IMAGERY-ENHANCED CBT FOR SOCIAL ANXIETY DISORDER

Also Available

Fight or Flight: Overcoming Panic and Agoraphobia [video]

Featuring Ronald M. Rapee

I Think They Think . . . : Overcoming Social Phobia [video]

Featuring Ronald M. Rapee
Imagery-Enhanced CBT for
Social Anxiety Disorder

Peter M. McEvoy
Lisa M. Saulsman
Ronald M. Rapee

THE GUILFORD PRESS

New York  London
Copyright © 2018 The Guilford Press
A Division of Guilford Publications, Inc.
370 Seventh Avenue, Suite 1200, New York, NY 10001
www.guilford.com

All rights reserved

Except as indicated, no part of this book may be reproduced, translated, stored in a retrieval
system, or transmitted, in any form or by any means, electronic, mechanical, photocopying,
microfilming, recording, or otherwise, without written permission from the publisher.

Printed in the United States of America

This book is printed on acid-free paper.

Last digit is print number: 9 8 7 6 5 4 3 2 1

LIMITED DUPLICATION LICENSE

These materials are intended for use only by qualified mental health professionals.
The publisher grants to individual purchasers of this book nonassignable permission to
reproduce all materials for which photocopying permission is specifically granted in a footnote.
This license is limited to you, the individual purchaser, for personal use or use with clients. This
license does not grant the right to reproduce these materials for resale, redistribution, electronic
display, or any other purposes (including but not limited to books, pamphlets, articles, video- or
audiotapes, blogs, file-sharing sites, Internet or intranet sites, and handouts or slides for lectures,
workshops, or webinars, whether or not a fee is charged). Permission to reproduce these
materials for these and any other purposes must be obtained in writing from the Permissions
Department of Guilford Publications.

The authors have checked with sources believed to be reliable in their efforts to provide
information that is complete and generally in accord with the standards of practice that are
accepted at the time of publication. However, in view of the possibility of human error or
changes in behavioral, mental health, or medical sciences, neither the authors, nor the editors and
publisher, nor any other party who has been involved in the preparation or publication of this
work warrants that the information contained herein is in every respect accurate or complete, and
they are not responsible for any errors or omissions or the results obtained from the use of such
information. Readers are encouraged to confirm the information contained in this book with
other sources.

Library of Congress Cataloging-in-Publication Data

Names: McEvoy, Peter M., author.
Title: Imagery-enhanced CBT for social anxiety disorder / Peter M. McEvoy,
  Lisa M. Saulsman, Ronald M. Rapee.
Description: New York : The Guilford Press, [2018] | Includes bibliographical
  references and index.
Identifiers: LCCN 2017023840 | ISBN 9781462533053 (paperback : alk. paper) |
  ISBN 9781462535491 (hardcover : alk. paper)
Subjects: LCSH: Social phobia—Treatment. | Cognitive therapy. | BISAC:
  PSYCHOLOGY / Psychopathology / Anxieties & Phobias. | MEDICAL / Psychiatry
  / General. | SOCIAL SCIENCE / Social Work.
Classification: LCC RC552.S62 M39 2018 | DDC 616.85/225—dc23
LC record available at https://lccn.loc.gov/2017023840
 About the Authors

Peter M. McEvoy, PhD, is Professor in the School of Psychology and Speech Pathol-
ogy at Curtin University in Perth, Australia. He is also Clinical Research Director at the
Centre for Clinical Interventions of the Western Australia Department of Health. An
associate editor of the Journal of Anxiety Disorders and the Journal of Experimental Psycho-
pathology, Dr. McEvoy has published articles on the treatment of anxiety and depression,
transdiagnostic approaches to mental disorders, and mechanisms of change.

Lisa M. Saulsman, PhD, has spent the majority of her career as a senior clinical
psychologist at the Centre for Clinical Interventions of the Western Australia Depart-
ment of Health. She is experienced in providing individual and group interventions for
adults with anxiety and depression and training mental health professionals in evidence-­
supported treatments for emotional disorders. Dr. Saulsman has published articles on
the use of imagery to enhance CBT and the role of personality in psychopathology. She
is now Director of Cognitive Behaviour Therapy Services, Western Australia, offering
CBT-based training and workshops to professionals, businesses, and the general public.

Ronald M. Rapee, PhD, is Distinguished Professor of Psychology at Macquarie Uni-

versity, in Sydney, Australia, and former Director of the University’s Centre for Emo-
tional Health. He is best known for his theoretical models of the development of anxiety
disorders and his creation of empirically validated intervention programs that are widely
used internationally. Dr. Rapee is a recipient of the Distinguished Career Award from
the Australian Association for Cognitive and Behaviour Therapy and the Distinguished
Contribution to Science Award from the Australian Psychological Society. He is an Aus-
tralian Research Council Laureate Fellow and has been appointed as a Member of the
Order of Australia for his contributions to clinical psychology.

v
 Preface

Human beings are social creatures living in a world built around relationships, so almost
any life circumstance can be seen as threatening to socially anxious persons. From direct
group or individual social interactions of any kind, to the possibility of being observed
when stepping out of the front door of their home, to the inadequacy of their “perfor-
mance” on virtually any task—social threat can be perceived everywhere. Social anxiety
disorder (SAD) is a common and distressing condition that, without being treated, can
be disabling and lifelong.
SAD can be challenging for therapists, but it is also tremendously rewarding to
treat. People with SAD want to relate well to people—they desire close, genuine, and
fulfilling relationships. They are people people, although they may not believe this about
themselves when they first seek help. People with SAD care about others, have a high
degree of empathy, and are keen to please—personal qualities that are highly valued by
others. The problem is they care too much. The probability and cost of not pleasing oth-
ers are perceived to be extremely high. Social situations are seen as threatening, which
triggers a cascade of anxiety symptoms, negative beliefs, and avoidant behaviors. In
severe SAD, “life” is threatening and virtually nowhere is safe. We hope the treatment
in this book helps to ease the suffering of people with SAD by helping them to abandon
the psychological factors that maintain their constant expectation of social catastrophe,
while allowing them to retain the wonderful personal qualities they have that facilitate
genuine and fulfilling relationships.
Cognitive-behavioral therapy (CBT) has been shown to be very helpful for SAD
over many research trials with clients who have severe and complex cases of the disorder.
CBT has been successfully delivered on a one-to-one basis and in groups, and in both
research units and “real-world” clinics. As our understanding of the mechanisms behind
SAD has improved, specific treatment enhancements have been designed to target these
mechanisms to attain even better outcomes. The core components of the program in this
vii
viii Preface

book have been extensively evaluated and shown to work, and they are more effective
than traditional cognitive-behavioral approaches. The novel contribution of this book
is the detailed description of an innovation from our own clinic—imagery-enhanced
CBT for SAD—that has been shown to improve our clients’ engagement and outcomes.
Since including the imagery enhancements in our protocol, treatment completion rates
have increased from 65% to 90%, and the impact on social anxiety symptoms has also
greatly improved.
Imagery-based CBT “enhances” traditional approaches by emphasizing the ben-
efits of facilitating cognitive and emotional change via the imagery mode. Multisensory
imagery is highly emotionally evocative, and more so than verbal activity. If our pri-
mary aim in therapy is to enable our clients to change their extreme emotional reac-
tions, it follows that therapy will be more potent within the imagery mode. Clients are
encouraged to incorporate vivid, multisensory imagery into every aspect of the treat-
ment described in this book.
We are bringing this book to you in the hope that your clients can benefit from
the very latest therapeutic developments. We hope these innovations help you to enjoy
working with clients suffering from SAD as much as we do and, most important, to ease
their suffering.
A brief note about pronouns: With the exception of specific examples, we alternate
between masculine and feminine pronouns throughout the book to avoid awkward
sentences.
 Acknowledgments

We owe a considerable debt of gratitude to the clinicians and clinical researchers (and
their clients) whose contributions this book builds on. Arnoud Arntz, David Barlow,
Aaron Beck, Judith Beck, James Bennett-Levy, Chris Brewin, David M. Clark, Albert
Ellis, Melanie Fennell, Jessica Grisham, Ann Hackmann, Richard Heimberg, Emily
Holmes, Michael Liebowitz, Michelle Moulds, David Moscovitch, Christine Padesky,
and Jennifer Wild are just a few of the giants on whose achievements our work relies.
Colleagues in our own services have also been tremendously inf luential, including Paula
Nathan, Jonathan Gaston, Maree Abbott, Bruce Campbell, and Mark Summers. We
are grateful to the National Health and Medical Research Council of Australia for its
support of our work through Project Grant APP1104007. We would also like to express
our appreciation to our families for their love and support. Finally, we acknowledge the
courageous socially anxious clients who have participated in this treatment within our
programs. Your experiences have helped shape this treatment and taught us so much.

ix
 Contents

PART I.  OVERVIEW OF SOCIAL ANXIETY

AND ITS TREATMENT

 1. What Is Social Anxiety Disorder? 3

What Is SAD?  6
Epidemiology and Impact of SAD  7
What Causes SAD?  9
Comorbidity 10
Differential Diagnoses  11
Social Anxiety: Dimension versus Subtypes  14
Summary 15

 2. Cognitive‑Behavioral Models and Treatments for SAD 16

Cognitive‑Behavioral Models of SAD  16
Key Cognitive‑Behavioral Maintaining Factors  20
What Treatments Work?  22
Imagery as an Important Treatment Target for SAD  26
Imagery as a Mode of Intervention in Emotional Disorders  28
Summary 30

 3. Overview of Imagery‑Enhanced CBT for SAD 32

A Model of SAD and Treatment Targets  32
Treatment Structure  38
Summary 48

xi
xii Contents

PART II.  TREATMENT MODULES

 4. Socializing Clients to the Treatment Model 51

About This Module: Beginning Treatment  52
Setting the Scene  53
Psychoeducation about SAD  59
The Treatment Model  61
Measures to Aid Diagnosis, Case Formulation, and Outcome Evaluation  64
Individualizing the Model: Jacquie’s Case Formulation  70
Treatment Rationale  71
Looking Forward  71
Summary 73
THERAPY SUMMARY GUIDE: Socializing Clients to the Treatment Model  75

 5. Negative Thoughts and Images 76

About This Module: Addressing Negative Thoughts and Images in SAD  76
Socializing Clients to Work with Imagery  78
Identifying Negative Thoughts and Images  84
Modifying Negative Thoughts and Images  91
Clinical Case: Modifying Negative Imagery  100
THERAPY SUMMARY GUIDE: Negative Thoughts and Images  101

 6. Avoidance and Safety Behaviors 102

About This Module: Addressing Avoidance and Safety Behaviors in SAD  103
Socializing Clients to Modify Avoidance and Safety Behaviors  103
Behavioral Experiments: Modifying Behavior to Challenge
Negative Thoughts and Images  113
Tolerating Anxiety: Coping Imagery  130
Clinical Case: Behavioral Experiments  135
THERAPY SUMMARY GUIDE: Avoidance and Safety Behaviors  137

 7. Negative Self‑Image 139

About This Module: Addressing Self‑Imagery in SAD  140
Identifying Negative Self-Images  141
Modifying Negative Self‑Images  143
Clinical Case: Modifying Negative Self-­Imagery  153
THERAPY SUMMARY GUIDE: Negative Self-Image  154

 8. Attention Biases 155

About This Module: Addressing Attention Biases in SAD  156
Introducing Attention Biases  157
Attention Retraining  163
 Contents xiii

Attention Focusing  166
Clinical Case: Attention Retraining  168
THERAPY SUMMARY GUIDE: Attention Biases  169

 9. Negative Core Beliefs 170

About This Module: Addressing Negative Core Beliefs in SAD  171
Traditional Approaches to Addressing Negative Core Beliefs  173
Imagery Rescripting to Undermine Negative Core Beliefs  178
Positive Imagery to Construct New Core Beliefs  189
Action Planning to Strengthen New Core Beliefs  194
Clinical Case: Modifying Negative Core Beliefs  195
THERAPY SUMMARY GUIDE: Negative Core Beliefs  197

10. Maintenance and Relapse Prevention 199

About This Module: Completing Treatment  200
When Are Clients Ready to Complete Treatment?  200
How to Complete Treatment  201
Clinical Case: Completing Treatment  205
THERAPY SUMMARY GUIDE: Maintenance and Relapse Prevention  206

APPENDIX.  REPRODUCIBLE WORKSHEETS 209

AND HANDOUTS

References 271

Index 279

Purchasers of this book can download and print copies of the handouts and worksheets
at www.guilford.com/mcevoy-forms for personal use or use with clients
(see copyright page for details).
 PA R T I

Overview of Social Anxiety

and Its Treatment
 CHAPTER 1

What Is Social Anxiety Disorder?

Jacquie’s Story
Jacquie, a single 22-year-old woman, described herself as having been a quiet
and “bookish” child who enjoyed her own company. Her parents were both
loving and supportive, and they had high expectations for her academic and
social performance. Her mother always encouraged her to “put her best foot
forward” and seemed disappointed with her shyness in social situations. Jac-
quie’s father was more sympathetic and also seemed to prefer to stay at home
with the family rather than socialize with others. When she was old enough,
he would often allow Jacquie to stay home if the family was going to visit
family or friends.
Jacquie attended a small local primary school before moving to a large
high school when she was 13 years old, which she remembered as being a
particularly difficult experience. She found it hard to make friends, and she
remembered having to give formal presentations in front of the class for the
first time, which she found terrifying. Jacquie tried to avoid these presenta-
tions by pretending to be sick, but her parents were both teachers and would
always send her to school anyway.
Jacquie remembered one particularly traumatic presentation when she was
15 years old. She had dreaded speaking in front of the class for weeks before-
hand as she had vivid images of herself stammering and then being paralyzed
by fear. She knew that she blushed when she was embarrassed, so she imag-
ined all her classmates laughing at her bright red cheeks. In her mind’s eye,
her peers could clearly see how awkward and incompetent she was, and she
feared that the few friends she had managed to make would ridicule and reject
her. On the day of the presentation Jacquie awoke feeling unwell and anxious.
She recalled having a headache and feeling too nauseous to eat breakfast. Just
3
4 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

before her presentation her heart and thoughts were racing, her palms were
sweaty, and she had a strong urge to escape.
Jacquie doesn’t recall much about the actual speech itself other than the
overwhelming sense of shame she felt about her performance. She had written
her speech word for word so that she didn’t forget anything, and so she could
look down at the paper rather than see the weird looks she thought her class-
mates must have been giving her. She remembered stumbling over her words,
having her mind go blank, and being on the brink of tears. She was sure that
her voice was trembling and quiet. She sat down without making eye contact
with anyone and felt humiliated.
Unfortunately for Jacquie the trauma didn’t end when the presentation
was over. She continued to ruminate about her poor performance in the
hours, days, and weeks afterwards. She repeatedly criticized herself, asking
herself why she was so stupid. In the years that followed, negative thoughts and
images of how she must have looked during the presentation came to mind
every time Jacquie thought she was the focus of attention (e.g., when eating
or drinking in public, or even walking down the street). Jacquie believed this
image warned her of imminent humiliation and occasionally caused her anxi-
ety to escalate to the point where she would have a panic attack.
Jacquie decided that she would start to protect herself from criticism and
rejection by rarely speaking in social situations, and in fact she became an
expert in avoiding social situations altogether by making excuses that she was
unwell or had other plans. Jacquie’s social anxiety became so severe at times
that she was unable to walk down the street in case she saw someone she knew,
or a stranger attempted to speak to her. When she did go out in public she
would walk down the most isolated streets, avoid any eye contact with other
people, and would cross the road to avoid passing another person. When Jac-
quie could not avoid social situations, she learned to ask questions so people
talked about themselves and she did not need to disclose anything about her-
self.
After high school Jacquie studied to become a librarian because she loved
books and it meant that she would not be expected to interact with people
very often. Unfortunately, as Jacquie isolated herself more and more, even
brief interactions she had with other staff and patrons began causing her sig-
nificant anxiety. Jacquie knows she is introverted and does not necessarily
want to change this, but she recognizes that her anxiety is more severe and
debilitating than it need be. Jacquie presented for treatment because she would
like a family one day, but she feels depressed because she does not believe this
is possible for her.

Max’s Story
Max is a 27-year-old actor who needs to attend auditions regularly. He has
been experiencing panic attacks with increasing frequency, particularly when
he is anticipating auditions or having to interact with colleagues. Max pre-
sented as a sociable and bright individual who is eager to please but nonetheless
 What Is Social Anxiety Disorder? 5

reported having been shy for his whole life. When he was young he remem-
bers hiding behind his parents when other people were around. Max reports
having had some friends at school, but he would often listen from the periph-
ery of the group rather than actively contribute to the discussions. He figured
that if he was quiet he would avoid saying something stupid or boring, and
people would tolerate him. As a consequence he usually felt disconnected
from others, and he had few close friends. Max believes his love of acting came
from his curiosity about people, but he also enjoys the fact that he has a clear
script to work from. Max reported that he thrives onstage where he can play
a character and his lines are written for him. However, whenever he has to
interact as himself he “falls to pieces.” Max’s social anxiety increased when he
left school and he had to meet new people in college, and again when he left
college to become a professional actor. He noticed that over time he started
to feel apprehensive in more and more social situations, to the point where
he even felt anxious with his family. He began drinking alcohol to “settle his
nerves” in the evenings and on weekends, and he recently started to carry
around a hip f lask of whiskey so that he could have a sip before having to meet
other actors or directors.
As time has gone on Max has become more and more self-­conscious
about his anxiety. He scrutinizes the warmth in his cheeks and the sweatiness
of his palms before interacting with others. He also closely studies his col-
leagues’ facial expressions for any sign that they can see just how anxious he is.
Although no one ever says anything to him directly, he believes he can read
their minds from the expressions on their faces. Max notices that his thoughts
are dominated by expectations of failure and negative evaluation from others
before, during, and after social situations. In his mind’s eye, he repeatedly sees
an image of his colleagues looking at him strangely, which just confirms that
he has failed and no longer enjoys their respect. He even interprets positive
feedback as a sign of “pity,” and he has started to find auditions intolerable.
Max has also recently started avoiding seeing his friends and family by making
excuses that he is too busy to see them. Max presented for treatment because
alcohol is no longer working, and his increasing panic attacks mean that he
can no longer concentrate on his acting career. It took Max a while to realize
that he has significant social anxiety because he has always been able to bluff
his way through social events with the use of alcohol. Max had also thought it
was impossible for him to have social anxiety, given that he could comfortably
perform onstage in front of a large audience. However, Max now recognizes
his anxiety is excessive and wants to do something about it.

Jacquie and Max present just two of the many faces of social anxiety disorder (SAD).
This book is designed to equip clinicians with new ways of integrating imagery- and
verbally based strategies when working with clients like Jacquie and Max who suffer
from SAD. The first part of the book provides clinicians with key information on SAD,
including the unique aspects and advantages of imagery-­enhanced cognitive-­behavioral
therapy (CBT) and the model that guides the treatment.
6 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

The second part of the book describes the components of imagery-­enhanced CBT
in sufficient detail so that they can be easily applied clinically. We provide sample scripts
that can be used with clients, detailed step-by-step descriptions of each treatment strat-
egy, suggested questions to optimize clients’ learning, and sample dialogues. We also
provide some clinical anecdotes that we hope will help therapists appreciate how the
various strategies have been used with our clients. Throughout the book we describe
potential difficulties that have arisen in our clinical work and suggest how these can
be managed. At the end of the book we provide client-­friendly handouts that describe
the rationale for each treatment component, as well as worksheets that can be used as a
framework to guide the application of specific treatment strategies and record clients’
examples.
We have used this treatment in both group and individual formats with success. In
Chapter 3 we provide a suggested structure for group treatment, which we have used in
our treatment evaluation trials (McEvoy, Erceg-Hurn, Saulsman, & Thibodeau, 2015;
McEvoy & Saulsman, 2014). To maximize the f lexibility with which the treatment can
be used in individual therapy, we have not written the book in a session-­by-­session struc-
ture. Instead, in Part II, we have devoted one chapter to each key maintaining factor in
the model that guides the treatment: (1) negative thoughts and images, (2) avoidance
and safety behaviors, (3) negative self-image, (4) attention biases, and (5) core beliefs.
Some clients might require more or fewer sessions targeting each of these maintaining
factors, and clinicians should be guided by their case formulation and experience when
determining the appropriate “dose” of each component. In the final chapter of the book
we discuss relapse prevention. Although this book is designed to enable clinicians to “hit
the ground running,” where possible it is highly recommended that relatively inexperi-
enced clinicians receive supervision by therapists who are accredited and experienced in
cognitive-­behavioral approaches.
In the rest of this chapter we provide clinicians with a working knowledge of SAD,
including its symptoms, common comorbidities, and how to distinguish it from other
disorders. It is also helpful to have an understanding of the epidemiology and causes
of SAD because clients are often surprised (and very reassured) by just how common
the disorder is, and they are interested in the factors that may have contributed to their
problem.

What Is SAD?
The core characteristic of people with SAD is excessive worry about or fear of other
people thinking badly of them in some way. The particular fears or worries vary slightly
from person to person—­some people worry that others will think they are odd or weird,
that they are “uncool,” incompetent, unlikable, weak, rude, and so on. But in all cases,
there is a basic concern that others will evaluate them negatively. As a result, people with
SAD find any situation where there is a possibility for scrutiny by another person to be
highly anxiety provoking. They avoid a wide range of situations where they might be
observed or might have to interact with others. Again, the specific situations will vary
 What Is Social Anxiety Disorder? 7

from person to person, but some of the common ones include meeting new people,
being the center of attention, work meetings, social functions, using public toilets, or
eating, drinking, or writing in front of others.
When working with socially anxious people, it is probably not critically important
whether they meet the full diagnostic criteria for SAD. However, there are times when
a formal diagnosis is needed, and most research on treatments for SAD has been con-
ducted on people who meet formal diagnostic criteria. Therefore having an appreciation
of SAD diagnostic criteria (e.g., the fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders [DSM-5; American Psychiatric Association, 2013]) and using diagnostic
information to assist treatment planning is advisable.
Jacquie and Max report long-­standing and severe shyness, inhibition, and social
avoidance across a variety of social situations because they anticipate being judged and
rejected for failing to meet others’ standards. When these social situations cannot be
avoided they report suffering from extreme anxiety symptoms and panic attacks, which
Max has tried to self-­medicate with alcohol. As is the case for other emotional disorders,
a diagnosis of SAD can only be given after other psychological or physiological causes
or medical conditions have been ruled out as better explanations. For instance, if a client
reports that he only loses his confidence and worries about negative evaluation when
he is in the middle of a depressive episode, then a diagnosis of major depressive disorder
rather than SAD should be considered. For both Jacquie and Max their social anxiety
is chronic, persistent, pervasive, and not due to another condition. It is also important
to consider sociocultural context when deciding whether anxiety is out of proportion
to the actual threat because there are cross-­cultural variations in the prevalence, nature,
and meaning of social anxiety (Furmark, 2002). As with any mental disorder, the key
issue is life impairment. Many people report being shy or quiet in some situations, but
a diagnosis is only appropriate when that shyness impacts significantly on one’s life.
Max and Jacquie both acknowledge that their social fears are excessive, and their social
and occupational functioning has clearly been chronically and severely affected by their
social anxiety.

Epidemiology and Impact of SAD

SAD is one of the most common anxiety disorders. Lifetime rates of SAD vary depend-
ing on the assessment method, but it appears to be most common in Western countries
such as the United States (18.2%), Australia (8.4%), and the nations of Europe (5.8–12%),
and less common in Africa (e.g., 3.3% in Nigeria) and Asia (2.4–5.3%; Demyttenaere
et al., 2004; McEvoy, Grove, & Slade, 2011). SAD typically begins in early adolescence
(around 10 to 13 years of age), which is several years earlier than other anxiety and affec-
tive disorders except specific phobias (Kessler et al., 2005; McEvoy et al., 2011). New
cases of SAD are uncommon after age 25, and people who report experiencing SAD
from an earlier age tend to be more severely affected (Grant et al., 2005).
A range of factors increases the chances of having SAD. There are mixed findings
on gender differences in children or adolescents, with some studies finding no difference
8 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

in rates between boys and girls (Beidel, Turner, & Morris, 1999; Wittchen, Stein, &
Kessler, 1999) and others finding higher rates in girls (Kessler et al., 2012). A consis-
tent finding is that more women than men in the general population have SAD (Asher,
Asnaani, & Aderka, 2017; Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012;
Wittchen et al., 1999), so we might expect more women than men to seek treatment.
Interestingly, however, this is not the case. Within clinical samples the ratio of women
to men is relatively even (Rapee, 1995). Cultural expectations for men to be more domi-
nant and assertive may result in greater impairments in social and occupational func-
tioning for men than women with SAD, and therefore higher rates of treatment seeking
(Asher et al., 2017).
Some important cross-­cultural differences in the expression of SAD have been doc-
umented (Furmark, 2002; Rapee & Spence, 2004). Taijin kyofusho (“interpersonal fear
disorder” in Japanese) is a culturally specific expression of social anxiety where the fear
is of acting in ways that are inadequate or offensive to others, rather than fear of nega-
tive evaluation by others in SAD. DSM-5 (American Psychiatric Association, 2013) lists
a range of specific fears of offending others due to emitting an offensive body odor
(olfactory reference syndrome), facial blushing (erythrophobia), too much or too little
eye gaze, awkward body movements or expression (e.g., stiffening), or body defor-
mity. Eastern collectivist cultures value introversion and humility, and prioritize “the
other” over “the self,” which may, at least in part, explain the higher prevalence of SAD
in Western countries, which value individualism and extraversion (Cain, 2012). The
higher value placed on individual achievement and performance in Western countries
may then create the perception of a more evaluative environment, and thus higher rates
of SAD, for more introverted individuals. In collectivist cultures, where the communal
rather than individual good is prioritized, the documented prevalence of SAD is lowest.
This literature highlights the need to understand mental disorders within an individual’s
sociocultural context.
SAD tends to be chronic without treatment. One study found that only 35% of
a clinical sample with SAD experienced full remission over an 8-year period, with a
rapidly diminishing rate of remission after the first 2 years (Yonkers, Dyck, & Keller,
2001). SAD has the lowest remission rate of all anxiety disorders, with a median length
of illness of 25 years (deWit, Ogborne, Offord, & MacDonald, 1999). A recent review
found that full remission rates in prospective studies of SAD varied between 36 and 66%,
whereas partial remission rates (i.e., not fulfilling all of the diagnostic criteria but con-
tinuing to have some social fears) varied between 54 and 93% (Vriends, Bolt, & Kunz,
2014). These findings might suggest that a reasonably high proportion of individuals
spontaneously remit over time, or alternatively that SAD follows a waxing and waning
course (Vriends et al., 2014). A range of factors was associated with an increased likeli-
hood of remission, including having a nongeneralized subtype of social anxiety, no panic
attacks, less avoidance, higher age of onset, less severe impairment, no comorbid mental
disorders, no alcohol use, being older than 65, being employed, being in a relationship,
higher socioeconomic status, fewer critical life events, and no parental history of SAD
or depression.
 What Is Social Anxiety Disorder? 9

Due to its high prevalence SAD has been found to account for a similar degree of
disability in the population as schizophrenia and bipolar affective disorder (Mathers,
Vos, & Stevenson, 1999). Individuals with SAD are more likely to have poorer aca-
demic functioning, to be unemployed, and to be single (Davidson, Hughes, George,
& Blazer, 1993; Kessler, Stein, & Berglund, 1998). SAD is therefore an early-onset,
common, chronic, and debilitating anxiety disorder that does not tend to remit without
treatment. Unfortunately some studies have suggested that as few as 5% of individuals
seek treatment for social anxiety (Keller, 2003) and, for those that do, the mean age of
presentation for treatment is around 30 years (Rapee, 1995). People with SAD tend to
wait longer to seek treatment than other anxiety disorders, which leads to an extended
period of disability. Given the interpersonal nature of the disorder, the fact that most
activities humans do in life involve interpersonal interactions, and the substantial delay
in treatment seeking, SAD can have a pervasive impact on people’s lives.

What Causes SAD?
As a truism, the causes of SAD almost certainly include a combination of nature and
nurture. Although individual studies show some variability in results, overall, evidence
from twins points to a consistent inherited component for social anxiety (Scaini, Belotti,
& Ogliari, 2014). It is interesting that the heritable component seems to be almost twice
as strong for symptoms of social anxiousness than for the actual clinical diagnosis of
SAD. This might suggest that whereas social anxiousness ref lects more of a fundamental
personality trait, whether a highly shy person develops the clinical syndrome (SAD)
might depend more on environmental factors (Spence & Rapee, 2016). There is some
evidence that SAD “breeds true” so that individuals with SAD are more likely to have
offspring with SAD compared to individuals without mental disorders (Fyer, Mannuzza,
Chapman, Martin, & Klein, 1995) and compared to individuals with a different disorder
(Lieb et al., 2000). However, most of the genetic inf luence seems to increase vulnerabil-
ity to emotional disorders in general rather than SAD in particular. In other words, what
is inherited seems to mostly be a general tendency to be “emotional”—often referred to
as neuroticism. Neuroticism refers to a general tendency to experience negative emo-
tional states and sensitivity to stress (Watson, Gamez, & Simms, 2005) and is a common
temperamental vulnerability factor for a range of emotional disorders.
Personality and temperamental factors can increase the risk of developing SAD.
Children who display a general tendency to be submissive, anxious, socially avoidant,
and behaviorally inhibited are more likely to develop SAD (Clauss & Blackford, 2012;
Rapee, 2014). Other personality dimensions have also been associated with SAD, par-
ticularly the combination of high neuroticism and low extraversion, and the personal-
ity style of low effortful control. Thus SAD is likely to result from a complex interplay
between temperamental factors.
A range of environmental factors has been associated with SAD, but most of the
evidence is based on retrospective self-­report and correlational designs. It is therefore
10 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

unclear if the relationships are causal, unidirectional, or reciprocal. Environmental risk

factors also appear to be similar across mental disorders rather than specific to SAD
(Kendler et al., 2011). Examples of social traumas that have been associated with anxiety
disorders in general and SAD in particular include bullying by peers, abuse, and a dys-
functional family of origin (Spence & Rapee, 2016).
Insecure attachment styles have also been associated with an increased risk of SAD
(Shamir-­Essakow, Ungerer, & Rapee, 2005). Trust in caregivers promotes exploration
of the social world, development of social skills, and self-­efficacy, whereas an absence
of a secure, trusting, and responsive caregiver may adversely impact social skills and
confidence. Parents of sociable and socially competent children tend to be warm and
supportive and set clear expectations. In contrast, parents of shy and socially withdrawn
children tend to be more overcontrolling, overprotective, distant, insensitive, reject-
ing, less sociable, stress the importance of others’ opinions, and use shame for discipline
(McLeod, Wood, & Weisz, 2007; Wong & Rapee, 2016).
It is important to emphasize again that these associations have been weak and mostly
based on correlations and retrospective recall. It is plausible that parents adopt these styles
in response to their children’s inhibition. For instance, a parent may take more control as
a way of trying to encourage a shy child to engage more fully with her peers with the
laudable aim of enhancing her social skills and confidence. Alternatively, sensitive to
their shy child’s discomfort, other parents might allow him to predominantly engage
in solitary activities. “Overcontrolling” and ‘”overprotective” parenting may thus be
a response to the child’s fearfulness and distress in social situations. In turn, reciprocal
relationships between a child’s temperament and parenting styles may serve to reinforce
threat expectations and avoidant coping strategies (Spence & Rapee, 2016; Wong &
Rapee, 2016).
In summary, the development of SAD probably involves a complex and recipro-
cal interaction among a range of genetic, temperamental, and environmental factors.
Genetic and temperamental factors can elicit responses from the environment that rein-
force or strengthen tendencies toward behavioral inhibition, and environmental factors
may act upon preexisting temperamental characteristics to reduce or increase the risk
for SAD. Each individual may be inf luenced by these factors to differing degrees, and
a wide range of idiosyncratic experiences are also likely to complicate the picture. On
an individual basis, when you meet a client with SAD, it is impossible to know exactly
what factors led to his presenting problems. For this reason, treatment is not aimed at the
“causes” of the disorder but rather at the current processes that maintain the problem.
We discuss these processes in a later section.

Comorbidity
SAD rarely occurs in isolation. In fact SAD frequently co-­occurs with other mental dis-
orders, especially depression, other anxiety disorders, substance use disorders, and per-
sonality disorders (Grant et al., 2005). At least half the people presenting for treatment
 What Is Social Anxiety Disorder? 11

with SAD will have a comorbid disorder (McEvoy et al., 2015), so it is important for
assessing clinicians to be “on the lookout” for additional problems. Mood disorders are
the most common co-­occurring disorders, followed by other anxiety disorders (Grant et
al., 2005). SAD is one of the earliest-­onset mental disorders, so most clients’ comorbid
disorders will have started after their SAD.
Concurrent conditions can interfere with treatment progress (Lincoln et al., 2003,
2005; McEvoy, 2007), so treating clinicians need to carefully consider how they might
need to feature in their case formulations and treatment plans. For instance, if major
depression is the most debilitating problem when the client presents for treatment, this
might need to be prioritized even if the depression started after the SAD. If left untreated,
depression symptoms such as lethargy, avolition, and profound hopelessness may inter-
fere with treatment engagement. Substance dependence may also interfere with progress
by causing anxiety symptoms (especially during short-term withdrawal), which can
reduce the effectiveness of the treatment strategies and ultimately reduce clients’ confi-
dence in the SAD treatment. However, it may be difficult for the client to reduce her
substance use if the social anxiety is not addressed. In these cases an integrative approach
to treating social anxiety and substance abuse is indicated, where both problems are
treated simultaneously by the same or complementary services (Stapinski et al., 2015).
It can sometimes be difficult to determine which problem should be treated first,
and this will typically be a decision that is made collaboratively with the client. We
will often have an open discussion with clients about the treatment options and the
pros and cons of each approach. In our experience, clients are usually well equipped to
decide whether, for instance, their depressed mood is likely to interfere with their abil-
ity to regularly attend treatment sessions and apply treatment strategies for their SAD. If
the client is suffering from severe depression and agrees that this needs to be addressed
first, we will prescribe psychological and/or pharmacological treatments for depression
before targeting his SAD. Once a collaborative decision has been made on the pre-
ferred treatment focus, the clinician can monitor comorbid problems and shift focus if it
becomes clear that they are interfering with treatment. Group treatment is less f lexible
in this regard, so at times it might be necessary to remove a client from a SAD group
if it becomes clear that comorbid problems are inhibiting treatment progress. After the
comorbid issue is addressed she can then recommence treatment for SAD.

