Treatment of social phobia in adults: considerations regarding family insertion within psychoeducational programs

Contexto: a participação da família na recuperação psiquiátrica é um facilitador importante. Objetivo: mostrar a visão geral atual de estudos psicoeducacionais relacionadas ao envolvimento da família no tratamento da fobia social. Método: uma revisão sistemática de literatura foi realizada baseada nas bases de dados VHL, PsycInfo e SciELO. Foram considerados estudos em adultos entre 18 e 65 anos de idade com condições concomitantes, exceto transtornos de personalidade e psicose. Foram incluídos todos os tipos de estudo e diferentes intervalos de tempo das medidas de resultados. Resultados: as bases de dados exibiram uma quantidade baixa de estudos envolvendo psicoeducação familiar para fobia social. Discussão: a literatura recente evidencia um número muito baixo de estudos abordando a participação familiar no tratamento da fobia social. Conclusão: foram encontrados somente estudos com pacientes adolescentes.

Tratamiento de fobia social en adultos: consideraciones sobre la inserción de la familia en programas psicoeducacionales Contexto: La participación de la familia en la recuperación psiquiátrica es un facilitador importante.Objetivo: Mostrar el panorama actual de estudios psicoeducacionales relativos al envolvimiento de la familia en el tratamiento de la fobia social.Método: Una pesquisa de literatura sistemática fue realizada con base en el banco de datos VHL, PsycINFO y SciELO.

Social Phobia: Discussion on Evidences
Most individuals have eventually experienced some level of anxiety, concern or fear in several social situations such as previously to a first date, job interview, public speaking, and so on.It may be considered a normal trait to be coped with in people's daily life which does not affect the expected outcome created by the actual situation (1) .Conversely, fear is an evolutive legacy whose positive and adaptive value is consistently being taken into account (2)(3)(4) .
However, for some individuals, fear and anxiety are intense and persistent feelings able to affect their lives by leading them to avoid the feared situation and thus SMAD, Rev. Eletrônica Saúde Mental Álcool Drog.Jan.-Mar.2017;13(1):52-59.
influencing and interfering into the individual's social and professional life.At evaluation, those individuals are generally diagnosed with social phobia or social anxiety disorder (1,3,(5)(6)(7) .Social phobic individuals show difficulty to become integrated in interpersonal relationships and/or situational performance caused by their exaggerated concern of being observed and evaluated by others and eventually by having presented inadequate and embarrassing behavior owing to the persistent presence of feelings of inefficiency, disapproval and rejection.Phobic persons blame themselves for their own problems and think no one will be able to understand them (8) .As a consequence, the phobic person feels lonely and set apart from others.
A great number of authors (9)(10)(11)(12) has accepted that systematic research on social phobia began to be considered relevant at the end of the 1980 decade only, and because of society's lack of information and the silence of those affected, the disease went on undiagnosed.As social phobia has only recently been identified as a distinctive disorder, clinical research and new therapeutic medical drugs shall certainly lead to new developments concerning that disorder (9) .
In addition to the lack of information related to social phobia as a specific disorder, psychiatric symptoms as anxiety, social isolation, and depression are not so well accepted as the disease's manifestations which are frequently thought to be deliberately controlled by the affected individuals (13) .From this perspective, the social phobic's pain or even the suffering of others affected by anxiety disorders could have been easily avoided (9) if the "myths" linked to these types of disorders were elucidated by the psychiatric disease legitimatization (13) , namely, the providing of information on diagnosis, symptoms, and expected outcomes.
At present, a number of studies shows prevalence of up to 13% (12) .Usually, social phobia manifestations occur during the adolescence period, though in some cases, even seven or eight year-old children show to be affected, unfortunately, with a less than hopeful prognosis (14) .Professionals' knowledge on social phobia disorders will certainly influence the patient's therapy since the disease is likely to impose some restrictions on the patient's life style.Therefore, based in those considerations, when comparing the social phobic patient's profile to control-subjects, they may come to mind as someone economically deprived, uneducated, single, dependent of others, affected by other mental disorders, difficulty to maintain a job, poor working performance, socially isolation caused by unacceptable social abilities, deficient social support and suicidal ideation (10,12) .

