The Cognitive Behaviour Therapist: e3, page 1 of 13                                        PRACTICEARTICLE
               doi:10.1017/S1754470X13000081
               Cognitive behaviour therapy using the Clark & Wells model:
               a case study of a Japanese social anxiety disorder patient
               NaokiYoshinaga1∗, Osamu Kobori2, Masaomi Iyo3 and Eiji Shimizu1
               1Department of Cognitive Behavioral Physiology, Chiba University Graduate School of Medicine,
               Chiba, Japan
               2Center for Forensic Mental Health, Chiba University, Chiba, Japan
               3Department of Psychiatry, Chiba University Graduate School of Medicine, Chiba, Japan
               Received 12 November 2012; Accepted 12 May 2013
               Abstract. Cognitive behaviour therapy (CBT) is widely regarded as an effective
               treatment for social anxiety disorder (SAD) in Europe and North America. The
               theoretical orientations underlying CBT models and treatment interventions developed
               in Western cultures were typically constrained by Western conceptualizations of
               SAD. This case study reports on the use of CBT for Japanese SAD, demonstrating
               the successful implementation of cognitive techniques grounded in the Clark &
               Wells model. The patient was a Japanese female with excessively high standards
               for workplace social performance. Therapy mainly comprised case formulation,
               behavioural experiments, and opinion surveying based on the Clark & Wells model.
               These techniques allowed the patient to reduce the strength of maladaptive cognitions
               and lower her excessively high standards for social performance. CBT treatment using
               the Clark & Wells model was effective and suitable for Japanese SAD, at least in the
               present case. We also discuss the cross-cultural differences of SAD and adaptation of
               CBT.
               Key words: Cognitive therapy, Japan, single case experimental study, social anxiety
               disorder.
               Theoretical and research basis for therapy
               Cognitive behaviour therapy (CBT) is widely regarded as an effective treatment for social
               anxiety disorder (SAD) in Europe and North America (Hofmann & Smits, 2008). CBT was
               introduced into Japanese psychiatry in the late 1980s, and awareness of the effectiveness of
               CBT has spread, not only among professionals and academics but also among the general
               public (Ono et al. 2011). Nevertheless, the number of facilities offering CBT is still limited;
               as of 2012, selective serotonin re-uptake inhibitors (SSRIs; fluvoxamine and paroxetine) are
               the only treatments covered by insurance for Japanese patients with SAD.
               ∗Author for correspondence: Dr N. Yoshinaga, Department of Cognitive Behavioral Physiology, Chiba University
               Graduate School of Medicine, 1-8-1 Inohana, Chuouku, Chiba, Japan (email: nao@chiba-u.jp).
               ©British Association for Behavioural and Cognitive Psychotherapies 2013
        2              N. Yoshinaga et al.
         Reports regarding the effectiveness of CBT come mostly from Europe and North America,
        with theoretical orientations underlying CBT models and treatment interventions typically
        constrained by Western conceptualizations of SAD. This is problematical, as cultural factors
        may be especially relevant to SAD pathology. For example, taijin-kyofu-sho (in Japanese,
        taijin means ‘interpersonal’, kyofu means ‘fear’, and sho means ‘syndrome’), is listed in
        the appendix to DSM-IV-TR as a ‘culture-bound syndrome’ unique to East Asia. However,
        fear of interpersonal relationships (e.g. Kleinknecht et al. 1997) can also be classified under
        existing DSM-IV-TR categories (e.g. Hofmann et al. 2010), and the conceptualization of fear
        ofinterpersonalrelationshipsaspurelyculture-bounddoesnotalwaysholdtrue.Further,there
        is little difference between Asian and Western manifestations of SAD; despite differences
        between the conceptualizations of SAD and taijin-kyofu-sho, SAD patients in different parts
        of the world have many features in common (Stein, 2009). This paper presents a case study
        wherein CBT based on the Clark & Wells (1995) model was successfully employed for a
        Japanese SAD patient.
        Casesummaryandmainpresentingproblem
        Thepatient,Mika(notthepatient’srealname),wasa42-year-oldunmarriedJapanesewoman.