Differential Diagnoses
Some psychological disorders can present in similar ways to SAD, but the differences
can have important treatment implications. Recurrent panic attacks can occur in SAD
but are not diagnosed as panic disorder unless uncued (unexpected) panic attacks that
are unrelated to social triggers are present (American Psychiatric Association, 2013).
The core negative cognitions differ between SAD and panic disorder, with the former
revolving around themes of evaluation and the latter around themes of catastrophic
consequences of somatic symptoms (e.g., heart attack). Individuals with panic disorder
12 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

may fear some social consequences of having a panic attack, but their panic attacks are
not invariably triggered by social cues, and the primary fear is of having a panic attack
or the consequences of a panic attack rather than of negative evaluation. Agoraphobic
avoidance may also resemble avoidance in SAD, but the function of avoidance in agora-
phobia is to prevent fear and panic attacks, whereas the function of avoidance in SAD is
to prevent social evaluation.
Body dysmorphic disorder (BDD) is another mental disorder that shares features
with SAD. People with BDD believe they have an abhorrent and unacceptable physi-
cal f law in their appearance (American Psychiatric Association, 2013). Individuals with
BDD and SAD can present with some similar affective, physiological, interpersonal,
and behavioral symptoms. Individuals with both disorders may report feeling anxiety,
shame, and humiliation, and they might appear behaviorally inhibited, avoid social con-
tact, and fear attention from others. Both disorders may also be associated with fear of
negative evaluation based on appearance, which may result in mirror gazing, camou-
f laging, and excessive grooming behaviors. However, with BDD the cognitions tend
to be more focused on rejection as a consequence of a specific perceived or exaggerated
physical f law (e.g., skin defects, nose size), and sufferers may have low insight into the
discrepancy between their perception and reality. Individuals with SAD tend to have
more general fears of rejection as a consequence of their social performance not meet-
ing others’ standards, which may extend to and include aspects of physical appearance.
It is important to do a careful assessment for the presence of comorbid BDD because
elements of treatment for SAD can be particularly grueling for these individuals (e.g.,
video feedback, see Chapter 7). When BDD is associated with very poor insight and is of
almost delusional intensity, differential diagnosis is critical and relatively straightforward.
However, in milder cases there is substantial overlap, and the concerns about aspects of
physical appearance can be missed without careful assessment.
Avoidant personality disorder (PD) is characterized by a pervasive pattern of social
inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation (American
Psychiatric Association, 2013) and ref lects a more severe variant of SAD. Individuals with
an avoidant personality will present as being more chronic, comorbid (e.g., depression,
substance abuse), and debilitated by their social anxiety. Negative core beliefs about the
self being inadequate, unlikable, and inferior, and of others being hostile, judgmental,
and superior, are likely to be “stickier” than for those without avoidant PD. Avoidance
behaviors will also be more pervasive, long-­standing, and rigid. These individuals can be
effectively treated using similar interventions as for SAD but may require a larger dose
of therapy to achieve comparable outcomes to clients without avoidant PD. Research has
found similar rates of improvement between those with and without comorbid avoidant
personality, but fewer individuals with avoidant PD achieve full remission (Cox, Turn-
bull, Robinson, Grant, & Stein, 2011).
Occasionally individuals with schizoid PD are referred for treatment of SAD. Schiz-
oid PD is characterized by a lack of interest in close interpersonal relationships and,
like avoidant PD and SAD, is associated with high neuroticism and low extraversion
 What Is Social Anxiety Disorder? 13

(Saulsman & Page, 2004). One 19-year-old man referred to our clinic was accompanied
by his very concerned father, who reported that his son had always been uninterested
in engaging with his peers and family unless it was necessary. A detailed assessment
revealed that the son simply did not find social interactions rewarding, and so he pre-
ferred solitary activities. He described apathy rather than anxiety in social situations, and
he did not meet criteria for major depression or dysthymia. Clearly this client was not
a good candidate for treatment of SAD, as he did not experience the primary feature of
this disorder, fear of negative evaluation.
SAD and depression often co-occur and have overlapping features. Like SAD,
depression is often associated with social withdrawal, inactivity, low self-­esteem, nega-
tive beliefs and perceptions about the self and others, and negative ruminations about
social interactions. Given its earlier average age of onset, it is more common for SAD
to precede rather than follow depression, suggesting that social anxiety and associated
withdrawal can lead to depression. Many clients will report this pattern when asked
what they recall first, feeling anxious in social situations or feeling depressed. For other
clients it will be more difficult to tease these symptoms apart. If clients deny feeling
socially anxious in between depressive episodes, this suggests that the primary disorder
is depression, and if this is successfully treated the social anxiety should resolve. If the
client reports that depression typically follows a period of social anxiety, then depression
may be masking an underlying SAD. In these cases, it may still be important to treat
the depression before the social anxiety, but we will often make this decision based on
client preference and whether the depression is so severe that it is likely to interfere with
engagement in SAD treatment.
A final issue we discuss here is a recognition that some clients referred for SAD may
genuinely elicit frequent rejection or interpersonal disputes. Individuals with SAD fear
negative evaluation, but almost invariably this is perceived evaluation. Friends or family
members might express some frustration at their inhibited behavior, or the individual
might avoid establishing social contact with others, but it is rare that someone with SAD
is overtly rejected by others. Clients who present with clear evidence of negative evalu-
ation and rejection may require a different form of treatment from what we describe in
this book, such as social skills training, anger management, interpersonal psychotherapy,
or dialectical behavior therapy. It is noteworthy that while there is evidence that chil-
dren with SAD demonstrate social skills deficits, most adults with SAD have perfectly
adequate social skills (Rapee & Spence, 2004). The problem is that they don’t think they
have adequate social skills. One of the most important goals of treatment is for clients
to learn that there is a large discrepancy between their perceived and actual social skills.
Avoidant behaviors (e.g., not making eye contact, staying quiet) may masquerade as
social skills deficits, but as these fall away during treatment one of the great pleasures of
treating clients with SAD is observing their natural social skills f lourish. Many SAD cli-
ents feel relatively comfortable with clinicians, so some of these skills are often apparent
in the initial assessment. Individuals with SAD desire relationships with others, they are
sensitive to others’ opinions and needs, and they are caring (albeit too much).
14 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

Social Anxiety: Dimension versus Subtypes
Normal shyness is typically considered to be a relatively mild social awkwardness that
does not significantly interfere with functioning. Up to 40% of nonclinical samples
report having felt shy at some point in their lives (Rapee, 1995), suggesting that it is a
common and normal experience. We have all probably had the experience of feeling
awkward within social situations. Perhaps you can recall an experience when every-
one else appeared to be engaged in conversations while you were standing alone in the
corner of the room with an hors d’oeuvre in your hand? Suddenly, the food or an item
of furniture became extremely fascinating as you attempted to appear preoccupied by
choice (rather than just appearing to be awkward and a loner). Perhaps you pretended to
look busy with your cell phone as you considered excuses for making a hasty exit (per-
haps you were Googling “how to make a hasty but subtle exit from a party”)? We have
all also had the experience of engaging in a pretty dull conversation or putting our “foot
in our mouth.” These are normal experiences that are very specific to particular situa-
tions (e.g., when we don’t know anyone) and mercifully quite rare, and the awkwardness
generally passes quickly. Even if these f leeting experiences occur relatively frequently
and we identify as being a shy person, we might not let them overly affect our life. On
the other hand, if we start to notice that these experiences are occurring frequently, are
associated with significant anxiety in anticipation of social situations, start to promote
avoidant behavior, and are having a negative impact on our life, then we have moved
beyond “normal” shyness into SAD territory.
Previous editions of the DSM (American Psychiatric Association, 1987, 1994, 2000)
distinguished between circumscribed (specific) and generalized social phobia. Specific
social phobia was diagnosed when clinically significant social anxiety was triggered by
one or two situations, whereas generalized social phobia was diagnosed when the client
experienced social anxiety in most social situations. The validity of this subtyping was
controversial, with researchers questioning whether the distinctions were more quanti-
tative (different severities) than qualitative (different forms of the disorder) (see Skocic,
Jackson, & Hulbert, 2015). Compared to specific social phobia, generalized social pho-
bia tends to be associated with an earlier onset, greater chronicity, more severe anxiety,
more avoidance and impairment, and more suicidal behavior (Furmark, Tillfors, Stattin,
Ekselius, & Fredrikson, 2000; Hook & Valentiner, 2001; Stein, Torgrud, & Walker,
2000). Avoidant PD is even more severe on each of these variables.
DSM-5 (American Psychiatric Association, 2013) removed the specific and general-
ized specifiers and instead introduced a “performance only” subtype. The performance
subtype is given when a client’s fear of being observed or scrutinized is limited to situ-
ations such as presentations, job interviews, and when eating or drinking in public, but
they do not fear interacting with people (Hofmann, Newman, Ehlers, & Roth, 1995;
Stein & Deutsch, 2003). Epidemiological research suggests that the performance subtype
of SAD is quite rare (Burstein et al., 2011). Apart from the specific subtype, and pub-
lic speaking fears in particular, SAD may best be considered along a continuum based
 What Is Social Anxiety Disorder? 15

on the number of feared situations and the associated degree of distress and disability
(Skocic et al., 2015). Avoidant PD remained as a separate disorder in DSM-5 despite
evidence that it is a more severe variant of SAD.

Summary
Jacquie and Max, our clinical cases at the start of this chapter, are typical examples of
what the diagnostic criteria and research tell us about SAD. They report long-­standing
shyness and behavioral inhibition, and in Jacquie’s case there is some suggestion that
her father was introverted and her mother had high expectations of social performance.
Although they are young adults, they have already suffered for a number of years with
their social anxiety, and they have presented for treatment at a time when they are
highly debilitated by their symptoms. Throughout this book we provide case examples
of individuals we have worked with who have undertaken the challenging but ultimately
rewarding journey through treatment. The aim of treatment is for our clients to feel that
they can make genuine choices in their lives without their social anxiety dictating what
they can and cannot do. Both Jacquie and Max have aspirations for a relationship, career,
and family. The ultimate marker of treatment success is when clients believe that they
can pursue their aspirations and lead fulfilling lives. Unfortunately, many individuals
like Jacquie and Max suffer through every facet of life in silence, either indefinitely or
for many years before seeking help.
In the next chapter we review cognitive-­behavioral models that describe factors that
maintain SAD and therefore inform the treatment described in Part II of this book. It is
important for clinicians to have a working understanding of these models because they
provide an understanding of why SAD persists and underpin the treatment rationale.
 CHAPTER 2

Cognitive‑Behavioral Models
and Treatments for SAD

SAD has been treated using a diverse range of psychological models, although CBT
has the strongest evidence from both stringent randomized controlled trials in research
settings and effectiveness studies within real-world clinics. A range of CBT-based treat-
ments has been evaluated, including those that emphasize behavioral exposure, cogni-
tive change, social skills training, and a combination of these components. This chapter
begins with a brief review of two of the most inf luential cognitive-­behavioral models of
SAD and then review the key mechanisms from these models that will be targeted by
the treatment in Part II of this book. We then brief ly review evidence that cognitive-­
behavioral approaches are effective for many people with SAD, but also that a substan-
tial minority of clients are not sufficiently helped by existing treatments. Finally, we
describe the rationale for enhancing CBT for SAD using imagery-­based techniques.

Cognitive‑Behavioral Models of SAD

The classification of SAD as an anxiety disorder in the third edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association,
1980) prompted a rapid escalation of research in the area. As our understanding of
SAD improved, further refinements to diagnostic criteria and theoretical models fol-
lowed. Two inf luential cognitive-­behavioral models of the maintenance of SAD were
initially published by David Clark and Adrian Wells (1995) and Ron Rapee and Richard
Heimberg (1997). Rapee and Heimberg’s model has since been updated and elaborated
(Heimberg, Brozovich, & Rapee, 2010, 2014). Interested readers are referred to Wong,
16
 Cognitive‑Behavioral Models and Treatments for SAD 17

Gordon, and Heimberg (2014) for a description of additional models that have also
increased our understanding of SAD.

Clark and Wells (1995)
Clark and Wells’s (1995) cognitive model of SAD describes factors that serve to main-
tain and exacerbate social anxiety despite repeated exposure to social situations. The
model also describes processes that occur before and after social situations that reinforce
negative beliefs and, in turn, increase vulnerability to future social anxiety. Clark and
Wells (1995; Clark, 2001) argue that individuals with SAD develop assumptions about
themselves and their social world based on early life experiences. These assumptions are
divided into three categories: excessively high standards for social performance (e.g.,
“I must never show signs of anxiety and weakness”), conditional beliefs concerning
the consequences of performing in a certain way (e.g., “If I express my opinion, I’ll be
rejected”), and unconditional negative beliefs about the self (e.g., “I am unlikable”).
These assumptions cause the individual to anticipate social threat due to an expected
failure to meet social standards, and to misinterpret ambiguous social cues as being con-
sistent with their negative assumptions (e.g., smiles from other people are interpreted as
sympathy for anxiety or poor performance rather than genuine approval).
The model suggests that a range of processes prevent disconfirmation of these nega-
tive beliefs. One of these processes is self-­focused attention. The model suggests that
individuals with SAD closely scrutinize themselves within social contexts, including
their performance, anxiety levels, and physiological symptoms (Clark & Wells, 1995).
Information gathered from this self-­focused attention is then used to guide a self-image
of how the individual believes he is seen by others, that is, from the observer perspective.
Unfortunately, the individual’s preexisting negative assumptions in conjunction with his
anxiety symptoms conspire to negatively bias this self-image. The anxiety symptoms are
believed to be obvious to others and are therefore seen as evidence of failure to meet
social standards. Negative evaluation is expected to follow. In this way, emotional rea-
soning, where the individual believes that because he feels anxious his symptoms must
be obvious to others, along with a “felt sense” of performing poorly, reinforce the nega-
tive self-image and associated negative assumptions.
Another process in the model builds on earlier work by Paul Salkovskis (1991, 1996)
and suggests that individuals with SAD engage in a range of safety behaviors. Safety
behaviors are subtle avoidance behaviors that are used in an attempt to prevent fears
from coming true. However, although on some occasions safety behaviors may provide a
temporary sense of control over the perceived threat and thus a reduction in acute anxi-
ety, Clark and Wells (1995) suggest that they actually serve to maintain perceived social
threat and SAD in the longer term. One way safety behaviors maintain the perception
of social threat is by individuals attributing the nonoccurrence of social catastrophe to
the use of the safety behavior, rather than as evidence that the perceived probability or
cost of the threat needs to be modified. For example, if an individual with SAD does
not disclose any personal information during a conversation and there is no evidence of
18 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

rejection, she may attribute the absence of rejection to the fact that the other person had
no information that would have invariably led to rejection. Negative core beliefs such as
“I am unlikable” and “others are judgmental” are therefore maintained, when in fact if
the person took the risk of self-­d isclosing she might learn that she is far more likable and
others far more accepting than expected.
Another way safety behaviors can maintain SAD is by “contaminating” the social
situation, which then becomes a self-­fulfilling prophecy. Extending the previous social
interaction example, if the individual with SAD remains quiet and fails to reciprocate
during the discussion, her conversational partner might conclude that she is aloof or
disinterested and abruptly terminate the conversation. By using the safety behavior for
the purpose of preventing negative evaluation, the individual with SAD has unknow-
ingly elicited negative evaluation. Another example is if someone uses alcohol as a social
lubricant, which leads to obnoxious or otherwise inappropriate behavior and, in turn,
negative evaluation.
Safety “behaviors” can include cognitive attempts to prevent social failure, such as
rehearsing conversations or hesitating to speak one’s mind for so long that the topic has
moved on and the point is no longer relevant. These processes maintain a preoccupation
with potential social failure and threat and distract people from the task at hand (e.g.,
the actual topic of the conversation or noticing cues from the conversational partner
that can be used to naturally formulate responses). As a consequence of being “stuck
in one’s head,” the individual with SAD may appear uninterested or even arrogant. In
these ways, safety behaviors may be interpreted by others as a lack of social skills, when
in fact the anxiety and associated attempts to prevent feared outcomes inhibit the indi-
vidual’s natural social skills—­social skills that come to the fore when the person is not
anticipating negative evaluation (e.g., when in the psychologist’s office or with a trusted
loved one).
Excessive self-­focused attention means that people with SAD are unable to notice
when they receive positive or neutral feedback from others. On occasions when they are
able to “look outside of themselves” feedback from others is often filtered through their
negative core beliefs, and they scan for any confirmation of social inadequacy. Feed-
back that can be interpreted as evidence of social failure is more likely to be noticed, to
the exclusion of feedback that disconfirms this belief. An absence of positive feedback
will also be seen as confirmation of negative evaluation. In fact, it’s not uncommon for
people with SAD to interpret unambiguously positive feedback as evidence of social fail-
ure. For example, encouragement from a boss might be interpreted as evidence of a need
to improve work quality rather than as a reward for meeting standards. Recent theory
and research suggest that positive feedback can elicit a fear of evaluation for people with
SAD. Either way, these are striking examples of the power of underlying assumptions to
negatively inf luence the processing of ambiguous (and even unambiguous) social cues.
Clients with SAD will tell you that the suffering does not start and end with the
social situation itself. Social events may be anticipated hours, days, weeks, months or
even years ahead of time. One client dreaded giving a speech at his daughter’s wedding
well before she even had a partner, let alone a proposal! As clients with SAD envision
 Cognitive‑Behavioral Models and Treatments for SAD 19

an upcoming social situation, they imagine their social fears playing out (i.e., nega-
tive evaluation and rejection). This primes them to perceive a threat, and to become
physically aroused and self-­focused, even before the event has occurred. Clark and Wells
(1995; Clark, 2001) argue that this anticipatory process kick-­starts the in-­situation pro-
cessing biases described earlier. This anticipatory processing and anxiety can even result
in wholesale avoidance, which of course denies people any opportunity to disconfirm
their fears.
Biased anticipatory and in-­situation processing can also drive biased postevent pro-
cessing, whereby the individual scrutinizes his social performance in a negative way after
the social event (Clark & Wells, 1995). Because people with SAD preferentially attend to
any possible sign of negative social feedback within social situations, they are naturally
going to have a negative impression of the event afterwards. Attention is the “micro-
scope of the mind” and dictates what will be encoded in memory. In the case of SAD,
benign and positive feedback falls out of the microscope’s range, so it is ignored and
lost forever. The individual therefore leaves the social situation believing his social fears
have been confirmed, which further reinforces his negative core beliefs and assump-
tions. Each “social failure” is recalled within the context of a long history of perceived
failures, which then inf luences what is expected in future social situations, and so the
cycle continues.
In summary, Clark and Wells’s (1995) model emphasizes the importance of nega-
tive assumptions and core beliefs, negative automatic thoughts, attentional biases (self-
focus), negative self-­images from the “observer-­perspective,” avoidance, safety behav-
iors, and anticipatory and postevent processing. Interventions targeting these processes
have proven to be highly effective in treating social anxiety (Clark et al., 2003, 2006).

Rapee and Heimberg (1997)
Rapee and Heimberg (1997) suggest that individuals with SAD hold assumptions that
(1) others are generally critical and are likely to judge them negatively, and (2) there is
a high perceived cost to negative evaluation from others. Similar to Clark and Wells’s
(1995; Clark, 2001) model, Rapee and Heimberg also acknowledge that perceived social
threat can trigger anxiety regardless of whether the social situation is anticipated (antici-
patory processing), actually encountered in the present moment (in-­situation process-
ing), or retrospectively ref lected on (postevent processing).
Central to Rapee and Heimberg’s (1997) model is that people with SAD form a
mental representation of the self, creating a vivid impression of how others see them (i.e.,
the observer perspective). Critically, this mental representation is not based on objec-
tive feedback, but rather is internally constructed based on a combination of long-term
memory (e.g., photos of the self, previous experiences within social situations), internal
cues (e.g., physical symptoms such as blushing, self-­images), and observable feedback
from others. The model suggests that the person’s attention is focused primarily on nega-
tive aspects of this mental representation (e.g., signs of anxiety perceived to be obvious to
others, such as blushing or shaking) and on monitoring for external threat from others.
20 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

For people with SAD, monitoring of potential external threat involves scanning the
social environment for any sign of evaluation, such as frowns, yawns, or essentially any
ambiguous feedback that could possibly be consistent with negative evaluation (e.g., a
couple laughing in the opposite corner of the room). Dividing attention across sources of
internal and external threat, along with the task at hand, is cognitively demanding and
can interfere with social performance.
Rapee and Heimberg’s (1997) model proposes that the mental representation of
the self is compared to the audience’s perceived social standards, and people with SAD
believe they fall woefully short of the mark. The magnitude of this discrepancy will
determine the perceived likelihood of negative evaluation from others. The perceived
likelihood and “cost” (i.e., consequences) of negative evaluation together determine the
perceived severity of the social threat, which, in turn, maintains physiological, cognitive,
and behavioral symptoms. For instance, the more likely or costly an individual believes
rejection to be, blushing will intensify and, in turn, the individual assumes her anxiety
is even more obvious to others. The self-image therefore becomes even more distorted,
and the use of subtle avoidance behaviors to prevent evaluation (e.g., not contributing
to the conversation, averting eye gaze to the ground) reinforces beliefs of social incom-
petence. The discrepancy between the mental representation of the self and perceived
social standards widens, maintaining the cycle.
Heimberg and colleagues (2010, 2014) updated and extended Rapee and Heimberg’s
(1997) model in several ways, but most relevant here was a renewed focus on imagery as
a treatment target and mode of intervention. We return to this point in detail later in this
chapter. Wong, Moulds, and Rapee (2014) describe subtle differences between existing
models of SAD, but there are also substantial commonalities in the key maintaining fac-
tors across the models.

Key Cognitive‑Behavioral Maintaining Factors

Three key maintaining factors across these cognitive-­behavioral models relate to nega-
tive cognitive content (i.e., negative automatic thoughts, negative self-­images, and nega-
tive core beliefs), behavioral avoidance and safety behaviors, and attentional problems
(self- and environment-­focused attention). We summarize these processes brief ly to
highlight the importance of targeting them in treatment. Each of these processes is
shown in the client-­friendly model used to guide the treatment in Part II of this book
(see Chapter 3, Figure 3.1).

Negative Cognitive Content: Thoughts, Images, and Core Beliefs

Negative cognitive content is considered to be of central importance to SAD, including
negative automatic thoughts and images. Negative thoughts and images in SAD relate to
the probability and cost of past, present, or future social threats. Perceptions of threat
 Cognitive‑Behavioral Models and Treatments for SAD 21

stem from beliefs that one will fail to meet expected social standards due to some com-
bination of (1) personal inadequacy, (2) high external social standards, and (3) judg-
mental others. Moscovitch (2009) suggested that perceptions of personal inadequacy
could be due to individuals believing that they have poor social skills and behaviors,
visible signs of anxiety, problems in physical appearance, and/or a f lawed character
(i.e., personality). Extensions to Rapee and Heimberg’s (1997) model, based on evo-
lutionary models (Gilbert, 2001), also suggest that positive evaluation can be socially
threatening for individuals with SAD (Heimberg et al., 2014). Exposure of perceived
self-­deficiencies and potential negative evaluation, or of upward threats to the social
hierarchy in the case of positive evaluation (i.e., standing out for good reasons, possibly
resulting in peer jealousy), are expected to be both highly probable and highly costly
(e.g., lead to rejection).
Distorted mental self-­images regarding social performance are guided by perceived
past failures and are reinforced by vigilance toward symptoms of physiological arousal,
which the individual assumes are obvious to others. In anticipation of social situations,
negative thoughts and images can serve to prime self-­focused attention and anxiety.
After the social event, negative beliefs and images about the self and others are heavily
reinforced during the cognitive “postmortem” because in-­situation self-­processing was
so negatively biased. Negative automatic thoughts and images derive from negative core
beliefs about the self (e.g., “I’m socially inept and unlikable”) and others (e.g., “others are
judgmental and hostile”). Clearly it is critical for treatment to target negative thoughts
and images, self-­images, and core beliefs.

Behavioral Avoidance and Safety Behaviors

Behavioral avoidance is a critical maintaining factor of negative thoughts and imagery in
all models. Negative cognitions cannot be optimally activated, challenged, and modified
without exposure to the perceived threat. Early negative social experiences will con-
tinue to be highly inf luential in driving perceptions of social threat if new, more real-
istic, competing memories are not created. Safety behaviors are subtle forms of avoidance
that (1) prevent negative cognitions from being genuinely and comprehensively tested
and modified, (2) conceal perceived self-­deficiencies, which deprives the individual of
opportunities to learn that the probability or consequences of exposing these aspects
of the self are far less likely and/or catastrophic than expected, (3) lead individuals to
attribute the nonoccurrence of the perceived catastrophe to the use of the safety behav-
ior, thus undermining the perceived need to recalibrate probability and cost estimates,
(4) attract negative evaluation themselves, thus becoming self-­fulfilling prophecies, and
(5) reinforce self-­focused attention and self-­consciousness. People with SAD are usually
acutely aware that they are using safety behaviors, which thereby increases self-­focused
rather than task-­focused attention. If threat perceptions are to be therapeutically modi-
fied, it is therefore important that social fears are not avoided, but instead genuinely
confronted in the absence of safety behaviors.
22 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

Attentional Problems: Self‑ and Environment Focus
Anxiety is designed to narrow attention on threats and away from extraneous (nonthreat-
ening) stimuli, which is critical for survival in genuinely threatening situations. In the case
of SAD an important perceived threat is self-­deficiency. Inf lexible self-­focused attention
increases hypervigilance to signs of physiological arousal, which, in combination with
negative thoughts and images, escalates the perception of social threat. For example, an
individual with social anxiety who becomes aware of warmth in her cheeks may become
more focused on these sensations. As a consequence, in her mind’s eye she might envision
herself blushing bright neon red, which increases the perceived likelihood of humiliation
and rejection. With any remaining attentional capacity she will strategically scan the envi-
ronment for (often ambiguous) sources of external social threat (e.g., two people laughing
in the corner of the room), which may be personalized (e.g., “They are laughing at me”).
Self- and environment-­focused attention (rather than task-­focused attention) can
directly result in a failure to meet social standards. For instance, by not focusing on the
topic of a conversation, individuals with SAD may miss important social cues for them
to contribute. Social awkwardness may ensue, which, in turn, leads to the appearance of
a social skills deficit. Training clients to redeploy their attention onto functional aspects
of social situations is important to break down many of the vicious cycles maintaining
acute social anxiety and SAD.
Now that we have an understanding of the key factors that maintain SAD, below we
summarize outcomes from treatments that target these factors.

What Treatments Work?
CBT Is the Treatment of Choice for SAD
Meta-­analyses offer the highest level of evidence for the effectiveness of a particular treat-
ment because they combine outcomes from multiple trials. Several recent meta-­analyses
have compared active treatments to wait-list controls or alternative treatments. Acarturk,
Cuijpers, van Straten, and de Graaf (2009) conducted a meta-­analysis of psychological
interventions (mainly forms of CBT) for SAD based on 29 randomized controlled tri-
als (RCTs) (N participants = 1,628) and found large effect sizes on measures of social-­
evaluative cognitions, depression, and general anxiety (Cohen’s d’s = 0.70–0.80). Treat-
ment outcomes did not differ based on age group (university students vs. older adults), type
of SAD (specific vs. generalized), intervention format (individual vs. group), recruitment
source (community volunteers vs. clinical population), or type of psychological interven-
tions (with vs. without cognitive restructuring; with vs. without exposure; with vs. with-
out social skills training). Overall, the findings of this meta-­analysis revealed that CBT is
more effective than wait-list and placebo control groups, and that few client or treatment
factors moderate these outcomes. These findings are consistent with earlier meta-­analyses
that also failed to find significant differences between exposure-­based, cognitive-­therapy
 Cognitive‑Behavioral Models and Treatments for SAD 23

based, and combined exposure plus cognitive-­therapy treatments, or treatment format

(group vs. individual therapy; Powers, Sigmarsson, & Emmelkamp, 2008; although see
Aderka, 2009). Two RCTs that directly compared individual to group treatment found
an advantage of individual treatment (Mörtberg, Clark, Sundin, & Åberg Wistedt, 2007;
Stangier, Heidenreich, Peitz, Lauterbach, & Clark, 2003), but the group effect sizes in
these trials were substantially smaller than is commonly found for group CBT (Heimberg
et al., 1990; McEvoy, 2007; McEvoy, Nathan, Rapee, & Campbell, 2012; McEvoy et al.,
2015; Rapee, Gaston, & Abbott, 2009).
Canton, Scott, and Glue (2012) recently conducted a systematic literature review of
pharmacotherapies and psychotherapies for SAD. CBT was identified as the psychologi-
cal treatment of choice, with interpersonal psychotherapy or mindfulness-­based therapies
being potential alternatives for those who do not respond. Selective serotonin reuptake
inhibitors (SSRIs) and dual serotonin–­norepinephrine reuptake inhibitors (SNRIs) were
recommended as first-line pharmacotherapies based on their efficacy and tolerability.
The authors suggested that nonselective monoamine oxidase inhibitors (MAOIs) may
be more potent, but they should be restricted to those who fail to benefit from SSRIs
or SNRIs due to their side-­effect profile, including interactions with a range of foods.
Canton and colleagues (2012) reported that SSRIs and psychological treatments
appear to be equally effective, although there is some evidence that cognitive therapy
may be superior (Clark et al., 2003). Several studies have also demonstrated that cogni-
tive therapy is superior to medication in terms of long-term maintenance of gains (Haug
et al., 2003; Liebowitz et al., 1999). Studies comparing medication alone to combined
medication plus CBT have found nonsignificant trends favoring the combined treat-
ment, although one study of benzodiazepines found a significant advantage of the com-
bined treatment (Canton et al., 2012). Studies of psychological treatment compared to
combined medication plus psychological treatment have also reported nonsignificant
trends favoring the combined treatment, although some studies have found clear evi-
dence of superiority for combination treatments (see Blanco et al., 2010). Canton and
colleagues note that many studies used relatively small sample sizes and so may have been
underpowered to detect differences.
Mayo-­Wilson and colleagues (2014) conducted the largest and most recent network
meta-­analysis of psychological and pharmacological interventions for SAD in adults. This
study included 101 trials (N participants = 13,164) of 41 interventions or control condi-
tions. Psychological treatments found to be superior to wait-list control (in order of effect
size) were individual CBT, group CBT, exposure and social skills training, self-help with
support, self-help without support, and psychodynamic psychotherapy. Exercise promo-
tion and other psychological therapy (interpersonal psychotherapy, mindfulness training,
and supportive therapy) were not superior to wait-list controls. Combined psychological
and medication interventions were also superior to wait-list controls. Of the psycho-
logical treatments, only CBT based on Clark and Wells’s (1995) model, individual CBT,
and enhanced CBT (Rapee et al., 2009) had greater effects than psychological placebo.
Pharmacological treatments found to be superior to pill placebos include MAOIs, SSRIs
24 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

(except citalopram), and SNRIs. Mayo-­Wilson and colleagues reported that there was
no consistent evidence of differential efficacy within pharmacotherapies. The authors
concluded that due to lower risk of side effects, comparable efficacy, and superior longer-­
term outcomes, psychological interventions should be the first line treatment for SAD.
The consistent indication across systematic reviews, meta-­analyses, and the most
recent National Institute for Health and Care Excellence (NICE; 2013) guidelines is that
CBT is the most effective psychological treatment for SAD. Individual CBT consistently
outperforms a range of other treatments, and group CBT is also highly effective. A large
body of evidence also suggests that CBT is effective and cost-­effective when delivered
over the Internet (Andersson, Cuijpers, Carlbring, Riper, & Hedman, 2014; Andrews,
Cuijpers, Craske, McEvoy, & Titov, 2010; Arnberg, Linton, Hultcrantz, Heintz, & Jons-
son, 2014; Boettcher, Carlbring, Renneberg, & Berger, 2013), although there is some
evidence that Internet-­based treatments may be less effective at improving broader mea-
sures of quality of life (Hofmann, Wu, & Boettcher, 2014). SSRIs and SNRIs are the
pharmacological treatments of choice due to their combined effectiveness and side-­effect
profiles, with MAOIs being effective but more poorly tolerated.
The National Institute for Health and Care Excellence (NICE; 2013) guidelines
suggest that other psychological treatments should not be routinely offered as a first-line
treatment, and should only be offered if clients refuse or do not respond to CBT that is
designed for SAD. Although there is early evidence that acceptance and mindfulness-­
based approaches, interpersonal psychotherapy, and psychodynamic psychotherapies may
be helpful for SAD, meta-­analyses and treatment comparison studies consistently show
that CBT is either superior or that the alternative treatments are at best equally effec-
tive (e.g., Goldin et al., 2016). Research evaluating these alternative therapies also tends
to be limited by a range of methodological problems and potential biases, including
publication bias, uneven “doses” across comparison treatments, unclear descriptions of
treatments and clinician training, a lack of power analyses, the use of superiority rather
than noninferiority designs with appropriate equivalence analyses, and a lack of data on
adherence to and competence of treatment delivery, interrater reliability of diagnosis,
or credibility ratings (Norton, Abbott, Norberg, & Hunt, 2015; Öst, 2014; although
see Goldin et al., 2016, for a recent exception). Consistent with recommendations from
a number of professional bodies, CBT should be the first treatment offered to people
with SAD. If clients have a strong preference against CBT and their concerns cannot be
addressed, or they do not respond, they could be offered pharmacotherapy or an alterna-
tive psychological treatment including exposure and social skills, self-help, or short-term
psychodynamic psychotherapy specifically designed for SAD (Mayo-­Wilson et al., 2014;
National Institute for Health and Care Excellence, 2013).

Enhanced CBT Is Superior to Traditional CBT

Rapee and colleagues (2009) conducted an RCT comparing three group treatments:
traditional CBT, enhanced CBT, and stress management. Traditional CBT involved
 Cognitive‑Behavioral Models and Treatments for SAD 25

cognitive restructuring (e.g., thought challenging) and graded in vivo exposure based on
a habituation model (i.e., repeated exposure will reduce anxious responding). Cogni-
tive restructuring targeted negative automatic thoughts but not core beliefs. Enhanced
CBT targeted more of the key maintaining factors reviewed earlier in this chapter (i.e.,
negative cognitive content–­negative automatic thoughts, negative self-­images, and nega-
tive core beliefs; avoidance and safety behaviors; and self-­focused attention). Cognitive
restructuring and in vivo exposure were important components of the enhanced treat-
ment, but exposure was conducted as behavioral experiments with a cognitive ratio-
nale (hypothesis testing and evidence gathering) rather than a habituation rationale.
Enhanced CBT also included challenging of negative underlying core beliefs, in vivo
exercises aimed at eliminating safety behaviors, attention retraining, and video feedback.
The stress management treatment included general psychoeducation about the fight-or-­
f light response that was not specific to social threat, relaxation skills, problem solving,
time management, and healthy lifestyle habits.
Rapee and colleagues (2009) found that the enhanced and traditional treatments
were both more effective than stress management in terms of the proportion of cli-
ents meeting diagnostic criteria for SAD at posttreatment. Clinically significant change
indicates that an individual’s symptom severity falls within the normative (nonclinical)
range after treatment. On symptom measures, a significantly higher proportion of cli-
ents in the enhanced group (31–42%) achieved clinically significant change compared
to the traditional group (18–22%). The enhanced group also had superior outcomes on
a measure of clinician-­rated severity. Therefore, overall enhanced CBT was superior to
more traditional CBT, and the findings suggest that broadly targeting the key cognitive-­
behavioral maintaining factors improves outcomes.
Other studies evaluating individual CBT that incorporated imagery-­based strategies
have found that this treatment is also highly effective. Clark and colleagues’ (2003; see
also Clark et al., 2006) treatment included strategies to reduce reliance on safety behav-
iors and self-­focused attention, and to shift attention onto the social situation. Video
feedback, behavioral experiments, strategies for reducing anticipatory and postevent pro-
cessing, and restructuring of dysfunctional assumptions were also core components of
the intervention. Clark and colleagues (2003, 2006) found that their approach was asso-
ciated with very large effect sizes that are among the largest in the literature. The manual
on which these treatments are based remains unpublished, although the procedures have
been described (Clark, 2001; Wells, 1997, pp. 167–199).

