A Reflexive Thematic Analysis of Therapist-Client Differences in the Treatment of Social Anxiety Disorder: A Case Study

Abstract

This case study explores the assessment, formulation and treatment of a male client in his 20s presenting with late-onset Social Anxiety Disorder (SAD) comorbid with Childhood-Onset Fluency disorder. The client took part in nine sessions of Cognitive Behavioral Therapy (CBT) delivered by a Clinical Psychologist in Training (i.e., the author of this thesis) differing from him in gender, religious background, and socio-economic status. Using the Clark and Wells (1995) model as a theoretical framework, treatment adaptations to CBT for SAD were made to integrate cultural and contextual factors unique to the Lebanese post-conflict setting. The study addressed two main research questions: 1) how the client experienced psychotherapy with a therapist differing from him in key identity domains, and 2) what adaptations to standard CBT emerged in the Lebanese post-war context. Data sources included session progress notes, two transcribed sessions, psychometric assessments (e.g., the LSAS-SR for SAD, the PHQ-9 for depression, the GAD-7 for anxiety, and the WHO-5 for well-being), and a reflective diary including personal reflections on the therapeutic process as well as documented supervision feedback. This allowed for triangulation across therapist self-reflection, session progress notes, and supervisory insights. A reflexive thematic analysis of the session transcripts, progress notes and reflective diary, in line with the Braun and Clarke (2021) model, revealed that therapist-client differences, when navigated with sensitivity, acted as experiential exposures facilitating corrective experiences and promoting “sudden gains” in SAD treatment (i.e., significant symptom reductions observed between therapy sessions). The adaptations made to CBT involved addressing the client’s reactance toward authority by encouraging greater directiveness on his part, whilst also increasing my own flexibility as a Clinical Psychologist in Training both within sessions and in the delivery of certain CBT components to better fit the client’s needs. The client demonstrated a positive response to treatment, with significant reductions in SAD symptoms and improvements in social engagement. The findings underscore the therapeutic potential of client-therapist difference in SAD treatment as a form of implicit exposure, and highlight the importance of therapist reflexivity and cultural awareness when delivering CBT for SAD in conflict-affected and diverse settings such as Lebanon.