Effect of brief Cognitive Behavior Therapy on level of Social Phobia among Nursing Students

Manoj Kumar L., Eugin S.B.

¹Lecturer, Psychiatric Nursing Department, Sree Gokulam Nursing College, Trivandrum

²HOD, Mental Health (Psychiatric) Nursing, Saraswathy College of Nursing, Trivandrum

*Corresponding Author’s Email: manojkumarlarson20@gmail.com

ABSTRACT:

Background: Anxiety and fear trigger an activation of the autonomic nervous system giving rise to several physiological symptoms such as palpitations, sweating, trembling and/or shaking. Anxiety is a natural reaction to stress that helps a person to overcome a problematic situation, but when anxiety exceeds the normal limits, it is considered as a disorder. About 30% of student nurses suffer from anxiety especially in specific situations including: test, examination and presentations. The unfavorable effects of anxiety experienced by nursing students will lead to the development of low self-esteem over a period of time which adversely affects their academic performance. One of these anxiety disorders is social anxiety disorder or Social Phobia. Social anxiety disorder is the most frequently diagnosed anxiety disorder and it is the third most commonly diagnosed psychological disorder. Objectives: To assess the level of social phobia; to assess the effect of brief cognitive behavior therapy (BCBT) on level social phobia and to find the association between level of social phobia and selected demographic variables. Methods: The study design was pre-experimental study with one group pre-test post-test design. Study was conducted at two nursing colleges and 30 nursing students were selected purposively after screening with mini social phobia inventory (mini-SPIN). A socio-demographic profile to gather sample characteristics and a structured social phobia scale to assess the level of social phobia was used as tools to collect data. After pretest a structured interventional package which consisted of six sessions of BCBT, which included self- introduction, assessment of feared situations, psycho-education, progressive muscle relaxation technique, graded exposure to fearful situations through role-plays, class presentations and interaction sessions of one hour each. Six sessions of BCBT with three days gap between each session was implemented. The effect of therapy was assessed by using the same social phobia scale after five days. Results: A statistically significant reduction in the level of social phobia was found after the BCBT (t=12.98, p < 0.001). A statistically significant association was observed between the level of social phobia and age and gender of nursing students. Conclusion: Brief cognitive behavior therapy was found effective in reducing level of social phobia among nursing students. Present study reveals the implications and importance of brief cognitive behavior therapy in reducing social phobia, and it is a short duration therapy comparing to the traditional cognitive behavior therapy protocols.

KEYWORDS: Social phobia; brief cognitive behavioral therapy; nursing students.

INTRODUCTION:

The term “phobia” has its origins in the Greek word φóβoς meaning terror or fear. In ancient times the god Phobos was believed to call forth fear and terror in the enemies of the Greek. Large numbers of fears have been named by adding “phobia” to a Latin or Greek prefix. Some examples of relevance to social anxiety are “scopophobia” (fear of being observed), “xenophobia” (fear of strangers), and “antrophophobia” (fear of people). Literary descriptions of shyness and social anxiety can be traced back to Hippocrates 400 B.C. But first explicit reference to social phobia, or “phobie des situations sociales” was made by Janet in 1903¹. The National Co morbidity Survey in the US observed that social phobia to be the third most common psychiatric disorder, after major depression and alcohol dependence². Social phobia is among the most frequent psychiatric disorders and shows a high lifetime prevalence of 12% and a 12 months prevalence of 7.1%³.Social phobia is common amongst academic society also, about 19 to 22% of undergraduate students suffered from the same and the incidence rate of social phobia during lifetime has increased from 4.2 to 16% in general population⁴. About 30% of student nurses suffer from anxiety especially in specific situations including: test, examination and presentations. The unfavorable effects of anxiety experienced by nursing students will lead to the development of low self-esteem over a period of time which adversely affects their academic performance⁵.

Social phobia is also called social anxiety disorder. Effective psychological and pharmacological interventions for social anxiety disorder exist but may not be accessed due to poor recognition, inadequate assessment and limited awareness or availability of treatments. The early age of onset of social phobia makes diagnosis in educational settings a challenging one⁶. The development of social phobia is possible by the demands for a performance, such as giving a speech and it is more common for older children, therefore, the possibility of conditioning experiences are more relevant for performance social phobia during adolescence. As interpersonal encounters and negative evaluation in interpersonal contact may occur at any age, this may explain the earlier age of onset of Generalized Social phobia. Patients with specific Social phobia, mostly performance anxiety, reported more “traumatic social experiences” such as being laughed in the classroom. But performance anxious individuals did attribute their fear to panic attacks and most of them had a panic attack before⁷.

For nursing students, anxiety levels may render learning difficulty, as high levels of stress and anxiety present a substantial effect over attention, with the possibility of leading to errors, lack of concentration and oscillation of attention levels. The Nursing students in a professional course is exposed during his/her education, to many factors, which contribute for the appearance of tensions, persistent sensations of fear, apprehension, discomfort and increasing stress levels. Attention has been defective towards the students in facing negative situations, at physical, psychological, or social-economic aspects⁸.

