behavior con-

gruence was associated with increased self- reports of QOL in a population of individuals with GAD. In terms of SAD, following an ex- posure-based treatment for SAD, including val- ues work in a full acceptance and commitment therapy (ACT) model, individuals reported greater functioning and QOL, in addition to greater values-behavior congruence (Dalrymple & Herbert, 2007). These authors noted that “the focus on experiential acceptance in the context of behavior change consistent with personal values may hold the potential to result in greater functional improvement and quality of life” (Dalrymple & Herbert, 2007, p. 546).

As the research suggests, individuals suffer- ing from SAD not only experience negative affect but also lack elements of positive well- being (Kashdan, 2007; Kashdan & McKnight, 2013; Weeks & Heimberg, 2012). Interventions fostering positive psychological functioning are important to SAD sufferers. Integrating values interventions in CBT treatment plans for SAD may facilitate this endeavor. Recently, similar integration approaches have been suggested. For instance, Macarthur (2013) proposes an as- similative integration approach to treating SAD, particularly with regard to addressing the core beliefs characteristic of this disorder. In a sim- ilar vein, Cameron, Reed, and Gaudiano (2014) proposed a rationale for incorporating values- based exercises into dialectical behavior ther- apy to treat borderline personality disorder. Similar to the current rationale, they reason that values integration could help to promote moti- vation to engage in treatment and adhere to treatment protocol (Cameron et al., 2014).

The current article discusses the integration of values clarification work from an ACT framework into CBT treatment for SAD. Many of the suggestions in this article have applica- tion to CBT in general; however, there are sev- eral compelling reasons for focusing on SAD. The threats associated with many anxiety dis- orders and phobias tend to be circumscribed to specific stimuli (e.g., fear of elevators), whereas in SAD, the nature of the threat is social and pervasive. SAD can interfere with vocational success and the quality of romantic relation- ships and life satisfaction; individuals with a diagnosis of SAD are less likely to be married or in a romantic relationship (Teo, Lerrigo, & Rogers, 2013), and are more likely to experi- ence social issues and impairments in education

13VALUES CLARIFICATION WORK

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(Van Ameringen, Mancini, & Farvolden, 2003) and employment (Bruch, Fallon, & Heimberg, 2003; Stein & Kean, 2000). Because of the pervasiveness and importance of values in all life domains, values work in SAD has particular salience.

Research indicates that although all anxiety disorders are associated with negative affect, SAD is unique in its association with low levels of positive affect (Kashdan et al., 2013) and high levels of experiential avoidance (Kashdan et al., 2013). In avoiding negative internal ex- periences, individuals with SAD often avoid social interactions. Kashdan et al. (2013) re- cently suggested that when working with indi- viduals with SAD, clinicians should incorporate more strategies targeting experiential avoidance and enhancing positive experience. The current article argues that values in the context of CBT treatment for SAD can support this strategy.

Prior to elaborating the rationale for incorpo- rating ACT values work in to CBT for SAD, a brief description of ACT as well as the defini- tion of values from this framework are pro- vided. Next, the rationale for incorporating ACT values work in to CBT for SAD is dis- cussed. Finally, suggestions for implementing this work, as well as directions for future re- search, are offered.

ACT Values Work: Fitting into CBT for SAD

ACT is a third-wave behavioral therapy, which aims to teach individuals to accept and embrace difficult psychological experience in order to live a life in service of their personal values (Hayes, Luoma, Bond, Masuda, & Lillis, 2006). ACT is composed of six components (acceptance, mindfulness, cognitive defusion, self-as context, values clarification, and com- mitted action). A full description of ACT is beyond the scope of this article (see Hayes et al., 2006, for a comprehensive presentation). Instead, we will focus on values and committed action as the components that have most to complement existing exposure-based methods of SAD treatment. These components were cho- sen because they give meaning to, and are the reason for the other ACT treatment processes, which “help clear the path for a more vital, values-consistent life. Values dignify these other processes and make them meaningful”

(Hayes, Levin, Plumb-Vilardaga, Villatte, & Pi- storello, 2013, p. 186). A focus on values in CBT can infuse meaning and motivation into the CBT treatment process. In addition, values and committed action work involves setting short-, medium-, and long-term behavioral change goals that support valued living (Hayes et al., 2013) and is highly congruent with tradi- tional CBT protocols (Hayes et al., 2013).