But Enhanced CBT Is Still Not Good Enough

CBT currently has the strongest evidence for its efficacy, but many people continue to
suffer with symptoms after completing gold-­standard treatment (Mayo-­Wilson et al.,
2014; McEvoy et al., 2012). Although effect sizes are large, with symptoms reducing
by around one standard deviation or more on average, most effectiveness studies have
found that only a minority of clients’ symptoms fall within the normative range after
26 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

treatment (McEvoy et al., 2012; Rapee et al., 2009). Moreover, attrition rates of 25–35%
are not unusual (Hofmann & Suvak, 2006; Lincoln et al., 2005; McEvoy et al., 2012).
We decided to revisit theory and recent research on emotion and treatment innovations
in an attempt to improve treatment engagement and outcomes, which led us to inject a
more comprehensive dose of imagery-­based strategies throughout Rapee and colleagues’
(2009) enhanced CBT protocol. Before describing the imagery-­based enhancements in
Chapter 3, we first present the evidence that led us to believe that this could be a fruitful
avenue to pursue.

Imagery as an Important Treatment Target for SAD

A distorted mental representation of the self that is highly discrepant with perceived
external standards is central to Rapee and Heimberg’s (1997) conceptualization of SAD,
and thus is a key treatment target. More recently Heimberg and colleagues (2010, 2014)
extended Rapee and Heimberg’s model by considering the potent role that imagery
plays in maintaining negative affect more broadly. Heimberg and colleagues (2010) also
elaborated the contribution of negative self-­imagery to SAD in particular by reviewing
evidence that negative self-­imagery is common in SAD, ref lects recollections of past
social situations from the observer perspective, and adversely affects performance in
social situations.

Negative Self‑Imagery Is Common in SAD

Accumulating evidence strongly suggests that individuals with SAD experience more
negative images of past social situations than nonanxious or low-­social-­anxiety controls,
before, during, and after social situations (Hackmann, Clark, & McManus, 2000; Hack-
mann, Surawy, & Clark, 1998; Hinrichsen & Clark, 2003). Compared to controls, these
images are also more distorted in people with SAD, ref lecting negative self-­referential
themes and feared predictions of negative evaluation. Consistent with the cognitive
models reviewed earlier in this chapter, the images also tend to be from the observer
perspective (through the audience’s eyes) rather than the field perspective (looking out-
ward from one’s own eyes) for those with SAD (Hackmann et al., 1998; Wells, Clark,
& Ahmad, 1998), particularly for highly anxiety provoking situations (Coles, Turk,
Heimberg, & Fresco, 2001). Hackmann and colleagues (2000) found that 100% of a
SAD sample (N = 22) reported negative, multisensory social imagery within social situ-
ations, and the negative imagery tended to be associated with social traumas occurring
around the onset of the disorder (“ghosts from the past”; see Hackmann, Bennett-­Levy,
& Holmes, 2011, p. 133). Hackmann and colleagues further speculated that the imagery
may have therefore contributed to the development of the disorder, or at least to the
exacerbation of symptoms. This finding is consistent with Clark and Wells’s (1995) and
Rapee and Heimberg’s (1997) models, which suggest that current negative cognitions
are informed by past social experiences.
 Cognitive‑Behavioral Models and Treatments for SAD 27

Subsequent research has found that most individuals high in social anxiety report
negative social imagery (Chiupka, Moscovitch, & Bielak, 2012). Importantly, Mosco-
vitch, Gavric, Merrifield, Bielak, and Moscovitch (2011) found that although low socially
anxious individuals also reported negative imagery, high socially anxious individuals
retrieve a higher ratio of negative-­to-­positive images and less detailed positive images.
Moreover, high socially anxious individuals experienced stronger negative affect and less
positive affect when retrieving negative images, and both Moscovitch and colleagues
and Chiupka and colleagues (2012) found that images in high socially anxious individu-
als contained more negative self-­related themes and had a greater adverse inf luence on
beliefs about themselves, others, and the world. Chiupka and colleagues suggested that
the negative meanings high socially anxious individuals attach to their negative imagery
may distinguish high versus low socially anxious individuals, rather than the occur-
rence of negative imagery per se, which is common across the social anxiety spectrum.
Interestingly, while anticipatory processing prior to a social stressor task was associated
with more negative social images and associated negative affect, negative images during
postevent processing after a social situation resulted in more self-­criticism.

Negative Imagery Adversely Impacts Social Performance

Experimental research has demonstrated that negative self-­imagery is associated with
adverse cognitive, behavioral, and emotional sequelae in both clinical and nonclinical
samples. In socially anxious individuals, holding negative self-­images in mind (compared
to neutral images) is associated with more negative self-­evaluations of anxiety intensity
and performance, as well as poorer performance as rated by blind assessors (Hirsch,
Clark, Mathews, & Williams, 2003; Hirsch, Mathews, Clark, Williams, & Morrison,
2006; Hirsch, Meynen, & Clark, 2004; Makkar & Grisham, 2011). Makkar and Grisham
(2011) used a similar methodology by asking high and low socially anxious participants
to hold negative or control self-­images in mind during a brief speech task, but these
researchers investigated an even broader array of consequences. Participants instructed
to hold a negative self-image reported higher anxiety, more self-­focused attention, more
negative self-­cognitions, stronger beliefs that their anxiety was visible to others, more
negative appraisals of their performance, and more negative postevent processing, even
after controlling for depression. In a systematic review, Ng, Abbott, and Hunt (2014)
examined the role of self-­imagery in social anxiety and found large effects of negative
self-­imagery on anxiety, and on observer- and self-rated performance appraisals.
Heimberg and colleagues (2010) cautioned that the act of intentionally holding
negative images in mind places considerable cognitive demands on participants that
may adversely affect performance independent of the content of the images. Addition-
ally, intentionally holding negative images in mind may not ref lect the naturally intru-
sive images experienced by individuals with SAD. Notwithstanding these caveats, these
studies do demonstrate that negative images, compared to control or positive images,
have a greater impact on a range of factors theoretically implicated in the maintenance
of social anxiety.
28 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

Updates to the Role of Negative Self‑Imagery in SAD

Heimberg and colleagues’ (2010, 2014) updated model includes two key additions to
the original model that are relevant to imagery, specifically observation/image of self and
audience behavior and postevent processing. Negative self-­imagery is fundamental to the for-
mer and also features prominently in the latter. The updated model emphasizes the use
of this image of the self and the audience’s behavior as a comparator for the audience’s
expected standard. The more negative and distorted this image, the greater the perceived
discrepancy with the audience’s perceived standard and, in turn, the higher the perceived
probability and cost of evaluation from the audience. This recent addition to the model
suggests that strategies that can effectively correct distorted self-­images are likely to min-
imize the discrepancy with the expected standard and thus reduce the behavioral, physi-
cal, and cognitive symptoms of SAD. Heimberg and colleagues (2014) also reviewed
evidence that negative images from past social failures guide self-­images before, during,
and after current social situations, and that these past images are more likely to be framed
from the observer perspective over time (Coles et al., 2001; Vassilopoulos, 2005).

Positive Imagery Deficits in SAD

In addition to excessive negative imagery, socially anxious individuals also have a paucity of
positive and neutral self-­images (Amir, Najmi, & Morrison, 2012; Moscovitch et al., 2011).
Pictet (2014) reviewed evidence that in addition to targeting negative imagery, eliciting and
elaborating positive imagery can be beneficial in social anxiety. SAD is associated with both
high negative affectivity and low positive affect (Weeks, 2015), and people with SAD are
less likely than others to approach or interpret situations positively (Alden & Taylor, 2004;
Kashdan, 2007; Weeks & Heimberg, 2012). Imagining positive events occurring in the
future has been found to influence the perception that the positive events are likely to occur
in the future (Carroll, 1978), and to enhance motivation and goal-­oriented behavior (Libby,
Shaeffer, Eibach, & Slemmer, 2007; Pictet, Coughtrey, Mathews, & Holmes, 2011). These
findings have been found to apply to social anxiety in particular, with evidence that positive
imagery is associated with less anxiety and superior performance in speech tasks, compared
to when negative images are held in mind (e.g., Stopa, Brown, & Hirsch, 2012; Stopa &
Jenkins, 2007). In treatment, individuals with SAD may therefore benefit from both (1)
challenging negative images and (2) bolstering positive images.

Imagery as a Mode of Intervention in Emotional Disorders

Imagery as an Emotional Amplifier
In addition to negative imagery being critical in the maintenance of SAD in particular,
there is strong evidence that imagery is powerfully associated with emotion more gener-
ally. The neural pathways and physiological, behavioral, and conceptual responses acti-
vated by imagery are similar to those activated by in vivo exposure to threatening stimuli
 Cognitive‑Behavioral Models and Treatments for SAD 29

(Kosslyn, 1994; Lang, 1979). Consistent with this idea, Kosslyn, Ganis, and Thompson
(2001) suggested that “mental imagery occurs when perceptual information is accessed
from memory, giving rise to the experience of ‘seeing with the mind’s eye,’ ‘hearing
with the mind’s ear,’ and so on “(p. 635). Experimental studies that have manipulated
participants’ use of verbal thoughts and imagery have demonstrated that imagery elicits
more intense affective responding than verbal-­linguistic activity (Holmes & Mathews,
2010). These findings extend to both negative and positive stimuli, such that negative
imagery elicits more intense negative affect than negative verbal activity and positive
imagery elicits more intense positive affect than positive verbal activity (Holmes, Lang,
& Shah, 2009; Holmes & Mathews, 2005).
This phenomenon is easy to demonstrate. If you read the word “zombie” here, you
are unlikely to have a strong emotional response. Now just take a minute to bring to
mind vivid images of zombies and note any physiological, affective, behavioral, and
cognitive responses you have to the images. Likewise, the words “happy child” may be
pleasant, but simply reading them is unlikely to elicit a strong affective response. Again,
bringing to mind vivid images of smiling, giggling children is likely to elicit a stronger
affective response than simply reading the words, at least for people who are fond of chil-
dren! Images of one’s own happy child might elicit stronger positive affect than those of
an unfamiliar child. Images of personal faux pas recalled from the past or anticipated in
the future might elicit stronger negative affect than those of others. So regardless of the
valence (positive or negative), imagery is likely to elicit more intense affect than read-
ing the words. If imagery intensifies emotional responses, and our aim in therapy is to
modify affective responses to social cues (i.e., up-­regulating positive affect and down-­
regulating negative affect), then treatment strategies within the imagery mode are more
likely to produce larger and more robust affective change.

Potential Mechanisms of Affective Change in Imagery‑Based Interventions

Three potentially complementary psychological models could explain how imagery-­
based interventions are more effective than verbal-­linguistic strategies: avoidance the-
ory (Borkovec, Alcaine, & Behar, 2004), emotional processing theory (Foa & Kozak,
1986), and retrieval competition theory (Brewin, 2006). The avoidance theory of worry
(Borkovec et al., 2004) proposes that worry is primarily experienced as verbal-­linguistic
activity and is negatively reinforced by suppressing more intense physiological responses
associated with imagery-­based processing. In this way, worry functions as a cognitive
avoidance strategy that prevents full emotional processing of fear stimuli and thus serves
to maintain emotional disorder. Worry is one form of repetitive negative thinking that
shares many features of other forms, such as anticipatory and postevent processing in
SAD. Imagery-­based approaches encourage clients to directly process arousing negative
imagery, thereby circumventing verbal-­l inguistic suppression of physiological arousal. In
contrast, verbally based approaches allow clients to remain in the verbal-­l inguistic mode,
thereby potentially inhibiting full emotional processing of negative imagery and limit-
ing modification of the fear network (Foa, Huppert, & Cahill, 2006).
30 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

Foa and Kozak (1986) argue that the entire fear structure, which includes stimulus,
response, and meaning propositions, must be accessed for extinction to occur. The emo-
tional processing theory proposes two necessary conditions for extinction: (1) the fear struc-
ture must be activated and (2) information that is incompatible with elements of the fear
structure must be made available. Foa and Kozak argue that physiological arousal indicates
that the fear structure has been activated, and habituation to the feared stimulus indicates
emotional processing. Consistent with Borkovec and colleagues (2004), Foa and Kozak’s
model suggests that higher physiological arousal experienced during imagery-­based strate-
gies, compared to verbal strategies, creates the opportunity for more complete emotional
processing, which should result in superior outcomes. It has been suggested that imaginal
exposure may be even more effective than in vivo exposure at activating all aspects of the
fear network because it is impossible to create all feared situations, and many feared conse-
quences are rare (Beidel et al., 2014). In contrast, anything is possible within imagery. More
recent behavioral accounts argue that the discrepancy between expectancies and actual out-
comes (i.e., prediction errors) is most important for new learning (Craske, Treanor, Con-
way, Zbozinek, & Vervliet, 2014). The capacity for imagery to contain vivid and specific
expectancies across a range of contexts that are not limited by practicalities may mean that
the opportunities for prediction errors during exposure tasks are maximized.
Brewin’s (2006) retrieval competition theory argues that the purpose of therapy is to
“alter the relative accessibility of memory representations containing positive and nega-
tive information” (p. 773). These memory representations can include knowledge struc-
tures, sensory features (e.g., episodic memories, images), somatic and motor responses,
and verbal-­linguistic activity. Brewin argues that successful therapy helps individuals
to create new, more positive representations in memory that effectively compete with
original negative representations. Brewin’s model therefore predicts that superior inter-
ventions will activate positive memories with more potency and valence, which will
more effectively compete with and reduce access to older negative memories.
Clearly these theories are highly compatible. Imagery-­based interventions circum-
vent imagery suppression (Borkovec, 1994; Borkovec et al., 2004), which may facilitate
more intense arousal and greater activation of the fear network. This facilitates greater
potential for habituation (Foa & Kozak, 1986) and inhibitory learning via prediction
errors (Craske et al., 2014), which, in turn, allow for more potent and positive memory
representations to be newly consolidated (Brewin, 2006). A comprehensive review of
these models and the evidence for the proposed mechanisms is beyond the scope of this
chapter. Suffice to say that the superiority of imagery compared to verbal-­linguistic
activity in promoting affective change in psychotherapy is on very safe theoretical and
empirical ground.

Summary
Contemporary cognitive-­behavioral models suggest that negative thoughts and images
(before, during, and after social events), avoidance, safety behaviors, biased self-­images,
 Cognitive‑Behavioral Models and Treatments for SAD 31

self- and environment-­focused attention, and negative core beliefs are critical maintain-
ing factors for SAD. The treatment in Part II of this book is structured around these
factors. By targeting these factors, existing treatments have resulted in large effect sizes.
Evidence that negative imagery is a common and prominent maintaining factor in SAD,
and that imagery is more potent at eliciting affect than verbal-­l inguistic activity, encour-
aged us to incorporate imagery-­based strategies throughout the treatment outlined in
Part II of this book. The use of imagery in psychotherapy is not new (Edwards, 2007),
and previous SAD treatments have incorporated some imagery-­based strategies (Clark
et al., 2003; Rapee et al., 2009). Imagery was always intended to be an important part
of CBT (Beck, Rush, Shaw, & Emery, 1979), but until recently it was relatively absent
from standard CBT for most emotional disorders, including social anxiety. Typically,
verbal-­linguistic methods such as “thought” challenging have been emphasized in treat-
ment. While self-­imagery has been targeted in CBT for SAD (Clark et al., 2003; Har-
vey, Clark, Ehlers, & Rapee, 2000), previous treatments have not explicitly and com-
prehensively incorporated imagery-­based strategies into all of their components and thus
may not have fully exploited the particularly powerful relationship between imagery and
emotion, and its capacity to optimize affective change (McEvoy et al., 2015).
The treatment from which the imagery-­enhanced CBT protocol was developed
has been extensively evaluated and shown to be effective within research, community
clinic, and private practice settings (Gaston, Abbott, Rapee, & Neary, 2006; McEvoy
et al., 2012; Rapee et al., 2009). The strategies from this treatment are included in this
book, but these have been comprehensively enhanced with additional imagery-­based
components. The imagery-­enhanced protocol described in the book has been evaluated
in an initial pilot (McEvoy & Saulsman, 2014) and in a larger open trial (McEvoy et al.,
2015). In our open trial the outcomes compared extremely favorably to international
benchmarks, exceeding previous group treatments and being comparable to some of the
largest effect sizes for individual therapy in the literature.
In Chapter 3 we provide an overview of the imagery enhancements incorporated
into Part II of this book, along with some guidance on treatment structure.
 CHAPTER 3

Overview of
Imagery‑Enhanced CBT for SAD

In this chapter we first provide an overview of the model used to guide treatment in Part
II of this book, followed by a brief description of the strategies used to target each SAD
maintaining factor. We then provide some guidance to therapists about structuring and
delivering individual and group-based imagery-­enhanced CBT for SAD.

A Model of SAD and Treatment Targets

The theories reviewed in Chapter 2 converge on six key maintaining factors that need
to be targeted in treatment for SAD. These factors are prominent in the model we use
with clients to formulate their social anxiety and treatment plan (see Figure 3.1). The
shaded aspects of the model suggest that particular triggers (social situations) lead to a
perception of social threat, which, in turn, leads to the fear response (i.e., fight or f light).
The fight-or-­f light response includes all the physical symptoms of social anxiety such as
sweating, shaking, blushing, hyperventilation, dizziness, urge to escape, and so on. We
next review each factor that maintains the perception of social threat, moving clockwise
around the model, which ref lects the order of treatment. We also discuss the strategies
used to target each factor in imagery-­enhanced CBT, and ways in which imagery-­
enhanced CBT may be similar to and different from other approaches.

Negative Social Thoughts and Images

The first focus of SAD treatment is to identify and target negative social thoughts and
images that elicit and maintain a perception of social threat. It makes intuitive sense that
if people hold more neutral or positive thoughts and images regarding social situations,
then other maintaining factors within the SAD model will resolve (i.e., avoidance, safety
32
 Overview of Imagery‑Enhanced CBT for SAD 33

Avoidance
Negative
Triggers social Safety Fear
thoughts behaviors Response
and images

Perception of
Social Threat

Negative Image of
core how I
beliefs appear to
Self- and others
environment-
focused attention

FIGURE 3.1.  A client-­friendly model of SAD.

behaviors, negative self-image, and self-­focused attention). These additional maintain-

ing factors are essentially attempts to prevent negative social thoughts and images from
coming true. While the relationship between all these maintaining factors is reciprocal
(i.e., modifying avoidance, safety behaviors, negative self-image, and self-­focused atten-
tion can alter negative social thoughts and images), within these relationships cognition
still holds a central and causal role. The therapist first needs to be aware of the specific
details of the client’s perceived social threat, revealed by the negative social thoughts and
images, as this allows the function of the other maintaining factors to be better under-
stood, and hence targeted with maximum effect later in treatment.
The approach to targeting negative thoughts and images shares key features with
other treatments that focus predominantly on negative thoughts, including monitor-
ing and then challenging unhelpful cognitions. Our approach diverges from most other
treatments in its explicit focus on imagery-­based cognitions. Imagery-­enhanced CBT
describes an extensive rationale to clients for focusing on imagery rather than only nega-
tive thoughts (i.e., imagery increases specificity, elicits stronger emotions, and facilitates
behavioral experiments). Rather than using thought records to monitor and challenge
cognitive products, imagery-­enhanced CBT uses imagery records. Negative thoughts
about the probability and cost of social fears are still monitored and targeted, but from
the first session, clients are socialized to attend to naturally occurring negative images
and to transform thoughts into images.
Once clients are able to identify thoughts and imagery, the restructuring process
can begin. At this stage clients are prompted to identify negative images and, as in other
34 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

approaches, are then encouraged to identify contrary evidence and develop more realis-
tic estimates of the probability and cost of their social fears. Our approach extends other
approaches by then encouraging clients to summarize these alternative perspectives into
a more helpful or realistic image, and then spend time actively bringing the more help-
ful image to mind before rerating the strength of emotions. The addition of visualizing
more helpful imagery is designed to improve consolidation of the new learning and
increase its emotional impact.

Avoidance
While entertaining more helpful imagery when embarking on social situations may
ease anxiety to some extent, seeing is believing. Clients can sometimes intellectually agree
that the new image is more helpful and realistic, but emotionally they still feel anxious.
As long as clients avoid feared social situations, they will be unable to directly and con-
vincingly test their negative images, so avoidance is the next maintaining factor to be
targeted in treatment via behavioral experiments. Reversing avoidance by actively gath-
ering evidence experientially is often a powerful way to bring the intellect and feeling
into alignment.
Behavioral experiments offer a structured way of directly testing negative social
images in the real world to maximize learning, and they are the most important com-
ponent of SAD treatment. Behavioral experiments resemble in vivo exposure in most
respects, with both techniques challenging expectancies, and in practice it is virtually
impossible to isolate behavioral from cognitive change. Although behavioral experi-
ments are initially labor intensive, as clients fully embrace and internalize this process
they become less formal. The empiricism promoted by behavioral experiments becomes
the new philosophy by which clients approach social situations they are apprehensive
about—being curious about their anticipatory imagery, participating fully in the situ-
ation rather than avoiding, and then ref lecting on the difference between imagination
and reality.
Behavioral experiments will initially need to be meticulously planned and con-
ducted and comprehensively debriefed within the session. Imagery challenging can ini-
tially be used to prepare clients to engage in behavioral experiments that they find
particularly anxiety-­provoking, but as clients have more success imagery challenging
may not be required. Most aspects of behavioral experiments used in this treatment are
similar to other CBT interventions, with two key differences. First, clients are asked to
describe their predictions using imagery, again so that predictions are as rich in detail,
breadth, and specificity as possible. Second, clients are encouraged to consolidate their
learning and increase its emotional impact after the behavioral experiment by eliciting a
vivid new image of the scenario that incorporates the new evidence observed.
Imagery-­enhanced CBT includes coping imagery as an additional treatment strategy
to assist with engagement with behavioral experiments. The use of coping imagery can
be conceptualized as an imagery-­based form of anxiety surfing. Clients are encouraged
to create a metaphorical image that represents their anxiety for them (e.g., drowning
 Overview of Imagery‑Enhanced CBT for SAD 35

at sea) and then create a resolution to the problem within the imagery (e.g., envisaging
oneself as a powerful Olympic swimmer who is able to overcome the swell and swim
to shore with a renewed sense of strength and self-­efficacy). Clients are encouraged to
attend to the emotional valence (e.g., excited, determined), meanings (e.g., strength,
power, confidence, capacity to cope, hope), physical aspects (e.g., body language), and
somatic associations that accompany this new image and creatively elaborate the new
image to enhance consolidation (e.g., paintings, paired with music or within additional
imagery). This new image can then be used in the service of approaching (not avoiding)
social situations during behavioral experiments and in social contexts in general.

Safety Behaviors
Avoidance of social situations altogether is only one way clients try to prevent social
fears coming true. Not all social situations can be avoided, so clients develop an arsenal
of more subtle and creative avoidance behaviors that can be deployed in an attempt to
prevent feared outcomes. These are known as safety behaviors and can take many forms
(e.g., using alcohol before attending a social function, averting one’s gaze from others to
reduce social engagement, using heavy makeup to cover blushing). Regardless of their
form, safety behaviors share a common purpose—­an attempt to prevent social catastro-
phe. Unfortunately, these strategies actually maintain and exacerbate social anxiety, so
they need to be addressed.
The approach used in imagery-­enhanced CBT to challenge the helpfulness of safety
behaviors, thereby providing a rationale for abandoning them, is similar to that used
in other approaches. After you discuss the function and impacts of safety behaviors,
clients complete a behavioral experiment that manipulates the use of safety behaviors
by contrasting the impact of using versus abandoning them during a social interaction.
This experiment ideally assists clients to recognize the unhelpfulness and futility of
these strategies. In imagery-­enhanced CBT this experiment diverges slightly from other
approaches by encouraging clients to elicit in advance vivid images of how they expect
the interaction to play out. The aim of this extra step is to maximize prediction errors by
creating specific, broad, and vivid predictions that will maximize any discrepancy with
the actual outcomes. In addition, imaginal rehearsal of not using safety behaviors can
help clients to become more familiar and comfortable with this new way of interacting.

Image of How I Appear to Others

Negative self-­images are a key feature of SAD, with sufferers believing that the image
in their mind’s eye is an accurate representation of what observers are seeing. This
self-image is typically highly distorted, often with physical symptoms being far more
obvious than they are in reality, which dramatically escalates the perceived likelihood
of negative evaluation. As with other negative social images, behavioral experimen-
tation is required to test their accuracy. All contemporary evidence-­supported treat-
ments of SAD, including imagery-­enhanced CBT, target negative self-­images in similar
36 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

ways. Clients may design experiments where they request feedback from trusted family
members, colleagues, teachers, or friends, but the most powerful experiment involves
video feedback because it provides an opportunity for clients to directly test negative
self-­images themselves. When setting up video-­feedback experiments in other CBT
approaches, clients are usually asked how they think they appear to others, and particu-
larly what anxiety symptoms they think are most obvious. In imagery-­enhanced CBT,
clients are asked to elicit a vivid mental image of how they appear to others when they are
socially anxious. Features of this mental image are then directly compared to a video-­
recorded image of them completing an anxiety-­provoking social task, such as a speech
task or social interaction. Imagery-­enhanced CBT adds one final step to this process to
further consolidate learning, whereby the client is encouraged to elicit the new more
objective self-image within a variety of contexts to generalize learning beyond the single
behavioral experiment.

Attentional Problems: Self‑ and Environment Focus
An important source of threat in SAD is the self because people with SAD fear negative
evaluation from others if their anxiety symptoms or social incompetence is exposed.
As a consequence, people with SAD closely scrutinize their anxiety and behavior to
ensure that it is meeting others’ perceived standards. In addition to self-focus, people
with SAD scrutinize their environment for any sign of negative evaluation from others.
For example, while talking to a friend they might be scanning the room for any sign
that others are looking in their direction or laughing. The individual with SAD then
assumes the laughter is directed toward them, when in reality it is unrelated to their
social performance.
One consequence of this self- and environment-­focused (i.e., “off-task”) attention
is that normal behaviors and f luctuations in physical sensations are more likely to be
noticed, which then triggers a range of predictions about negative social consequences.
Individuals whose attention is off task are also less likely to detect and therefore respond
appropriately to social cues, which may then lead to underengagement in conversations
and the appearance of aloofness, which, in turn may increase the actual likelihood of
negative evaluation. It is therefore critical that people with SAD increase their awareness
of when their attention wanders off task (e.g., away from the content of the conversa-
tion), and then actively deploy their attention back onto the task at hand. Like other
treatments (Clark et al., 2003; Rapee et al., 2009), imagery-­enhanced CBT uses behav-
ioral experiments comparing self-­focused attention versus task-­focused attention during
a social interaction to demonstrate the impact of off-task attention on anxiety and social
performance. Imagery-­enhanced CBT diverges from other approaches by encouraging
clients to imagine themselves being task focused prior to completing the interaction.
The rationale for this step is to clarify exactly which elements of the social experience
they would be attending to if they were more task focused, and prime them to engage
in these behaviors during the task so they are less likely to revert to habitual self-focus.
 Overview of Imagery‑Enhanced CBT for SAD 37

Consistent with other treatments (e.g., Rapee et al., 2009), clients are taught
attention-­retraining and attention-­focusing tasks. These tasks are designed to increase
clients’ awareness of where they are deploying their attention, first in nonsocial and then
in social contexts, and to strengthen their ability to shift their attention onto the task
at hand. These strategies are described as approaches for strengthening the “attention
muscle,” which can then be used when needed in social situations to disengage from
unhelpful self-­focused attention.

Negative Core Beliefs
Negative core beliefs about the self, others, and the world guide the negative thoughts
and images people hold regarding socializing in the here and now. In the social anxiety
model used in this treatment, negative core beliefs occupy a bubble that may seem to be
on par with the other maintaining factors, but they can be conceptualized as an under-
lying factor that ultimately gives rise to the other maintaining factors. If someone has a
negative core belief about herself (e.g., as defective) and others (e.g., as judgmental), then
it makes sense that all the other maintaining factors addressed in the model will emerge
as a result of this core belief (i.e., negative social thoughts and images, avoidance, safety
behaviors, negative self-image, and self-­focused attention). These factors arise as a means
of warning and (ostensibly) protecting the client from the threat of negative social con-
sequences once her core “defectiveness” is exposed.
Negative core beliefs drive the various maintaining factors in the model, but the
relationship is reciprocal such that the other factors also reinforce core beliefs. For exam-
ple, if the client has very negative social thoughts and images of rejection in an anticipated
social situation because of his negative core beliefs, this generates the same felt experi-
ence as actual rejection, which serves to fuel his core beliefs. This cycle promotes avoid-
ance of the social situation, which deprives the client of the opportunity to have positive
or neutral experiences that would contradict his core beliefs. Therefore, core beliefs are
not modified and continue to drive the vicious cycle.
If the client does approach the social situation, but only while engaging in safety
behaviors, then positive or neutral experiences may be attributed to the safety behaviors,
again preventing core beliefs from being modified. While in the social situation, if the
client is experiencing very negative self-­images, this will be taken as confirmation of his
negative core beliefs regarding the self. Finally, if his attention is highly self-­focused dur-
ing the experience, then unpleasant feelings, sensations, and images will be encoded
at the expense of more benign aspects of the situation. Heightened anxiety and self-­
consciousness, which self-­focused attention promotes, provides a felt sense that his core
belief in his own “defectiveness” is accurate. In addition, when any remaining attentional
capacity is focused on perceived threats in the environment (e.g., two people sharing a joke
and laughing on the other side of a room), this leads to the interpretation of ambiguous
social cues in a negative manner (“They are laughing at me!”), providing further con-
firmation of the accuracy of the client’s negative core beliefs regarding others.
38 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

Unlike some negative thoughts or images, core beliefs cannot be tested and modi-
fied from a single behavioral experiment; instead they only begin to shift following
extensive experiential learning. Sufficient experiential learning can only be gained from
the accumulation of new positive or neutral social experiences, or by coping with nega-
tive social experiences. The cognitive, behavioral, and attentional changes promoted
by addressing the previous maintaining factors in the model are likely to be necessary
before clients with SAD are in a position to accumulate and process social experiences
in an adaptive way. For these reasons, core beliefs are usually explicitly targeted later in
treatment.
Consistent with other treatments (e.g., Rapee et al., 2009), imagery-­enhanced CBT
includes downward-­arrowing techniques for identifying core beliefs, and evidence gath-
ering for modifying core beliefs. In addition, imagery-­enhanced CBT incorporates two
imagery-­based strategies for directly modifying core beliefs. The first one is imagery
rescripting. Imagery rescripting has been used for a range of disorders and within indi-
vidual CBT for SAD (e.g., Clark et al., 2003), but we have also successfully used it
within our SAD groups. The rescripting approach used in this treatment is informed by
Arntz and Weertman’s (1999) and Wild and Clark’s (2011) imagery rescripting process.
In this approach, past traumatic events (i.e., memories) from which negative core beliefs
have developed are identified. Within imagery, clients then have the opportunity to
reexperience these past events from new perspectives, which can facilitate more func-
tional meanings to the events and hence undermine negative core beliefs.
The second imagery-­based strategy targeting negative core beliefs derives from
Padesky and Mooney’s (2005, cited in Hackmann et al., 2011) “Old System/New Sys-
tem” approach, which recruits positive imagery as a platform for constructing new more
helpful and positive core beliefs. These new positive core beliefs can then be strength-
ened through in vivo activities. This process is seen as a more helpful alternative to just
breaking down old negative core beliefs because it focuses the client on building a posi-
tive view by imagining how they would like to be in the world. Imagining this more adap-
tive way of operating, and then purposely acting in a manner that is consistent with this
positive image, can provide a path to building and strengthening new core beliefs over
time.

Treatment Structure
Individual Therapy
Individual therapy affords the f lexibility of targeting each component of the client’s idio-
syncratic case formulation. Clinicians are limited only by their creativity in designing
behavioral experiments that will provide opportunities to directly test negative thoughts
and imagery and maximize the “prediction errors” for each individual. The client and
therapist can ensure that time is efficiently and effectively spent working through each
 Overview of Imagery‑Enhanced CBT for SAD 39

component of the treatment, only moving on to each successive component when the
client has developed competence and confidence in applying the earlier principles. Indi-
vidual therapy also offers more f lexibility to repeat or complete additional behavioral
experiments within the same session or across sessions to consolidate learning.
In individual therapy, the therapist can titrate each component to the client’s needs,
and the number of sessions will vary depending on client severity, complexity, and
engagement. In our clinic we typically plan for 12–15 weekly, 50-minute sessions to
work through each of the modules in sufficient depth. Longer sessions can be sched-
uled (e.g., 90 minutes) if the therapist believes this is required to ensure enough time
to fully process and debrief from a strategy (e.g., imagery rescripting) or to complete an
extended behavioral experiment session. Although there is some f lexibility in treatment
length, imagery-­enhanced CBT was designed as an efficient and effective time-­limited
treatment, so we would rarely offer more than 15 sessions plus follow-­ups. However, if
clients are not engaging well with the treatment, or if they do not seem to be benefiting,
obstacles to change need to be addressed as soon as possible before proceeding.
As outlined in the treatment session guide in Table 3.1, we usually spend two to
three sessions socializing clients to the model and then introducing thought and imagery
monitoring and challenging. The module on avoidance, safety behaviors, and behav-
ioral experiments is the focus for the next three sessions. At least one of the behavioral
experiment sessions involves a series of in vivo experiments with the therapist out in

TABLE 3.1.  Individual Treatment Session Guide

Session Content Chapter
Sessions 1–3 Introduction to social anxiety, model, imagery monitoring 4 and 5
and challenging

Sessions 4 and 5 Avoidance and behavioral experiments, coping imagery, 6

hierarchies, safety behaviors

Session 6 Within-session behavioral experiments, review hierarchies 6

Session 7 Self-imagery: video feedback 7

Session 8 Attention retraining and focusing 8

Session 9 Within-session behavioral experiments (challenging cost 6

using shame attacking)

Session 10 Rescripting past imagery 9

Sessions 11 and 12 Positive imagery and action planning: constructing new 9

core beliefs

Session 13 Review and relapse prevention 10

Session 14 Follow-up: progress, dealing with setbacks, future imagery 10

Note. Session numbers can vary based on individual client needs.

40 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

the “real world.” Clients do need to be able to identify the content of their cognitions
with minimal prompting but do not need to be highly skilled at imagery challenging
before behavioral methods are introduced. Given that behavior change creates the best
opportunities for cognitive change, we don’t want to delay this by waiting for the cli-
ent to perfect imagery challenging. Imagery challenging will be a skill they continue to
develop over treatment. The skills covered in the first five or six sessions are reviewed
at the beginning of each therapy session thereafter, to ensure that the client continues to
regularly apply the principles.
One session is then dedicated to challenging negative self-­images via video feed-
back, followed by another session on introducing the concept of self-­focused attention
and practicing the skills of attention training and focusing. At this point, and before
targeting core beliefs, we often schedule another behavioral experiment session with
the therapist, but this time with a clear focus on more challenging “shame-­attacking”
exercises that are designed to evaluate the true cost of drawing attention to ourselves.
One or two sessions are dedicated to imagery rescripting, depending on the number of
images that require rescripting, followed by another two sessions on developing more
positive core beliefs.
It is important not to lose sight of the main aim, which is not to “cure” the client of
negative core beliefs. Instead, the aim is to ensure that clients are operating in the world
in such a way that they are continually undermining their old negative core beliefs about
themselves and others and strengthening their new balanced perspective. It is about plac-
ing them on the path to core belief adjustment over time.
A final relapse prevention session involves a review of all the treatment components
and of the client’s progress, as well as the development of a self-­management plan for
maintaining and building on progress made during treatment. Two or three monthly
follow-­up sessions might also be scheduled to check on progress and to ensure the client
maintains his momentum.
Therapy is completed when all treatment components have been covered and cli-
ents can independently engage in imagery challenging, behavioral experiments without
safety behaviors, and task-­focused attention in their daily lives. Once they are doing so,
their social anxiety should improve in a meaningful way, with some clients experiencing
modest improvements and others experiencing large and highly significant shifts. If they
have a clear plan for how they can continue to apply the strategies and deal with setbacks,
larger gains will be made as they spend more time in the social world.