Screening and preventing phobic schemas prior can help to lead an efficient professional life, as nursing profession is very much concerned with interaction and performance. A need for providing a brief and effective short term intervention for nursing students with social phobia was also a matter of concern. It was evident from various studies that Cognitive Behavior Therapy was one of the most effective non pharmacological interventions for social phobia. Thus deriving concepts from the cognitive behavior therapy researcher was inspired to implement a brief form of cognitive behavior therapy for nursing students with social phobia.

MATERIAL AND METHODS:

In order to accomplish the objectives of the present study, the researcher used a Quantitative research approach. Since the study intends to assess the effect of brief cognitive behavior therapy on level of social phobia among nursing students, a pre-experimental, one group pre-test post-test research design was adopted for the study. 30 Nursing students from two nursing colleges in Trivandrum district with social phobia were selected purposively as samples for the present study.

Instruments:

Tool 1: Mini – SPIN: mini social phobia inventory is a standardized tool used to do screening for social phobia. It consists of 3 items with 5 point likert scale ranging from 0 to 4. A total score of 6 or greater is considered as having specificity for social phobia. Tool 2: Demographic profile: It consists of demographic data of the selected samples. Tool 3: Social Phobia Scale: The tool included total of 30 items with a 5 point likert scale ranging from ‘Not at all to extremely’. Scores 0 – 30: Mild social phobia, 31 – 60: Moderate social phobia, 61 – 90: Severe social phobia and 91 – 120: Very severe social phobia.

To ensure the content validity, the tool was submitted to experts from mental health/psychiatric nursing, psychiatry and research. After validation, the tool was subjected to test for its reliability. The reliability of the social phobia scale was established using Pearson’s test re-test method. The reliability of the scores obtained was ‘r’= 0.92, which showed a high correlation.

Ethical consideration:

The intervention was carried out in a separate non disturbing room. Administrative approval for conducting the study was obtained from respected principals of selected nursing colleges. Informed consent was obtained from the participants and assured about the anonymity of the research.

Intervention:

Samples were selected purposively after screening with the mini-SPIN. Pretest was conducted using social phobia scale and intervention was implemented. In the present study intervention (BCBT) refers to a psycho social therapy provided to nursing students in groups with components such as facing a group, psycho education, Progressive muscle relaxation technique, Modeling and graded exposure. This is done by making nursing students to confront fearful situations which they commonly encounter such as interacting with new patients, presenting a speech, singing a song, participating in a role play in front of audience in a controlled manner. It includes 6 sessions, each session consists of 60 minutes per day and three days gap between each session. After five days of intervention post test was conducted using the same social phobia scale.

RESULTS:

Sample characteristics:

The frequency and percentage distribution of nursing students was, majority 24(80.00%) of them belonged to the age group of 18 years. Majority 22(73.30%) of nursing students were females, Twenty three (76.70%) of them were educated from state syllabus whereas 5(16.70%) from VHSE and 1(03.30%) each from CBSE and ICSE respectively. The medium of education for most of the nursing students 17(56.70%) were English. More or less similar percentage of nursing students 15(50.00%) were hindus and 13(43.30%) were Christians, only 2(06.70%) were Muslims. Majority 21(70.00%) of nursing students were from rural area, About 21(70.00%) of them were hostlers whereas only 09(30.00%) were day scholars. Among the nursing students, 26(86.70%) were from nuclear family and 4(13.30%) were from joint family. Only 01(03.30%) had broken family and twenty four (80.00%) of them were first child. With regard to presence of any medical illness almost all of them 28(93.30%) doesn’t had any chronic illness.

Level of social phobia among nursing students

Table I (n=30)

Level of social phobia	Range of score	Frequency (f)	Percentage (%)
No social phobia	0	00	00.00
Mild social phobia	1-30	03	10.00
Moderate social phobia	31-60	18	60.00
Severe social phobia	61-90	09	30.00
Very severe social phobia	91-120	00	00.00

From the table it is clear that there is a statistically significant association was found between level of social phobia and age of nursing students at p <0.05 level of significance. There was no association with other elicited demographic variables.

DISCUSSION:

Social phobia is a common mental health problem in which the affected people used to think no need of seeking medical treatment. Many pharmacological and psychological interventions have been used to treat social phobia. The present study was conducted to evaluate the effect of brief cognitive behavior therapy on level of social phobia among nursing students. The frequency and percentage wise distribution of level of social phobia shows that majority of them 18(60.00%) had moderate, 9 (30%) had severe and 3 (10%) had mild level of social phobia in pretest. In post test it shows that majority of them; 26(86.70%) had mild, 4 (13%) had moderate level of social phobia.