In ACT, values are defined as “chosen qual- ities of purposive action that can never be ob- tained as an object but can be instantiated mo- ment by moment” (Hayes et al., 2006, p. 9). Unlike goals, values can never be achieved but can be continually expressed in moment-to- moment behavior. A commonly used metaphor in ACT is that values are more like a direction on a compass, as opposed to a destination or goal (Yadavaia & Hayes, 2009). For example, if the value is “living generously,” it is possible to achieve a goal of raising $2,000 for a local charity or of giving an hour of your time weekly to visit your elderly grandmother; however, the quality of generosity can never actually be achieved. Values also cross contexts; one can be generous in a variety of times and situations. I can be generous with time; generous with mon- ey; generous in my compassion for friends, family, or coworkers; or even generous with myself, by making time for self-care. Helping clients with SAD understand the way that val- ues cross contexts can help them to apply new learning from CBT more broadly. This is par- ticularly important in SAD, given its pervasive impairments to daily living.

According to the ACT conceptualization, val- ues are freely chosen; they are not needed to please others or to avoid negative consequences (Ciarrochi, Fisher, & Lane, 2011; Plumb et al., 2009; Wilson, Sandoz, Kitchens, & Roberts, 2010). As such, they should be intrinsically motivating, inherently rewarding, and satisfy- ing. For example, one should value generosity for its own sake and not because one gets rec- ognition or praise from others. Although valued living is rewarding, it is not always easy and can be painful (Hayes et al., 2013). Accordingly if the difficulties of exposure in SAD treatment can be related to goals that are values consis- tent, motivation even in the face of psycholog- ical barriers may increase.

This is particularly relevant with SAD, in which anxiety, fear, and negative emotions pre-

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vent individuals from engaging in activities that create a sense of worth. For example, it is well- documented that anxiety about social perfor- mance often promotes avoidant behavior in in- dividuals with SAD (Dalrymple & Herbert, 2007). Research has shown that helping indi- viduals to focus on what is deeply important to them (i.e., what they value) can help them to persist in valued directions even in the face of hardship. For instance, values interventions have been found to increase persistence in pain- tolerance tasks (Páez-Blarrina et al., 2008). There is also evidence to indicate that including values work in therapy can enhance treatment adherence (Forman, Butryn, Hoffman, & Her- bert, 2009; Woods, Wetterneck, & Flessner, 2006). Helping individuals to clarify their per- sonal values and commit to values-congruent action is a promising way of increasing motiva- tion for exposure.

To do such work, clients need to be helped to connect their personal value to the treatment process and understand its relevance to the chal- lenges of exposure (e.g., negative internal ex- perience). Individuals with SAD can then be helped to use their values as a guide to decision making and behavior, replacing the use of neg- ative internal experience as a guide and facili- tating the use of approach, rather than avoid- ance-based, behaviors (Kashdan & McKnight, 2013). For example, if an individual values liv- ing vitally but is reluctant to engage in some difficult aspects of treatment, it might be worth- while to connect the hard work in treatment to the experience of vitality in the long term. Us- ing the values example of living generously, the act of attending a friend’s birthday dinner can be understood as generosity to a friend and might improve client motivation to tolerate the difficulty of the event. Different values can serve the same goal. For example, a socially anxious person who values authentic connec- tion but is afraid of social rejection might be motivated to attend the birthday dinner to create an opportunity for strengthening her connection with the friend. A SAD sufferer who has clari- fied the value of promoting harmony in the world might see the dinner as an opportunity to interact harmoniously. The value may serve as the basis for increasing motivation in the con- text of the difficult exposure task. As described above, challenge of exposure tasks in the treat- ment of SAD can be mitigated if clients can

clarify personal values and translate them to committed action in service of a value. The process of values clarification and fostering val- ues-congruent behavior is elaborated in greater detail below.

