Cognitive therapy for social anxiety (CT-SAD)

At a glance

Compared with waiting

Much better than waiting. In a combined analysis of 101 trials, individual CBT for social anxiety had the largest effect of any treatment.

Compared with other treatments

Better than a pill placebo, better than an SSRI medicine plus self-practice, and better than exposure with relaxation, in trials from the UK.

How many get better

In one trial of 62 people, 84 in 100 no longer had social anxiety disorder after treatment.

Does it last

Gains held at one-year follow-up in the trials that checked.

What it takes

Usually up to 14 weekly sessions with a trained therapist, or an online version with much less therapist time.

What it is

Cognitive therapy for social anxiety disorder (CT-SAD) is a type of CBT made for social anxiety. CBT (cognitive behavioural therapy) is talking therapy that works on how you think and what you do. CT-SAD was developed in Oxford by David Clark and Adrian Wells. It is based on their model of what keeps social anxiety going.

Face-to-face, it usually takes up to 14 weekly sessions. In therapy you and your therapist:

• Draw your own loop. You map what you fear, where your attention goes, and what you do to protect yourself. What keeps social anxiety going explains the loop.
• Test safety behaviours. You have a conversation twice: once with your usual safety behaviours (rehearsing, avoiding eye contact), once without. A small study of 8 people found that dropping safety behaviours lowered anxiety more than exposure alone.
• Watch yourself on video. You compare how you think you looked with how you actually looked. It is usually much better than you expected.
• Train your attention outward. You practise noticing the other person and the room, not your own body.
• Run behavioural experiments. These are planned tests of a fear, such as “if I pause, people will think I’m stupid”. You do the thing and see what really happens.
• Stop the replay. You learn to drop the post-mortem after social events.

What the evidence shows

• It beat a fair comparison. In a UK trial of 62 people, 84% no longer had social anxiety disorder after CT-SAD. With exposure plus relaxation, 42% did. On a waiting list, none did. The difference held a year later.
• It beat a medicine. In another UK trial of 60 people, CT-SAD did better than the SSRI fluoxetine plus self-practice. It also did better than a placebo pill plus self-practice. The gap was still there a year later.
• It tops the big comparison. A study that combined 101 trials found that individual CBT for social anxiety had the largest effect compared with waiting. It was also one of only two treatments that clearly beat a placebo. The other was SSRI and SNRI medicines.
• It is good value. A cost study using the same data found individual cognitive therapy the most cost-effective option.
• It works online. In a UK trial of 102 people, the internet version (iCT-SAD) worked about as well as face-to-face therapy. It used 6.45 hours of therapist time instead of 15.8. Face-to-face had a small advantage on one behaviour test. A trial in Hong Kong found the online version also helped there.
• It helps teenagers. In a trial of 43 teenagers aged 14 to 18, 77% lost the diagnosis after the online version, compared with 14% on a waiting list.

What the trials have not answered

• Does it work as well outside Oxford? Many trials come from the team that created it. Researchers who believe in a treatment often get better results with it. The online version is now used in England’s NHS Talking Therapies, which is a step toward real-world evidence.
• What about long term? Most trials followed people for a year. Few looked further.

How to get it

1. Ask for CBT made for social anxiety, not general CBT for anxiety. You can ask: “Do you use the Clark and Wells model, with video feedback and behavioural experiments?”
2. Ask about the online version. In England, some NHS Talking Therapies services offer internet cognitive therapy for social anxiety. Elsewhere, availability depends on your country and clinic.
3. Expect homework. The experiments happen between sessions, in your real life. That is where most of the change comes from.

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