Family Insertion into Psychiatric Pathologies
Since the beginning of the last century mental illness has been an active study topic.In 1921, several analysis were directed towards the influence of psychopathology on family functioning (15) .However, it was only at the end of the 1950s and first years of the 1960s that more in-depth studies were carried out in order to elucidate the impact caused by a member's mental illness on the family.At the end of 1980, studies were intensified by the developing of DSM III and DSM III-R criteria (15) .At present, the family's role may be considered as that of a caregiver.Since there was the deinstitutionalization of psychiatric treatment, changes occurred in the patient's rehabilitation, such as the family's role to that of a central figure in this process.However, this new role had to be performed with very few or no information whatsoever on the disease etiology, the previous psychiatric treatment, or even the way to deal with the patient's symptoms (16) .
Approximately 50% to 90% of psychiatric patients live within their family environment (17) and as a consequence, the usual family caregiver member may also be affected by his/her responsibilities and come to suffer negative mental effects as anxiety, depression, fear, and guilt in addition to difficult communication with the patient (13,16,-21) .Based in those caregivers' problems, and because of recent investigations on the subject, new strategies have been developed to ease the caregiver's burden (20) .However, even in spite of the latest advancements in the psychiatric treatment area, few mental healthcare services are able to provide specific supporting programs for caregivers.
To date, the family's role may be considered as custodial only (13) .
By having a daily contact with the psychiatric patient, family members should be able to report their acquired knowledge at assisting that type of patient; unfortunately, caregivers have very few opportunities to exchange their experiences with the attending multi-professional team, and also, usually have to be submitted to a frustrating and disorderly interaction with the mental care services (16,22) .Many times, Sztamfater S, Savoia MG. health must include family members and caregivers since the results attained by this type of education will not be successful enough without their involvement in the patient's rehabilitation process (34).

Psychoeducation and Family: present overview and social phobia patient's perspectives
Up to now, it could be observed that there had been a number of improvements in rehabilitation programs cases (13,35) .Several psychoeducational programs were developed in the last two decades directed towards family members and caregivers in different formats as time duration, training location, type of approach and participation form: individual family, family groups, or both possibilities alternately (35) .
This method is intended to teach the caregiver about aspects and procedures related to the psychiatric patient's treatment, developing capacity, expected abilities, avoidance of illness relapse, problem solving strategies and harmonious companionship (35) .
Studies carried out in different countries show that psychoeducation provides the caregivers with higher satisfaction levels, decreases the family burden, promotes the patient's higher adherence and acceptance of treatment, reduces the caregiver's preoccupation and frustration and decreases levels of relapses and rehospitalizations (16,(36)(37)(38)(39)(40) .
Despite chronic and incapacitating nature and high population incidence levels, the number of studies concerning family participation and impacting support when dealing with the anxiety disorders patients are still scarce.However, research findings related to compulsive-obsessive symptoms and posttraumatic stress (41) confirm that family participation is effective in those patients' treatment (42) .Even with proven evidence that this type of intervention is shown to be effective in anxiety disorders, other pathologies the professional/caregiver interactional success is impaired by the lack of attention given to the caregivers reports on their experience; however, some studies state that interventions which do not consider the caregivers specific needs are not as effective as those that facilitate the means to deal with those needs (23) .At present, the psychiatric rehabilitation goal aims to help chronic patients in developing their emotional, intellectual and social abilities in order to be prepared for life in society since, when reaching this stage, patients should have the capability to work or study but also have free access to professional help whenever necessary.Lately, the paradigm healthdisease underwent a number of changes regarding the psychiatric pathologies field in which chronic patients previously considered as incapacitated are seen today as dysfunctional individuals in need of professional and family support in his/her readaptation to social life (19) .
In order to readapt the patient to live in society, it is necessary to reintegrate him/her into the working market since occupational tasks have proven to be beneficial to such patients (24)(25) .Working tasks may lead to professional development, widen social contacts, increase the individual's self-esteem, improve the quality of life, and also facilitate the individual's economic independence, in addition to his/ her social integration.
Related investigations (26)(27)(28)(29) state that in addition to those patients' ability to carry out working tasks, they may learn a great variety of social abilities, most of all when applied to their daily life.
Recently, the training of social skills has become a very popular rehabilitation method which includes both family and community involvement even though such training represents a long-term endeavor (19,26,(28)(29)(30) .
Usually, the psychiatric treatment is carried out within the patient's natural environment.However, some studies corroborate with the idea that psychiatric patients are still designated as "different", in spite of the deinstitutionalization movement (17)(18)(31)(32)(33) .
Consequences generated by this kind of discrimination include the difficulty for the individual to be inserted into the working market, financial restrictions, few social relationships, and low quality of life, all of them aspects entirely unfavorable to a satisfactory readaptation into society.related to this disorder, as for example the social phobia syndrome, are still disregarded (41) .
Given all these considerations, the support of family members is currently the most important factor to facilitate recovery of the psychiatric patient.This support can be through the participation of the family in psychoeducational program, whose scientific study proved consistent for this purpose (35) .
The present paper was intended to show the current overview of psychoeducation studies related to the participation of family members in adult social phobic patients' treatment.