In addition to supporting motivation for ex- posure, the addition of values work in CBT for SAD may also serve to foster positive function- ing (e.g., enhancing meaning in life) and well- being. Efficacy of CBT for SAD is often gauged in terms of symptom reduction. Although this is an important goal, well-being is more than the absence of psychological distress (Duckworth, Steen, & Seligman, 2005). Subjective well- being (SWB), or “happiness,” a widely used measure of well-being, is comprised of two components: life satisfaction, and the relative presence of positive affect and absence of neg- ative affect (Diener, 2000). Furthermore, from a positive psychology perspective, experiencing positive emotions, having a sense of meaning in life, and engaging in rewarding activities all contribute to SWB (Duckworth et al., 2005). However, research indicates that individuals with SAD have impaired positive functioning (Kashdan, 2007; Weeks & Heimberg, 2012), including less positive emotions, less meaning in life, as well as lower self-esteem when com- pared with their nonclinical counterparts (Kash- dan & McKnight, 2013). Effort toward living with a greater purpose in life has been associ- ated with greater positive emotions, increased self-esteem, and greater meaning in life in indi- viduals with SAD (Kashdan & McKnight, 2013). Though values and purpose are not syn- onymous, the constructs are closely related: “Purpose can be viewed as a subcategory of values, reflecting the most important or central. As a self-organizing system, purpose provides a framework for people to create goals and then specific behaviors that, if pursued, reflect com- mitted action” (Kashdan & McKnight, 2013, p. 1150). However, individuals with SAD report greater obstacles and failures and less intrinsic motivation in working toward their purpose (Kashdan & McKnight, 2013). Methods to ef- fectively address values are potentially useful in this work. Using values to foster purpose and meaning in life throughout the therapeutic pro- cess in CBT for SAD may result in enhanced well-being for clients.

Given the pervasive nature of values (across both time and contexts), values work in the

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context of CBT for SAD might also be a useful tool for maintaining gains and even continuing to achieve new gains following termination of treatment. For instance, a client might be helped and supported by a therapist to drop several safety behaviors (e.g., sitting at a far distance from others in a social situation) over the course of treatment. With a clear sense of values as well as an understanding of how this behavior interferes with values-congruent goals (e.g., meeting new people for a client who values novel experience and authentic connection), the likelihood of maintaining these treatment gains and reducing safety behaviors might be en- hanced. Furthermore, with a commitment to working toward a values-congruent lifestyle, the client might also drop other safety behaviors that are perhaps more difficult to relinquish (e.g., avoiding eye contact in order to avoid being noticed or having to engage in a conver- sation) following the termination of treatment. Values work might help motivate the client to initially engage in exposure and drop safety behaviors in the face of significant distress. If a client masters these behaviors, it may foster a sense self-efficacy and provide the impetus to continue making gains that serve valued ends. Thus, CBT treatment for SAD with values work as an adjunct may produce impacts beyond symptom reduction, foster a sense of meaning and vitality, and aid in the maintenance and continuation of gains following the termination of treatment, even in the face of debilitating anxiety.

Treatment: Implementation of Values Work into CBT for SAD

The strategies of values work are an impor- tant part of ACT. These may have utility in individual psychotherapy (CBT for SAD), group activities in cognitive behavioral group therapy, and homework between sessions. Within an ACT framework, typically this work involves two fundamental components: values clarification and committed action interven- tions. These two components are described and case vignettes demonstrate their implementa- tion and integration within a CBT for SAD framework.

Values Clarification

Values clarification work is aimed at helping individuals to clarify their personal values. To this end, clinicians help clients look for areas in their life in which they derive vitality, meaning, and purpose, and to differentiate these from extrinsically motivated endeavors (Hayes et al., 2013). This information is used to help clients identify their personal values in various life domains. Both structured and experiential types of exercises are useful for this purpose (see Luoma, Hayes, & Walser, 2007, for interven- tion examples).

For instance, structured exercises include questionnaires such as the Valued Living Ques- tionnaire (Wilson et al., 2010), which asks re- spondents to rate the importance of 10 valued life domains (e.g., parenting, spirituality, recre- ation) and the extent to which their behaviors are congruent with values in these areas, and the Survey of Guiding Principles (SGP; Ciarrochi & Bailey, 2008), which asks respondents to rate the importance of 60 ACT-based values (e.g., “being creative”), as well as the motivational origin of these values (i.e., intrinsically or ex- trinsically motivated), and the degree of success at living congruently with these values. Another structured exercise commonly used is a card- sorting task, derived from the SGP (Ciarrochi & Bailey, 2008). It requires clients to examine an assortment of 60 cards (each with a single value statement written on it; e.g., “gaining wisdom”) and sort them in to three piles: “not very im- portant to me,” “of moderate importance to me,” and “of highest importance to me.” Fol- lowing this step, clients are often instructed to progressively narrow down their top values (e.g., from the top 15 to the top 5).

