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Journal of Clinical Pharmacy and Therapeutics (2011) doi:10.1111/j.1365-2710.2011.01299.x
ORIGINALARTICLE
Efficacy of the trial-based thought record, a new cognitive
therapy strategy designed to change core beliefs, in social
phobia
I. R. de Oliveira* MD, PhD,V.B.Powell*PsyD,A.Wenzel PhD,M.Caldas*PsyD,
C.Seixas*PsyD,C.Almeida*PsyD,T.Bonfim*PsyD,M.C.Grangeon*PsyD,M.Castro*
˜
PhD,A.Galvao* MD, R. de Oliveira Moraes* MD and D. Sudak MD
*Department of Neuroscience and Mental Health, University Hospital Professor Edgard Santos, Federal
University of Bahia, Salvador, Bahia, Brazil, Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA, and Department of Psychiatry, Drexel University, Philadelphia, PA, USA
SUMMARY Distress Scale (SADS), Beck Anxiety Inventory,
and Clinical Global Impression – Improvement.
What is known and Background: Social anxiety In addition, a one-way ANCOVA, taking baseline
disorder(SAD)oftenfollowsachroniccourseand values as covariates, showed that TBTR was sig-
is associated with substantial impairment in nificantly more efficacious than CCT in reducing
functioning. Although results from clinical trials the scores of FNE (P =0Æ01 at mid-treatment and
clearly establish evidence for efficacy of cognitive P =0Æ004 at post-treatment), and SADS (P =0Æ03
behavioural therapy in treating this disorder, up at post-treatment).
to 50% of patients with SAD show little or no Whatis new and Conclusion: This study provides
improvement. Thus, new approaches that have preliminary evidence that TBTR is at least as
promised in improving the efficacy of treatment efficacious as CCT in reducing symptomsofSAD,
for SAD are needed. One such approach is the pointing to the need for additional studies of
trial-based thought record (TBTR), which targets TBTR in SAD and other psychiatric disorders.
the restructuring of patients’ core beliefs.
Objective: To determine whether patients receiv- Keywords: cognitive therapy, psychological treat-
ing TBTR would report fewer symptoms of social ment, randomized trial, social anxiety disorder,
anxiety and general psychiatric distress following trial-based thought record
treatment, relative to conventional cognitive
therapy (CCT).
Methods: A two-arm randomized trial comparing WHATISKNOWNANDOBJECTIVE
TBTR (n = 17) with a set of CCT techniques
(n = 19), which included the standard seven- Social anxiety disorder (SAD), the most common
column dysfunctional thought record and the anxiety disorder, often follows a chronic course and
positive data log in SAD patients according to is associated with substantial impairment in func-
DSM-IV. tioning. Over the past two decades, much effort has
Results: Scores on many outcome measures been devoted to developing cognitive behavioural
decreased significantly across the course of treat- approaches to treat this condition. Although results
ment in both groups (P <0Æ001), including the from clinical trials clearly establish evidence for
Liebowitz Social Anxiety Scale, Fear of Negative cognitive behavioural therapy’s (CBT) efficacy (1,
Evaluation Scale (FNE), Social Avoidance and for a comprehensive meta-analysis), in many
instances, 40–50% of patients with SAD show little
Received 17 April 2011, Accepted 09 August 2011 or no improvement (2). Recently, scholars have
´
Correspondence: Professor I. R. de Oliveira, Programa de Pos- refined cognitive behavioural treatments to target,
˜ ´ ´
Graduac¸ao em Medicina e Saude, Hospital Universitario Pro-
fessor Edgard Santos, Salvador, Bahia CEP 40110-060, Brazil. more specifically, cognitive processes believed to
Tel.⁄fax: +55 71 32417154; e-mail: irismar.oliveira@uol.com.br maintain and exacerbate symptomatology (3, 4).