Group Therapy
Group treatment offers less f lexibility than individual treatment but has other advantages.
Our clients often nominate meeting other people with SAD as one of the most helpful
aspects of the intervention. They find it tremendously destigmatizing and normalizing
to meet other people who genuinely understand what it is like to live with SAD. Group
treatments offer opportunities for vicarious learning, which can be particularly helpful
 Overview of Imagery‑Enhanced CBT for SAD 41

for clients who would otherwise be reluctant to take risks in therapy. On countless occa-
sions we have observed reticent group members “take the plunge” after observing the
success of other group members, which appears to have more impact than only learning
about the principles from therapists. Group CBT for SAD has also been found to be
highly effective in research trials. Our early outcomes using imagery-­enhanced group
CBT have been very promising, with effect sizes that are comparable to or exceed those
of other individual and group treatments in the literature.
Our group program consists of 12 weekly 2-hour sessions, plus a 1-month follow-
­up. A group treatment session overview, along with a detailed session outline, are pro-
vided in Tables 3.2 and 3.3, respectively. Groups are co-­facilitated by two clinicians,
usually one clinical psychologist and a trainee therapist. We have facilitated groups with
between 6 and 12 clients with success, although we find that around 8–10 clients is ideal
for balancing the need for sufficient time and attention for each individual while main-
taining a therapeutic group process. One or two clients may discontinue treatment with
the group, which can have a disproportionately negative inf luence on smaller groups.
We have also found that larger groups increase the likelihood of having at least a couple
of clients who are particularly eager to apply the treatment principles, which appears to
have a positive inf luence on the progress of the group as a whole (including the thera-
pists).

TABLE 3.2.  Group Treatment Session Overview

Session Content Chapter
Session 1 Introduction to social anxiety, model, imagery monitoring 4 and 5

Session 2 Imagery challenging 5

Session 3 Avoidance and behavioral experiments, coping imagery 6

Session 4 Avoidance and behavioral experiment hierarchies 6

Session 5 Safety behaviors 6

Session 6 Self-imagery: video feedback 7

Session 7 Within-session behavioral experiments, review hierarchies 6

Session 8 Attention retraining and focusing 8

Session 9 Rescripting past imagery 9

Session 10 Within-session behavioral experiments 6

Session 11 Positive imagery and action planning: constructing new core beliefs 9

Session 12 Review and relapse prevention 10

Session 13 Follow-up: progress, dealing with setbacks, future imagery 10

42 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

TABLE 3.3.  Detailed Group Session Plan

Session Content Handouts/worksheets Chapter
Session 1 Introduction to social anxiety, model, imagery monitoring What Is Social Anxiety 4 and 5
Content Disorder? (H1)
• Set agenda Recording Thoughts and
• Welcome, housekeeping, program overview, importance Images (H2)
of homework, change expectations, group structure and My Model of Social Anxiety
guidelines (20 min) (W1)
• What is social anxiety disorder and epidemiology? Personal Fear and Avoidance
(10 min) List (W2)
• Overview of treatment model (25 min) Looking Forward (W3)
• Break (5 min) Thought and Imagery Record
• Role of imagery in SAD (15 min) (W5)
• Psychoeducation: imagery rationale, SUDS (15 min)
• Thought and imagery monitoring (20 min)
• Three take-home messages (5 min)
• Homework and preview of next session (5 min)
Homework (provide sheet itemizing homework and new list of
accumulating skills each week)
• Set agenda
• Read handouts
• Complete My Model of Social Anxiety
• Complete fear and avoidance list
• Complete Looking Forward handout
• Thought and imagery recording

Session 2 Imagery challenging Challenging Negative 5

Content Thoughts and Images (H3)
• Set agenda Thought/Image–Feeling
• Homework review (30 min) Connection (W4)
• Thought/imagery–feeling connection (15 min) Imagery Challenging Record
• Imagery challenging (15 min) (W6)
• Break (5 min)
• Imagery-challenging practice: personal examples
(45 min)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read handouts
• Imagery challenging

Session 3 Avoidance and behavioral experiments; The Cycle of Avoidance and 6

coping (metaphorical) imagery Anxiety (H4)
Content Behavioral Experiments (H6)
• Set agenda Coping (Metaphorical)
• Homework review (20 min) Imagery (H9)
• Rationale for tackling avoidance (10 min) Imagery Challenging Record
• Behavioral experiments (30 min) (W6)
• Break (5 min) Behavioral Experiment Record
• Coping (metaphorical) imagery (45 minutes) (W7)
Coping Imagery (W10)
(continued)
 Overview of Imagery‑Enhanced CBT for SAD 43

TABLE 3.3. (continued)
Session Content Handouts/worksheets Chapter
Session 3 • Three take-home messages (5 min)
(continued) • Homework and preview (5 min)
Homework
• Read handouts
• Continue imagery challenging
• Start generating ideas for behavioral experiments
• Elaborate coping image and practice using it daily

Session 4 Avoidance and behavioral experiment hierarchies Behavioral Experiment 6

Content Hierarchies (H8)
• Set agenda Behavioral Experiment
• Homework review (15 min) Hierarchy (W9)
• Within-session behavioral experiment setup: walking in Behavioral Experiment Record
single file along street (15 min) (W7)
• Conduct behavioral experiment (20 min) Imagery Challenging Record
• Break (5 min) (W6)
• Complete Behavioral Experiment record (5 min)
• Debrief behavioral experiment (15 min)
• Start developing individualized hierarchies (35 min)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read handouts provided
• Plan two hierarchies
• Complete at least four behavioral experiments and records
• Continue practicing imagery challenging and coping
imagery

Session 5 Safety behaviors Safety Behaviors (H5) 6

Content Safety Behaviors Experiment
• Set agenda (W8)
• Homework review (20 min) Behavioral Experiment Record
• Safety behaviors: psychoeducation (15 min) (W7)
• Safety behaviors: imagery exercise (25 min) Imagery Challenging Record
• Break (5 min) (W6)
• Safety behaviors: experiment (35 min)
• Safety behaviors and hierarchies (10 min)
• Three take-home messages (5 min)
• Homework and preview (5 minutes)
Homework
• Read handouts
• Drop safety behaviors within social situations
• Complete behavioral experiments on hierarchy
• Continue imagery challenging
• Use coping imagery to prepare for behavioral
experiments
(continued)
44 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

TABLE 3.3. (continued)
Session Content Handouts/worksheets Chapter
Session 6 Self-imagery: Video feedback Self-Image: How I Really 7
Content Appear to Others (H10)
• Set agenda Speech Form (W11)
• Homework review (20 min) Speech Rating Form (W12)
• Self-imagery: how I appear to others (10 min) Behavioral Experiment Record
• Video speech task (30 min) (W7)
• Break (5 min) Imagery Challenging Record
• Watch recordings in session (45 min) (W6)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read handouts
• Watch speech another three times, then rerate
• Continue dropping safety behaviors and doing behavioral
experiments
• Continue image challenging and coping imagery

Session 7 Within-session behavioral experiments Behavioral Experiment Menu 6

Content (H7)
• Set agenda Behavioral Experiment Record
• Homework review (20 min) (W7)
• In-session group behavioral experiments—from menu Imagery Challenging Record
(45 min) (W6)
• Break (5 min)
• Review individual behavioral experiment hierarchies
(40 min)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read handouts
• Complete four planned behavioral experiments
• Continue image challenging and coping imagery

Session 8 Attention retraining and focusing Self-, Environment-, and Task- 8

Content Focused Attention (H11)
• Set agenda Attention Retraining and
• Homework review (20 min) Focusing (H12)
• Psychoeducation: role of attention (10 min) Self- versus Task-Focused
• Attention retraining (30 min) Attention Experiment
• Break (5 min) (W13)
• Attention focusing (30 min) Attention Retraining Record
• Behavioral experiment hierarchies (15 min) (W14)
• Three take-home messages (5 min) Task-Focused Attention
• Homework and preview (5 min) Exercise (W15)
Behavioral Experiment Record
Homework (W7)
• Read handouts Imagery Challenging Record
• Practice attention retraining multiple times daily and (W6)
monitor
• Practice attention focusing during social interactions
(continued)
 Overview of Imagery‑Enhanced CBT for SAD 45

TABLE 3.3. (continued)
Session Content Handouts/worksheets Chapter
Session 8 • Monitor one conversation during the week using task-
(continued) focused attention exercise worksheet
• Complete four planned behavioral experiments, including
attention focus.
• Continue previous skills as required.

Session 9 Rescripting past imagery Past Imagery Rescripting 9

Content (H13)
• Set agenda Past Imagery Rescripting
• Homework review (15 min) (W16)
• Imagery rescripting introduction and image identification Behavioral Experiment Record
(20 min) (W7)
• Identifying the perspective of the “older self ’ ” (10 min) Imagery Challenging Record
• Break (5 min) (W6)
• Past imagery rescripting (35 min)
• Debrief (25 min)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read handouts provided
• Work on behavioral experiment hierarchies
• Rescript past images and/or work with image from
today’s session
• Continue previous skills as required

Session 10 Within-session behavioral experiments Behavioral Experiment Menu 6

Content (H7)
• Set agenda Behavioral Experiment Record
• Homework review (30 min) (W7)
• Within-session individual behavioral experiments— Imagery Challenging Record
from menu (60 min) (W6)
• Debrief (20 min)
• Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Read session handouts
• Continue working on behavioral experiment hierarchies
• Continue using previous skills as required
• Arrange a meeting with other group members to do
between-session behavioral experiments

Session 11 Positive imagery and action planning: Constructing New Core 9

constructing new core beliefs Beliefs (H14)
Content Constructing New Core
• Set agenda Beliefs (W17)
• Homework review (25 min) New Core Belief Action Plan
• Positive imagery rationale (5 min) (W18)
• New core belief imagery (15 min)
• Break (5 min)
• Generalize impact of new core beliefs (45 min)
(continued)
46 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

TABLE 3.3. (continued)
Session Content Handouts/worksheets Chapter
Session 11 • Action plans (15 min)
(continued) • Three take-home messages (5 min)
• Homework and preview (5 min)
Homework
• Identify icon consistent with new system of core beliefs
• Start implementing action plans
• Continue working on behavioral experiment hierarchies
• Continue with previous skills

Session 12 Review and relapse prevention Skills Toolbox (H15) 10

Content Dealing with Setbacks (W20)
• Set agenda
• Homework review (30 min)
• Review treatment components (15 min)
• Relapse prevention and dealing with setbacks (20 min)
• Brief imagery exercise: looking forward (10 min)
• Take-home messages from the course, questions,
follow-up (10 min)
• Posttreatment questionnaires (35 min)
Homework
• Continue applying skills

Session 13: Progress review, dealing with setbacks, Your Progress (W19) 10
Follow-up future plans and imagery
Content
• Set agenda
• Welcome back (5 min)
• Your progress: review (30 min)
• Dealing with setbacks: review (20 min)
• Brief imagery exercise: looking forward (10 min)
• Final questions (10 min)
• Follow-up questionnaires (45 min)
• Close group

Who Is Qualified to Provide the Treatment?

The treatment protocol outlined in Part II should be delivered by therapists with super-
vised experience with CBT so that it is applied competently and with fidelity. Our ther-
apists are all registered or trainee clinical psychologists who receive regular and ongoing
supervision, but any appropriately trained and supervised mental health professional can
deliver the treatment. We would encourage therapists without a period of supervised
CBT practice to seek regular supervision from a CBT specialist, at least for the first few
times they deliver the intervention. It is also highly recommended that all outcomes be
evaluated using validated measures (see the “Measures to Aid Case Formulation and
Outcome Evaluation” section in Chapter 4). Clinicians should compare their outcomes
to those in the published literature to ensure their clients are benefiting to a similar
degree. If not, it is critical that they seek additional professional development.
 Overview of Imagery‑Enhanced CBT for SAD 47

Therapists who are highly socially anxious themselves and unwilling to challenge
social norms may not be well equipped to effectively treat individuals with SAD. It
is important that clinicians who themselves are overly fearful of negative evaluation
address their own social anxiety using many of the components outlined in this treat-
ment, either independently or with the assistance of a professional. Of course, many of
the behavioral experiments can be at least mildly embarrassing, even for the therapist,
but the therapist needs to be willing to model to the client that these emotions can be
genuinely experienced and tolerated without it being a social or personal catastrophe.
It is critical that therapist anxiety does not lead to avoidance of behavioral experiments,
particularly if this approach is novel. Sometimes therapists believe their job is to make
clients feel good, rather than help them become good at feeling. In fact our job as thera-
pists is to treat the long-term disorder, not the acute anxiety. Comfortable sessions are
usually wasted sessions that are ultimately unhelpful for our clients and are more about
meeting therapists’ needs. We discuss this issue in more detail in Chapter 6 because if
this is not addressed it is likely that therapist anxiety will compromise clients’ progress.

Who Can Benefit from the Treatment?

Few reliable predictors of treatment outcome have been identified, which may be disap-
pointing to therapists who wish to predict which clients are best suited to this approach.
Reviews of the empirical literature fail to identify replicated sociodemographic or clini-
cal predictors of poor treatment outcome. People whose SAD is more severe at the start
of treatment tend to remain most severely affected at the end of treatment, but they
appear to improve at the same rate as people with less severe cases. Age, chronicity, and
gender are poor predictors of outcome.
The good news from there being very few predictors of outcome is that all clients
with SAD have more or less the same chance of benefiting from treatment. As long as
the clinician closely monitors progress each session and responds to treatment obstacles,
then most clients will benefit, at least to some degree. Clients who do not benefit often
acknowledge that they are continuing to avoid social situations and are not applying
the treatment principles between sessions. If the case formulation and treatment plan is
developed collaboratively, many of these compliance problems can be preempted one
way or another. Clients who are unwilling to engage in the challenging tasks required
in imagery-­enhanced CBT will choose to not proceed past the assessment, although this
is rare in our clinic.
There is some evidence that comorbid depression can adversely impact outcomes,
but again this is inconsistent in the literature. Clients with severe depression would also
typically be referred for treatment for their depression first before determining whether
they have a separable SAD that warrants treatment. However, if the depression is clearly
temporally and functionally secondary to SAD, and the client has a preference for target-
ing her SAD, she may be treated for SAD first. We routinely exclude clients who have
a comorbid substance use disorder that is likely to interfere with engagement and prog-
ress. If substance use is clearly secondary to SAD and thus can be easily formulated as a
safety behavior, and the client is willing to reduce her use in general and abstain during
48 OVERVIEW OF SOCIAL ANXIETY AND ITS TREATMENT

treatment sessions and behavioral experiments, then she may not be excluded from treat-
ment. However, if her use is daily and involves a probable physical dependence, we
would refer her for individual treatment of her substance use first, or for an integrative
approach that simultaneously targets social anxiety and substance use.
When deciding which comorbid problem to address first in therapy, it can be use-
ful to assess the functional relationships between the comorbid conditions. A useful
question is “If I had a magic wand and could take away your problem (e.g., depression),
would you still be anxious in social situations?” This question can then be asked in the
opposite way to determine if the client believes the comorbid problem would continue if
her social anxiety was removed. If the client believes her social anxiety would disappear
if the comorbid problem was addressed, then the comorbid problem should be targeted
first. If she believes that her social anxiety would continue if comorbid problems disap-
peared, then it may be best to start treating her SAD (unless, as previously mentioned,
the comorbid disorder is more debilitating at the time of assessment). If the comorbid
problem does not resolve as expected after successful treatment for SAD, the remaining
issues are likely to need further intervention.
Client selection for group CBT requires careful consideration. Clients with atypical
presentations such as comorbid psychosis are routinely excluded from our groups. An
important consideration is that a SAD group should be normalizing, destigmatizing,
and validating for all participants. If a client’s experiences are substantially different from
those of other group members, this can have the opposite effect and interfere with group
cohesion and process. In a similar way, clients with crisis needs such as suicidal urges
or self-­harming behaviors can take a disproportionate amount of therapist time in the
group and would normally be better placed in individual treatment. If we are in doubt,
we would treat the client individually. More studies on the effectiveness of CBT for cli-
ents with comorbid substance use, bipolar disorder, and psychosis are required to guide
clinical decision making.

Summary
Imagery-­enhanced CBT for SAD targets similar maintaining factors to other evidence-­
based protocols (e.g., Clark et al., 2003; Rapee et al., 2009). The main point of depar-
ture is its emphasis on facilitating affective change by using the imagery mode across all
strategies. The treatment modules in Part II of this book are structured around social-
izing clients to the SAD model (Chapter 4) and then focusing practically on how to
address the key maintaining factors in the treatment model, which include negative
thoughts and imagery (Chapter 5), avoidance and safety behaviors (Chapter 6), negative
self-image (Chapter 7), self- and environment-­focused attention (Chapter 8), and nega-
tive core beliefs (Chapter 9). Finally we look at the process of completing treatment,
with a focus on the maintenance of gains and relapse prevention (Chapter 10).
 PA R T II

Treatment Modules
 CHAPTER 4

Socializing Clients
to the Treatment Model

Therapist: Hello, Jacquie, welcome back to the clinic. As we discussed at the end
of your assessment last week, the aim of today’s session is for us to start putting
together a picture of why your social anxiety continues to be a problem. By the
end of this session, I am hoping that we will have a shared understanding of
what keeps your social anxiety going and, most importantly, what can be done
to help you to manage it better and move forward in your life. How does that
sound?
Client: Great. But do you really think I can be helped?
Therapist: Actually, I am very hopeful that by the end of our sessions together you
will have a range of skills and strategies that will help to reduce the impact of
social anxiety on your life. This treatment has been shown to be effective for a
lot of people just like you.
Client: That’s great to hear and I really do want to change, but I think it is going
to be very difficult. I’ve just been this way for so long.
Therapist: It certainly sounds like you’ve really suffered with social anxiety for a
long time—it has dictated how you live your life, robbing you of the ability to
make genuine choices about what you would like to do. And I’m really sorry to
hear that it has been so difficult for you. The good news is that this treatment
has been shown to be helpful for people of all ages, regardless of how long they
have suffered with social anxiety. You are right to expect that it will be a chal-
lenging process. Using some of the strategies might initially be quite anxiety
provoking, but I will be here to support you throughout the process and it will
get easier with practice. How do you feel about committing to therapy knowing
that it is going to be challenging at times?
51
52 TREATMENT MODULES

Client: Well, I can’t lie. I am anxious about it, but things have to change. I just
can’t go on like this.
Therapist: It’s great to hear that you are ready to make changes, and I’m looking
forward to working with you on this. Although it is difficult, it is also tremen-
dously rewarding for people when they start the process of change. And I’ll be
interested to hear how you’re managing at every stage of the process, both when
things are going well and when you are struggling. In fact, I can be of most help
to you when you’re finding it hard. So I hope that you always feel that you can
be open with me throughout treatment because to make progress we need to
work together as a team. How does that sound?
Client: Scary, but I’ll give it a go.
Therapist: That’s a great answer because it acknowledges that you are committed
to the process of change even though you are aware that it will be difficult at
times. OK, so let’s talk about the factors that are maintaining your social anxi-
ety. Once we understand these factors, it should then be clear why the different
strategies you will be learning throughout treatment are going to be helpful to
you because the strategies are designed to target each factor. After all, if you’re
going to be pushing yourself to make changes, it is important that you believe
that your efforts will be worthwhile in the longer term.

About This Module: Beginning Treatment

The most important tasks when beginning treatment are to start building rapport and a
strong therapeutic alliance, to build cohesion if the program is being delivered in a group
format, to instill a strong sense of hope and optimism for change, and to socialize clients
to the maintenance model of SAD used to guide treatment. Once the client understands
how the model can help to explain what drives his social anxiety, the rationale for the
treatment components will become clear. No one would willingly engage in highly
distressing tasks in therapy without first being confident that it could be beneficial.
Every time we ask our clients to try something new we are asking them to tolerate
uncertainty about whether their fears will come true, which is a terrifying prospect for
them. This process takes considerable courage and perseverance. Having clients under-
stand the potential payoff, within the context of a supportive therapeutic relationship, is
therefore critical to engaging them in the process of change. Time spent collaboratively
developing a shared understanding of social anxiety and strategies for better managing
the problem is invaluable. This module outlines the process of introducing the treatment
approach and model to the client, individualizing the model to the client’s presentation,
and integrating all sources of available information to develop a case formulation that
will guide treatment. At the end of this process the client and therapist should have a
shared understanding of what maintains the client’s SAD and, most importantly, what
changes are needed for treatment to be successful.
 Socializing Clients to the Treatment Model 53

Setting the Scene
Building Rapport
It is critical that therapists are able to rapidly build rapport with clients with SAD. The
therapist may need to do most of the talking early in the first session until the client’s
anxiety starts to reduce. Some clients might speak openly from the beginning of the ses-
sion if they have been in therapy before, or if they believe they are unlikely to be nega-
tively evaluated (i.e., expect unconditional positive regard) by a trained therapist. Other
clients will be able to speak more freely as the session progresses, and for others it might
take a few sessions before their natural social skills are less inhibited by their anxiety.
If a client appears to find it difficult to interact with the therapist during the first
session, there are at least three strategies that could be used. The first option is for the
therapist to persevere in asking questions and receiving monosyllabic answers, but this
is likely to be inefficient and anxiety provoking for the client. The second option is for
the therapist to temporarily change topics and discuss more benign topics, such as the
client’s hobbies or personal information that is unrelated to social anxiety (e.g., who is
in her family, where she was born, travel experiences) until her anxiety subsides some-
what. The therapist will need to be cautious that this does not set a precedent for future
sessions, where the client and therapist retreat to “safe” topics to avoid discomfort. The
third option is to pay attention to the process in the room by opening up discussion of
how the client feels about speaking with the therapist. A sample dialogue might be:

Therapist: Tell me more about the sorts of social situations that you find anxiety
provoking?
Client: I’m not sure. (Looks at the floor.)
Therapist: I’m aware that speaking to me about social anxiety can be very dif-
ficult. I’m just wondering what’s going on for you right now?
Client: Yeah, it’s hard. It’s all just so stupid. It’s embarrassing.
Therapist: I’m really sorry that you’re feeling uncomfortable right now. It makes
sense that it would feel awkward to talk about private experiences that you’ve
been working so hard to hide for so long. I suspect that a lot of the people I
see for the first time feel the same way. And they are probably worried that I
will judge them if they are open with me about their thoughts and feelings. I’m
wondering if this is the case for you?
Client: Yes. I know you’re a professional and you’re not supposed to judge people,
but I still feel embarrassed.
Therapist: I think it is very common to feel embarrassed and reluctant to disclose
personal information the first time you meet someone. I want you to know that
I have seen many people with social anxiety and I understand how difficult this
process can be. My hope is that you will never feel judged by me during our
54 TREATMENT MODULES

time together, but if you do then please let me know so that we can talk about
it. You are also welcome to let me know if you would prefer to not answer a
question, or if we need to slow down a bit. If it’s OK with you, I might just
check in now and then about how we are doing together—­how you are feeling
in the room with me—­because it is important to me that you always feel we are
working together on the same team. Would that be OK?
Client: Yeah, that’s OK. I’m starting to feel a bit more comfortable now.
Therapist: That’s great to hear. How would you feel about describing some of the
social situations that you find most challenging? Feel free to go into as much or
little detail as you like . . .

If highly anxious clients continue to find it difficult to describe their social anxiety,
at this point the therapist might decide to ask them about topics they are more able to
speak freely about, such as work or school, hobbies, pets, or family members. Once the
client’s anxiety diminishes and rapport has been strengthened, the therapist can venture
back to the topic of social anxiety.
Clients with SAD have overcome numerous hurdles just to arrive at the therapist’s
office. They first needed to identify that they have a significant problem in their lives.
This is not an easy task. Many people do not know they are suffering from a diagnos-
able disorder and that effective treatments are available. Clients may have endured years
of anxiety and shame before garnering the courage to admit this to themselves and then
disclose the problem.
As a first step toward building rapport, it is important to validate how difficult it is
for clients to have made the decision to attend the appointment. Many clients with SAD
are not entirely sure that they will attend until the moment they are called from the
waiting room, and they may have endured many sleepless nights as the first appointment
approaches. Therapists do well by their clients by first acknowledging the important first
step toward change they have made simply by attending the appointment. It is often
fruitful to ask clients what led to their decision to attend therapy for SAD at this time,
as these reasons may need to be revisited at length when treatment becomes particularly
challenging.

The Client Is Not Alone

By its very nature SAD is an often lonely disorder that is rarely openly discussed. Our
clients generally have never knowingly met another person with SAD so that experi-
ences could be shared, validated, and to some extent normalized. Unsurprisingly, our
clients don’t go to parties and introduce themselves as someone with SAD, so they have
no opportunities to discover just how common it is! An important maintaining fac-
tor that needs to be counteracted is self-­stigmatization, where people with SAD judge
themselves as being weak, different, inadequate, and unacceptable for experiencing
social anxiety. These negative self-­judgments are often assumed to be shared by others.
 Socializing Clients to the Treatment Model 55

It is important that the clinician share how common SAD is in the general commu-
nity so clients appreciate that they are not alone. Clinicians should also describe some of
their experiences of working with social anxiety, so the client is confident that the clini-
cian is genuinely aware of his plight and has expertise in effective treatment approaches.
Ensuring clients understand that SAD is one of the most common anxiety disorders and
that it affects millions of people can be very helpful. It is useful for therapists to know the
approximate rates of SAD in their own country based on relevant population surveys.

There Is Hope
It is also a sad fact that many people suffering from SAD do not seek treatment, and few
of those who seek treatment receive an empirically supported intervention. It is impor-
tant to engender a strong sense of hope by describing outcomes from treatment trials of
CBT for SAD and even giving some clients references if they want them. Fortunately
the strong evidence that CBT is efficacious in research settings and effective in “real-
world” settings gives us reason to be optimistic with our clients about the prospect of
a good outcome. It is important that we are generous with this optimism. Part of this
discussion may include dispelling any myths about potential obstacles to change, such
as age, duration of anxiety, or comorbidities. All clients have the potential to do well if
they are willing to take some risks during treatment and regularly apply the treatment
strategies.

Expectations of CBT and Change

It may be helpful to discuss clients’ expectations of the program. Some clients may have
completed treatment before, in which case it is especially important to elicit their expec-
tations from them. Clients may have had good experiences before and want more of the
same, or may have had bad experiences and want something different. Identifying what
the client sees as the positives and the negatives from her prior therapy experience will
be very useful to help adjust current expectations. You can emphasize the similarities of
what you are about to do to her prior positive experiences and emphasize how different
this will be from her negative experiences. Overall, it is important the client understand
that this program is about learning skills for better managing social anxiety. In other
words, it is commonsense and practical, and requires active engagement. The program
is not about just talking about the problem or focusing only on the past, but rather it
is about focusing on what is maintaining the problem in the present, and regularly and
repeatedly doing things differently in day-to-day life.
It is often helpful to ask clients how they see the change process playing out—that is,
assessing their theory of change. The following questions can be informative:

• “What do you think will help you to improve your social anxiety and achieve
your goals?”
• “What do you think needs to change before you are likely to feel less anxious?”
56 TREATMENT MODULES

• “Do you expect your anxious feelings to change before you are able to approach
social situations, or do you think you will need to change what you do before you
can build confidence and manage your anxiety better?”
• “Do you expect improvement to occur smoothly, or do you expect it to be a bit
up and down?”
• “If you are finding an aspect of treatment challenging, how do you think we
could manage that together so that you continue to move forward?”

CBT is unlikely to be helpful for clients who wish to just talk about their problems
without engaging in active behavior change, or for clients who believe they need to
feel no anxiety before behavior change can begin. It is critical that therapists collabora-
tively develop an active theory of change with their clients. The questions listed above
are designed to get the client talking about what he believes he needs to do to progress
in therapy and manage difficulties. This approach will assist the client rather than the
therapist to take ownership of the process of change. We are often candid with our cli-
ents, letting them know that we wish we had a “magic wand” that could take their social
anxiety away, but realistically the only way we know how to effectively change their
social anxiety is by supporting them in making gradual behavioral changes.
The process of change is likely to be rocky, with periods of progress followed by
plateaus or even setbacks. Setbacks can be discouraging for clients, so it is useful to
challenge any unrealistic expectations. The therapist and client can formulate a plan for
managing setbacks so that the client returns to a positive trajectory as soon as possible.
This plan can involve recognizing that setbacks are a normal part of the change pro-
cess, experiencing a setback can help the therapist and client learn more about potential
obstacles to change or triggers for lapses, and working through the setback can help
to build clients’ confidence in their ability to recover from one in the future. Relapse
is common in emotional disorders, and it is just as important to learn how to recover
from a setback as it is to experience an initial reduction in symptoms. Opportunities to
overcome setbacks during therapy should be framed as a positive therapeutic experience
that builds resilience. Once clients appreciate that the goal of therapy is not to remove
all social anxiety, but instead to learn to manage their anxiety, distress, and uncertainty
with more confidence, they may be able to better appreciate that learning to recover
from setbacks is an integral part of becoming and staying well.

CBT Is Collaborative
It is critical that clients are on board with the collaborative nature of treatment. Clients
are experts in themselves and their lives, and therapists are impotent without mining
the riches of this expertise. Therapists bring to the table their knowledge of factors that
maintain SAD and treatment strategies that have shown to be effective. Clients need to
appreciate that both the client and therapist need to be active participants in treatment
to maximize the chances of success. Therapists should normalize that treatment can
be challenging and there may be times when the client is unsure whether he wishes to
 Socializing Clients to the Treatment Model 57

continue. The therapist needs to acknowledge that halting therapy is an option always
available to clients, but it is important to emphasize that challenging times are precisely
when it is most important to keep the communication channels open. The therapist
needs to engender a strong sense of trust that he will be nonjudgmental if the client
expresses any concerns, doubts, or reluctance to engage in any aspect of treatment. The
client needs to take on the responsibility of discussing any issues with the therapist so that
they can be resolved, or treatment deferred if necessary. Maintaining a strong therapeu-
tic alliance needs to be the priority at all times.

The Socratic Method
The Socratic method, which is critical to the collaborative approach of CBT, has been
defined as “a method of guided discovery in which the therapist asks a series of carefully
sequenced questions to help define problems, assist in the identification of thoughts and
beliefs, examine the meaning of events, or assess the ramifications of particular thoughts
or behaviors” (Beck & Dozois, 2011, p. 401). The idea is that guiding the client’s dis-
covery through ref lective questioning will be more productive than simply telling the
client what to do and how to do it. If a client is guided by the therapist to articulate a
narrative of how his thoughts, emotions, physical sensations, and behaviors interact to
maintain his problem, and then to reexamine his assumptions, this will result in more
genuine and enduring change than the therapist attempting to provide the client with
all the answers. Clients are experts in their own experience, and therapists may not
truly understand how the client sees the world if they make assumptions, and therefore
treatment may not be optimally targeted to the client’s personal experience. The client
is also likely to have more “buy-in” to the treatment if she is articulating the principles
of change herself, rather than being told by a therapist. An overarching aim of CBT is
to develop the client’s self-­efficacy—­confidence in her own ability to manage her prob-
lems. The Socratic method helps clients to achieve this by teaching them how to think
more helpfully, not what to think.
Often the most challenging aspect of the Socratic method for new therapists is that
it is more time-­consuming than more didactic methods. At times therapists may feel
that they need to “give the client something” or that they could speed things up and
get to the crux of the matter by being more directive. There are certainly times when
a more direct approach may be necessary (e.g., when clients are at high risk of harming
themselves), but generally speaking therapeutic time is well spent by asking questions
that will help clients to consider information that might be outside their awareness so
that they can reach new perspectives (Beck et al., 1979; Clark & Egan, 2015; Kennerley,
2007). Christine Padesky (1993) suggests that the Socratic method helps clients consider
all relevant information and explore alternative explanations in an open, curious, and
empathic manner. Synthesizing questions can then be asked to encourage the client to
consider whether this new information offers any fresh perspectives compared to their
initial beliefs (e.g., “It’s interesting that when I asked the last time you were overtly criti-
cized it was hard for you to think of a specific example. What might this tell us about
58 TREATMENT MODULES

the thought that ‘people always think I’m stupid’?”). The Socratic method is invaluable
for preventing the therapist and client from reaching an impasse that could derail the
therapeutic alliance.
In all of the sample dialogues and questions in this book the therapist adopts the
Socratic method. You will notice that the therapist takes a curious, agnostic stance when
gently probing clients about their experience. The therapist does not presume that the
client’s perspective is wrong or misguided, but rather expresses genuine interest in the
client’s worldview with questions that encourage him to ref lect on his own experience
in a way that may generate new perspectives.

The Importance of Homework

Homework is not an optional extra in CBT, but is the most important ingredient. It is
vital to emphasize this with clients before commencing treatment. Clients have com-
menced treatment because they want to better manage their anxiety in their lives, not
within the four walls of the therapist’s office. It is therefore critical that skills practiced
in session are applied between sessions. There is a considerable body of evidence that
both quantity and quality of homework are associated with better outcomes, and it is
important that clients are aware of this before they begin. To clarify any misconceptions
about the critical role homework plays in achieving a positive treatment outcome, we
will often say to clients something like:

“Clients often think that coming to these appointments is the ‘therapy.’ I don’t see
these appointments as the therapy. These appointments are just preparation for the
real therapy, which takes place when you apply the strategies we will be learning in
your day-to-day life. Initially these strategies will need to be set as formal home-
work to maximize their effectiveness. However, at some point the strategies will no
longer seem like homework, as they will just become the new way you are living
your life.”

Session Structure
The clinician should set an agenda at the start of each session so that the client knows
what to expect. If the client and therapist collaboratively set homework during the previ-
ous session this should always be reviewed at the beginning of the next session. As clients
learn to expect that their homework will always be reviewed, they will understand how
valuable it is. If the clinician sets homework and fails to review it in the next session, the
client will learn that it is unimportant, and noncompliance will likely follow. Once the
agenda is set and homework is reviewed, new content is introduced and practiced before
new homework consistent with the content is collaboratively set for the coming week.
We routinely ask clients to ref lect on three take-home messages at the end of the ses-
sion to ensure a shared understanding of the key learning points of the session, to clarify
any misunderstandings, and to consolidate learning. Much can happen in a session, and
 Socializing Clients to the Treatment Model 59

it is important that clients have some clarity regarding what has been meaningful and
helpful to them. It is good practice always to ask clients how they feel the session went
and whether they felt understood by the therapist. The client will learn that the therapist
genuinely values the therapeutic relationship by taking the time to check in and ensure
that the alliance remains strong. Remember that many clients with SAD will be worried
about upsetting you and will not want you to think badly of them, so they may heav-
ily edit their feedback. Look out for feedback that doesn’t match their affect and gently
allow them every opportunity to provide honest and open discussion.