One experiential exercise used in ACT values clarification is the Eulogy exercise, which asks clients to imagine what they stand for and how they would want to be remembered and de- scribed at their funeral. Alex, who suffers from SAD, visualized her cousin talking about how kind she had been in her life, highlighting her work at the animal shelter where she currently volunteered. It was a place where she did not experience anxiety. With encouragement, Alex elaborated how, in spite of her shyness, she truly wanted to be someone who never hurt others and in fact helped them to feel valued and important. With this value in mind, she was able

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to go to a job interview focusing not just on how frightened she was but also on being kind to the interviewer. Similarly, the Sweet Spot exercise (Wilson, 2005) directs clients to visualize and then express sweet moments from their lives. Information from experiential exercises like these is used to begin to clarify a value that is worthy of commitment. Unstructured values discussions and examples of values in therapeu- tic stories are also useful in working toward a clarified value. Once a solid value is articulated, committed action work can be initiated.

Committed Action

Committed action work is aimed at helping clients to develop consistent patterns of behav- ing that are congruent with personal values. Clients are often helped to set short-term, me- dium-term, and long-term values-congruent goals to support this process (Hayes et al., 2013). When working with committed action interventions as such, journaling can be used to track progress between sessions. The Bulls Eye Values Survey can also be used to track the congruence between values and behavior over time (Lundgren, Luoma, Dahl, Strosahl, & Me- lin, 2012). Preparing clients for barriers that are likely to arise in the process of implementing their values is also recommended (Hayes et al., 2013). Internal barriers, such as anxiety, fear, and self-doubt, as well as external barriers, such as time, are both important to discuss.

When working with clients with SAD, a fo- cus on internal barriers is particularly pertinent. It is crucial to help clients understand that val- ued living is not always pleasant and can elicit distressing thoughts and emotions. Given that much SAD behavior is aimed at avoiding neg- ative internal experience, clients need psychoe- ducation on persisting despite internal barriers. Values work can be used as a stand-alone in- tervention (e.g., assigning values-focused homework, such as journaling about values- congruent behavior) or assimilated into existing CBT interventions. For instance, values can be framed as motivational tools in the context of exposure and eliminating safety behaviors. Cli- ents can be helped to understand the value- related consequences associated with avoidant behaviors and the value-related benefits associ- ated with successfully completing exposure ex- ercises and dropping safety behaviors. The be-

havior is not just treatment for a symptom, but a way of living that supports a life purpose. Finally, within a CBT for SAD context, the rationale for incorporating values work can be shared with the client to inspire and sustain motivation for the treatment. The pervasive and stable nature of values, and living a values- driven life, endure long after the termination of treatment and provide a continuing motivation to maintain treatment gains.

Case Vignettes

Nina. During CBT treatment for SAD, Nina and her therapist used the card-sorting task to initiate the process of identifying her top five values: connecting with nature, acting with courage, being ambitious and hardworking, helping others, and having genuine and close friends. Following this exercise, the therapist and Nina worked together to choose a single value to begin working with in therapy. To- gether they determined that the value of having genuine and close friends was most important to her and also pertained most to her presenting concerns. Experiential exercises were then used to help Nina elaborate this value in a more personally meaningful way. Nina elaborated that she values authentic connection with close friends.

Consistent with the CBT approach, the ther- apist and Nina worked to understand that al- though avoidance of social situations and en- gaging with her mobile phone when she is with others reduced her anxiety in the short term, these behaviors actually intensified anxiety in the long term. The identification of values al- lowed her to also see that living this way re- duced her opportunities for genuine connection. Framed in this way, Nina was able to develop the motivation and courage necessary to work her way through the exposure hierarchy devel- oped in treatment. She was able to work her way up from an exposure task requiring her to ask a classmate for the time to hosting a small dinner party in her home, viewing it as an ideal opportunity for authentic connection. Prior to incorporating values work, Nina often failed to complete homework and reverted to safety be- haviors. Keeping in mind that authentic connec- tion was deeply important to her, she more often faced the anxiety and fear of the exposure tasks

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and was able to gradually decrease her use of safety behaviors.

Matthew. Matthew completed the Sweet Spot exercise. He closed his eyes and savored his experience of hiking in nature on a camping trip with his childhood best friend. Through further exploration with his therapist, he identi- fied that he valued living adventurously and having novel experiences. His therapist helped him to explore how his SAD symptoms had been preventing him from fully living out that value. Initially, Matthew joined a local hiking group, working through a series of social expo- sure tasks in this pleasurable context. Achieving these goals built his confidence to pursue a long-term goal. He had long wanted to hike around the world, but had been paralyzed by his anxiety about interacting with others. He set a goal of signing up for a hiking trip to Europe and a committed action plan was developed. Despite his anxiety, Matthew signed up for a trip with his hiking group. While filling in the application and making preparations, he re- ferred regularly to how the trip was congruent with his deeply held value of living adventur- ously and having novel experiences. The afore- mentioned values clarification and committed action interventions were incorporated into a traditional CBT for SAD treatment plan.