2011 Blackwell Publishing Ltd 1
2 I. R. de Oliveira et al.
Results from these investigations suggest that these attorney’s plea [evidence not supporting the core
targeted protocols result in greater reductions in belief (14)], prosecutor’s response to the defendant’s plea
self-reported social anxiety than earlier cognitive [point-counter-point by discounting the evidence
behavioural protocols. Despite these gains, scholars (15)], defense attorney’s response to the prosecutor’s plea
havecalledforcontinuedinvestigationintotargeted [sentence reversal (16)], juror’s verdict [debriefing
cognitive behavioural strategies to maximize the and upward arrow technique (13, 17)] and prepara-
efficacy of treatment and eliminating strategies that tion for the appeal [positive data log (PDL) (6, 18)].
prove to be unnecessary (5). It is possible that TBTR is a cognitive behavio-
Oneapproach that has the promise to be fruitful ural approach that could improve the efficacy of
in the cognitive behavioural treatment of SAD is the CBT for SAD, as it focuses on the deepest level of
modification of core beliefs. Core beliefs are global, cognition (i.e. core beliefs) that is theorized to drive
rigid and fundamental beliefs that people have the expression of socially anxious symptoms. Our
about themselves, the world and⁄or the future (6). objective was to compare TBTR (8, 9) with con-
Core beliefs influence the types of cognitions that ventional cognitive therapy (CCT) in patients who
people experience in specific situations. For exam- met DSM-IV criteria for generalized SAD (19).
ple, a person with the core belief, ‘I am incompe- Specific strategies implemented by therapists in
tent’, will likely predict that he will be unable to CCT included the seven-column dysfunctional
function adequately during a job interview. A per- thought record (DTR) (14) and the PDL (6, 18).
son with the core belief, ‘I am unlikable’, will likely These two strategies were used in the CCT condi-
predictthatotherswillnotbeinterestedinwhatshe tion because they mirrored the tools used in TBTR.
has to say at a social gathering. As a result, both of Specifically, TBTR is, in itself, a thought record that
these people would likely experience a great deal of is modified to reflect the courtroom nomenclature.
social anxiety. Although patients receiving CBT Moreover, the therapeutic work that takes place
usually report significant improvement after during the ‘preparation for the appeal’ is similar to
developing strategies to modify unhelpful situa- the activity that is performed using the PDL, in that
tional cognitions, cognitive theory and clinical both tools require patients to record evidence that
experience suggest that the greatest amount of supports a new, more adaptive core belief. In other
change is usually observed when unhelpful core words, many of the therapeutic activities that take
beliefs are identified and modified (7). place in session are similar between the two con-
Recently,anovelcognitivebehaviouralapproach ditions, but TBTR packages these tools in a con-
to address unhelpful core beliefs has been devel- ceptual framework that is designed to be
oped, called the trial-based thought record (TBTR) particularly compelling, engaging and generaliz-
(8, 9), which is part of a broader approach, trial- able.
based cognitive therapy (TBCT) (10, 11). This The purpose of this study was to assess the dif-
approach uses a judicial process as a metaphor, in ferential efficacy of TBTR and CCT in the treatment
which the therapist engages the patient in a simu- of social phobia. It was hypothesized that patients
lation of a trial. By means of TBTR, patients re-acti- receiving TBTR would report decreased symptoms
vate unhelpful core beliefs and associated negative of social anxiety and psychiatric distress following
emotions and reduce their effect with disconfirma- treatment to at least the same degree as patients
tory evidence. The repeated use of TBTR has the receiving CCT. Such a finding would suggest that
potential to result in deactivation of unhelpful core TBTR is another targeted cognitive behavioural
beliefs, modifying their structure and content. The approach that has promise in improving the effi-
ultimate outcome of the TBTR approach is the neu- cacy of treatment for SAD.
tralization of unhelpfulcorebeliefsasmorecredible
evidence in support of helpful core beliefs is incor-
porated. TBTR includes several strategies already MATERIALANDMETHODS
used in cognitive therapy (CT), labelled with court- Design
room nomenclature, including the inquiry [down-
ward arrow technique (12, 13)], prosecutor’s plea This is a two-arm clinical trial comparing TBTR
[evidence supporting the core belief (14)], defense with a set of CCT techniques, which included the
2011 Blackwell Publishing Ltd, Journal of Clinical Pharmacy and Therapeutics
Efficacy of the trial-based thought record 3
standard seven-column DTR, as proposed by Participants’ characteristics are presented in
Greenberger and Padesky (14), and the PDL, as Table 1.