Psychoeducation about SAD
It is often informative for the therapist to begin by asking clients what they understand
about the main features of SAD. To start disentangling the different aspects of the cli-
ent’s experience, it can be helpful to frame this discussion around five columns headed
with “common triggers,” “thoughts/images,” “behaviors,” “body,” and “feelings” on a
whiteboard or sheet of paper. The clinician can then start to elicit common triggers for
the client’s social anxiety, cognitive themes, idiosyncratic safety behaviors and avoided
situations, physical sensations, and emotional responses. To encourage engagement in
the process, the client should be encouraged to write down her experiences in the col-
umns as they are discussed, rather than the therapist taking charge of this process. The
assessment of these aspects of the client’s experience does not need to be exhaustive at
this stage, and only a few examples in each column should be sufficient. More details
will be elicited in each of these areas across the treatment. Some examples of Socratic
questions to facilitate this process include:

• “What sorts of social situations do you find yourself feeling particularly anxious
in?” [common triggers]
• “When you are expecting a situation like this, what do you imagine happening?
When you’ve been in these situations in the past, what have you worried will
occur, or what do you remember occurring? After social situations, what thoughts
or images go through your mind about the situation?” [thoughts/images]
• “If you can’t avoid a social situation, what do you do to try and prevent your social
fears from coming true?” [safety and avoidant behaviors]
• “When you are in social situations, what feelings in your body are you most aware
of?” [bodily sensations] And how do you feel emotionally? [feelings]

It can be helpful to spend a few minutes eliciting any feedback loops the client might
notice between the thoughts/images, behaviors, and bodily sensations and feelings they
experience. For example, the therapist might ask something like:

“I’m just curious. When you have that thought or image about what might happen,
are you more or less likely to go to the party? And if you don’t go to the party, what
60 TREATMENT MODULES

impact do you find that has on the strength of the thoughts/images over time? Does
it strengthen them or weaken them? And if your belief that [something bad] will
happen strengthens over time, what impact do you find this has on your anxiety?
The more anxious you feel, what then happens to the sensations you experience in
your body?”

You will notice that the therapist is taking a curious approach to encourage the client to
really explore the links among his thoughts, behaviors, feelings, and physical symptoms.
The therapist’s aim at this point is just to start drawing the client’s attention to how his
responses to the thoughts and images might serve to maintain or exacerbate the thoughts
and images and hence his social anxiety over time.
Many clients with SAD see their fear of evaluation as a weakness and generally as
a negative trait that needs to be expunged from their personality. They are less aware
of the positive qualities that often accompany a fear of negative evaluation, including
empathy, caring, and sensitivity to others’ needs, which are all attractive qualities that
can facilitate relationships. It can therefore be helpful to discuss social anxiety and the
underlying fear of evaluation as a continuum. Each of us can be placed anywhere along
the continuum, from very low to very high. People who care little about being evalu-
ated by others are at one end, those who care about being evaluated to some degree may
be somewhere in the middle, and those who care too much may be at the upper end of
the continuum.
We often find it useful to elicit from the client any negative characteristics she asso-
ciates with people who have an extremely low fear of evaluation. Some clients might
say that such people are “happy” or “relaxed,” but after asking them to ref lect on people
they know who really don’t care at all about what others think, most clients are able to
identify negative characteristics (e.g., unempathic, selfish, arrogant, domineering). Ask-
ing clients how helpful these traits are for fostering quality relationships can often lead
them to reconsider seeking to “not care at all” about what others think of them. We then
ask clients to identify any positive characteristics of people who care a lot about being
evaluated by others, and they start to appreciate that they might like to retain some of
their positive qualities, such as empathy, caring, and a desire to form close relationships
with others.
This exercise can be extremely helpful for destigmatizing social anxiety and to
emphasize the fact that the aim of the treatment is to reduce the degree to which clients
care about evaluation (i.e., shift down the continuum a bit), so that their lives are not
dictated by social anxiety. The goal is not to change their personality so that they are
the most gregarious person at parties, or so that they are aggressive and always must have
their own way, but rather to learn skills so that their social anxiousness does not interfere
with their life. This can be a relief to some clients, who fear that the treatment might
turn them into the sort of person they currently find intimidating.
The next task when beginning treatment is to socialize clients to the treatment
model. Handout 1, What Is Social Anxiety Disorder?, contains useful psychoeducation for
 Socializing Clients to the Treatment Model 61

clients about social anxiety and the model used to guide this treatment. Below we pro-
vide examples of how each specific component of the treatment model can be described
to clients. It is useful to have a copy of the model (Worksheet 1, My Model of Social Anxi-
ety; see the Appendix) in front of the client as each component is described. Although a
sample script is provided below, it is important for the therapist to regularly check that
the client understands each component and encourages discussion of relevant personal
examples.

The Treatment Model
“This model provides an explanation for what maintains SAD, and is used to guide
treatment. The shaded area on the left includes all the situations that trigger anxiety.
A shaded arrow then leads to the ‘perception of social threat.’ This perception of
social threat then activates the fear, or fight-or-­f light, response.”

Triggers
“We have already discussed several triggers earlier in the session. These included par-
ties, interviews, eating or drinking in front of people, using public toilets, or just
being observed by others. Are there any others you would add? For most people
with SAD these triggers are virtually impossible to avoid completely—­there are
people everywhere! And usually when we try to avoid people it can affect our over-
all quality of life.”

Perception of Social Threat
“When we encounter a trigger there is an automatic perception of threat—­we think
that (a) something bad is likely to happen and (b) it will be catastrophic when it
does. We can consider the probability and cost of being evaluated by others as being
separate but related beliefs. I might believe that it is highly likely that I will be nega-
tively evaluated by someone, but if I don’t think it matters very much (low cost), I’m
unlikely to feel particularly anxious about it. If I believe it is unlikely that I will be
evaluated, but it would be devastating if I were, then I might start feeling anxious
in social situations because I believe that a catastrophe is possible. If I believe social
evaluation is both highly likely and would be devastating, I am likely to feel very
anxious because I believe that a catastrophe is probable. The trigger itself has not
directly caused the fear because other people who encounter those same situations
may not feel the same way. There must be something happening in between the
trigger and the fear response. Our model suggests that it is our perceptions of the
probability and cost of being negatively judged that determines the severity of our
anxiety response.”
62 TREATMENT MODULES

The Fight, Flight, and Freeze Response

“The fear, or ‘fight-or-­flight,’ response includes all the uncomfortable symptoms
of anxiety you notice when in a social situation, such as the ones you mentioned
before [i.e., sweating, shaking, heart racing]. Although the symptoms feel extremely
uncomfortable, believe it or not they are designed to help us when we are under
threat. What do you already understand about the fight-or-­f light response? [Give
clients an opportunity to discuss their current understanding.]
“The fight-or-­f light response prepares our body for action, whether it be fight-
ing a threat or f leeing from it. We start to overbreathe to increase the oxygen in our
bodies, our muscles tense up in preparation for running or fighting, we sweat to help
cool the body as we manage the threat, and so on. Actually, if we don’t believe we
can fight or f lee from a threat our body is likely to freeze, which is also designed
to protect us. Imagine if you are being chased by a lion in the African savannah at
night and you know you can’t run from the lion, and you certainly won’t beat it in a
fistfight. Your best chance of survival is to play dead or stay still so that it doesn’t see
you. If we perceive that we can’t cope with a social situation our body might freeze
in an attempt to avert a catastrophe. For this reason, this fear response is sometimes
called the fight, f light, and freeze response. Our body’s ability to manage threats in
these ways has been critical to our survival.
“But what if we only ‘think’ there is a threat? It turns out that this is enough
to trigger the fight, f light, and freeze response, even in the absence of a true threat.
This is sometimes referred to as a ‘false alarm,’ and this is why we can experience
severe anxiety even when objectively there is no actual threat. On these occasions,
all the resources generated by the fight, f light, and freeze response (e.g., extra
oxygen and adrenaline, tense muscles, sweating) are not used (unless we want to
start fighting people at a party or in an interview—­not a great idea because it will
certainly lead to negative evaluation!), so we experience the symptoms as uncom-
fortable anxiety.”

Maintenance of Social Anxiety
“The question is, what keeps this perception of social threat going? The white bub-
bles in the model represent six important maintaining factors that keep our percep-
tion of social threat going, and these will be the targets of treatment. The first is
negative social thoughts and images, which may be from the past (i.e., past social events),
the present (i.e., what is happening right now), or the future (i.e., what we expect to
happen). The more negative thoughts and images you have, the greater the percep-
tion of social threat. What are some typical negative thoughts and images you have
before, during, or after social situations?
“The second bubble is avoidance. Most people with significant anxiety avoid
some of the triggers of their anxiety as a way of trying to avoid having their negative
 Socializing Clients to the Treatment Model 63

thoughts and images come true. [Elicit two to three situations the client avoids as
well as an example of the feedback loop to perception of social threat.] What are
some common situations you avoid for fear of evaluation from others? How might
avoidance keep your perception of social threat going (e.g., don’t get to test fears and
find that they may be inaccurate)?
“The next bubble refers to what we call ‘safety behaviors.’ Safety behaviors are
those subtle avoidance behaviors we use when we can’t actually avoid a situation.
For example, I might go to a work meeting, but I won’t say anything as a way of
avoiding being criticized. So I haven’t completely avoided the situation, but at the
same time I have still protected myself from my fears coming true. Sometimes safety
behaviors can be really hard to identify—­for example, you might go to a party but
not make very much eye contact with people so others won’t try to start a conversa-
tion with you in case they find you uninteresting; or you might dress in really light
clothes when you go out to reduce the chances that you will get hot and blush or
sweat. [Elicit two to three examples of safety behaviors, as well as an example of the
feedback loop to perception of social threat.] What are some of the safety behaviors
that you recognize yourself using from time to time? How might these keep your
perception of social threat going (e.g., I still don’t get to test my fears—by not talk-
ing I don’t learn that others are unlikely to criticize me)?
“The next bubble is the image of how you appear to others. [Elicit some exam-
ples of anxiety symptoms that the client believes are obvious to others, social per-
formance that the client believes he is really bad at, and/or the client’s perceptions
of his physical attributes, imperfections, or attractiveness.] In your mind’s eye, what
do you imagine other people see when they are looking at you? When you have that
image in mind, does it increase or decrease your perception of social threat? Often
people with SAD can have a more negative image of themselves in their mind’s eye
than what other people actually see.
“The next bubble refers to self-­focused and environment-­focused attention.
[Guide clients to recognize their tendency to be self-­focused on physical sensations of
anxiety, negative thoughts and images, and safety behaviors. Clients might often use
the term ‘self-­conscious.’ Also, elicit examples of negative environment-­focused atten-
tion, such as looking for any sign of negative evaluation from other people in the
area. Then guide the client to recognize that it would be most helpful to focus on
the task at hand, such as the topic of the conversation, their own contributions, and
what conversation leads they can take from what the other person is saying.] When
you’re in a social situation, what are you most aware of? What captures your atten-
tion most? What impact does focusing on these things have on your ability to focus
on the task at hand? Where would be a more helpful place to focus your attention
when socializing?
“Finally, the last bubble refers to negative core beliefs, which are very broad and
general ways in which you see yourself, others, and the world. Core beliefs guide
the specific negative thoughts and images you have in day-to-day social situations.
64 TREATMENT MODULES

For example, if I hold the belief that I am boring, I’m more likely to have negative
thoughts and images about others wanting to avoid me. I might then start to avoid
social situations, regardless of whether my core belief is true or not. [Elicit one or
two core beliefs if the client is readily able to do this, but don’t dwell too much
on them at this stage. Reassure the client that you will come back to this later in
therapy.] What general conclusions have you come to about yourself, other people,
or the world when it comes to socializing? These beliefs are important and we will
come back to them later in treatment.”

Once the client understands the model she should be encouraged to consider
how each component relates to her own experience. Using Worksheet 1, My Model of
Social Anxiety, the client can record examples from her experience as each component
is described in session. The questions outlined in the treatment model section above,
along with a range of self-­report questionnaires, can help the therapist and client better
understand how the components of the model relate to the client’s experience. Below
we brief ly describe some questionnaires that could be used to complement the clinical
assessment and help with case formulation. These measures can also be used to assess
change during treatment and therefore the effectiveness of the intervention.

Measures to Aid Diagnosis, Case Formulation,

and Outcome Evaluation
In this section we describe some measures that may help therapists to diagnose SAD and
develop case formulations using Worksheet 1, My Model of Social Anxiety (in the Appen-
dix). These measures can also be used to assess change during treatment and therefore
the effectiveness of the intervention. Some therapists are hesitant to use psychometric
measures because they feel that it disturbs the client rapport or burdens the client. In
fact, most clients will see a thorough evaluation as very useful. It usually helps clients
to feel that (1) the therapist is being very thorough and professional and has a complete
understanding of his problem; and (2) he is not alone and that these sorts of problems
and feelings are known and studied. After describing some examples of measures you
could administer to your clients we illustrate how information can be integrated to
create a personalized case formulation. Interested readers may want to consult the com-
prehensive review of SAD symptom and mechanism measures by Wong, Gregory, and
McLellan (2016).

Establishing a Diagnosis: Structured Diagnostic Interviews
There are several structured diagnostic interviews that can help clinicians determine
whether or not a client meets criteria for SAD. Unfortunately, most of these interviews
are not in the public domain and need to be purchased. These costs can be prohibitive in
 Socializing Clients to the Treatment Model 65

some treatment settings such as community mental health clinics. The Anxiety Disor-
ders Interview Schedule (ADIS-5; Brown & Barlow, 2014), published by Oxford Uni-
versity Press, comprehensively assesses DSM-5 criteria for anxiety, mood, obsessive–­
compulsive, trauma, and related disorders. The Structured Clinical Interview for DSM-5
(SCID-5; First, Williams, Karg, & Spitzer, 2016), published by the American Psychiatric
Association, is a semistructured interview that can be used to establish DSM-5 diag-
noses. Various versions of the SCID are published for different purposes (e.g., clinician
version, research version, personality disorders, clinical trials), and the publishers will
grant relatively cheap licenses to public and not-for-­profit clinics. However, the ADIS-5
and SCID-5 are time-­consuming to administer, and this level of detail is unlikely to be
necessary in the majority of clinical settings.
A briefer and cheaper alternative is the MINI International Neuropsychiatric Assess-
ment (MINI; Lecrubier et al., 1997; Sheehan et al., 1998). Clinicians may be able to
obtain permission from the developers to make copies of the MINI for their own per-
sonal clinical and research use. We have used the MINI in our clinic, and in our experi-
ence it can be administered in around 20 minutes, or less if fewer modules are admin-
istered.
You may feel that a structured interview imposes too many constraints on your
clinical intuition and is too detailed for your needs. The critically important issue as far
as the treatment described in this book is concerned is that you are able to accurately
identify that social anxiety is your client’s primary problem. However, research evidence
indicates that even experienced clinicians are less accurate in diagnoses when they rely
on unstructured questioning rather than structured interviews. Even if you decide not
to use structured interviews in the long run, we strongly urge you to read over one or
more of these interviews to give yourself an appreciation for the sorts of questions that
are asked and how they are structured and organized. Clear, systematic data collection is
critical for an accurate diagnosis.

Triggers and Fear Response
Worksheet 2, Personal Fear and Avoidance List (in the Appendix), can be helpful in iden-
tifying triggers of social anxiety and obtaining baseline fear and avoidance ratings. We
routinely readminister this worksheet at both the beginning and the end of treatment
so that clients can fully appreciate the changes they have made. Anxiety and avoidance
typically reduce for social situations clients have worked on in treatment, which rein-
forces the value of applying the treatment principles. It is often valuable for clients to
also notice that they remain anxious in some situations they are still avoiding because it
strengthens the rationale for reducing avoidance and provides some guidance about areas
to continue working on after therapy.
In our clinic we use the Social Interaction Anxiety Scale (SIAS) and the Social Pho-
bia Scale (SPS) as primary symptom and outcome measures (Mattick & Clarke, 1998).
The SIAS and SPS are self-­report questionnaires with 20 items each. They were designed
66 TREATMENT MODULES

as companion measures to assess two related but distinct facets of social anxiety. As the
name suggests, the SIAS assesses anxiety during the initiation and maintenance of social
interactions, such as making eye contact with others, speaking with authority figures,
disagreeing with others, and meeting people at parties. The SPS measures performance
anxiety in situations where an individual might be observed, such as eating, drinking,
writing, and public speaking. SIAS scores of around 34–36 have been identified as clini-
cal cutoffs in some studies (Heimberg, Mueller, Holt, Hope, & Liebowitz, 1992; Peters,
2000), although the average score for our clients in a community mental health clinic
is around 55 (standard deviation around 12; Carleton et al., 2014; McEvoy et al., 2015).
On average, clinical samples tend to score around 33 to 42 on the SPS (Carleton et al.,
2014; Heimberg et al., 1992; Mattick & Clarke, 1998).
We use the full 20-item versions of both measures, but shorter versions have recently
been published that reduce the burden on clients and are more practical in busy clinical
practices. Nick Carleton and colleagues (2009) published a 14-item version called the
Social Interaction Phobia Scale (SIPS), which comprised three factors: social interaction
anxiety (five SIAS items), fear of overt valuation (six SPS items), and fear of attracting
attention (three SPS items). Another three short versions have been developed, with
12 or 21 items (Fergus, Valentiner, McGrath, Gier-­Lonsway, & Kim, 2012; Kupper
& Denollet, 2012; Peters, Sunderland, Andrews, Rapee, & Mattick, 2012). The items
vary considerably across the short versions. In a recent study Carleton and colleagues
(2014) compared each of these short versions in terms of factor structure, sensitivity to
change during cognitive-­behavioral group therapy for SAD, and convergent validity
with related measures. There was no clear winner psychometrically across the measures,
although the SIPS (Carleton et al., 2009) and SPS–6 and SIAS–6 (Peters et al., 2012)
performed consistently well. These measures are in the public domain and are freely
available by contacting the authors or via a quick Internet search.

Negative Thoughts:
Fear of Evaluation and Repetitive Negative Thinking
Fear of negative evaluation (FNE) is a key theme of negative thoughts and images in
SAD. A commonly used measure to assess FNE is the Brief Fear of Negative Evaluation
Scale (BFNE), which has 12 items that were originally derived from the 30-item Fear
of Negative Evaluation Scale (FNE) (Watson & Friend, 1969). The BFNE is faster to
administer than the FNE, and its 5-point Likert scale (1 = not at all characteristic of me;
5 = extremely characteristic of me) is more sensitive to change than the FNE’s dichoto-
mous response format (true/false). One problem with the BFNE is that four items are
reverse scored because they are negatively worded (i.e., a high rating means a low fear
of negative evaluation). Negatively worded items can be confusing for respondents, and
they tend to perform more poorly psychometrically. Rodebaugh and colleagues (2004)
have evaluated the psychometrics of the eight positively worded items and have found
evidence that these items alone are superior to the 12-item version (also see Weeks et
al., 2005). This version, called the straightforwardly-­worded Brief Fear of Negative
 Socializing Clients to the Treatment Model 67

Evaluation Scale (BFNE-S), can be easily and quickly completed by clients to monitor
changes in this core feature of SAD during treatment. The BFNE can easily be located
using a web search. The negatively worded items (items 2, 4, 7, 10) are simply omitted
if the 8-item version is desired.
Fear of positive evaluation has been defined as “feelings of apprehension about oth-
ers’ positive evaluations of oneself and distress over these evaluations” (Weeks & How-
ell, 2012, p. 83). Recent elaborations of cognitive-­behavioral theory have incorporated
fear of positive evaluation as a key maintaining factor of SAD (Heimberg et al., 2010,
2014), and recent evidence suggests that it predicts SAD symptoms above and beyond
FNE (Weeks, Heimberg, Rodebaugh, & Norton, 2008). The idea is that people with
SAD wish to be acceptable enough to avoid negative evaluation, hence they fear nega-
tive evaluation. On the other hand, they also do not wish to be so impressive that oth-
ers feel threatened and therefore become critical and rejecting, hence they fear positive
evaluation. The 10-item fear of positive evaluation (FPE) scale can be used to assess this
construct during treatment. Sample items are “I am uncomfortable exhibiting my talents
to others, even if I think my talents will impress them” and “It would make me anxious
to receive a compliment from someone that I am attracted to.” A clinical cutoff score of
22 has been identified. Mean scores (standard deviations) have been reported for clinical
samples of 39.60 (SD = 14.92; Weeks, Heimberg, Rodebaugh, Goldin, & Gross, 2012).
Again, a Web search will reveal the FPE scale.
Additional self-­report measures of cognitive processes have been developed to assess
repetitive negative thinking before social situations (anticipatory processing) and after
social situations (postevent processing). The anticipatory event processing (AnEP) ques-
tionnaire developed by Laposa and Rector (2016) is a measure of anticipatory process-
ing, but this is particular to a videotaped speech task. The Anticipatory Social Behaviors
Questionnaire (ASBQ; Hinrichsen & Clark, 2003) is a 12-item measure of anticipatory
processing that assesses negative thoughts about what might happen in a social situation,
thoughts about how the individual would look to others, plans for escape or avoidance,
and recollections of past failures. The Post-Event Processing Questionnaire (PEPQ;
Rachman, Grüter-­A ndrew, & Shafran, 2000) was developed to measure rumination after
social stressors, and recent refinements to the measure have resulted in a 7-item measure
(Laposa & Rector, 2011). Anticipatory and postevent processing are closely related to
each other (Laposa & Rector, 2016), so for many clinical settings a single measure of a
client’s tendency to engage in repetitive negative thinking in response to a stressor may
be adequate to assess changes during treatment in vulnerability to both anticipatory and
postevent processing. A brief measure we commonly use for this purpose is the 10-item
Repetitive Thinking Questionnaire (McEvoy, Thibodeau, & Asmundson, 2014), which
assesses engagement in thoughts and images.
Other measures have also been developed to assess negative thoughts during pub-
lic speaking, such as the Self-­Statements during Public Speaking Scale (Hofmann &
­DiBartolo, 2000) and the Performance Questionnaire (Rapee & Lim, 1992), or during
social interactions, such as the Social Interaction Self-­Statement Test (Glass, Merluzzi,
Biever, & Larsen, 1982).
68 TREATMENT MODULES

Imagery Content, Use, and Ability

The most comprehensive assessment of imagery in relation to SAD, the Waterloo Images
and Memories Interview (WIMI), was developed by David Moscovitch and colleagues
(Moscovitch et al., 2011) by modifying the Autobiographical Interview (Levine, Svo-
boda, Hay, Winocur, & Moscovitch, 2002). Interviewers examine mental images and
associated autobiographical memories for positive (non-­anxiety-­provoking) and negative
(anxiety-­provoking) social situations. Respondents are first asked to spontaneously recall
these images and memories, and then to elaborate on these recollections via probing
questions. Administration of the WIMI requires training, and recording and transcrib-
ing of responses, so using it with fidelity is likely to be impractical in many clinical set-
tings. However, interested readers may wish to read the original paper as a guide to some
probing questions that may assist with accessing clients’ images. We provide compre-
hensive examples of how to assess for mental imagery in Chapter 5 of this book, which
is likely to be sufficient in most clinical contexts for assessing the content of distressing
mental imagery including self-­images.
Several measures of imagery ability are available that may be helpful in assessing the
degree to which clients are tuned in to mental imagery. The Spontaneous Use of Imag-
ery Scale (SUIS; Reisberg, Pearson, & Kosslyn, 2003) is a 12-item measure of an indi-
vidual’s awareness and habitual use of imagery in everyday life. Sample items are “when
going to a new place, I prefer directions that included detailed descriptions of landmarks
(such as the size, shape, and colour of a petrol station) in addition to their names.” The
Vividness of Visual Imagery Questionnaire (VVIQ; Marks, 1973) is a measure of imag-
ery ability. The original VVIQ consists of 16 items assessing imagery ability across four
scenarios, although a four-item version including only one of the scenarios has also been
used (McEvoy et al., 2015). Each scenario is brief ly described, and then respondents
are asked to manipulate the scenario within imagery in four ways and to indicate the
vividness of the imagery. Clinicians may wish to use the VVIQ as a quick assessment of
clients’ ability to engage with the imagery mode given its emphasis in this treatment,
although it may be that this ability improves as clients become more “tuned in” to their
imagery during treatment. A low score at pretreatment may therefore not preclude the
use of imagery-­based techniques.

Avoidance and Safety Behaviors
The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) is the most common
clinician-­administered measure in clinical trials. An advantage of the 24-item LSAS is
that it assesses both fear and avoidance of social situations, rather than just fear alone.
Like the SPS and SIAS, the LSAS assesses the dimensions of social interaction anxi-
ety and performance anxiety, resulting in four subscales: Fear of Social Interaction,
Avoidance of Social Interaction, Fear of Performance, and Avoidance of Performance.
Clinician-­administered measures allow for a detailed exploration of situations that cli-
ents fear and avoid most, as well as discrepancies between fear and avoidance. Some
 Socializing Clients to the Treatment Model 69

highly feared situations might be rarely avoided if the task is highly valued by the client.
For instance, a client whose career is fundamental to her identity might regularly speak
at work meetings despite finding this highly anxiety provoking. Other tasks that are less
anxiety provoking might nonetheless be more frequently avoided if they are perceived to
be less important or are just more easily avoided (e.g., writing in front of others, return-
ing goods to a store).
The Subtle Avoidance Frequency Examination (SAFE) is a 32-item measure of
safety behaviors that was developed to assist with case formulation and assess for changes
in this maintaining factor during treatment (Cuming et al., 2009). The SAFE has three
subscales assessing the restriction or inhibition of behavior to avoid attracting attention,
more active attempts to improve performance in social situations, and strategies that aim
to reduce physical symptoms of blushing and sweating. Cuming and colleagues (2009)
found that the SAFE was responsive to change during treatment. The SAFE is down-
loadable from the Centre of Emotional Health’s website at Macquarie University (www.
mq.edu.au/__data/assets/pdf_ file/0008/137078/SAFE_English_copyright_2015.pdf ).

Self‑ and Environment‑Focused Attention
There are a few measures that can be used to assess focus of attention. The Focus of
Attention Questionnaire (FAQ; Woody, Chambless, & Glass, 1997) was developed to
assess focus of attention during a social interaction in particular. The FAQ consists of
two, five-item subscales assessing self-­focused attention or externally focused attention.
The self-­focused subscale assesses focus on what the individual will say or do next, the
impression she is making on the other person, her level of anxiety, internal bodily reac-
tions, and past failures. The external focus subscale includes items regarding aspects of
the situation other than the client himself, including the other person’s appearance or
dress, the physical surroundings, what the other person might be feeling toward the cli-
ent, thoughts about the other person, and what the other person was saying or doing (see
Woody et al., 1997).
The Self-­Consciousness Scale (SCS; Carver & Scheier, 1978; Fenigstein, Scheier, &
Buss, 1975; Scheier & Carver, 1985) is another measure of self-­focused attention. The
SCS (revised version; Scheier & Carver, 1985) is a 22-item measure of the dispositional
tendency to be aware of oneself privately or publically. Private self-­consciousness includes
hidden aspects of the self not observable to others such as beliefs, values, and feelings.
Public self-­consciousness includes aspects of the self that are observable to others, such as
behavior, mannerisms, and expressions, and is especially relevant to social anxiety.

Negative Core Beliefs
The concept of core beliefs might be difficult for clients to grasp at this early stage, and
so this can always be left blank in Worksheet 1, My Model of Social Anxiety, and explored
in more detail later in treatment if necessary. Alternatively, self-­report measures may
70 TREATMENT MODULES

be a useful adjunct to a clinical assessment. The 15-item Self-­Beliefs Related to Social

Anxiety (SBSA) Scale (Wong & Moulds, 2009; Wong et al., 2014) may be helpful for
assessing three types of maladaptive beliefs related to social anxiety based on Clark and
Wells’s (1995) model (see Chapter 2): high standards, such as “I have to get everyone’s
approval” and “I need to be liked by everyone”; conditional beliefs, which take the
form of “If . . . then . . . ” statements such as “If I make mistakes, [then] others will
reject me” and “If I don’t say something interesting, [then] people won’t like me”;
and unconditional, broad, and global core beliefs such as “People think I am inferior.”
Other measures of core beliefs have also been developed, including the Social Thoughts
and Beliefs Scale (STABS; Turner, Johnson, Beidel, Heiser, & Lydiard, 2003), Core
Extrusion Schema (Rodebaugh, 2009), and the Maladaptive Interpersonal Belief Scale
(Boden et al., 2012).
If the client is unable to readily provide personal examples for a particular com-
ponent of the My Model of Social Anxiety case formulation, then the therapist can spend
more time addressing this gap in his understanding. The gap can be resolved by admin-
istering a selection of the formal measures just reviewed and/or with the more detailed
eliciting questions described in Chapters 5–9, which correspond to each maintaining
factor in the model. Clients should be encouraged to ask questions about the model
to seek clarification. Therapists should actively invite any queries and ask if there are
any aspects clients believe are particularly relevant to them, or any elements they see as
being less relevant.

Individualizing the Model: Jacquie’s Case Formulation
If you recall Jacquie’s story from the beginning of Chapter 1, we can now consider her
case formulation. The therapist and Jacquie first worked through the section earlier in
this chapter titled “The Treatment Model” to help Jacquie understand the maintaining
factors of her social anxiety and better understand how each component relates to her
own personal experiences. The therapist also asked Jacquie to complete Worksheet 2,
Personal Fear and Avoidance List, for a baseline of how severe her anxiety was in a range
of situations that were important to her and how frequently she avoided them. Jacquie
also completed the SIAS as a general measure of the severity of her anxiety in social
interaction situations and she scored 55, which is well within the clinical range for
SAD. Jacquie’s responses on the Fear of Negative Evaluation Scale (straightforwardly
worded version) and Fear of Positive Evaluation Scale revealed that she had a severe
fear of negative evaluation and she also felt very uncomfortable when others focused on
her for positive reasons. Clinical assessment and her score on the Repetitive Thinking
Questionnaire–10 revealed that Jacquie often experienced negative social thoughts and
images before, during, and after social situations, which typically involved her antici-
pating or ref lecting on perceived social catastrophes. Jacquie’s ratings on the Vividness
of Visual Imagery Questionnaire revealed high imagery ability, which suggested that
 Socializing Clients to the Treatment Model 71

she was likely to be able to engage well with the imagery aspects of the treatment with
little prompting. Scores on the Subtle Avoidance Frequency Evaluation helped Jacquie
to understand how frequently she relies on safety behaviors in social situations, and she
was surprised to learn that some of the strategies she used to try and prevent her social
fears may actually be maintaining her social anxiety. She reported that the behaviors are
usually so automatic that she is not even aware she is using them. Ratings on the Focus
of Attention Questionnaire showed that Jacquie’s attention is predominantly focused on
herself or unhelpful aspects of the environment that she perceives as indicative of social
evaluation, rather than on the task at hand (i.e., the conversation). Finally, her scores on
the Self-­Beliefs Related to Social Anxiety Scale revealed that she strongly endorsed a
range of extremely high social standards and negative core beliefs about her perceived
inferiority. After considering all of the information collected from the clinical interview,
discussions about the treatment model, and the self-­report measures, Jacquie and her
therapist included some examples in each component of Worksheet 1, My Model of Social
Anxiety, to create her own personalized model of social anxiety (Figure 4.1). This model
was then regularly referred to throughout treatment to ensure that each maintaining
factor was being effectively modified.

Treatment Rationale
The treatment rationale follows directly from the model. The therapist can describe
how the treatment is designed to modify the perception of threat by teaching skills to
address each of the six maintaining factors described in the model. The client will learn
strategies to (1) identify and challenge negative social thoughts and images, (2) gradu-
ally reduce avoidance, (3) reduce reliance on safety behaviors, (4) challenge negative
self-­images and discover how she actually appears to other people, (5) redirect attention
to the task at hand, and (6) modify negative core beliefs. The therapist can then express
curiosity about whether the client believes this approach could be helpful and why. This
provides another opportunity to engage clients in the process of change as they hear
themselves advocating for the value of addressing each of the target areas.

Looking Forward
Worksheet 3, Looking Forward, can be a helpful way of ending the initial phase of treat-
ment. Successful treatment requires commitment and perseverance, and these qualities
are going to be tested in our clients throughout the program. The Looking Forward exer-
cise is an opportunity for clients to consider the potential costs and benefits of a future
with and without change. For most clients thinking about a future without change is a
depressing prospect, as they envision limited opportunities in their career and relation-
ships and continued suffering. Envisaging a future with change is more optimistic and
 Avoidance
Safety
Avoid social situations behaviors
where possible, avoid leaving
Write speeches word
the house, cross the road
for word, look down at
Negative social to avoid people, become
paper, rarely speak, make
Triggers thoughts and images a librarian (to try and Fear Response
excuses to avoid social
avoid interacting)
Everyone will see my anxiety situations, walk down isolated
Presentations and laugh or reject me, streets, ask questions to Anxiety
everyone is looking at me avoid speaking myself
Speaking with Panic
work colleagues
Blushing
Walking down Perception of Social Threat
the street Probability Cost Nausea
How likely is it that my What are the consequences
Being observed Headaches
fears will come true? of my fears coming true?

72
Very likely I will be humiliated, Urge to flee
rejected, and alone

Negative Images of how

core beliefs I appear to others
Stammering, paralyzed
I am so stupid; I am inferior; Self- and
by fear, bright red face,
others are critical environment-focused awkward, mind going
attention blank, voice trembling
Focused on my symptoms
of anxiety; scanning for
negative evaluation

FIGURE 4.1.  My Model of Social Anxiety (Worksheet 1), completed by Jacquie.

 Socializing Clients to the Treatment Model 73

involves a more fulfilling and valued life. It is important for clients to elaborate both of
these alternative futures to be clear about the importance of using treatment, right at this
moment, to start working toward a more positive future. At this point the therapist can
guide clients through an imagery exercise where they are first encouraged to imagine
themselves in a social situation in the future with high social anxiety (e.g., work, social
event, job interview, on a date). Clients can then reimagine the situation but this time
seeing themselves as more confident. With these alternative futures vividly in mind, the
value of changing sooner rather than later is clear.
The Looking Forward exercise also requires clients to consider potential obstacles
to change that may threaten to derail their progress in therapy. These obstacles might
include having to tolerate heightened anxiety in the short to medium term, difficulties
maintaining motivation, having limited time to devote to homework, managing set-
backs, and upsetting the status quo when other people expect them to be their agreeable
and passive old selves. Some clients are also willing to admit that if they don’t try and
don’t succeed, then at least they still have hope that if they do make a genuine attempt
later on they could get better. The core fear is that if they genuinely engage with the
treatment and it fails, then they could not cope with losing what they consider to be
their “last hope.”
The final aspect of the exercise is clients considering what they might lose by chang-
ing their social anxiety. Clients might report that they would become even less likable
because they will become aggressive. Others acknowledge that if they no longer have
social anxiety they will have to confront some difficult issues and tasks in their lives
and therefore leave their “comfort zone,” which they are currently able to avoid. If they
begin the difficult process of change, they might be concerned that others will start to
expect too much of them and then be disappointed.
We hope it is clear from these examples how critical it is to address these issues
before clients commence the process of change. Time spent preempting and planning
for identified obstacles is time well spent. Worksheet 3, Looking Forward, can be referred
to when clients encounter these issues during therapy so they can remind themselves
why they embarked on this difficult process ( for an alternative future), to normalize the
obstacles (Ah, we thought this might come up at some stage, and here it is!), and to plan helpful
responses when they do arise (Do you remember how you thought you might deal with this issue
if it arose? Given that you thought it might come up, tell me about how you made the decision to
persist with treatment anyway.).