Current Status and Future Directions

There is evidence to suggest that the full ACT model, including the values component, is ef- fective in treating SAD (Brady & Whitman, 2012; Dalrymple & Herbert, 2007). ACT has been shown not only to decrease self-reported SAD symptoms but also to increase QOL and values-behavior congruence following treat- ment. There is also evidence to suggest that the values component in ACT is effective in reduc- ing psychological distress and promoting posi- tive well-being (e.g., increased life satisfaction and QOL) in other clinical populations, includ- ing those suffering from GAD (Michelson et al., 2011), chronic pain (McCracken & Yang, 2006), epilepsy (Lundgren et al., 2008), and cancer (Ciarrochi, Fisher, & Lane, 2011). The inclusion of values clarification interventions within a behavioral therapy framework is prom- ising and supports the idea of including values in the context of CBT for SAD to foster moti- vation to engage in treatment (especially in the

context of exposure), and promote positive psy- chological functioning (e.g., life satisfaction, QOL, personal growth).

To date, no studies have examined the impact of the ACT values component in treating SAD or in the context of CBT. Both quantitative and qualitative studies could elaborate this area. It would be particularly worthwhile to compare CBT for SAD with and without the added val- ues component to determine whether values work increases the efficacy of CBT. Measures of motivation and therapy progress (e.g., prog- ress monitoring measures, such as the Partners for Change Outcome Management System; Miller, Duncan, Sorrell, & Brown, 2005) would also lend insight in to the process and potential benefits of using this approach to treat SAD. Research in this area is warranted, as values work in the context of CBT holds promise for improving the lives of individuals with SAD not only through symptom reduction but also through fostering a vital and meaningful life worth living.

References

American Psychiatric Association. (2013). Diagnos- tic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Pub- lishing.

Bardi, A., & Schwartz, S. H. (2003). Values and behavior: Strength and structure of relations. Personal- ity and Social Psychology Bulletin, 29, 1207–1220. http://dx.doi.org/10.1177/0146167203254602

Brady, V. P., & Whitman, S. M. (2012). An accep- tance and mindfulness-based approach to social phobia: A case study. Journal of College Counsel- ing, 15, 81–96. http://dx.doi.org/10.1002/j.2161- 1882.2012.00007.x

Bruch, M. A., Fallon, M., & Heimberg, R. G. (2003). Social phobia and difficulties in occupational ad- justment. Journal of Counseling Psychology, 50, 109 –117. http://dx.doi.org/10.1037/0022-0167.50 .1.109

Cameron, A. Y., Reed, K. P., & Gaudiano, B. A. (2014). Addressing treatment motivation in bor- derline personality disorder: Rationale for incor- porating values-based exercises into dialectical be- havior therapy. Journal of Contemporary Psychotherapy, 44, 109 –116.

Ciarrochi, J. V., & Bailey, A. (2008). A CBT practi- tioner’s guide to ACT: How to bridge the gap between cognitive behavioural therapy & accep- tance & commitment therapy. Oakland, CA: New Harbinger.

18 GRUMET AND FITZPATRICK

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Ciarrochi, J., Fisher, D., & Lane, L. (2011). The link between value motives, value success, and well- being among people diagnosed with cancer. Psy- cho-Oncology, 20, 1184 –1192. http://dx.doi.org/ 10.1002/pon.1832

Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., . . . Louis, B. (2003). Cognitive therapy versus fluoxetine in gen- eralized social phobia: A randomized placebo- controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058 –1067. http://dx.doi.org/10 .1037/0022-006X.71.6.1058

Cougle, J. R., Keough, M. E., Riccardi, C. J., & Sachs-Ericsson, N. (2009). Anxiety disorders and suicidality in the National Comorbidity Survey- Replication. Journal of Psychiatric Research, 43, 825– 829. http://dx.doi.org/10.1016/j.jpsychires .2008.12.004

Craske, M. G., Kircanski, K., Zelikowsky, M., Myst- kowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy. Behaviour Research and Therapy, 46, 5–27. http://dx.doi.org/10.1016/j.brat.2007.10.003

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning ap- proach. Behaviour Research and Therapy, 58, 10 – 23.