demonstratedbyTompkinset al.(18).Concealment
of random allocation was provided by an inde- Treatment protocol
pendent person not participating in the treatment
protocol. Treatment was provided by five well- Treatment comprised 12 one-hour individual ses-
trained cognitive therapists (see description sions of either TBTR (experimental group) or CCT
below), who followed a therapist manual for both (contrast group) during 10 weeks and every
TBTR and CCT. Because the purpose of this study 2 weeks during the last 4 weeks (4-month dura-
was to assess the role of belief change on SAD tion). Sessions 1–5 in both treatment conditions
symptoms, exposure was not actively encouraged. consisted of psychoeducation concerning the cog-
nitive model and cognitive errors and completion
Participants of the conceptualization diagram (6). From session
Participants were recruited by means of adver-
tisements in local newspapers and interviews by Table 1. Patients demographic characteristics
the first author in local radios and televisions about
social anxiety. People who met DSM-IV (19) criteria Variablea TBTR (n = 17) CCT (n = 19)
for generalized SAD were included in the study.
All patients were assessed at an anxiety disorders Gender
clinic in a university teaching hospital. The Ethics Women, n (%) 12 (70Æ6) 15 (78Æ9)
Committee at the University Hospital Professor Age
Edgard Santos of Federal University of Bahia Mean (SD) 33Æ9(9Æ9) 34Æ9 (13Æ4)
Range 19Æ0–56Æ019Æ0–68Æ0
approved the study. Education, n (%)
Participants who signed the informed consent 1st degree (8 years) 2 (11Æ8) 0 (0Æ0)
form were assessed using the Mini International 2nd degree (3 years) 9 (52Æ9) 12 (63Æ2)
Neuropsychiatric Interview (MINI), a short struc- College⁄university 6 (35Æ3) 7 (36Æ8)
tured diagnostic interview developed by psychia- Marital status, n (%)
trists and clinicians in the United States and Europe Married⁄living together 5 (29Æ4) 7 (36Æ8)
to determine DSM-IV and ICD-10 psychiatric Divorced⁄widowed 2 (11Æ8) 2 (10Æ5)
disorders with an administration time of approxi- Single 10 (58Æ8) 10 (52Æ6)
mately 15 min (20). The Brazilian version of the Ethnic status, n (%)
MINIshowedsatisfactorypsychometricproperties, White 6 (35Æ3) 8 (42Æ1)
with j >0Æ50, sensitivity > 0Æ70 and specific- Black 3 (17Æ6) 1 (5Æ3)
ity > 0Æ70) (21). This interview was conducted by Mixed 8 (47Æ1) 10 (52Æ6)
three interviewers (MC, AG and ROM) who had Monthly family
incomeb
extensive experience in using it in previous studies Mean (SD) 2286 (3714) 2036 (1711)
by our group (22). To be included in the study, Employment⁄
participants met the following criteria: fulfil DSM- occupation
IV criteria for SAD, generalized type; be of age Employed 8 (47Æ1) 7 (36Æ8)
18–70; be able to read and write; and be able to Student 3 (17Æ6) 7 (36Æ8)
understand and sign the informed consent. Exclu- Homemaker 3 (17Æ6) 1 (2Æ8)
sion criteria included major comorbid Axis I psy- Sick-leave⁄Retired⁄ 3(5Æ9) 4 (2Æ8)
chiatric disorders (e.g. major depression, Unemployed
schizophrenia and bipolar disorder), alcohol or Concurrent medication, 1(5Æ9) 2 (10Æ5)
substance use⁄abuse in the past 6 months; suicide n (%)
risk; inability to read and write; and presently aNo significant differences were found in any of the above
being in psychotherapy. Use of psychotropic variables.
medications was accepted if used in stable doses in b
US$equivalence to local currency (Brazilian ‘real’) in 4 October
the past month. 2010: US$ 1Æ00 = R$ 1Æ67.