Summary
Socializing clients to the model and actively engaging them in the treatment rationale
is where half the battle is won or lost. If a client understands the model, it fits with his
experience, and he can articulate the potential benefits of modifying the maintain-
ing factors, the value of fully engaging in the treatment strategies will be clear. Once
clients understand what treatment involves, they will ideally feel a mix of excitement,
74 TREATMENT MODULES

anxiety, hope, dread, and enthusiasm (among many other emotions) as they embark on
the course of therapy. These mixed emotions suggest that they understand they are going
to find the process difficult, but also that the effort will be worthwhile and ultimately
highly rewarding. It is critical that therapists pay close attention to the therapeutic alli-
ance and client motivation throughout therapy. In the coming chapters we describe each
maintaining factor in more depth, look more specifically at socializing clients to work
on these factors, and introduce a range of treatment strategies that are designed to effec-
tively target each maintaining factor in turn. It is the combination of these treatment
strategies that will lead to a comprehensive and thorough therapy for SAD.
 Socializing Clients to the Treatment Model 75

THERAPY SUMMARY GUIDE:

Socializing Clients to the Treatment Model
Therapy Aim:  Establish rapport, hope, and expectations of change, provide
psychoeducation about social anxiety disorder, and socialize clients to the treatment
model.

Therapy Agenda Items:

Setting the scene
]]
Building rapport
\\
The client is not alone
\\
There is hope
\\
Expectations of CBT and change
\\
CBT is collaborative
\\
The importance of homework
\\
Session structure
\\
Psychoeducation about SAD
]]
The treatment model
]]
Triggers
\\
Perception of social threat
\\
The fight, f light, and freeze response
\\
Maintenance of social anxiety (including measures to aid case formulation)
\\
Individualizing the model
]]
Treatment rationale
]]
Looking forward
]]

Therapy Materials:
Handouts
]]
Handout 1, What Is Social Anxiety Disorder?
\\
Worksheets
]]
Worksheet 1, My Model of Social Anxiety
\\
Worksheet 2, Personal Fear and Avoidance List
\\
Worksheet 3, Looking Forward
\\
 CHAPTER 5

Negative Thoughts and Images

Therapist: What makes social situations difficult for you?

Client: Well, I feel like people are always judging, just waiting for me to slip up, it
is like all eyes are on me and I don’t like it.
Therapist: So, you have the thought “people are judging me, waiting for me to
slip up,” and you may even have an image that goes with that thought of every-
one’s eyes being focused on you, so understandably that makes the situation very
intimidating?
Client: But it doesn’t feel like a thought or my imagination, it feels like the truth.
Therapist: Well, I guess one possibility is that you are absolutely right and people
are judging and watching. Another possibility is that this isn’t true and you just
think and imagine that this is what is going on. We only need to think we will
be judged for the fear response to be triggered, so we can’t rely on our feelings
as an accurate guide about whether we actually are being evaluated. We need to
take a step back and see whether our feelings fit with what is actually happening.
In therapy, we will have the opportunity to find out what you are thinking and
imagining in social situations, and whether or not these thoughts and images
are accurate.

About This Module: Addressing Negative Thoughts

and Images in SAD
The first focus of SAD treatment is to assist clients to become more aware of and to
question the specific negative beliefs (cognitions) that emerge for them on a regular basis
in social situations that they typically find anxiety provoking. These situation-­specific
76
 Negative Thoughts and Images 77

negative automatic cognitions may be verbal or imagery based in nature, and may ref lect
the past (i.e., recalling past social events), the present (i.e., what is occurring socially
right now), or the future (i.e., what is expected to occur socially). This module cov-
ers the practicalities of targeting this level of cognition, including socializing clients to
working within the imagery modality and methods for eliciting and modifying prob-
lematic thoughts and images.
As was previously mentioned in Chapter 3, another important cognitive component
of the treatment model, negative core beliefs, is addressed much later in treatment. It is
not uncommon for clients (and therapists) to question why core beliefs are not targeted
first, given they are so inf luential in determining negative thoughts and images. The
following rationale might be given should this issue arise:

“These negative core beliefs, which at the moment seem like core truths of who you
are as a person, how other people are generally, and how the world is generally, can
develop from our life experiences and how we have made sense of those experiences
at the time. For example, we might interpret bad experiences as meaning something
bad about ourselves or other people generally or the world generally, and therefore
we might expect that bad stuff to occur again and again in life. In this way, the core
beliefs color and taint what we expect here and now, acting like old baggage that we
are carrying from the past into the present.
“We find that just talking about these core beliefs, trying to challenge them
straight away ‘head on,’ just doesn’t work and can be very frustrating for people.
These beliefs are highly entrenched, so the best way to tackle them is by having
many new experiences that don’t fit with these core beliefs, showing that the core
belief is outdated. The best way to get those new experiences is to start thinking
and behaving in ways that give us the opportunity to learn something new in life—­
something new about ourselves, others, and the world. Tackling the other elements
in the model will allow us to do this. For example, if we are entering social situa-
tions with an open mind, rather than avoiding and being preoccupied with negative
thoughts and images, we may then have the opportunity to experience others not
being judgmental, the social situation going OK, ourselves as being socially capable
and coping when things don’t go according to plan. Gathering these sorts of experi-
ences is the best way to weaken your negative core beliefs. So when we are working
on the other elements of the model first, we are still implicitly working on your core
beliefs. When we have made some progress with these other elements, we will then
be in a better position to return to the core beliefs toward the end of treatment and
tackle them more directly.”

The main message is that clients will need to start thinking in more open-­m inded
and unbiased ways so they can enter rather than avoid social situations and process
these experiences in a manner that allows the accuracy of their core beliefs to be tested.
Addressing negative social thoughts and images is the first step in promoting the open-­
mindedness required for core belief change, and hence effective treatment.
78 TREATMENT MODULES

Socializing Clients to Work with Imagery

Negative social images are a prominent cognitive feature in social anxiety; however,
this can be an unfamiliar cognitive modality for many clients. People are generally more
familiar with verbally based learning: talking, discussion, and being asked what they
think about certain things (either in everyday life or by their therapist). “Tuning into”
the pictures or multisensory images that f lash through their consciousness is not some-
thing customarily asked of our clients. A client may have all manner of preconceptions
about working with imagery, for example, ideas that it is an odd, magical, embarrassing,
or foolish process, or that she “can’t do it” because she perceives herself as not a very
“visual person.” She might believe that having images run through her mind is abnor-
mal or a sign of insanity. Taking time to socialize clients to what imagery is, and the
reasons for focusing treatment on identifying and modifying negative social images, not
just verbally based cognition, is therefore important for engagement. The rationale for
working with imagery is important for clients and therapists alike. With a solid rationale
in place, therapists will have greater confidence working within this modality. The ways
we go about introducing clients to imagery have been heavily informed by Hackmann
and colleagues (2011).

Introducing Imagery
Imagery Discussion
It is important to set the expectation with clients that treatment will involve becoming
aware of the negative social images they hold, not just negative verbal thoughts. One
way of introducing the concept of imagery is by first asking clients about their under-
standing of what is meant by “image” or “imagery.” During this discussion, therapists
should look for any comments about visual or pictorial representations. In addition, they
can ask, “What points in time can an image capture?” This can lead to the observation
that images can be of experiences in the past (i.e., memories), the present (e.g., how I
am coming across to others now), or the future (e.g., how I will come across to others).
Imagery is best introduced as an experiential exercise, so feel free to keep verbal discus-
sion brief.
The discussion can be extended by asking clients, “Do you think you are ‘good’
or ‘not so good’ at visualizing or thinking in pictures and images?” Encourage clients
to be curious and to adopt a “let’s find out” attitude. This can lead into the following
experiential exercise.

House Imagery Exercise
“Would you be willing to try a simple imagery exercise where we try to bring a
particular everyday image to mind to get a better sense of what imagery is all about?
 Negative Thoughts and Images 79

Now, you may be able to form a clear image of the place I’m about to describe, or it
may be fuzzy, more a ‘felt sense’ of the place (i.e., where you feel like you are in the
place, but you don’t have a vivid picture of it in your mind). Either is OK.
“If you feel comfortable doing so, just close your eyes for a minute while you
imagine the front of your house. [pause] How many windows does it have? [pause]
What color and texture are the walls? And what about the roof? What is the yard
like? What does the front door look like? [pause] Now imagine yourself walking
through the front door. [pause] Notice any ways in which you might be experienc-
ing this image with your body or other senses. Open your eyes . . . ” (elaborated
from Hackmann et al., 2011, p. 62).

When debriefing the House Imagery Exercise, it is important to normalize varying

experiences of imagery. Emphasize that there is no right or wrong. Give permission for
fuzzy images, images that come in and out of awareness, or images that are predomi-
nantly experienced through nonvisual senses (e.g., auditory, tactile, olfactory, gustatory).
The following prompts may be useful in facilitating discussion of client experiences:

• “Was the image clear or fuzzy? Was it more a ‘felt sense’ of being outside your
house?”
• “Did the image take time to form or was it instant? Did the image drift in and
out?”
• “Was it like a film or more like snapshots?”
• “Was it realistic or more fantasy-­like?”
• “Was it just visual or were other senses involved? Touch (e.g., feeling the outside
wind or sun on your skin, or the temperature shift when moving from outside to
inside the house)? Sound (e.g., hearing the dog bark, or leaves in the yard rustle)?
Smell (e.g., the fragrance of the f lowers in the garden, the cooking aromas when
you entered the house)? Taste (e.g., a sense of thirst and the urge to grab a drink
of water as you entered the house)?”

If clients have difficulty accessing imagery, normalize their experience, for example:

“Difficulties are normal, and I can help you learn how to think in pictures . . .
remember imagery is a mode we don’t refer to a lot in everyday life. We use words
all the time and are often asked what we think about something, but we rarely close
our eyes to picture something, and we are rarely asked about images passing through
our mind.”

In summary, imagery can involve any sensory (e.g., visual, auditory, tactile, olfac-
tory, gustatory) mental representation (e.g., an object, place, person, past event, current
event, future event) that occupies our mind either very brief ly or for more prolonged
periods of time.
80 TREATMENT MODULES

Free Association Exercise
To consolidate what the client has learned from the House Imagery Exercise, the Free
Association Exercise can also be useful.

“I will say a few words in a moment, and I just want you to notice what pops into
your mind . . . car . . . summer . . . clown . . . Christmas . . . f lower . . . beach . . .
What did you notice? Was it words or images that arose in your mind?”

Typically, clients will be able to acknowledge that imagery of varying quality (brief,
fuzzy, transitory, vivid, sustained, etc.) entered their mind with each word stimulus,
rather than verbally based cognition. Thus, this exercise can help increase their general
awareness of imagery-­based cognition.

Negative Social Imagery Examples

Having introduced the concept of imagery more broadly, you can then narrow your
discussion to exploring negative social images more specifically. For example:

“Just as we have mental images to represent most things in life, it is likely that when
we are socially anxious, we have images going through our minds that represent our
social fears. People with social anxiety often say that they have pictures or snapshots
of themselves behaving or appearing in a negative way; or of others reacting to them
in a negative way; or even snapshots of past negative social experiences that seem like
a scene frozen in time that keeps popping into their head in current social situations.
Are you aware of what some of your common negative social images are?”

If clients are unable to access their negative social imagery early on from this more
general discussion, again normalize this experience. It is likely that later use of Work-
sheet 5, Thought and Imagery Record (in the Appendix), to monitor their imagery in rela-
tion to specific social situations will assist in accessing their negative social imagery.

Rationale for Working with Imagery

Before embarking on further imagery work with clients, it is important to clarify why
imagery is a central component of treatment. There are three key reasons why imagery is
emphasized in treatment that can be discussed with clients, with each reason highlight-
ing that the usefulness of imagery is not to be underestimated.

Imagery Promotes Cognitive Specificity

Many of the negative thoughts people have when they are socially anxious are cata-
strophic, abstract, and overgeneralized. For example, the most common response when
 Negative Thoughts and Images 81

a socially anxious client is asked, “What do you think will happen in a particular social
situation?” is something like “I will look like an idiot” or “people will think I am an
idiot.” But what does looking like an “idiot” actually mean? These types of responses are
so overgeneralized, it is unclear exactly what clients are predicting will happen in social
situations. Vague predictions are a recipe for ineffective behavioral experiments (as will
be addressed further in the next chapter). It is difficult to find effective ways to challenge
and change vague and overgeneralized predictions.
Therapists can elicit specific details of social fears verbally by repeatedly asking cli-
ents for more specific descriptions. However, imagery immediately places clients within
the feared situation, is associated with heightened negative affect, and is thus likely to
activate the fear network more broadly and intensely. In our experience this process
yields substantially richer and more specific details of feared outcomes. This then places
clients in a much better position to effectively challenge and modify their predictions,
hence facilitating effective treatment.
Rather than asking clients what they think might happen, we instead ask clients to
“close your eyes and tell me what you envision happening in the social situation.” To this
a client might say, “I see myself shaking, stuttering, bright red, having nothing to say”
(which is more specific than “I will look like an idiot”), or “I hear others laughing at
me, criticizing me, they turn away and avoid speaking to me” (which is more specific
than “they will think I am an idiot”). The process of envisaging social catastrophes thus
provides specific and testable hypotheses (i.e., “Did you actually shake, stutter, go bright
red, and have nothing to say like you had imagined? Did others actually laugh, criticize,
turn away, and avoid you?”).

Imagery Elicits Stronger Emotions

Research shows that imagery is more strongly linked to our emotional and physiological
responses than words. You could use one or both of the following exercises to illustrate
this concept with clients.

CHOCOLATE CAKE IMAGERY EXERCISE

“First silently say the words ‘chocolate cake’ to yourself a few times . . . notice how
you feel. Now close your eyes and visualize a piece of chocolate cake in front of you.
How do you feel? How does your mouth feel? Do you notice any physical sensa-
tions? Do you notice any urges? Open your eyes.”

When debriefing this exercise, compare clients’ emotional and physiological experi-
ences between thinking in “word” mode versus “picture” mode. It is important to note
that a client’s reaction doesn’t need to be positive for the exercise to have been useful.
Aversive reactions are good too (e.g., “I feel sick because I hate chocolate cake, it’s too
rich”). Noticing a more intense emotional and/or physiological response in the picture
mode compared to the word mode is the aim of the exercise. If the food is one the client
82 TREATMENT MODULES

neither loves nor hates, it will elicit limited emotional or physiological reactivity. If this
is the case, you could redo the exercise, but first check you have a food the client is likely
to be reactive to. Imagining eating a lemon (as suggested in Hackmann et al., 2011,
p. 62) is another option you could try, as it is likely to generate an aversive physical reac-
tion. A lack of difference in reaction could also occur if saying the word automatically
generates an image (as in the Free Association Task), making the two conditions too
similar to detect a difference. Likewise, if the client struggled to develop an image, then
the two conditions may be too similar.
Following this exercise, you can discuss it with the client:

“Given the aim of treatment is to overcome the emotional and physiological reaction
of feeling anxious in social settings, it makes sense that we work in the ‘mode’ (i.e.,
imagery rather than words) that is most strongly connected to, and hence most likely
to impact that emotion.”

BRAIN INPUT AND OUTPUT EXERCISE

It can be useful to elaborate the concept that imagining something can have the same
impact on our brain and body as if what we imagine were actually happening in real-
ity. This concept can be expanded by using the following dialogue and the diagram in
Figure 5.1, which are adapted from Gilbert (2009, p. 205).

Imagined Chocolate Cake Imagined Social Rejection

Real Social Rejection

Real Chocolate Cake

Salivate Anxiety,
shame,
sadness

FIGURE 5.1.  Schematic diagram of the equivalent physiological and emotional impacts of internal
images and actual experiences.
 Negative Thoughts and Images 83

Start by drawing a person’s face (see Figure 5.1), and then discussing and adding in
the following components:

“If we have food we really like in front of us (e.g., a real-life chocolate cake) and it
is processed by our brain, how does our body react? By salivating. Similarly, if we
imagine the same food (i.e., an imagined chocolate cake), our body has the same
reaction of salivating. Let’s look at an example relevant to social anxiety. If we are
rejected socially by someone, we may feel anxiety, shame, sadness. Equally, if we
imagine being rejected socially, we are likely to have a similar reaction.”

This concept could be used with other examples such as threat (i.e., a real danger
versus an imagined danger can both generate the “fight-or-­f light” response) or sexual
arousal (i.e., sexual contact versus a sexual image can both generate sexual arousal).
The idea is to show that the same emotional/physiological output from the processing
of an external stimulus (i.e., the “real thing”), also occurs when an equivalent internal
stimulus (i.e., the “imagined thing”) is processed. It is important to check that clients
understand this discussion.

“The take-home message is that imagining something can be almost as powerful

as the real thing. Our brains are not very good at distinguishing imagination from
reality. Research shows that the same parts of the brain, the same neural processes,
are involved in imagining doing something (e.g., lifting your arm) as actually doing
it. This explains why images are more strongly linked to our emotions than words
because our brain processes images as if what we are imagining is real.”

It is important to relate all this information back to social anxiety treatment specifi-
cally.

“So if we think about your social anxiety, the downside is that holding an image in
mind of being rejected prior to going into a social situation can elicit the same feel-
ings as actual rejection, and hence stop you from entering the social situation. But on
the upside, if we can work together to develop more helpful images of being socially
acceptable and competent, this can elicit the same feelings as actual social acceptance
and competence, making you more inclined to give social situations a go.”

Imagery Facilitates Exposure and New Learning

Helping clients to be more aware of their negative social imagery can also facilitate
exposure. Following a client’s negative social image from beginning to end is essentially
a form of imaginal exposure. If clients can stick with and follow through their negative
social imagery, rather than suppress it, they have the opportunity to run it on past the
worst point of the feared situation, which is likely something they very rarely do. This
84 TREATMENT MODULES

imaginal exposure element can challenge their initial fears by leading to a reevaluation
of the real cost and their true coping abilities should they face a social catastrophe.
The benefits of following negative social imagery past the worst point could be
explained to clients in the following way:

“It is likely that when you have a negative social image pop into your head, you dwell
on the worst part of it for a little bit, then when it becomes too distressing you sup-
press it, trying to push the image out of your mind. However, research shows that
thought suppression often backfires, making you think even more about the thing
you don’t want to think about. So you get stuck in the worst part of the image as you
think about it, then suppress it, think about it, then suppress it, and so on. Overall
this keeps your anxiety and concerns about the situation very high. The alternative
is to think about the negative social image fully from beginning to end, rather than
suppressing it. By doing this you won’t get stuck at the worst point. Instead you can
run it on past this point and see what you discover about yourself and other people.
You might be surprised to discover that your fears aren’t as scary, or that you are able
to cope better than you thought. It is likely that when you take this approach, your
anxiety and concerns will be more like a wave, subsiding when you allow yourself
to move past the worst point.”

It is important to note that contemporary behavioral theory deemphasizes the need

for anxiety reduction (i.e., habituation) during exposure tasks. Inhibitory learning the-
ory (Craske et al., 2014) suggests that the most critical aspect of exposure is expectancy
violation—­whereby the client’s negative expectations are directly tested and found to
be highly discrepant from the actual outcome. This approach prioritizes the amount of
“surprise” clients experience from their exposure tasks rather than anxiety reduction.
From this perspective, the lack of constraints on imagery (any aspect of feared social
situations can be imagined) compared to in vivo exposure (access to contexts and social
situations is more limited) may enhance learning. More specific, elaborate, and vivid
predictions can be generated in imagery, thereby potentially maximizing the number of
“surprises” during either imaginal or in vivo exposure.

Identifying Negative Thoughts and Images

Thought/Image–Feeling Connection
The Thought/Image–­Feeling Connection Exercise can be a useful way of socializing
clients to the important role that thoughts and images have in eliciting emotion gener-
ally and, in particular, the role of negative social thoughts and images in eliciting anx-
ious feelings. The exercise involves guiding clients through the completion of Worksheet
4, Thought/Image-­Feeling Connection (in the Appendix). In this exercise a hypothetical
 Negative Thoughts and Images 85

trigger situation is provided (i.e., a friend is late meeting me at a café), as are four pos-
sible emotional reactions (i.e., angry, anxious, sad/depressed, neutral). Clients are asked
to generate possible thoughts and images that might go through the protagonist’s mind
to generate each of these feelings. The exercise is used to illustrate the relationship
between thoughts/images and emotions, and how different thoughts/images lead to
different emotional reactions. Using a hypothetical example initially to facilitate this
learning may help clients subsequently be more open to exploring their own problematic
thoughts and images and the emotions these generate.

Eliciting Thoughts and Images

When identifying clients’ own negative social thoughts and images, the two key themes
for therapists to look for are:

1. Overestimation of the perceived likelihood or probability that negative events

will happen in social situations, and
2. Overestimation of the cost or consequences of negative events occurring in social
situations.

Therapists may be more familiar with eliciting verbally based negative social
thoughts. Typically, this involves choosing a specific social anxiety trigger, which will
often be an upcoming social situation clients anticipate going badly, but may also be a
past social situation they perceive did not go well. Common questions used to elicit ver-
bally based cognitions might include:

• “What concerns you the most about the situation?”

• “What are you worried about in this situation?”
• “What are you predicting will happen? What do you think happened?”
• “How do you think people will react? How do you think people reacted?”
• “How do you think you will come across? How do you think you came across?”
• “What do you think people will think about you? What do you think people
thought of you?”
• “What’s the worst part of the situation for you?”
• “What’s bad about that?”
• “What does that mean to you?”
• “What does that mean about you?”

Given that recent theory and evidence suggest that people with SAD may be fearful
of both negative and positive evaluation, it might be worthwhile asking clients, “How
do you feel when you receive positive attention?” If they report feeling uncomfortable,
the questions above are likely to elicit the idiosyncratic negative meanings of positive
evaluation.
86 TREATMENT MODULES

Some typical SAD thoughts that may be revealed by these questions include:

• “They will judge me.”

• “They won’t want to know me.”
• “I made a bad impression.”
• “I said the wrong thing.”
• “They think I am an idiot, stupid, weird, weak, boring.”
• “I won’t know what to say, or I’ll say something stupid.”
• “I looked awkward, anxious, foolish.”
• “I will do something embarrassing.”
• “I will be humiliated.”
• “I won’t be able to cope.”
• “They will laugh at me.”
• “They might think I’m a snob.”

When it comes to eliciting negative social images, as with eliciting verbal thinking,
it is useful to start with a specific social anxiety trigger. Once a specific trigger has been
identified, clients can then be asked to imagine the scenario, and during this experience
the therapist asks questions to uncover negative social images. The imagined social situ-
ation may be in the future, or a memory of a past social situation that they perceive went
badly. The following questions can be used as a guide to facilitate this process:

“Close your eyes and imagine being in that situation as if you are there right now
experiencing it firsthand. So, looking through your own eyes out at the situa-
tion . . . ”
• “Where are you?”
• “What are you doing? What is happening?”
• “What can you see? Are there any other sensations of note (sounds, smells,
sensations on your body/skin)?”
• “Who is there?”
• “What are other people doing? How are other people responding to you?
What are other people noticing about you?”
• “What happens next?”
• “What are you thinking?”
• “How are you feeling? Where do you feel that in your body? What physical
sensations go with that feeling?”
• “How are you handling the situation? How are you coping?”
• “What part of this situation bothers you most?”

These questions are a guide only. Depending on the scenario being explored, thera-
pists will need to judge which questions are most helpful to use, how many questions to
use, and how circular the line of questioning needs to be (i.e., “what is happening . . .
what are people doing . . . what are you thinking . . . what are you feeling . . . what
 Negative Thoughts and Images 87

happens next . . . now what are you doing . . . how are other people reacting now . . .
what are you thinking now . . . how do you feel now . . . now what is happening . . . ,
and so on.”). When uncovering negative social images, clients are initially encouraged
to adopt a first-­person, present-­tense, field perspective (i.e., “looking through your own
eyes out at the situation . . . ”). During the course of eliciting imagery, clients may natu-
rally switch to an observer perspective, identifying imagery about how they are appear-
ing and performing socially from others’ perspectives. This can be considered a specific
subtype of negative social imagery, that is, the negative self-image. Images of this nature
will be addressed more explicitly in Chapter 7.
The negative social images clients report will generally be richer elaborations of the
previous themes uncovered when eliciting verbal thoughts. The imagery may be literal
or more metaphorical in nature. Common images might include:

• “I am alone in the corner of the room, separate from everyone else. Everyone else
is talking and having a good time, and I am not part of it.”
• “I say something stupid and others laugh and turn away, not wanting to hang
around me anymore.”
• “I trip and drop my things. I look like a bumbling fool, and others laugh or stare
at me strangely.”
• “Other people are talking about me behind my back, sniggering and pointing at
me.”
• “I see myself trembling, shaking, and looking as bright red as a beetroot.”
• “I can hear my voice, it sounds squeaky, stuttery, unstable, like my voice is breaking.”
• “I have this sensation of being hot, under a spotlight, all eyes zeroing in on me.”
• “Specific past memories of being bullied or humiliated at school f lash through
my mind.”

Thought and Imagery Record
Self-­monitoring outside of therapy sessions can be a useful method of identifying thoughts
and images. Discuss with clients the usefulness of Worksheet 5, Thought and Imagery
Record (and see Handout 2, Recording Thoughts and Images—both are in the Appendix) as
a means of “catching” or “tuning in” to their negative social thoughts and images, which
typically have been very automatic and unconscious for some time. Explain that paying
more attention to these thoughts and images and writing them down will give us the
best opportunity to do something about them.
The record can be completed anytime between sessions (and also within session)
when clients feel socially anxious, using anxiety as the cue to complete the record.
When clients notice this cue, the Thought and Imagery Record prompts them to note the
trigger situation, trying to be specific regarding the “where,” “what,” and “who” of the
social situation that is bothering them. They then ref lect on what thoughts are going
through their mind about the situation. Separate from the verbal thoughts they identify,
clients should then try to notice any specific visual images that arise from or with these
88 TREATMENT MODULES

thoughts. They can also note if there are any other sensory qualities aside from the visual
domain that accompany the image (i.e., sensations of sound, body/touch, tastes, or smells
that may be part of the image). Finally, they must note how they feel emotionally, which
will likely be some variant of an anxiety/fear response but may also include other emo-
tions such as shame or humiliation. The Subjective Units of Distress Scale (SUDS) is
used to rate from 0 to 10 the intensity of their emotional reaction.
Complete a full example in the Thought and Imagery Record collaboratively in session
with clients first to increase their confidence that they can complete the form indepen-
dently for homework. Generally, clients would use this monitoring form for one week
as a homework exercise, with the aim of increasing their awareness of negative social
thoughts and images and the impact of these cognitions on their emotions. Doing this
will lay the foundation for subsequent cognition modification strategies (i.e., imagery
challenging and behavioral experiments).

Difficulties Accessing Negative Thoughts and Images

Some clients may be able to readily identify and monitor their negative social thoughts
and images, while others may struggle with accessing thoughts, images, or both. Com-
mon difficulties may include the following:

Cognitive Avoidance
Negative social thoughts and images are going to be anxiety provoking, with negative
social images likely to be more anxiety provoking than thoughts. In either case, avoid-
ance of thoughts and/or imagery may be a client’s habitual coping strategy. If clients are
particularly anxious and avoidant of imagery, ensure that the rationale for working with
imagery to enhance the effectiveness of the treatment has been adequately addressed.
Normalize any elevation in anxiety that occurs from identifying negative thoughts and
images, reassuring clients that this is likely to be temporary, and even reframing this as
a positive sign that they are challenging their anxiety. Clients need to appreciate that
rather than avoiding these thoughts or images they need to start paying attention to
them, so they can then do something about them. The following metaphor may be use-
ful in communicating this concept.

“It is a bit like boxing with a blindfold on, it is pretty hard to do when you can’t see
your opponent. If you take off the blindfold your opponent may initially look scary,
but you will be in a much better position to plan a strategy for how to overcome
them once you can actually see them.”

Behavioral Avoidance
Some clients may not be experiencing much day-to-day social anxiety due to pervasive
social avoidance, which limits opportunities to catch their negative social images and
 Negative Thoughts and Images 89

thoughts. Clients may need to purposely confront social situations, or use imaginal social
scenarios to activate thoughts and imagery that can then be used for monitoring. It may
be useful to engage clients in real or imagined social situations within the session, so the
therapist can assist them both in reversing avoidant behavior and accessing their cogni-
tions.

Limited Cognitive Awareness
If clients report no awareness of mental images or thoughts, you could try the following,
which all rely on the notion that when affect is activated, cognitions will be more easily
accessible.

•• Identify a very specific recent example of when a client has felt socially anxious,
and then imaginally reexperience the scenario (e.g., “Close your eyes and pretend to be
back in the supermarket line about to approach the cashier”). You can then question what
thoughts or images are going through his mind, being back in the scenario experiencing
it firsthand as if it were happening now (e.g., “I’m thinking I don’t know what to say—
get me out of here,” “I am awkward, I’m stuttering, I can’t string a sentence together,”
“everyone is staring at me”). If that line of questioning is unproductive, you could stay
with his recollection of the scenario and ask what he concludes from it now (e.g., “I
looked like a bumbling fool, I just have no social skills”). Again, if this leads nowhere ask
him to guess “What do you think could go wrong here?” Alternatively, you could pose
the likely opposite expectation, such as “are you thinking that talking to this person will
be really easy and go really smoothly?” These questions should help to elicit the client’s
negative expectation, even if it hasn’t been labeled as an actual thought or image.
•• Identify an upcoming anxiety-­provoking social situation (e.g., attending a work
party) and encourage clients to imaginally visualize how they predict the scenario will
play out. For example:

Therapist: Close your eyes and imagine you are entering the party right now,
what do you see?
Client: Everyone is having a good time—­laughing, chatting.
Therapist: Where are you in the picture?
Client: I am all alone, no one is talking to me.
Therapist: What happens next?
Client: People are staring at me.
Therapist: How are you feeling?
Client: Really nervous.
Therapist: What concerns you about people staring?
Client: They are probably thinking “Oh no, what’s he doing here?”
90 TREATMENT MODULES

•• Create an anxiety-­provoking situation that can be completed within the therapy

session (e.g., the client dropping paperwork on the f loor of the waiting area). The ques-
tions previously outlined to elicit cognitive content can be used prior to, during, or after
the task. Even if clients are too anxious to follow through on the task, elevated anxiety
is a sign that negative social thoughts and images are activated, and therapists can focus
their efforts on accessing these.

Fear of Negative Evaluation
Fear of negative evaluation may present itself in the therapeutic relationship and inter-
fere with identifying negative thoughts and images. Clients may perceive their thoughts
and images to be stupid or illogical, or may question whether the thoughts and images
they are identifying are “right.” Thus, they may be reluctant to disclose their thoughts
and images because they feel embarrassed and may fear being judged by the therapist.
It is important to explicitly communicate that whatever thoughts or images arise for
clients, there are no right, wrong, or stupid examples, again reinforcing the importance
of awareness to facilitate change. To normalize cognitions about negative evaluation,
clinicians might describe some examples from past clients, or even some of their own
thoughts and images in social situations.
When it comes to accessing social imagery in particular, clients may find the process
of closing their eyes in front of the therapist embarrassing and anxiety provoking. They
may become distracted by concerns over what the therapist is seeing and thinking. This
issue can usually be solved by the therapist agreeing to drop his gaze to the f loor, turn-
ing therapist and client chairs back to back, or having clients start with their eyes open
and dropping their gaze to the ground, working up to eyes-­closed imagery work. This
reluctance can be framed as an opportunity for in-­session graded exposure or behavioral
experimentation.

Tips for Accessing Negative Thoughts and Images

Using Thoughts to Identify Imagery
Clients may be able to identify thoughts readily but struggle with associated imagery. If
this is the case, the following questions can be useful:

• “What does that thought (e.g., ‘I’ll look like an idiot’), look like as a picture?”
• “When you think (e.g., ‘I’ll look like an idiot’), what do you see or hear hap-
pening? What do you envisage playing out? What do you imagine? If this were
playing out like a movie, describe to me what would be happening in the scene.”
• “If I were there (e.g., when you were looking like an ‘idiot’), what would I be
seeing and hearing?”
• “Sit with the feelings, sensations, and thoughts this situation brings up for you and
see if you can allow an image to emerge that represents how you feel. It might not
 Negative Thoughts and Images 91

be an image of a real thing. It could be a fantasy or purely imaginary representa-

tion of your fear (e.g., an image of being a lot smaller in stature than the other
person you’re interacting with, or an image of being onstage under a spot light
with a hundred eyes on you).”

Using Imagery to Identify Thoughts

Conversely, clients may be able to identify images readily but struggle with associated
verbal meaning. If this is the case, the following can be useful questions:

• “How would you summarize what is happening in that picture?”

• “What does the image mean to you?”
• “What does the image mean about you?”
• “What does the image mean about other people?”
• “What is that picture overall suggesting about how you are coming across, per-
forming, or appearing, or the observability of your anxiety?”
• “What is that picture overall suggesting about other people, their reactions to you,
or their evaluations of you?”
• “What is that image suggesting about other social interactions you may encoun-
ter?”

A client in one of our social anxiety groups experienced severe anticipatory anxiety
about making phone calls, which resulted in almost wholesale avoidance of using the
telephone. Despite extensive and varied questioning from her therapist, she was having
great difficulty identifying any specific concerns about making phone calls. The thera-
pist eventually asked her to imagine that she was involved in a conversation and that this
was playing out on the television screen. She was encouraged to see herself and the other
person on the screen, separated by a diagonal line as depicted in the old TV shows in the
1960s. The therapist then asked how the other person was looking on the screen. The
client described the other person as looking irritated for being kept from other activities
she would prefer to be doing. In this example, the imagery enabled the client to identify
the predictions that friends would be inconvenienced and irritated by her calling them
and that they did not want to speak to her, which explained her anxiety and avoidance
of phone calls.

Modifying Negative Thoughts and Images

Once clients can identify their negative social thoughts and images using the Thought
and Imagery Record, the next step is to work on challenging and modifying these cogni-
tions using Worksheet 6, the Imagery Challenging Record (in the Appendix). While clients’
awareness of their cognitions is necessary for the modification process, it is important
to move to the task of modifying cognitions as soon as possible. Identifying negative
92 TREATMENT MODULES

thoughts and images is the first important step toward cognitive change, but awareness
is not enough to produce enduring emotional change. It is important that clients have an
early experience of success or change in therapy, so don’t delay moving to the challeng-
ing process unless the client is really stuck on basic cognitive awareness.
The Imagery Challenging Record assists clients to make more accurate judgments about
perceived social danger by challenging the overestimation of both the probability and
consequences of social catastrophe. The notion of cognitive challenging can be intro-
duced to clients in the following manner.

“Now that we are more aware of some of your typical negative social thoughts and
images, we are in a good position to take a step back and look at how accurate they
are. Previously these thoughts and images have been so quick and automatic, that
understandably you have just accepted them without question. Up until now, you
haven’t had the opportunity to question them, to be curious about them, to check
them out further. The Imagery Challenging Record will be the tool we will use to
do this. When we do this, it will be a bit like taking the stance of a lawyer or detec-
tive, putting the negative thoughts and images on trial and looking at the factual
evidence that does or does not support them, to see how they ‘hold up.’ If we get
to the end of the process and find out that your negative social thoughts and images
are valid, then this means there is a real problem going on for you that needs to be
addressed, and we could then use problem-­solving strategies to do this. However, if
we get to the end of the process and discover that your negative social thoughts and
images may be inaccurate in some way, then we can update them to better ref lect
reality, which should in turn have an impact on how fearful you are in social situ-
ations.”