Dalrymple, K. L., & Herbert, J. D. (2007). Accep- tance and commitment therapy for generalized so- cial anxiety disorder: A pilot study. Behavior Mod- ification, 31, 543–568. http://dx.doi.org/10.1177/ 0145445507302037

de Haan, E., van Oppen, P., van Balkom, A. J. L. M., Spinhoven, P., Hoogduin, K. A. L., & Van Dyck, R. (1997). Prediction of outcome and early vs. late improvement in OCD patients treated with cogni- tive behaviour therapy and pharmacotherapy. Acta Psychiatrica Scandinavica, 96, 354 –361. http://dx .doi.org/10.1111/j.1600-0447.1997.tb09929.x

Diener, E. (2000). Subjective well-being: The science of happiness and a proposal for a national index. American Psychologist, 55, 34 – 43.

Duckworth, A. L., Steen, T. A., & Seligman, M. E. (2005). Positive psychology in clinical practice. Annual Review of Clinical Psychology, 1, 629 – 651. http://dx.doi.org/10.1146/annurev.clinpsy.1 .102803.144154

Eskildsen, A., Hougaard, E., & Rosenberg, N. K. (2010). Pre-treatment patient variables as predictors of drop-out and treatment outcome in cognitive behav- ioural therapy for social phobia: A systematic review. Nordic Journal of Psychiatry, 64, 94 –105. http:// dx.doi.org/10.3109/08039480903426929

Feske, U., & Chambless, D. L. (1995). Cognitive behavioral versus exposure only treatment for so- cial phobia: A meta-analysis. Behavior Therapy,

26, 695–720. http://dx.doi.org/10.1016/S0005- 7894(05)80040-1

Foa, E. B., & Kozak, M. J. (1986). Emotional pro- cessing of fear: Exposure to corrective informa- tion. Psychological Bulletin, 99, 20 –35. http://dx .doi.org/10.1037/0033-2909.99.1.20

Foa, E. B., & McNally, R. J. (1996). Mechanisms of change in exposure therapy. In M. Rapee (Ed.), Current controversies in the anxiety disorders (pp. 329 –343). New York, NY: Guilford Press.

Forman, E. M., Butryn, M. L., Hoffman, K. L., & Herbert, J. D. (2009). An open trial of an accep- tance-based behavioral intervention for weight loss. Cognitive and Behavioral Practice, 16, 223– 235. http://dx.doi.org/10.1016/j.cbpra.2008.09.005

Gould, R. A., Buckminster, S., Pollack, M. H., Otto, M. W., & Massachusetts, L. Y. (1997). Cognitive- behavioral and pharmacological treatment for so- cial phobia: A meta-analysis. Clinical Psychology: Science and Practice, 4, 291–306. http://dx.doi .org/10.1111/j.1468-2850.1997.tb00123.x

Hambrick, J. P., Turk, C. L., Heimberg, R. G., Sch- neier, F. R., & Liebowitz, M. R. (2003). The experience of disability and quality of life in social anxiety disorder. Depression and Anxiety, 18, 46 – 50. http://dx.doi.org/10.1002/da.10110

Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behav- ioral science: Examining the progress of a distinc- tive model of behavioral and cognitive therapy. Behavior Therapy, 44, 180 –198. http://dx.doi.org/ 10.1016/j.beth.2009.08.002

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behav- iour Research and Therapy, 44, 1–25. http://dx.doi .org/10.1016/j.brat.2005.06.006

Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety disorder: Current status and future directions. Biological Psychiatry, 51, 101–108. http://dx.doi.org/10.1016/S0006-3223(01)01183-0

Heimberg, R. G., & Becker, R. E. (2002). Cognitive- behavioral group therapy for social phobia: Basic mechanisms and clinical strategies. New York, NY: Guilford Press.

Hettema, J., Steele, J., & Miller, W. R. (2005). Mo- tivational interviewing. Annual Review of Clinical Psychology, 1, 91–111. http://dx.doi.org/10.1146/ annurev.clinpsy.1.102803.143833

Hope, D. A., Burns, J. A., Hayes, S. A., Herbert, J. D., & Warner, M. D. (2010). Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder. Cogni- tive Therapy and Research, 34, 1–12. http://dx.doi .org/10.1007/s10608-007-9147-9

Hope, D. A., Heimberg, R. G., & Bruch, M. A. (1995). Dismantling cognitive-behavioral group