        She had suffered from social anxiety for 5 years and panic for 10 years. Her presenting
        problemwas‘Igotstagefrightperforminginfrontofco-workers’(e.g.inthemonthlydepart-
        mentalmeetinganddailymorningplenarymeetings).Sheexperiencedahauntingfearthatco-
        workerswouldnoticesignsofheranxiety,resultinginaheightenedsensitivitytoevaluationby
        co-workers. Although Mika had opinions that she wanted to share in departmental meetings,
        sheavoidedanybehaviourthatmightattractattention,simplystating‘Iagree’.Inaddition,she
        could not use public transport to come to our hospital because of panic symptoms. Treatment
        goals included disagreeing and engaging in negotiation without excessive anxiety. She wanted
        to be able to speak in front of large groups; a concrete goal was to make a speech at a friend’s
        wedding. Mika also had an unrelated inability to use public transport such as crowded buses
        or trains, experiencing shortness of breath and stomach discomfort.
        Treatment consisted of 14 weekly 90-min individual therapy sessions, based on the Clark
        & Wells model. Sessions were audiotaped, and Mika was encouraged to listen to these
        recordings as homework. Follow-up sessions were offered 1 month and 6 months after the
        fourteenth session. Therapy was conducted both inside and outside of the treatment room, and
        between-session homework was designed in collaboration with the patient. In order to reduce
        Mika’s self-consciousness and summarize discussions, notes were made on a whiteboard
        during all sessions (Fig. 1).
        History
        At the age of 32, Mika suddenly began to experience intense nausea whenever she boarded
        the bus. She was referred to a psychiatric clinic and diagnosed with panic disorder. Although
        she was prescribed paroxetine, she stopped taking it due to nausea. Five years later, while
        presiding at morning meeting, she suddenly experienced an uncontrollable shaking of her
        hands so serious that she was unable to hold her notes. She tried various SSRIs and serotonin
        norepinephrine reuptake inhibitors (SNRIs) but continued to experience severe workplace
        social anxiety. She experienced heart palpitations and her hands shook just from participating
                     CBTforJapaneseSAD         3
               Fig. 1. Using a whiteboard to develop case formulation.
      in both departmental and plenary meetings. At this time, she was diagnosed with SAD by her
      general practitioner, and was referred to our hospital.
      Caseassessment
      After referral to our hospital, Mika was again diagnosed with SAD and panic disorder by
      an experienced psychiatrist, using the Structured Clinical Interview for Axis I Disorders
      (SCID-I). She had no comorbid Axis II disorders before starting therapy. She had previously
      been treated with duloxetine at 20 mg/day and clonazepam at 1.5 mg/day, and this regimen
      remained stable throughout CBT treatment.
       Mika had been working for a prestigious construction company as an assistant architect
      for 10 years (involved mainly in the design and supervision of the construction of small
      buildings). Her highest academic qualification was secondary school. She had experience in
      salesforamajorautomotivecompanyandasatemporaryofficeworkerforvariouscompanies.
      She lived on her own near her office. Her hobbies included reading novels and socializing
      with friends. Mika presented no serious social or economic problems at the beginning of
      therapy.
         4               N. Yoshinaga et al.
         Fig. 2. Case formulation demonstrating how maladaptive behaviours and cognitions maintain and
         exacerbate social anxiety.
         Therapist details and supervisory arrangements
         Thetherapist was a Japanese psychiatric nurse, in the first year of a CBT training programme
         at Chiba University (Chiba – IAPT training course). The therapist attended weekly group
         supervision(60min)andfortnightlyindividualsupervision(30min)sessionswiththeauthors.
         Multiple supervisors and other trainees supported and assisted in planning sessions.
         Formulation
         Case formulation was collaboratively developed (see Fig. 2). Typical triggering situations for
         anxiety were (a) presiding over or participating in plenary meetings, (b) stating her opinion
         or participating in departmental meetings, and (c) instructing junior staff about drawing using
         PCs.
          In these situations, Mika had automatic thoughts such as ‘I will go blank if co-workers
         notice my anxiety, or if they roundly criticize my opinions’. Her belief ‘I always need to look
         competent to [my] co-workers’ activated these automatic thoughts.
          Automatic thoughts generated somatic symptoms such as heart palpitations and shaking
         hands. She also experienced cognitive symptoms; her mind went blank and it was extremely
         distressing for her to tolerate the situation.
          In response to these symptoms, Mika had the following safety behaviours:
         (a) Hiding her anxiety: she would hide her hands under her desk, clench her handkerchief,
           and stand upright without touching anything on the desk.