2011 Blackwell Publishing Ltd, Journal of Clinical Pharmacy and Therapeutics
4 I. R. de Oliveira et al.
6 forward, both treatments focused on restructur- at intake, mid-treatment, post-treatment and at 12-
ing core beliefs by means of, respectively, the month follow-up assessments. The LSAS was the
TBTR and CCT. TBTR differed from the contrast primary efficacy measure, and the remaining
group in that, besides simulating a judicial trial, assessments were regarded as secondary efficacy
patients were actively encouraged to discount the measures.
positives after they gathered the evidence not
supporting the unhelpful core belief and then, by Statistical analyses
means of the sentence-reversal approach (17),
were engaged in a second round searching for the All patients who provided at least one post-initial
evidence that supported the helpful core beliefs. intervention assessment (sixth session onwards for
This second round was not part of the conven- LSAS and seventh session onwards for FNE and
tional approach. TBTR also differed from the SADS) were included in the analyses with last
conventional approach in that the new core beliefs observed data carried forward (LOCF). Data
were uncovered by means of the ‘upward arrow collected at intake (baseline), mid-treatment
technique’ (13, 17). (7 weeks), post-treatment (4 months) and follow-
up (12 months) were used for statistical analyses.
Therapists Weusedt-tests and chi-squared tests to identify
differences between the groups in demographic
Therapists were psychologists who had attended and clinical variables. A mixed ANOVAANOVA was used to
a two-year cognitive therapy specialization course evaluate the effectiveness of the interventions
organized by two of us (IRO and VBP). They during treatment and 12-month follow-up period,
were invited to participate because they were the number of evaluations being computed as
among those who had the best performance within-subject factor (time) and treatment modal-
during their training. This course included 384 h ity as a between-subject factor (group). The
of theoretical information, 60 h of clinical work following assumptions were tested: independence
with patients and 86 h of supervision. Also, of observations, normality and sphericity. When
knowledge and competence was assessed in a sphericity was violated, the degrees of freedom
total of 23 monthly written exams. In addition to (d.f.) were adjusted using the Greenhouse-Greisser
being certified by this specialization course, all corrected values, a conservative approach to deal
therapists had at least 1 year of experience in with multiple comparisons (27). To assess any
private practice as certified cognitive therapists at differences between groups at baseline, we used
the time of this clinical trial start-up. All the one-way analyses of variance (ANOVASANOVAS). Then, we
therapists had their training in the same group in used one-way analyses of covariance (ANCOVAANCOVAs)
the course; thus, therapists in both arms (i.e. with baseline scores as covariates. Level of sig-
TBCT and CCT) had equivalent experience and nificance was set at 0Æ05. All analyses were con-
expertise. ducted with SPSSSPSS 13.0 software. Within-subjects
Cohen’s d effect sizes (ES) were also calculated
Assessment (28).
All measures completed by participants were self- RESULTS
report in nature, except the Clinical Global
Impression – Improvement (CGI-I) (23), which is Of the 77 patients who provided informed consent
an observer-rated measure. The Liebowitz Social and completed initial assessment (Fig. 1), 30 did
Anxiety Scale (LSAS) (24) and Beck Anxiety not meet inclusion criteria. Therefore, 47 patients
Inventory (BAI) (25) were assessed weekly during were randomized to the treatment groups – 25
treatment and again at 12-month follow-up. The were allocated to TBTR and 22 were allocated to
CGI-I was also assessed weekly and at post-treat- CCT. However, four participants (three in the
ment, but not at follow-up. The Fear of Negative TBTR group and one in the CCT group) withdrew
Evaluation Scale (FNE) (26) and the Social Avoid- from the study before treatment. Of the 43 partici-
ance and Distress Scale (SADS) (26) were assessed pants who started treatment, 13 (30%) terminated
2011 Blackwell Publishing Ltd, Journal of Clinical Pharmacy and Therapeutics
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