19VALUES CLARIFICATION WORK

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

ti on

or on

e of

it s

al li

ed pu

bl is

he rs

. T

hi s

ar ti

cl e

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

therapy for social phobia. Behaviour Research and Therapy, 33, 637– 650. http://dx.doi.org/10.1016/ 0005-7967(95)00013-N

Kashdan, T. B. (2007). Social anxiety spectrum and diminished positive experiences: Theoretical syn- thesis and meta-analysis. Clinical Psychology Re- view, 27, 348 –365. http://dx.doi.org/10.1016/j.cpr .2006.12.003

Kashdan, T. B., Farmer, A. S., Adams, L. M., Fers- sizidis, P., McKnight, P. E., & Nezlek, J. B. (2013). Distinguishing healthy adults from people with social anxiety disorder: Evidence for the value of experiential avoidance and positive emo- tions in everyday social interactions. Journal of Abnormal Psychology, 122, 645– 655. http://dx.doi .org/10.1037/a0032733

Kashdan, T. B., & McKnight, P. E. (2013). Commit- ment to a purpose in life: An antidote to the suf- fering by individuals with social anxiety disorder. Emotion, 13, 1150 –1159. http://dx.doi.org/10 .1037/a0033278

Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P. (1994a). Prognostic factors in the behavioral treat- ment of panic disorder with and without agorapho- bia. Behavior Therapy, 25, 689 –708. http://dx.doi .org/10.1016/S0005-7894(05)80204-7

Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P. (1994b). Predictors of treatment outcome in the behavioural treatment of obsessive-compulsive disorder. The British Journal of Psychiatry, 165, 781–786. http://dx.doi.org/10.1192/bjp.165.6.781

Kessler, R. C. (2003). The impairments caused by social phobia in the general population: Implica- tions for intervention. Acta Psychiatrica Scandi- navica Supplementum, 417, 19 –27. http://dx.doi .org/10.1034/j.1600-0447.108.s417.2.x

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve-month and lifetime prevalence and life- time morbid risk of anxiety and mood disorders in the United States. International Journal of Meth- ods in Psychiatric Research, 21, 169 –184. http:// dx.doi.org/10.1002/mpr.1359

Lincoln, T. M., Rief, W., Hahlweg, K., Frank, M., von Witzleben, I., Schroeder, B., & Fiegenbaum, W. (2003). Effectiveness of an empirically sup- ported treatment for social phobia in the field. Behaviour Research and Therapy, 41, 1251–1269. http://dx.doi.org/10.1016/S0005-7967(03)000 38-X

Lombardi, D. R., Button, M. L., & Westra, H. A. (2014). Measuring motivation: Change talk and counter-change talk in cognitive behavioral ther- apy for generalized anxiety. Cognitive Behaviour Therapy, 43, 12–21. http://dx.doi.org/10.1080/ 16506073.2013.846400

Lundgren, T., Dahl, J., & Hayes, S. C. (2008). Eval- uation of mediators of change in the treatment of

epilepsy with acceptance and commitment ther- apy. Journal of Behavioral Medicine, 31, 225–235. http://dx.doi.org/10.1007/s10865-008-9151-x

Lundgren, T., Luoma, J. B., Dahl, J., Strosahl, K., & Melin, L. (2012). The Bull’s-Eye Values Survey: A psychometric evaluation. Cognitive and Behav- ioral Practice, 19, 518 –526. http://dx.doi.org/10 .1016/j.cbpra.2012.01.004

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: An acceptance & commitment therapy skills-training manual for therapists. Oak- land, CA: New Harbinger.

Macarthur, J. (2013). An integrative approach to ad- dressing core beliefs in social anxiety. Journal of Psychotherapy Integration, 23, 386 –396. http://dx .doi.org/10.1037/a0035043

McAleavey, A. A., Castonguay, L. G., & Goldfried, M. R. (2014). Clinical experiences in conducting cognitive-behavioral therapy for social phobia. Be- havior Therapy, 45, 21–35. http://dx.doi.org/10 .1016/j.beth.2013.09.008

McCracken, L. M., & Yang, S. Y. (2006). The role of values in a contextual cognitive-behavioral ap- proach to chronic pain. Pain, 123, 137–145. http:// dx.doi.org/10.1016/j.pain.2006.02.021

McEvoy, P. M., Nathan, P., Rapee, R. M., & Camp- bell, B. N. (2012). Cognitive behavioural group therapy for social phobia: Evidence of transport- ability to community clinics. Behaviour Research and Therapy, 50, 258 –265. http://dx.doi.org/10 .1016/j.brat.2012.01.009