Notice that the stance that is taken in this explanation is one of curiosity about
the accuracy of client’s cognitions, rather than a presumption that her cognitions are
“wrong.” It is important for therapists to adopt this genuinely agnostic attitude dur-
ing the cognitive challenging process, and to instill this same attitude in their clients.
Cognitive challenging is not intended to be a process of interrogation, persuasion, or
entrapment. It is an invitation for clients to curiously explore the accuracy of their ideas.
It is often helpful to socialize clients to the challenging process by completing an
Imagery Challenging Record on a hypothetical example that is unrelated to their primary
concerns (see Handout 3, Challenging Negative Thoughts and Images, in the Appendix for
a completed example). Clients typically find it easier to familiarize themselves with the
process of cognitive restructuring when they are unencumbered by their own emotion-­
laden examples. Once clients are familiar with this process, they can then use the Imag-
ery Challenging Record to tackle their own real-life examples. Their first attempt at this
should be done with the therapist in session. Depending on how well they apply this
new skill, they can then try doing this independently as a homework exercise any time
they feel socially anxious. Highly avoidant clients who are unable to identify specific
 Negative Thoughts and Images 93

thoughts or images will need to imaginally or behaviorally expose themselves to social

scenarios so they have some “grist for the mill.”
When using the Imagery Challenging Record there are eight steps involved in the
modification process. The first three steps should be familiar to clients, as they center on
identifying negative social thoughts and images, and are essentially a streamlined version
of the Thought and Imagery Record they have already been using. The remaining five steps
will be new to clients and may require greater discussion.

How to Challenge Negative Social Images

The eight steps of imagery challenging as explained to clients are outlined below, and
are also included in Handout 3, Challenging Negative Thoughts and Images. The handout
can be provided to clients as psychoeducational reading material to assist them when
acquiring this new skill. As you will see, imagery features specifically at steps 2, 6, and 7
of the imagery challenging process. Essentially the only deviation from standard cogni-
tive therapy is to put more emphasis on ensuring the initial negative automatic thought
is accessed in the imagery modality, and the new balanced or helpful thought at the end
of the restructuring process is also in the imagery modality and accessed as such. This
is not a radical shift from other forms of cognitive restructuring. However, this simple
adjustment is intended to enhance an already tried and true technique by increasing the
intensity of the emotional connection. As will be discussed later, imagery can also be
incorporated in other ways during the restructuring process when the therapist judges
this to be useful.

Step 1: Trigger Situation
“What is the social situation concerning you? Brief ly and objectively describe the
situation (e.g., where it is, what is happening, who is there). This might be a past
situation that you are ref lecting on or a future situation that you are anticipating.”

Step 2: Negative Image
“Describe the negative visual images and thoughts going through your mind about
the trigger situation. Also, describe any other senses that are part of the image (i.e.,
sounds, body/touch sensations, tastes, smells). If thoughts in the form of words are
most prominent, try to close your eyes and see what picture arises that represents
those thoughts.”

Step 3: Emotion
“Describe the emotions you are feeling in relation to the trigger situation, and indi-
cate their intensity using the Subjective Units of Distress (SUDS) rating (0–10).”
94 TREATMENT MODULES

Step 4: Contrary Evidence
“Look for contrary evidence that suggests these thoughts and images may not be
entirely accurate, and consider alternative ways the situation could play out. The
focus on contrary evidence is because people tend to be very good at remember-
ing experiences that confirm their fears but find it more difficult to recall contrary
experiences. The best way to counteract this bias is to think about evidence that
does not support your negative thoughts and images. It is important to recognize
that your initial negative thoughts and images portray just one of many possible out-
comes, so it can be useful to entertain alternative perspectives. Asking the following
questions can assist in uncovering contrary evidence and alternative views.”
• “Have I had any experiences that show that this image is not completely true
all of the time?”
• “Are there any small things that contradict my image that I might be ignoring?”
• “Have I been in this type of situation before? What happened? Is there any-
thing different between this situation and previous ones? What have I learned
from prior experiences that could help me now?”
• “Is my image based on facts, or am I ‘mind reading’? What evidence do I
really have?”
• “Am I jumping to conclusions that are not completely justified by the evi-
dence?”
• “If someone who loves me knew I was having this image, what would they
say to me? What evidence would they point out that would suggest that my
image was not 100% true?”
• “Are there other ways of looking at this situation?”
• “What are all the possible explanations in this situation? Are there any alter-
natives to mine?”
• “What’s the best that could happen?”
• “What’s the worst that could happen? What’s so bad about that? Could I cope
with this? Would life go on? What could I do that would help?”
• “Will this still bother me in 1 week/month/year?”
• “If the roles were reversed, how might I judge the situation/other person?”
• “Regardless of whether the image is true, is it helpful to think this way? What
are the negative consequences of thinking this way? What would be a more
helpful way to think or a more helpful image to hold?”

Step 5: Realistic Probability and Consequences

“Given the contrary evidence and alternative perspectives, now consider the most
realistic probability and consequences. If you are completing the record regard-
ing a past social situation, you might want to think about the true probability that
your interpretation of events was entirely accurate. If you are certain that your
 Negative Thoughts and Images 95

interpretation is accurate (based on good evidence), you might want to spend more
time focusing on the true consequences in a balanced way.”

PROBABILITY

“What is the most likely outcome? If the situation is in the future, how likely is it that
your negative image will actually occur? If the situation is in the past, how likely is
it that your negative image is an accurate and balanced picture of the whole situa-
tion? You might want to also consider how likely it is that a negative outcome would
occur in the same situation in the future.”

CONSEQUENCE

“What are the most likely consequences? If something bad happened, then so what?
Is it really a catastrophe? What can you do to cope? If you anticipate something bad
happening, how bad would it really be? Will you still be thinking about it a day,
week, a year, or 10 years down the line? If not, can you let it go now?”

Step 6: Helpful Image
“Given what you have learned for steps 4 and 5, now develop a more helpful or real-
istic image of the situation. In as much detail as you can, create a new picture of how
things are likely to go. If this is about a situation that has already happened, then
create a more helpful image that incorporates your contrary evidence and realistic
consequences.”

Step 7: Visualize Helpful Image
“Now spend a few moments visualizing the helpful image. Spend at least 2 minutes
bringing this new image to mind. Doing this is important, as it will allow you to
experience the full emotional impact of your new more helpful and/or realistic
image.”

Step 8: Rerate Emotion
“Describe and rate the strength of how you feel visualizing the helpful image. Use
the SUDS rating (0–10).”

The Contrary Evidence and Realistic Probability and Consequences sections of the
Imagery Challenging Record are essentially standard verbally based cognitive challenging
techniques. One could use the questions strictly in this manner and then summarize
the findings from this line of questioning by developing a more helpful image (i.e., step
96 TREATMENT MODULES

6), and then activating the image by visualizing it (i.e., step 7). The addition of steps 6
and 7, which are not standard in traditional thought records, is intended to enhance the
emotional connectedness of any cognitive shifts that have been achieved. Having a new
cognitive perspective represented in an imagery format, and then activating that image
by purposely bringing it to mind, should elicit a stronger emotional impact than keeping
the new cognitive perspective purely in a verbal format.
Therapists can also encourage clients to find ways to work in imagery mode through-
out the whole thought-­challenging process, not just when prompted at steps 2, 6, and
7. For example, at step 5, when encouraging clients to consider the true consequences
of social mishap, encouraging them to imagine things going wrong and running this
image on past the worst point may help shed light on the severity and longevity of social
catastrophe. In addition, at step 4 when clients recall experiences that provide contrary
evidence to their negative social images, the therapist can ask them to imaginally reex-
perience these events to give the evidence more emotional weight. The following dia-
logue illustrates how this might be done:

Therapist: Are there any experiences you have had, no matter how small, that
don’t quite fit with the image that people at your office party are going to stare,
not talk to you, and be wishing you weren’t there?
Client: I don’t know . . . I guess the other day one of my coworkers asked me if I
was going to the party, and when I said yes she seemed pleased.
Therapist: How did that make you feel?
Client: Good, I guess . . . at the time.
Therapist: It might be useful to get a bit more in touch with that “good” feeling.
I am wondering if you could take a moment right now to close your eyes and
imagine being back in the situation when your colleague spoke to you, as if it
is happening right now. So looking out of your own eyes at the situation . . .
what’s happening?
Client: I am at the coffee machine, I’m almost done with getting my coffee, and
I turn around and see Tania heading for the machine after me. She says hi and
smiles . . . I say hi back. I turn to leave, and she says, “So are you going to the
party?” I say, “Yeah, I think so.” Tania says “Great, I’ll see you there.” Again
she is smiling and cheery.
Therapist: How are you feeling now?
Client: Positive, happy, it feels nice to have someone being friendly and seeming
to want me around . . . but she was probably just being polite.
Therapist: For now, I want you to stay with the positive feeling, rather than
allowing your mind to steer you away from that. How do you know you feel
happy? Where do you feel it in your body?
Client: In my chest.
 Negative Thoughts and Images 97

Therapist: What do you feel in your chest?

Client: Lightness, energy, warmth.
Therapist: What about your body posture and facial expression, what are they
doing as you feel this sense of happiness?
Client: I am smiling, head up, shoulders back as I walk away.
Therapist: Can you do that now . . . smile with your head up and shoulders
back . . . See if you can stay with that feeling a little bit longer . . . when you are
ready you can open your eyes. So, Tania seeming happy about you attending the
party, is that contrary evidence that we can jot down?

At step 7, when clients are encouraged to visualize the more helpful and/or realis-
tic image, therapists may need to prompt them to engage and persist with this process,
revisiting the rationale that this will generate a greater emotional impact than just look-
ing at the words on the paper. Therapists can facilitate this process with some combina-
tion of the following prompts, depending on what seems appropriate for the image being
explored. In group treatment, therapists can follow the prompts exactly. In individual
treatment, clients will be able to give verbal feedback in response to the prompt ques-
tions, and their feedback will guide the prompts selected:

“Close your eyes and spend a few moments visualizing this new more helpful and
realistic image as if you are experiencing it firsthand right now.”
• “What do you see, hear, sense?”
• “What is happening?”
• “Where are you?”
• “Who is there?”
• “What are you doing?”
• “What is your posture like?”
• “What is your facial expression like?”
• “How do you feel?”
• “Where do you feel it in your body?”
• “What physical sensations do you notice?”
• “What are you thinking?”
• “What happens next?”

The final step of the Imagery Challenging Record allows client and therapist to ref lect
on the experience of visualizing the more helpful image, particularly exploring the
emotional impact of the visualization. Aside from emotional impact, it can be useful to
take the impact of the imagery challenging one step further, discussing any effect on the
client’s preparedness to enter the social situation in the future. This can provide a nice
bridge into the behavioral experiments to come.
98 TREATMENT MODULES

The helpful image developed from the imagery challenging process can then be
called to mind anytime clients notice they feel anxious regarding the event in ques-
tion. It is important that clients realize this is not a guarantee of how things will occur
in reality. This is not a case of imagine it and it will come true. Nor is the image to be
misused as a safety behavior, with clients feeling compelled to hold these helpful images
in mind constantly to prevent their fears coming true and enable them to cope. Instead
the image is a shorthand reminder of a more realistic and helpful perspective, and elicits
the feelings associated with this perspective. Some mental rehearsal of the image may be
appropriate, as is calling it to mind brief ly before, during, or following the social event,
with the overall aim of the image being to assist clients to more f lexibly consider alterna-
tive helpful and realistic images, and hence engage and persist with much-­needed social
behavior change.

Tips for Challenging Negative Thoughts and Images

The most common material worked with in imagery challenging for social anxiety
centers on anticipatory anxiety about an upcoming social situation. The thoughts and
images identified often ref lect a fairly literal but negative conception of how clients
imagine social scenarios will play out. After looking at contrary evidence and realistic
probabilities and consequences, the client will create a new image that will ref lect a
more realistic and literal version of events. However, sometimes the material worked on
in imagery challenging may be more fantasy or metaphorically based (e.g., “I am walk-
ing a tightrope as onlookers jeer and shout at me”). In this case, the new image may be
metaphorical in nature too, conveying a more helpful perspective (e.g., “People aren’t
really interested in watching me on the tightrope, they are caught up watching some
other performer, so I just start playing around, trying a few jumps and f lips, and there is
a net underneath to catch me, so there isn’t any real danger”). We have therefore referred
to this image in the Imagery Challenging Record as the “Helpful Image” to accommodate
images that might be realistic or metaphorical in nature. To prompt for a new metaphor-
ical image after the client has considered contrary evidence and realistic probabilities and
consequences, the therapist might ask, “What needs to change in your original negative
image, so the image better ref lects this information we have just uncovered?”
If the initial negative image is literal in nature, it is OK if the more realistic image
happens to take on a more fantasy-­based or metaphorical tone, provided it is capturing
the more helpful perspectives gained from filling out the Contrary Evidence and Realis-
tic Probabilities and Consequences sections of the worksheet and has a helpful emotional
impact. For example, the initial negative image may be of one’s peers being nasty and
openly critical, and the new helpful image may be of these peers being the size of mice
to convey the perspective that their opinions aren’t that important. With this principle in
mind (i.e., that the content of the new image is irrelevant, it is the meaning represented
that is most important), there may be some therapeutic credibility to the old lay advice for
performance anxiety given to many of us by well-­meaning relatives, that of imagining
one’s audience in their underwear. This type of image communicates the sentiment that
 Negative Thoughts and Images 99

the audience is not superior, judgmental, or any real threat to us. However, it is important
that the new helpful image be the client’s own creation, communicating helpful meaning
in an idiosyncratic way, rather than a prescription from the therapist, like a glib old uncle
telling us, “Just imagine everyone is in their underwear and you’ll be all right!”
An Imagery Challenging Record may also be applied to social situations that have already
occurred that clients judge have gone badly. In these circumstances, it is important to
remember that the negative image they hold is still a representation of the event that is
laden with meanings they have attached to it, even if the event was objectively negative
(e.g., someone openly being rude and calling them “weird” in front of other people).
In these circumstances, all the questions of step 4 designed to elicit contrary evidence
and alternative perspectives are still relevant, except for “What’s the best that could hap-
pen?” and “What’s the worst that could happen,” as the event has already transpired.
However, these questions could be asked about whether there are likely to be ongoing
consequences into the future. When it comes to examining realistic probabilities and
consequences, focusing more on the consequences may be particularly helpful in these
instances, using questions like:

• “Was it really as bad as the negative image I’m holding?”

• “How biased is the negative image?”
• “What was the real cost or the consequences?”
• “Did I cope? Survive? Get through it?”
• “What could I do now to cope with it?”
• “Will this still matter in 1 week/one month/one year/etc.?”

The helpful image will then incorporate the alternative perspectives that have been
generated. For example, the image may include people staring at the other person for
being so rude, and may also include other people encountered at the same event who
were pleasant. Playing out the whole image from beginning to end will reduce the risk
of getting stuck at the most distressing aspect of the situation, and instead will involve
moving past that point to focus on how clients coped with the rest of the event. It might
also be helpful to fast-­forward the image to a year later, imagining what clients might
be doing and how much they will care about the negative event or negative person with
the passage of time.
A common difficulty during imagery challenging is a lack of contrary evidence.
This can either be the result of clients having endured an unusually large number of
negative social experiences due to exposure to a specific negative environment (e.g.,
highly critical family members) and/or a pervasive and long-­standing pattern of avoid-
ance that leaves clients with limited social experiences to draw on. It may be necessary
in these instances to design behavioral experiments (see Chapter 6) in generally “safe”
environments as a means of gathering new evidence. As new evidence is collected in the
here-and-how, clients will become more aware that their negative experiences were spe-
cific to a certain time and place, and may not hold true now or in other environments.
Behavioral experiments then become the means of gathering contrary evidence.
100 TREATMENT MODULES

Another difficulty encountered in standard thought challenging work is the discon-

nect between rational knowledge (i.e., the “head”) and emotion (i.e., the “gut”). This is
usually captured by clients saying at the end of thought challenging, “I know logically
that my thoughts aren’t true, but I still feel like they are.” The use of imagery in the cog-
nitive challenging process is designed to bridge the gap between head and gut, connect-
ing emotion to cognitive change, and hopefully minimizing this common discrepancy.
However, if the disconnect persists, you can explain to clients that together you will
“check out” whether their thoughts and images are true later by using behavioral experi-
ments, which will help them to really believe their new evidence at an emotional level.
A final difficulty that can emerge regarding imagery challenging is the sheer effort
involved in developing this skill. Early in treatment clients will need to formally com-
plete the Imagery Challenging Record to get the maximum benefit, which may seem an
onerous task. It must be acknowledged that applying this skill does take some effort, but
is a means to an end, the end being to retrain the mind to become more f lexible and pro-
duce more realistic and helpful thoughts and images. Reassure clients that with practice
and persistence, entertaining more helpful perspectives will become a more automatic
and less effortful cognitive process.

Clinical Case: Modifying Negative Imagery

A client who was extremely fearful of walking along a populated café strip had the negative image of
many people along the street and in the cafés staring at him as he walked past, frowning and sneering
at him, with their dirty looks indicating that they were thinking he wasn’t “good enough.” After consider-
ing the contrary evidence and the realistic probabilities and consequences, he could logically accept
that it was unlikely people would be paying him much attention, as they would likely be caught up in
their own world. When constructing a new image that captured this knowledge, a more fantasy-­based
metaphorical image came to mind of the people being replaced by dogs and cats. We played around
with the image, imagining dogs and cats dressed in human clothes going about human business,
for example the barista dog making the client’s coffee. We had a good laugh at this together. We dis-
cussed that it didn’t necessarily matter that the new image wasn’t reality based, it was the meaning it
represented that was important. When asked about its meaning the client said, “Well, dogs love you
unconditionally, and cats don’t give a s    about you.” Hence, the new image represented the mean-
ing we were looking for, that there was no need to fear negative judgment because people are mostly
accepting and nice, or couldn’t care less about you.
 Negative Thoughts and Images 101

THERAPY SUMMARY GUIDE: Negative Thoughts and Images

Therapy Aim:  Identify and modify negative social thoughts and images ref lecting a
high probability and cost of social catastrophe.

Therapy Agenda Items:

Introduce imagery:
]]
Imagery discussion
\\
House Imagery Exercise
\\
Free Association Exercise
\\
Negative social imagery examples
\\
Provide a rationale for working with imagery:
]]
Imagery promotes cognitive specificity
\\
Imagery elicits stronger emotions, as illustrated by the Chocolate Cake Imagery
\\
Exercise and the Brain Input and Output Exercise
\\Imagery facilitates exposure and new learning
Identify negative thoughts and images:
]]
\\Worksheet 4, Thought/Image–­Feeling Connection
\\Worksheet 5, Thought and Imagery Record—review hypothetical examples, then
apply to client examples with therapist assistance, then complete independently for
homework when social anxiety is triggered
Modify negative thoughts and images:
]]
Worksheet 6, Imagery Challenging Record—review hypothetical examples,
\\
apply to client examples with therapist assistance, client completes the record
independently for homework when social anxiety is triggered, and later in therapy
as preparation for behavioral experiments

Therapy Materials:
Handouts
]]
Handout 2, Recording Thoughts and Images—includes Thought and Imagery
\\
Record Example
Handout 3, Challenging Negative Thoughts and Images—includes Imagery
\\
Challenging Record Example
Worksheets
]]
Worksheet 4, Thought/Image–­Feeling Connection
\\
Worksheet 5, Thought and Imagery Record
\\
Worksheet 6, Imagery Challenging Record
\\
 CHAPTER 6

Avoidance and Safety Behaviors

Therapist: So, how have you usually tried to manage your social anxiety?
Client: Mostly I just stay away from people. I can’t be judged if there is no one
around to judge me.
Therapist: So, avoiding people is one way you cope. Are there ever situations that
you just can’t avoid and you have to suffer through them?
Client: It is hard to avoid people completely, so yes. You know I have to go to
work, grocery shop, those sorts of things that I need to do just to live. I can’t
completely avoid people.
Therapist: In these sorts of situations what do you do to control your anxiety or
avoid others judging you?
Client: At work I don’t say much to people, just keep to myself and make sure I
always look too busy to be chatting with others. At the shops, I only go really
late at night when there is hardly anyone there, and I am in and out really quick,
I don’t hang around.
Therapist: So, it sounds like when you can’t outright avoid a situation you do
other things to try to keep yourself safe, like stay quiet, look busy, be strategic
about the time you go, or rush through the experience. These are what we call
“safety behaviors.” Safety behaviors are subtle forms of avoidance. Do you think
avoiding people and using these sorts of safety behaviors have been helpful ways
to cope with the problem?
Client: Well, it keeps the anxiety at bay, otherwise it would be completely unbear-
able.
Therapist: In therapy, we will have the opportunity to look at these avoidance and
safety behaviors in more detail. On the surface or in the short term it might feel
like they are helping, it might feel like you are managing the problem. But we
102
 Avoidance and Safety Behaviors 103

need to be curious and look at the impact of these behaviors in the long term,
to see if they might be making the problem worse in some way.

About This Module:
Addressing Avoidance and Safety Behaviors in SAD
Most people with significant anxiety avoid some or all the triggers of their anxiety.
People with SAD often avoid any situation in which they perceive that social threat is
likely and costly. While on the surface it may be clear that clients are avoiding particu-
lar trigger situations, what they are more specifically avoiding is the possibility of their
negative social thoughts and images coming true in these situations.
Some social situations will be completely avoided, whereas others may be endured
with distress, at least until escape is possible. In these situations, it is likely that some
form of safety behavior will be at work. Safety behaviors are subtle covert avoidance
behaviors that are used when overt avoidance is not possible. For example, an individual
might attend an obligatory work meeting while using the safety behavior of not speak-
ing to prevent feared images of being criticized by colleagues from coming to fruition.
On the surface safety behaviors look different from avoidance, but they serve exactly the
same function. Wholesale avoidance and safety behaviors are both methods of trying to
prevent feared social thoughts and images from becoming a reality.
Successful treatment of SAD depends on identifying all forms of avoidance and safety
behaviors, helping clients understand how these overt and subtle forms of avoidance play
an important maintaining role in their SAD, helping to instill a willingness to drop
avoidance and safety behaviors, and using these behavioral changes as an opportunity
to experientially test the validity of clients’ feared thoughts and images. This module
covers the practicalities of getting clients on board with and appropriately implement-
ing this part of treatment, with behavioral experiments being the central strategy for
addressing avoidance and safety behaviors. All other components covered in this chapter
(e.g., behavioral experiment hierarchies, coping imagery) are implemented in the service
of behavioral experiment engagement and effectiveness. In our experience, behavioral
experiments are the most effective component of treatment, occupy the most time and
attention during therapy, and are usually the most challenging aspect of treatment for
both clients and therapists.

Socializing Clients to Modify Avoidance and Safety Behaviors

Identifying Avoidance and Safety Behaviors
The first step in motivating clients to target their avoidance and safety behaviors is to
identify the behaviors most relevant to them. The following questions may be useful for
eliciting avoidance behaviors.
104 TREATMENT MODULES

• “What are some common situations you avoid for fear of . . . [negative evaluation
from others/people thinking badly of you/others judging you/being the focus of
attention/being noticed/standing out/interacting with others/performing badly
in front of others/others observing you]?”
• “What situations make you feel socially anxious? Do you avoid these situations or
suffer through them?”
• “Is there anything you are not currently doing that you would like to be doing?
Why aren’t you doing these things? Are you avoiding these things because of
social anxiety?”

Avoided situations can be pervasive, varied, or quite select. Some clients may avoid
all forms of interpersonal interaction, while others may steer clear of particular types of
interactions. Some clients might cope very well in situations generally considered to be
more challenging (e.g., performing in public), yet avoid seemingly easier situations (e.g.,
a one-on-one conversation). Professional actors with SAD, like our case-study subject
Max from Chapter 1, for example, often feel quite at home performing from a script on
camera or in front of a large audience, but they find the prospect of interacting socially
with others offstage terrifying. It is important to remember that it is not so much the type
of situation that determines if someone has social anxiety, but that the avoidance is driven
by the perception of social threat. Humans are social creatures, and it is very difficult
to avoid people in most modern societies. The potential triggers for social anxiety are
therefore many and varied. Box 6.1 lists a range of possible situations that socially anxious
people may avoid. As you will see, many of these involve simple tasks of daily living.
When identifying safety behaviors in particular, the following questions may be
useful:

• “When you can’t avoid a situation, do you do anything to prevent your . . . [fears/
predictions/negative social images] from coming true?”
• “When you can’t avoid a situation, do you do anything to make yourself feel . . .
[safer/less anxious/more at ease]?”
• “When you feel anxious in a social situation, do you do anything to . . . [hide your
anxiety/stop your anxiety/conceal yourself/not draw attention to yourself/come
across better to others]?”

When exploring the common safety behaviors clients use in social situations, be
aware that they might use different safety behaviors in different situations. For exam-
ple, they might rely on alcohol at casual social events, overpreparation at work, mental
rehearsal of what they are going to say before conversations, scripting what they will
say during presentations, and wearing sunglasses or pretending to use a mobile phone
while walking down the street. Therefore, encourage clients to first think about some of
the different social situations that trigger their anxiety, and then record all the strategies
identified (beside outright avoidance) to try and prevent their negative social thoughts
and images from coming true.
 Avoidance and Safety Behaviors 105

BOX 6.1.  Possible Social Anxiety Triggers

• One-on-one interactions • Eating out or in front of others

• Small-group interactions • Public speaking, presentations
• Large-group interactions • Expressing an opinion
• Initiating conversation • Speaking to authority figures
• Maintaining conversation • Being in a public place (e.g., walking
• Contributing to discussions down the street, getting in a crowded
• Meetings, classes elevator)
• Public transportation • Performing a task in front of others
• Shopping • Writing in front of others (e.g., signing
one’s name)
• Leaving the house
• Attending appointments (e.g., doctors,
• Public toilets
hairdressers)
• Parties
• Drawing attention to oneself (e.g., differ-
• Interacting with strangers/unfamiliar ent hairstyle, bright clothing)
people
• Handing money to a cashier
• Interacting with acquaintances
• Joining hobby or sporting groups
• Interacting with close/familiar people

Normalizing the Function of Avoidance and Safety Behaviors

Some clients will feel embarrassed by or ashamed of their avoidant coping strategies. It
is important to normalize the use of these behaviors for clients by acknowledging that
avoidance and safety behaviors have an intended purpose or function, typically aimed
at protecting and keeping them safe. They are in fact very understandable, and in some
ways they have been valuable to clients. It can be useful to link avoidance and safety
behaviors to negative social imagery, so clients can explicitly see what these behaviors
are designed to prevent. A useful question in this regard is “What do you imagine hap-
pening if you didn’t avoid the situation or didn’t use this safety behavior?”
You could record this information using two columns noting what the avoidance or
safety behavior is, and what negative image it is designed to prevent. Table 6.1 provides
some common examples.
Obvious avoidance behaviors are usually easier to detect than safety behaviors. Ther-
apists can sometimes be unsure if a behavior qualifies as a safety behavior. It is important
to remember that the function of the behavior, rather than the behavior itself, determines
if it is a safety behavior. If the primary aim of the behavior is to prevent feared negative
social thoughts and images from coming true, then it is serving an avoidant function
(just like outright avoidance) and can be classified as a safety behavior. For example, one
socially anxious client always wore headphones for his portable music player on public
transport. Around the same time the therapist was seeing him for treatment, she also
regularly caught the bus to work and was doing the exact same thing. The therapist and
client talked about how they both listened to music on public transportation, but that
106 TREATMENT MODULES

TABLE 6.1.  Common Examples of Avoidance and Safety Behaviors and Their Intended Function
Avoidance of . . . Aimed at preventing . . .
Parties Being alone with no one to talk to

Public places All eyes on me, looking awkward and out of place

Shopping People getting angry as I hold everyone up in line while I fumble for
my wallet

Dating Saying the wrong thing and offending my date

Work Not performing my duties properly and people saying behind my back
that I am useless

Conversations Having nothing to say, long awkward silences, and other people
getting annoyed with me

Safety behavior is . . . Aimed at preventing . . .

Avoiding eye contact Someone starting a conversation with me and me not knowing what to
say back

Wearing sunglasses Others noticing my anxiety and looking at me like I am weak

Alcohol/drugs People at a party finding me boring and moving away

Using my cell phone Appearing awkward and anxious, not knowing where to put my arms

Overrehearsing conversations Long silences with nothing to contribute, making the other person feel
uncomfortable and want to get away

Not contributing to conversations Saying something stupid and being criticized; looking awkward if I’m
the focus of attention

Overpreparing speeches Stuttering, umming, going blank, long pauses, making no sense,
people being confused or laughing

Hair covering my face Bright-red blushing cheeks being noticed

Makeup Bright-red blushing cheeks being noticed

Inconspicuous clothing People noticing me, looking, and judging

Keeping hands in pocket People noticing my hands shaking and thinking I am a weirdo

the reasons behind their behaviors differed. For the therapist, it was because she enjoyed
listening to music on the journey to and from work, and if for some reason the battery
ran out or she forgot her music player that day she felt disappointed but could still get on
the bus, and it had no impact on her anxiety. However, the client used this behavior to
reduce the likelihood that someone would start a conversation with him and he would
appear awkward and not know what to say. For him, to not have his music device would
mean a huge increase in his anxiety and a strong likelihood he would avoid using public
transportation altogether. So, when it comes to safety behaviors, it is not what you do,
 Avoidance and Safety Behaviors 107

but why you are doing it that is the primary issue. When it is being used in an attempt
to stop feared negative social thoughts and images from coming to fruition, and hence
to reduce anxiety, it is unhelpful in the context of effective SAD treatment and needs to
be addressed.
Useful questions to determine if a behavior is indeed a safety behavior are:

• If you couldn’t do the behavior, what would happen?

• What would happen to your anxiety?
• What would happen to your ability to be in that situation?

Highlighting the Maintaining Role of Avoidance and Safety Behaviors

Once relevant avoidance and safety behaviors have been identified, it is important to
normalize their occurrence, but then start instilling a sense of curiosity regarding their
helpfulness. Clients can be introduced to the vicious cycle of avoidance using Socrati-
cally guided psychoeducation as follows (which is also described in Handout 4, The Cycle
of Avoidance and Anxiety, in the Appendix):

“People with social anxiety often rely on avoidance. Avoidance might take the form
of complete avoidance of particular situations or, when situations can’t be avoided,
subtler forms of avoidance called safety behaviors. Safety behaviors like [insert client
examples] are often used because people believe they will help to prevent their fears
from coming true. On the one hand, avoidance seems like a very sensible strategy. It
makes sense to avoid things that we think are dangerous to us. On the other hand,
avoidance is the main reason that social anxiety persists.
“In what way do you think avoidance is a problem? What have been the neg-
ative consequences of continuing to avoid social situations? Although avoidance
brings some relief of anxiety in the immediate short term, what has it done to your
anxiety over the long term? How might avoiding social situations be keeping your
social anxiety going? How might avoidance keep your perception of social threat
going?”

The following concepts should be covered during this discussion about the conse-
quences of avoidance.

We Never Get to Test Our Negative Images

“When we avoid a social situation, we are assuming that our negative images are
accurate ref lections of reality. However, avoidance never gives us an opportunity
to directly test our fears. If we did, we might discover that our images are actually
inaccurate. We might learn that in fact what we fear rarely occurs and instead that
things often turn out pretty well. We might also find that even if social experiences
don’t go according to plan sometimes, we can cope with this as well. So avoidance
108 TREATMENT MODULES

prevents us from getting an accurate impression of the true probability and cost of
our fears coming true.”

We Never Get Opportunities for Positive Experiences

“If we avoid social situations, we have no chance of having positive social experiences
that would motivate us to socialize more.”

Loss of Self‑Esteem
“Because people with social anxiety aren’t doing what they would really like to do,
they tend to be very self-­critical and can have low self-­esteem. They may ruminate a
lot about aspects of life that are passing them by, which leaves them more vulnerable
to further anxiety and depressed mood. In fact, people with social anxiety can often
use their avoidance as just another reason to criticize themselves.”

Avoidance and Anxiety Can Generalize

“As we avoid situations and lose confidence in one area of our lives (e.g., relationships
with peers), our anxiety can start to generalize to more and more domains of life
(e.g., work, family relationships).
“The vicious cycle of avoidance and anxiety that captures all of these long-term
problems might look something like this . . . [Draw Figure 6.1 collaboratively with
the client on a whiteboard or piece of paper.] In social anxiety we can get very stuck
in this cycle, as avoidance keeps our negative social images in place, hence maintain-
ing our anxiety and narrowing our quality of life.
“To overcome social anxiety, we need to break or reverse this cycle, and the
most tangible place we can start is with our behavior (i.e., avoidance). We need to
drop our avoidance behaviors, and instead gradually place ourselves in situations that
bother us. We also need to do this without the precautions of using our safety behav-
iors because we need to find out what happens when we allow ourselves to just be
in the situation. Now, of course we will initially feel anxious when we do this. But
as someone with social anxiety living in what is a very social world, you are kind of
used to that feeling. So if we persist with the situation, and ride through that initial
anxiety, what might happen? What might we have the opportunity to discover?
[Draw Figure 6.2 collaboratively with the client to illustrate reversing the cycle.]
“What do you see as the take-home message of our discussions? How helpful
do you think your avoidance is now that we have had the chance to think about it
more? . . . The key message is that by no longer avoiding or using safety behaviors,
we have the opportunity to test the validity of our negative social thoughts and
images, an opportunity that avoidance has robbed us of for so long. These new social
experiences may then update these images to be more realistic, which in turn will
 Avoidance and Safety Behaviors 109

Negative social images

Never test negative images

Miss out on positive experiences Anxiety
More self-critical
Start feeling anxious in more situations

Avoidance

FIGURE 6.1.  The vicious cycle of avoidance and anxiety.

Helpful image

Opportunity to test negative images

Opportunity for positive experiences Less anxiety
Less self-critical
Start feeling confident in more situations

Approach social
situations without safety
behaviors

FIGURE 6.2.  The positive cycle of approach and reduced anxiety.

110 TREATMENT MODULES

have the effect of reducing anxiety and increasing our willingness to try further
social situations, which may further update more of our social thoughts and imagery
to be more realistic. And so the cycle continues, but this time in a positive direc-
tion.”

The covert avoidance afforded by safety behaviors is also useful to address with
Socratically guided psychoeducation, as shown below (and described in Handout 5,
Safety Behaviors, in the Appendix).

“We may use safety behaviors because we think they help us cope in the short term;
how do you think they may not work so well over the long term? The more you
have used safety behaviors like [insert client’s particular safety behaviors], what do
you notice has happened to your social anxiety overall? When you use a safety
behavior like [insert a specific safety behavior], how do you know if your fear that
[insert predicted negative image] is accurate? How can safety behaviors backfire?
What are the downsides of using safety behaviors?”

The following concepts should be covered during this discussion about the conse-
quences of using safety behaviors.

Safety Behaviors Stop Us from Directly Testing Our Fears

“Although we haven’t avoided the situation completely, by using our safety behaviors
we are not directly testing our fears. For instance, if I attend a work meeting but
don’t contribute, then I never get to test my image of ‘saying something stupid and
other people laughing or looking confused at my answers.’ When the next meet-
ing comes along the same image will come to mind, and again I will be gripped
by fear. If I directly test my fear by making a comment in the meeting, I have an
opportunity to discover that my negative image may be inaccurate. After I test the
image numerous times and find that it does not come true, then the negative image
can be seen for what it is—just an image that does not ref lect reality. It will have less
emotional impact and it will no longer need to dictate what I do.”