Method
A systematic search was carried out within the related literature using Virtual Health Library (VHL) database, PsycINFO and SciELO until 2014 by crossing the words "psychoedu*", "social phobia" and "family".The following types of study were eligible: case studies, clinical trials, crossover trials, systematic reviews, meta-analyzes and observational (cohort).
Inclusion criteria: studies involving social phobic adult patients (18-65 years) whose family members also participate in treatment.
Co-morbidities: we accepted studies with medical or psychiatric co-morbidity, excluding personality disorders and psychotic disorders.

Types of interventions: psychosocial interventions.
Timing of outcome assessment: we studied treatment outcomes in three time frames: -short-term: less than three months after treatment was concluded; -medium-term: three to nine months after treatment was concluded; -long-term: nine or more months after treatment was completed.

Results
All data bases considered showed a low number of studies involving family psychoeducation in social phobia as shown in Table 1.
Table 1 -Number of studies involving family and psychoeducation in adult social phobic patients' and main databases, Sao Paulo, SP, Brazil, Disorder Databases

VHL SciELO PsycInfo
Social Phobia 1 0 4 (a) This Table was constructed by considering the crossing of terms as described in Method.

Discussion
Recent literature shows a very small amount of studies approaching family participation in children and adolescent's treatment of social phobia (43)(44)(45)(46)(47) but no study approaching family participation in adult patient's treatment.Only one similar study (43) was found through PubMed but it solely described the systematization of performed investigations on adolescent anxiety disorders, and at the same time, emphasized the importance for family doctors to correctly evaluate, diagnose and treat anxiety disorders involving avoidance and opposition behaviors in adolescent individuals.
Four references found through PsycInfo (44)(45)(46)(47) are also directed to adolescents or children with only one reference exhibiting an interventionist nature.It Another study (45) describes the case of a 13 yearold adolescent girl whose childhood was affected by interactional difficulties and refused to attend school.Using a published description, the case is discussed; the prescribed treatment and therapy are analyzed, while psychoeducation, school and family involvement, exposure, modeling, role playing and cognitive restructuring are also approached.The third (46) reference reports a selective mutism case (dissertation) while the fourth (47) reference quotes passages from a book on phobia therapy.Both references inform about the new applied techniques.
In the specific case of adult social phobia, it is of great importance to follow a psychoeducational program viewing the aspects the caregiver has to cope with: -Persons living with a social phobic patient have to help or teach him/her behaviors as the need to look for a job, leave home, speak in public, interact with other people, since all of those behaviors are linked to individual performance or interpersonal relationships; -Legitimating illness would help families and community to better understand social phobia by eliminating or decreasing prejudicial or rejection behaviors by making the patient aware that he/she is not to blame for his/her difficulties and other may understand them; -If at present recovery includes the training of social abilities, it is fundamental for family members to know of their importance since one of the main social phobia characteristics concerns the lack of those abilities.Thus, family members could act as facilitators in the acquisition of those abilities, which would help the phobic patient in society reinsertion; -Readaptation to daily life, legitimization of the disease, and acquisition of social abilities would enable the patient be inserted into the working market and acquire financial independence and also improve his/her social environment; -Phobic patient's adhesion to treatment is very unsatisfactory (48) .However, either pharmacological and psycho-therapy treatments are proven effective, so it is of the most importance that family members are informed of those treatment forms and their significance for the patient's recovery.Patients must be constantly motivated to continue their treatments and the best way to do it is through family support and understanding.This study identified trends in the production of field research considered, besides suggesting continuity prospects for future research projects in the area.

Conclusion
for the psychiatric patient to be reinserted into society.This movement is based in the family as an active and central figure in the patient's readaptation.A new developmental technique psychoeducational family intervention -strives to meet the needs of both patient and family.The psychoeducation technique was first applied to schizophrenic patients' caregivers and since the 1990s its use was expanded to the treatment of other pathologies as the bipolar syndrome and depression is a school-based intervention specifically developed for young students and using group therapy focused on training social and academic abilities and also individual therapy.Parents may participate in two psychoeducational meetings approaching social phobia and provide adequate information related to both treatment and the way to deal with the child's anxiety.Meetings are also attended by teachers who apply the acquired information to their classrooms.
Social phobia, as a disorder, has only been recently studied in depth either by psychiatric and psychological fields, while few investigations have been approaching the type of care family must provide to the phobic patient.Studies involving the family support usually deal with adolescent patients -16 or 17 year-old -and eventually such studies, just involving a group of subjects, are not adequately documented or protocol-followed.To involve family members in the adult patient's care is vital since social phobia is a chronic disease and without clinical intervention little chance of improvement may be observed; it must be continued during the patient's life span and associated to the negative consequences caused by the patient's functional losses.