Michelson, S. E., Lee, J. K., Orsillo, S. M., & Ro- emer, L. (2011). The role of values-consistent be- havior in generalized anxiety disorder. Depression and Anxiety, 28, 358 –366. http://dx.doi.org/10 .1002/da.20793

Miller, S. D., Duncan, B. L., Sorrell, R., & Brown, G. S. (2005). The partners for change outcome management system. Journal of Clinical Psychol- ogy, 61, 199 –208. http://dx.doi.org/10.1002/jclp .20111

Mörtberg, E., Clark, D. M., & Bejerot, S. (2011). Intensive group cognitive therapy and individual cognitive therapy for social phobia: Sustained im- provement at 5-year follow-up. Journal of Anxiety Disorders, 25, 994 –1000. http://dx.doi.org/10 .1016/j.janxdis.2011.06.007

Newman, M. G., Hofmann, S. G., Trabert, W., Roth, W. T., & Taylor, C. B. (1994). Does behavioral treatment of social phobia lead to cognitive changes? Behavior Therapy, 25, 503–517. http:// dx.doi.org/10.1016/S0005-7894(05)80160-1

Páez-Blarrina, M., Luciano, C., Gutiérrez-Martínez, O., Valdivia, S., Ortega, J., & Rodríguez- Valverde, M. (2008). The role of values with per- sonal examples in altering the functions of pain: Comparison between acceptance-based and cogni- tive-control-based protocols. Behaviour Research

20 GRUMET AND FITZPATRICK

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

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A ss

oc ia

ti on

or on

e of

it s

al li

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bl is

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e in

di vi

du al

us er

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is no

t to

be di

ss em

in at

ed br

oa dl

y.

and Therapy, 46, 84 –97. http://dx.doi.org/10 .1016/j.brat.2007.10.008

Plumb, J. C., Stewart, I., Dahl, J., & Lundgren, T. (2009). In search of meaning: Values in modern clinical behavior analysis. The Behavior Analyst, 32, 85–103.

Sareen, J., Cox, B. J., Clara, I., & Asmundson, G. J. (2005). The relationship between anxiety disorders and physical disorders in the U.S. National Comor- bidity Survey. Depression and Anxiety, 21, 193– 202. http://dx.doi.org/10.1002/da.20072

Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: Individual versus group treatment. Behaviour Research and Therapy, 41, 991–1007. http://dx.doi.org/10.1016/S0005-7967(02)00176-6

Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. The American Journal of Psychiatry, 157, 1606 –1613. http://dx.doi.org/10.1176/appi .ajp.157.10.1606

Teo, A. R., Lerrigo, R., & Rogers, M. A. (2013). The role of social isolation in social anxiety disorder: A systematic review and meta-analysis. Journal of Anxiety Disorders, 27, 353–364. http://dx.doi.org/ 10.1016/j.janxdis.2013.03.010

Van Ameringen, M., Mancini, C., & Farvolden, P. (2003). The impact of anxiety disorders on educa- tional achievement. Journal of Anxiety Disorders, 17, 561–571. http://dx.doi.org/10.1016/S0887- 6185(02)00228-1

Weeks, J. W., & Heimberg, R. G. (2012). Positivity impairments: Pervasive and impairing (yet non- prominent?) features of social anxiety disorder. Cognitive Behaviour Therapy, 41, 79 – 82. http:// dx.doi.org/10.1080/16506073.2012.680782

Wilson, K. G. (2005, July). Eroding the illusion of separation: The interplay of core ACT processes in group training. Paper presented at the 2005 ACT/ RFT Summer Institute II, Lasalle University, Phil- adelphia, PA.

Wilson, K. G., Sandoz, E. K., Kitchens, J., & Rob- erts, M. (2010). The Valued Living Questionnaire: Defining and measuring valued action within a behavioral framework. The Psychological Record, 60, 249 –272.

Woods, D. W., Wetterneck, C. T., & Flessner, C. A. (2006). A controlled evaluation of acceptance and commitment therapy plus habit reversal for tricho- tillomania. Behaviour Research and Therapy, 44, 639 – 656. http://dx.doi.org/10.1016/j.brat.2005.05 .006

Yadavaia, J. E., & Hayes, S. C. (2009). Values in acceptance and commitment therapy: A compari- son with four other approaches. Hellenic Journal of Psychology, 6, 244 –272.

Received July 21, 2014 Revision received April 7, 2015

Accepted April 13, 2015 �

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