Paired t test was done to find out the effect of brief cognitive behavior therapy on level of social phobia among nursing students. It was found that there is a statistically significant difference between pretest and post test scores. The mean pretest score of 30 samples was 52.33 and standard deviation of 13.88 and mean post test score 17.60 and standard deviation of 11.62. The calculated ‘t’ value is 12.98 with df 29 and it is significant at p < 0.001 level. Paired t test revealed that there is significant reduction in level of social phobia in pre test and post test scores. Hence the research hypothesis H_1-there will be significant decrease in the level of social phobia, was accepted. This result was supported by a pre experimental study which was conducted at Dalhousie University in Canada to find the efficacy of brief cognitive behavior therapy and compared brief form with traditional comprehensive cognitive behavior therapy. The results showed significant decline in social phobia scores (t = 2.19, p < 0.05). This brief cognitive behavior therapy has shown to be an effective treatment for undergraduates with high social anxiety and consisted only 6 sessions, thus making it a good choice for therapists with limited time or less severe clients⁹.

The association between levels of social phobia with selected demographic variables was find out by using ANOVA test. From the calculation it is evident that there is statistically significant association between level of social phobia with age and gender of nursing students at p <0.05 level of significance. Hence the research hypothesis H_2-there will be a significant association between levels of social phobia and selected demographic variable,was accepted. There is no association between variables such as place of stay, birth order, previous pattern of education and family type.

NURSING IMPLICATIONS:

In the past few years, the field of psychiatric nursing has taken steps to expand beyond the confines of conventional, stereotyped practice. In this connection, psychiatric nurses especially those holding administrative and managerial positions, are today capable to develop policies and standards of care, for the promotion of mental health services in India¹⁰. The findings of the study have implications for nursing practice, nursing education, nursing administration and nursing research.

Nursing practice:

The psychiatric nurses have to play a vital role in enabling effective identification and management of social phobia. This can be facilitated by motivating the nurse to,

· Learn about identification and management of social phobia among students.

· Teach parents and teachers about the identification and management of social phobia.

· Teach student nurses to rule out socially anxious clients and to identify symptoms in clinical practice.

Nursing Education:

· Ensure that students learn about prevalence, identification and management of social phobia

· Provide adequate clinical exposure in different settings for nursing students to grasp features of social phobia presenting by patients.

· Arrange for workshops for students to participate so that they gain information about social phobia.

· Make available literature related to social phobia in the library for student’s reference.

· Teach the parents about the broad symptomatology of social phobia.

Nursing Administration:

· Collaborate with governing bodies in formulating policies to employ specially qualified nurse in psychiatric unit to supervise the teaching programme.

· Conduct in-service education programme in identification and management of social phobia and its application in various fields.

· Provide opportunities for nurses to attend training programmes on identification and management of social phobia.

· Improve facilities for identification and supportive management of patients with social phobia in various settings.

Nursing Research:

· Encourage further studies on assessment of social phobia on students as very few Indian studies have been conducted in last few decades.

· As evident from the review of literature, more research can be conducted on various psychological and nursing interventions for the management of social phobia.

· Disseminate the findings of research through seminars, workshops and publishing nursing journals.

· Nurses should encourage further research to be conducted in the area of social phobia and its management.

LIMITATIONS:

· The study was confined to nursing students.

· The sample selection was done with a miniature version of a screening inventory.

· Due to time constraints the interventional package has to be confined in a short time period.

· Long term effect of the intervention was not assessed due to lack of time.

· Follow up assessments which were done in large studies of social phobia was also not able to perform due to lack of time.

· Cognitive restructuring based on schemas of disorder which is a principle in comprehensive cognitive behavior therapy was not able to implement.

RECOMMENDATIONS:

· Similar study can be conducted with a control group.

· Study can be done to assess the prevalence of social phobia in various settings such as schools, because in various studies it has been reported that social phobia is more common among school children.

· Study can be done to assess the effect of exposure therapy on level of social phobia.

· Comparative study can be done to assess the prevalence of social phobia in males and females.

· Study can be done to assess the knowledge and practice of parents with regard to the social phobia of children.

· Similar study can be done by strengthening or modifying the intervention package and can also include the some aspects of social phobia such social avoidance, fear of negative evaluation and performance fears.

ACKNOWLEDGEMENT:

The author express his sincere thanks to respected guide and teacher Mrs. Eugin S.B, Head of the department, Mental Health Nursing, Saraswathy College of Nursing and his beloved friend Ms.Libina Babu, Lecturer, Sree Gokulam College of Nursing for their kind support throughout the research.

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	Mean	Standard deviation	t value	p value
Pre test	52.23	13.88
			12.98^***	< 0.001
Post test	17.30	11.62

Age	Level of social phobia						ANOVA F value	p value
	Mild		Moderate		Severe
	F	%	f	%	f	%
17 years	02	06.67	00	00.00	00	00.00	5.926	0.007*
18 years	00	00.00	16	53.33	08	26.67
19 years	01	03.33	02	06.67	01	03.33