Safety Behaviors Can Become “Self‑Fulfilling Prophecies”

“Safety behaviors can actually cause the outcomes we are trying to prevent by using
them. For instance, if I use alcohol because otherwise I don’t believe that I could
interact with people, I might find myself overindulging at times and acting in ways
that result in negative evaluation from others (e.g., drunken behavior). So the “safety
behavior” has increased the chance of negative evaluation rather than reduced it.
Similarly, my boss might be more frustrated with me for not contributing in meet-
ings than if I did contribute from time to time.”
 Avoidance and Safety Behaviors 111

If Our Fears Don’t Come True, We Mistakenly “Thank” the Safety Behavior

“If we use our safety behaviors and our fears don’t come true, we might believe that
the safety behaviors ‘prevented’ our fears from happening. As a result, we never feel
less anxious about the situation, as we still think it was dangerous if not for the safety
behavior. We can become very dependent upon our safety behaviors and start to feel
even more anxious if they can’t be used (e.g., no alcohol available, being ‘put on the
spot’ to speak at a meeting). The truth may be that our fears were unlikely to have
come true even without the safety behavior, but we never discover this as long as we
continue relying on them.”

Safety Behaviors Increase Our Self‑Focused Attention

“When people use safety behaviors they often scrutinize themselves very closely
(what they are doing, how they are doing it, monitoring their thoughts), which can
be very distracting. Self-­focused attention hijacks attention from the ‘task at hand’
(e.g., the conversation), which can make it even more difficult to keep up with con-
versations and contribute.
“So, for all these reasons safety behaviors maintain social anxiety in the longer
term. If anxiety remains high after repeatedly confronting a social situation, chances
are you are using safety behaviors that are preventing you from directly testing your
fears.”

Using Imagery to Understand the Impact of Safety Behaviors

An imagery exercise could be used to encourage clients to evaluate the impact of using
the safety behaviors they have identified, as a means of enhancing motivation to drop
these behaviors. This may be useful for clients who recognize that their outright avoid-
ance behaviors are unhelpful, but view their safety behaviors as harmless and more of a
helpful “coping strategy.” Of course this point could be made during a verbal discussion.
However, using imagery may allow clients to feel the impact of using safety behaviors
and may also serve as an opportunity to mentally rehearse dropping safety behaviors,
making it easier to do so in reality. The following instructions are a guide to help clients
experience the impact of using safety behaviors.

Impact of Safety Behaviors Imagery Exercise

IMAGE 1

“First I would like you to choose one situation in which you use safety behaviors . . .
If you feel comfortable doing so, close your eyes and spend 2–3 minutes imagining
yourself in that situation and using all of your safety behaviors . . . What is happen-
ing? What are you doing? What are you most aware of? Where is your attention?
112 TREATMENT MODULES

What do you notice about your posture? How is the other person responding? What
are they noticing about you? How do you feel? Where do you feel this in your
body?”

IMAGE 2

“Now I would like you to rewind and imagine the same situation again, but this time
with no safety behaviors and instead in a more open, assertive, relaxed manner . . .
What is happening? What are you doing instead of using safety behaviors? How is
your posture now? What are you focusing your attention on? How is the conversa-
tion f lowing or the situation progressing? What are you now able to notice about the
situation that you missed before while using your safety behaviors? How is the other
person responding? What are they noticing about you? How do you feel? Where do
you feel this in your body?”

In group treatment, these scripts are read verbatim and experiences are then elic-
ited and debriefed at the end. In individual treatment, as clients are guided through this
exercise they will be able to respond to therapist-­prompted questions, and therapists can
record their responses for use in the debrief discussion. During the debrief, it is impor-
tant to contrast client experiences whilst envisioning the alternative images. Differences
that may be discussed include how anxiety provoking each image was, other feelings
that may have arisen, body sensations, posture, self-­consciousness, social performance,
and other people’s responses.
Some clients might report that the image of using safety behaviors was more anxiety
provoking. Therapists should prompt clients to identify specifically what was different
in the image. Clients may mention that they appeared more confident and relaxed in
the image without the safety behaviors. These outcomes can lead to a discussion about
the true value of continuing to use safety behaviors, which can be further tested with
an actual behavioral experiment (see the section on safety behavior experiments later in
this chapter).
Other clients might report that the image of using safety behaviors was less anxiety
provoking. This possibility can be entertained as a hypothesis that might be valuable
to “test out” (i.e., “Your imagination tells you that using safety behaviors is better,
how can we be sure? How can we test this out in reality?”). Encourage curiosity about
which image is most accurate, which again would lead into the Safety Behavior Experi-
ments outlined later in this chapter. It may also be useful to separate client feelings from
what the other person within each image is seeing and how they are responding (e.g.,
“although you may feel less anxious in the short term using your safety behaviors, what
may be some of the consequences in terms of how the other person relates to you?”).
Clients might be able to take the “observer perspective” and report that they appear
more confident when they are not using their safety behaviors. Another approach might
be to normalize the fact that given their habitual use of safety behaviors, it may not be
 Avoidance and Safety Behaviors 113

surprising that this felt more comfortable. However, given all the other potential prob-
lems with safety behaviors (discussed previously), the pros and cons of relying on them
can be further discussed.

Behavioral Experiments: Modifying Behavior
to Challenge Negative Thoughts and Images
Avoidance and safety behaviors maintain SAD because they limit opportunities to face
feared situations and experientially discover if the negative social thoughts and images
fueling these fears are valid. As such, avoidance and safety behaviors keep social-­anxiety-­
related cognitions firmly in place, robbing clients of the natural cognitive challenging
process that comes with behavioral exposure.
Behavioral experiments are a powerful method of changing avoidance and safety
behaviors, with the primary purpose of challenging the thoughts and imagery that
maintain social threat perception. Behavioral experiments are essentially tasks that cli-
ents undertake, within and outside therapy sessions, with the purpose of directly testing
their cognitions. The form that behavioral experiments take can vary, such as modify-
ing behavior within social situations to observe the consequences or conducting sur-
veys, and they are a common transdiagnostic CBT strategy with numerous applications
(for more detail, see the Oxford Guide to Behavioural Experiments in Cognitive Therapy;
Bennett-­Levy et al., 2004). In the area of SAD, behavioral experiments will typically
involve clients stepping out of their comfort zone by gradually reversing avoidance
behaviors and dropping safety behaviors in social situations, and being curious about
whether or not the actual outcome matches their a priori negative social thoughts and
images.
Behavioral experiments therefore focus on testing cognition via experiential learn-
ing. Identifying key cognitions of interest is the central focus, followed by devising
behavioral methods of testing these cognitions, specifying evidence to observe during
the experiment that would either confirm or disconfirm the cognition being tested,
conducting the experiment and noting the outcome, and ref lecting on how the out-
come relates to the cognition under examination. It may be useful to query anticipated
SUDS when planning the task, to get a sense of how challenging the task is for the
client and hence the likelihood of task completion, but monitoring SUDS during the
task is not essential in behavioral experiments (unless one of the key predictions to be
tested is the client’s anticipated severity of anxiety and its trajectory), as habituation
of anxiety is not the primary focus. Behavioral experiments are often graded to assist
with engagement in what is a challenging process for clients, but this is not essential
for a successful behavioral experiment. The experiment task only needs to be con-
ducted for as long as it takes for the cognition in question to be tested, and therefore
may not need to be prolonged. Likewise, repetition only needs to occur until the client
and therapist are satisfied the cognition has been fully tested and they can be confident
114 TREATMENT MODULES

in the validity of the information they have gathered. Clients may need to replicate an
experiment several times and in several contexts before the strength of a belief suffi-
ciently diminishes (e.g., < 5%). Thus, some experiments may be repeated many times
and others may only need to be done once. The critical condition is a “prediction
error”—a discrepancy between the client’s expectancies of the social situation and the
actual outcome. The larger the prediction error, the more powerful and enduring the
learning will be.

Introducing Behavioral Experiments
Behavioral experiments are typically the most emphasized, powerful, and challenging
part of treatment for clients with SAD. Much of the time in therapy is devoted to set-
ting up, conducting, and debriefing repeated behavioral experiments to recalibrate cli-
ents’ social expectations. Therefore, socializing clients to this component of treatment is
particularly important to increase engagement in this crucial part of therapy. Based on
the rationale already provided to clients regarding the importance of tackling avoidance
and safety behaviors, behavioral experiments can be introduced as a powerful technique
for reducing reliance on avoidance and increasing self-­efficacy. The following pointers
provide some ideas that may also be helpful:

Curious Scientist
Conducting behavioral experiments can be likened to adopting the role of a curious
scientist. That is, the client has a specific hypothesis in mind regarding social situations,
and the challenge is to find ways to test that hypothesis. Introducing this concept can
introduce some objectivity and hence emotional distance toward the behavioral task and
its outcome.

Next Logical Step
Framing behavioral experiments as the next logical step onward from the imagery chal-
lenging work already done can be helpful.

“We have done a lot of work questioning your negative thoughts and images, look-
ing at the contrary evidence, and developing more realistic and helpful thoughts
and images . . . but how are we going to know for sure which is correct—­your old
negative images or your new helpful images? What would need to happen to find
out once and for all?”

The aim is to help clients acknowledge that action (behavioral experiments) rather
than speculation (imagery challenging) is ultimately the best method for challenging
their social fears.
 Avoidance and Safety Behaviors 115

Previous Success
It can be helpful to elicit examples of when clients have completed a task out of their
“comfort zone” only to find that it did not go in the negative way they had expected. If
they are able to recall such an experience, you can then frame it as a behavioral experi-
ment. Focus clients on what the experience was like for them, how they felt before and
after, and what they gained from it. You can then summarize that they already know
how to do a behavioral experiment, and that the behavioral experiments completed in
therapy will just be a bit more strategic and planned.

The Most Active Ingredient in Therapy

Acknowledge that while the idea of changing their behavior may initially sound chal-
lenging or scary, at the end of treatment other clients have reported that this is the most
powerful and effective part of treatment, and that the short-term “pain” was worth the
longer-­term “gain.” It can be helpful to communicate that this is the most effective way
you know as a therapist to overcome social anxiety. Emphasizing the old adage that “we
must do something differently if we want a different outcome” may focus clients on
behavior change rather than continued avoidance.

The Graded Nature of Behavioral Experiments

It may be reassuring for clients to give them permission to start with easier experi-
ments that might initially be like “dipping a toe in the water” before moving to harder
experiments as confidence builds, so that eventually they might be willing to “take the
plunge.” Reassure clients that the guiding principle will be to set up experiments that
are “manageable challenges.” If experiments aren’t challenging, then clients aren’t doing
anything therapeutic that challenges their social anxiety, and so nothing will change. If
clients do find an experiment more challenging than they expected, this can also be an
important learning opportunity. The clinician can focus on any discrepancy between
perceived versus actual coping during the experiment. These challenging experiences
can be particularly helpful for reducing relapse when clients encounter any negative
social experiences after therapy.

Therapist Support
Reassure clients that you (the therapist) are willing, where practical, to participate in
the behavioral experiments too, so they are not alone in this process. Therapists may
need to model some of the experiments as a first step to engaging clients in the pro-
cess. From a cognitive perspective, clients can learn about the likelihood of negative
evaluation by observing others. Therapists can also be useful allies during behavioral
experiments, prompting clients in vivo to focus their attention in the service of gather-
ing evidence against their feared outcomes. However, clients will need to complete
116 TREATMENT MODULES

experiments themselves so that they learn that they too can cope with the possibility of
negative evaluation, or with actual negative evaluation should this occur.

Preparation before Action
If clients are still resistant to the idea, encourage them to go through the process of set-
ting up a behavioral experiment with no expectation that they have to do it. This may
warm them up to the idea and increase their willingness to try it out eventually. Ideally,
this would be an experiment that can be done during the therapy session, and possibly
one that the therapist could do first to model the process (e.g., dropping some papers in
the reception area of the clinic, having a conversation with the therapist about a common
topic like movies or travel). You may even be able to turn the behavior of declining to
do behavioral experiments into a behavioral experiment. What did they envision would
happen if they said no, compared to what actually happened?

A Note about Therapist Anxiety
Therapists don’t need to cover all the ideas above with their clients with SAD. Often
therapists’ anxiety about behavioral experiments can lead to excessive justifications to
convince clients to “get on board.” Sometimes this need can be about convincing the
client, but other times it is about convincing ourselves as therapists to neutralize our
own anxiety. Sometimes therapist anxiety can steer us away from promoting the use of
behavioral experiments with our clients altogether.
Therapist anxiety regarding behavioral experiments will often relate to some nega-
tive thoughts and imagery we hold about clients not coping with their anxiety or the
behavioral experiment turning out badly (i.e., the client’s negative thoughts and images
coming true!). Such images may then activate our own core beliefs regarding what it
means to be a “good therapist” (e.g., “a good therapist must always make her clients feel
good, take away client distress, and ensure all therapy tasks are always a positive expe-
rience”). As such, therapist anxiety may arise because, although we may intellectually
know that behavioral experiments are highly therapeutic, they can also make us feel that
we are treading a little too close to the brink of potentially being a “bad therapist.” This
is a common experience many therapists face. If this applies to you, you may need to
do your own imagery challenging and behavioral experiments to explore further your
predictions about behavioral experiments and your beliefs about what it means to be a
“good therapist,” particularly if some of your beliefs are interfering with using behav-
ioral experiments in therapy.
Excessively long discussions and justifications for behavioral experiments with cli-
ents, rather than just doing them, can exacerbate client anxiety as they have more time
to worry about the process. Unless there is obvious reluctance, it may be worth getting
right into the behavioral experiment process and giving clients some credit for being able
to handle more than we imagine. We believe it is critical that therapists assume that their
clients are more robust and capable than clients believe themselves to be. If therapists
 Avoidance and Safety Behaviors 117

believe their clients are fragile and that anxiety is unacceptable and must be avoided, it
will be difficult for clients to believe otherwise.
It may be worth reminding ourselves that tolerating anxiety is a valuable skill for
everybody to learn. In addition, while positive and neutral outcomes from behavioral
experiments are helpful for challenging beliefs about the probability of social catas-
trophes, negative outcomes can also be therapeutic. Negative experiences offer clients
the opportunity to discover that the true cost or consequences when things don’t go
smoothly may not be as bad as first thought, and that they can cope with those con-
sequences. Resilience will come from coping with negative outcomes, not just from
believing negative outcomes are unlikely. Therefore, whether the behavioral experiment
outcome is positive or negative, it is a “win–win” situation when it comes to therapy.
As an example of this “win–win” philosophy in action, in one memorable behavioral
experiment, one of our clients entered a bookstore while simulating extreme and clearly
observable shaking to test his belief that it is unacceptable to appear nervous. He duti-
fully and vigorously shook his whole body while reading magazines within the store for
some time. As he was leaving the store a staff member called out to him, “Excuse me sir,
you’ve left your medication on the counter.” The medication was not his. Needless to say,
the therapist was initially concerned about how the client would respond to this appar-
ently clear evidence that others had noticed his shaking. During the debrief the therapist
asked the client what he learned from the experience, and he was very balanced in his
appraisal. He reported learning that others seemed to just get on with their own business,
and his usual shaking, which is far less obvious compared to what he displayed during this
experiment, was therefore unlikely to draw negative attention in the future. The thera-
pist, noticing that he appeared to be ignoring the medication issue, took a breath and then
asked directly what he thought about that. The client simply answered with indifference,
“Well, it wasn’t mine.” This was an important experience for the therapist, who learned
not to catastrophize when unexpected things occur during behavioral experiments!

The Process of Behavioral Experiments

Once clients understand the rationale for behavioral experiments, the therapist can review
the eight steps involved in conducting a behavioral experiment. A handout outlining
these steps can be provided to clients for psychoeducational purposes (see Handout 6,
Behavioral Experiments, in the Appendix). When setting up behavioral experiments with
clients for the first time, it may be useful to first describe the process of using Work-
sheet 7, the Behavioral Experiment Record (in the Appendix) by referring to a hypothetical
example (see the example included in Handout 6). Completion of all eight behavioral
experiment steps should initially be done within therapy sessions with the guidance of
the therapist, including conducting the behavioral experiment itself. Once clients are
familiar with the process, the next step is to set up experiments in session (steps 1–4),
conduct the experiments outside of session (step 5), and then return to debrief the find-
ings in subsequent sessions (step 6–8). The final aim would be for clients to do all eight
steps independently as homework exercises.
118 TREATMENT MODULES

Step 1: Negative Image
This involves identifying a specific social situation that triggers anxiety and bringing
to mind an image of what clients envision will happen in the situation. Clients should
have already developed some skill in this area from using Worksheet 5, the Thought and
Imagery Record and Worksheet 6, the Imagery Challenging Record. Clients should spend a
couple of minutes running the image through their head in detail from start to finish, as
if it were a show on TV. They can then write a description (in words or pictures) of this
image. Helpful prompts to guide clients through the image are:

• “What is happening?”
• “What are you seeing, hearing, smelling, tasting, touching?”
• “What are you doing?”
• “What are other people doing?”
• “How are they responding to you?”
• “How will they respond to you in the future as a consequence?”
• “What happens next?”
• “How does the image start and end?”

Step 2: SUDS
Clients then rate the intensity of their anxiety about this situation (SUDS: 0 = no anxi-
ety, 10 = maximum anxiety). That is, how anxious do they feel as they think about and
envision the situation? Clients may have some predictions about how anxious they will
be when they are actually in the situation, and this would be part of the negative image
to be tested (e.g., “I will be so uncontrollably anxious I won’t be able to speak”).

Step 3: Experiment
The next step is to plan an experiment to test the negative image. What could clients
do to find out how accurate their image is? What situation could they put themselves
in or create to test the accuracy of their image? It is important to plan the experiment
as specifically as possible to increase the likelihood of appropriate completion. Specify
what needs to be done, where it will take place, when it will take place, and who will be
involved in the experiment.
When planning the experiment, particular attention should be paid to safety behav-
iors that would typically be used during the situation in question. That is, aside from
avoiding the situation altogether, what other things might clients do with the aim of pre-
venting negative imagery from coming true? Help clients understand how these behav-
iors will contaminate the results of the experiment, preventing them from truly testing
the cognition in question. If the experiment goes well, the client will attribute it to the
safety behavior, rather than learning that the situation is safe. Make sure it is clear what
safety behaviors need to be dropped (e.g., hunched posture and not making eye contact
 Avoidance and Safety Behaviors 119

to avoid attention) and what needs to be done instead (e.g., standing up straight, head
up, shoulders back, making general eye contact).

Step 4: Evidence to Observe
Before doing the experiment, it is very important to specify what evidence clients need
to look for to confirm or disconfirm the negative image. This evidence must be unambig-
uous (i.e., clear, observable, objective evidence). A useful approach is to consider whether
the evidence would hold up in a court of law, or if the judge would “throw it out of
court” because it was too subjective. Discuss some examples of ambiguous social cues
that can be easily misinterpreted (e.g., a yawn or looking at one’s watch being a sign
of boredom). Clients should also explicitly consider where their attention needs to be
placed during the experiment (see Chapter 8 for more information).

Step 5: Do the Experiment

Step 6: Results
Now it is time to ref lect on what actually happened. Ensure clients stick to the facts.
Specifically, what evidence either for or against the negative image was observed?

Step 7: Conclusion
Encourage clients to ref lect on the following questions and draw some conclusions from
the experiment.

• “How do the results compare to the negative image?”

• “What do the results tell us about the accuracy of the initial negative image?”
• “What did you learn from the experiment?”

The conclusions clients develop may be about the discrepancy between the:

• Imagined threat versus actual threat.

• Imagined cost of something going wrong versus the actual cost.
• Imagined reactions of others versus actual reactions.
• Imagined social abilities versus actual social abilities.
• Imagined coping versus actual coping.
• Imagined anxiety versus actual anxiety.

Step 8: Update Imagery
Clients are then encouraged to close their eyes and spend a few minutes re-­creating
the image in their mind, but this time incorporating what they have learned from the
120 TREATMENT MODULES

experiment. This step essentially involves reliving the experiment and observing the
situation as it was, rather than how they initially envisioned it would be. The prompt
questions used in Step 1 are equally useful for this imagery exercise. The following ques-
tions are useful if clients automatically revert back to the initial negative image:

• “How does the image need to change to better ref lect reality?”
• “How can you update the image to be more realistic/more in tune with reality/
incorporate what you now know/better ref lect or represent what you discovered
from your experiment?”

Once clients have fully accessed this new updated image, the therapist can help them
ref lect on the experience of this new image compared to the initial negative image. How
is it different? What does the new image mean to them? How does the new image make
them feel?

A Note about Imagery Enhancements for Behavioral Experiments

The use of imagery in Steps 1 and 8, which is not a standard feature of behavioral experi-
ments, has been included to enhance the behavioral experiment process in a number of
ways. First, traditional behavioral experiments that are set up in a more verbal manner
require clients to develop a prediction of what they think will happen. Requesting that
clients develop an image of what they envision will happen instead is designed primarily
to increase the specificity of client predictions. This places the therapist and client in a
stronger position to devise an appropriate and effective experiment, as the prediction
being tested should have greater detail, richness, and clarity by being in imagery format.
The specificity of the imagery-­based prediction then makes it more obvious what evi-
dence needs to be observed for the image to hold true, as essentially we would have to
see that exact image play out for the prediction to be confirmed.
The addition of updating the negative image to better ref lect reality at Step 8 is
intended to enhance the emotional impact and memorability of the experiment. Behav-
ioral experiments, unlike thought records, are already an experiential mode of learning,
generating large emotional shifts even without the use of imagery. Adding imagery to
this technique may then be thought of as a way of “supercharging” an already emo-
tionally powerful therapy tool. Also, if clients have held one view for so long (e.g., that
they are socially unacceptable), and their behavioral experiments contradict this view,
they may be too quick to move on from these experiences as a form of minimization to
preserve their old world view. Sitting a little longer with the experience and emotions
associated with it via the imagery updating section may therefore prolong the experience
and increase the chance of this experience being fully processed and consolidated.
As previously mentioned in Chapter 3, Brewin’s (2006) retrieval competition theory
suggests that how we feel about any given situation is governed by the memory represen-
tations we retrieve about that situation. That is, we hold positive and negative memory
 Avoidance and Safety Behaviors 121

representations for most aspects of our life (e.g., social, work, relationships, self ) that
compete for retrieval. More accessible memories will win out and govern how we feel
about the situation at hand. Clients with SAD may have an absence of positive memory
representations of social situations or very accessible negative memory representations of
social situations. Therefore, asking them to relive a positive social experience they have
had during behavioral experiments may help increase the memorability and accessibility
of the experience, thereby increasing the chances that it may win out during retrieval
competition in the future.

Different Types of Behavioral Experiments

Standard Future‑Focused Experiments
Most experiments that clients will complete in SAD treatment will fit into this cat-
egory. Clients will have certain types of social situations that bother them (e.g., going to
parties, interacting with a checkout clerk, spontaneous social chitchat with colleagues,
speaking in classes). Linked to these situations will be negative imagery representing
what they predict will happen (e.g., “I am stuttering and not getting my words out right,
people are looking at me confused and others are laughing at me, people now turn away
from me and find other people to talk to with, I am alone and look awkward and out
of place”). Upcoming situations (i.e., the next party or class session) or purposely con-
structed situations (i.e., having a social conversation with a therapist’s colleague, giving
a talk to any people the therapist can recruit from their building to listen) can then be
used as opportunities to test clients’ negative social images. These types of experiments
will typically require repetition, as one positive experience will generally not be enough
to modify clients’ default negative social thoughts and images. Experiments should be
repeated until clients’ expectations of the relevant social domain (e.g., walking down a
crowded street, speaking to work colleagues in the lunchroom) have been updated to
incorporate their behavioral experiment findings. As a result, clients’ predicted imagery
when entering the social domain in question on new occasions should better align with
reality. When this is achieved, they can progress to more challenging behavioral experi-
ments.
Standard future-­focused experiments typically involve attempting to engage in a
social situation in a fairly standard manner without using any safety behaviors that may
inhibit standard social engagement. For example, instead of using typical safety behav-
iors such as looking down and staying quiet, clients may be more conscious of making
eye contact, speaking up, asking questions, and making a personal contribution to the
discussion. It is probably useful to start SAD treatment with this standard type of behav-
ioral experiment. Some examples of common SAD behavioral experiments are listed in
Box 6.2. The choice of experiment will be guided by the situations that are bothersome
to clients and the specific negative imagery associated with those situations that requires
testing.
122 TREATMENT MODULES

BOX 6.2.  Examples of Common SAD Behavioral Experiments

• Talking to a checkout cashier • Attending group gatherings

• Making social conversation with work col- • Ordering food or coffee at a restaurant or
leagues or classmates café
• Speaking in meetings or classes • Starting a conversation with a stranger
• Speaking to people in authority (e.g., • Asking for information from someone in a
manager, teacher) customer service role
• Spending time in public places (e.g., pub- • Making a phone call
lic transport, shopping centers) • Joining an interest or sporting group/club
• Speaking to someone attractive

Once clients have had the opportunity to complete their own behavioral experi-
ments under the therapist’s supervision and the therapist is confident that they are famil-
iar with the experience of a properly conducted behavioral experiment, clients can then
start to regularly engage in these types of experiments as homework exercises between
sessions. These experiments will predominantly test the likelihood of social catastrophe
occurring. Generally, clients find that their engagement in social interactions goes better
than expected, thereby reducing the estimated probability of social threat. On the rare
occasion that it does go poorly, they then have an opportunity to test the true cost of
things not going smoothly and their ability to cope when this occurs.

Shame‑Attacking Experiments
Standard behavioral experiments effectively adjust the perceived likelihood of social catas-
trophe because the overwhelming majority of client fears will not come true. This may
be a great relief to our clients, but one risk is that the perceived costs of social catastrophes
will remain unchanged. If clients leave therapy believing that their fears are unlikely
to come true, but that if they did the consequences would be intolerable, then they
will remain vulnerable to anxiety. Most of us encounter socially awkward situations
at times, and future faux pas could trigger a relapse for clients if they catastrophize the
consequences. Therefore, it is important to construct experiments that are specifically
designed to test the cost of breaking social norms. These types of experiments are known
as “shame-­attacking” experiments because we are purposely trying to draw attention
to ourselves by doing something that is socially unconventional. The idea of purposely
doing something embarrassing can be quite threatening for our socially anxious clients,
so it is important to spend time providing a strong rationale regarding the purpose and
usefulness of these exercises. Completing experiments with the therapist, at least initially,
can provide much-­needed moral support and a bond-­strengthening shared experience.
Eventually clients will need to conduct these experiments alone to ensure that the thera-
pist’s company does not become a safety behavior. The following points can be discussed
with clients to emphasize the therapeutic value of shame-­attacking experiments:
 Avoidance and Safety Behaviors 123

1% LIKELIHOOD VERSUS 100% COST

“So far our behavioral experiments have mostly tested the likelihood of something
going wrong socially, and we have mostly found that things go better than expected.
However (remembering the social anxiety model), it is also important to test the
cost, not just the likelihood, as both determine our sense of social threat. Even if you
believed that the likelihood of things going wrong socially was only 1%, if you still
thought the cost would be really bad if it did go wrong—100% bad—you would still
be really anxious, worrying about when that 1% is going to happen, hence leaving
you feeling socially vulnerable.”

BANDWIDTH AND TIGHTROPE METAPHOR

“People with social anxiety often have a very narrow ‘bandwidth’ for what they
believe other people will accept when it comes to social behavior and what they
believe they can cope with. In terms of what they think is socially acceptable in life,
it is as if they have been walking a tightrope, and if they put a foot wrong they are
‘a goner.’ They are socializing under a lot of stress and pressure because of this. But
what if these experiments provided an opportunity to discover that what is consid-
ered socially acceptable behavior is not as narrow as a tightrope, but in fact more like
a wide plank or even a secure and wide bridge, and that there is a lot more leeway—­
then how would you feel when socializing? Safer because there is less pressure, less
of a precarious ‘life-and-death’ situation.”

Once clients are socialized to the concept of shame-­attacking behavioral experi-

ments, the therapist can present them with a menu of behavioral experiment options
to choose from (see Handout 7, Behavioral Experiment Menu). In group therapy, we ask
clients to vote on their preferred experiment from the menu options and choose the top
two for the whole group to complete in the session. You can always collaboratively con-
struct your own set of shame-­attacking experiments, and tailor them more specifically
to the client’s areas of concern. This is particularly relevant if clients’ anxiety relates to
specific concerns about how other people may react to anxiety symptoms they believe
are obvious to others, such as blushing, shaking and sweating. In these circumstances,
shame-­attacking experiments may involve going out in public and purposely exaggerat-
ing the symptom of concern (e.g., putting on excessive red blush, or purposely shaking
profusely, or putting water under their armpits and on their forehead). This may be quite
radical for clients, as they have typically spent much time trying to conceal such symp-
toms, and they are now being encouraged to manufacture and magnify the symptoms to
discover the true cost of drawing attention to these areas.
Shame-­attacking experiments are set up in a similar manner to standard behavioral
experiments. The Behavioral Experiment Record (Worksheet 7) is completed (i.e., Steps
1–4), although in many instances the experiment is already known, particularly if the
client has chosen it from the menu. Thus the focus is not on thinking of an experiment,
124 TREATMENT MODULES

but on identifying the negative image of what the client envisions will happen when she
does the selected experiment, and hence the evidence to observe. In terms of evidence,
clients may say things like “people will look, laugh, and yell abuse.” It is important that
clients be very specific about these predictions. For example, in their image what propor-
tion of people are looking, laughing, yelling? In what manner are they doing these things
(e.g., how long do they look, what expression is on their face, what specifically do they
yell)? When planning the experiment ensure safety behaviors are dropped, particularly
those that interfere with gathering evidence (e.g., looking down). Therapists then com-
plete the task with clients (i.e., Step 5). Before they embark on the experiment, remind
clients that the aim is not to feel calm and relaxed, possibly self-­d isclosing that you find
these tasks somewhat embarrassing too. The aim is to test if feeling embarrassed is the
worst thing that happens, if they are able to tolerate and cope with feelings of embarrass-
ment, and to experience the transient nature of these feelings.
Following the experiment, the therapist and client return to the therapy room to
complete the remainder of the Behavioral Experiment Record (i.e., Steps 6–8). The debrief-
ing process should particularly focus on the impact of the experiment on “broadening
the bandwidth” of the client’s perception of socially acceptable behavior. Conclusions
that are typically drawn from these experiments are:

• “People are focused on themselves and their own activity rather than caring very
much about what I am doing.”
• “People seem to accept other people doing unusual things.”
• “People are less hostile than I initially thought.”
• “It can actually be fun to do silly things sometimes.”
• “The worst consequence is feeling embarrassed—­I can cope with feelings of
embarrassment and the feelings pass.”

Many clients may be reluctant to engage in shame-­attacking experiments as they

involve really taking the plunge, and some may not be willing to do this at all. This
can occur in individual treatment and group treatment settings alike. Our experience
is that although most clients find these tasks highly anxiety provoking and challenging,
the positive peer pressure available in group treatment settings helps with motivation to
engage in the tasks, particularly if the group has a critical number of particularly enthu-
siastic members. Regardless of whether the reluctance is occurring in an individual or
group treatment context, it can be handled in the same manner. Therapists should take
the stance that they are not forcing clients to do something against their will, they are
just providing the opportunity to do something that other clients have found very help-
ful in the treatment of their social anxiety. If they don’t wish to participate, the experi-
ment can still be done as an observational experiment in the hope that they will learn
from seeing how people react to someone else engaging in unusual social behavior.
This modeling experience can be provided by either the therapist alone in an individual
treatment setting or the therapist and other group members in a group treatment set-
ting. Above all, it is about clients making an informed choice in treatment once they are
 Avoidance and Safety Behaviors 125

aware of the value of shame-­attacking experiments in fully treating their social anxiety
by challenging the cost of social mishaps.
As already mentioned in Chapter 3, therapists who are highly socially anxious them-
selves and unwilling to challenge social norms may not be well equipped to effec-
tively treat individuals with SAD. It is important that clinicians who themselves are
overly fearful of negative evaluation conduct their own shame-­attacking exercises prior
to treating clients with SAD, or the therapist’s anxiety will compromise client engage-
ment in shame-­attacking behavioral experiments. In addition, when initially observing
their therapist breaking social norms some clients may overempathize with the therapist,
feeling embarrassed and anxious for the therapist. In these instances, it is important that
the therapist redirect clients’ attention to the actual consequences observed, rather than
allowing clients to become preoccupied with their own emotions. Unfettered “anxiety
by proxy” may strengthen social fears via the same in-­situation processing biases that
have maintained the problem in the past (e.g., self-­focused attention preventing clients
from observing that strangers accept or completely ignore the therapist’s unusual behav-
ior).

Past‑Oriented Behavioral Experiments
On most occasions the Behavioral Experiment Record will be used to plan for future social
situations, but at times a past social situation will be bothersome and may then become
the platform for a subsequent behavioral experiment. For example, clients may report a
social situation they perceive went poorly (e.g., “I tried saying hello to a work colleague
and he walked straight past me, he clearly thinks I am an idiot and doesn’t want to know
me”; “my in-class presentation was awful, I spoke gibberish and made no sense”). An
experiment can then be constructed to test if their interpretation or imagery represen-
tation of what happened is valid or distorted (e.g., say hi to the same colleague and ask
two questions to see if the same response occurs, or wait for their grade and feedback
from the instructor as a more objective indicator of their public speaking performance).
Under these circumstances, Worksheet 6, the Imagery Challenging Record, is also useful
in dealing with perceived or actual negative outcomes. For example, if the colleague
doesn’t respond again or the instructor’s grade and comments are poor, then finding a
helpful way to make sense of these experiences that is not solely based on clients’ social
acceptability will be important, as will developing a more helpful image to capture this
perspective.

Safety Behavior Experiments
The need to drop safety behaviors is an important consideration when planning all
behavioral experiments. It is important for clients to appreciate the importance of drop-
ping the various “crutches” they have developed to cope with their SAD, and a behav-
ioral experiment that specifically tests the true value of using safety behaviors can be
useful for this purpose.
126 TREATMENT MODULES

Safety behavior experiments involve manipulating the use of safety behaviors, that
is, contrasting using safety behaviors with not using them and observing the difference.
This could be done in several ways, and it is preferable to initially complete these experi-
ments with the therapist. A regular and easily repeated situation in which clients typi-
cally use safety behaviors could be used (e.g., traveling on public transportation, buying
groceries, eating in the lunchroom), or a situation could be constructed. In group ther-
apy, we ask clients to choose a relatively unknown group member with whom they will
have two 5-minute conversations on a topic of their choosing (e.g., places they’ve been,
jobs they’ve had, places in the world they’d like to visit, music/TV shows/books/movies
they like). In individual treatment, this can be done with one of the therapist’s colleagues
or with the therapist. During the first 5-minute conversation clients use as many of their
safety behaviors as they can for the whole conversation. In the second conversation they
use no safety behaviors. We find the contrast of the two conversations useful, as it tends
to be a good illustration that focusing so much attention on using safety behaviors leaves
little attention for effective engagement in the conversation, making the interaction far
more taxing and unnatural.
Regardless of what situation is used to compare the use and nonuse of safety behav-
iors, Worksheet 8, the Safety Behaviors Experiment, can be used to guide the experiment.
Once a situation or task has been designed, the next step is for the client to close her
eyes and picture the worst possible outcome she fears in this type of situation. Once she
has a clear image, she can then use it to pay attention to what safety behaviors she would
normally use to prevent her worst outcome from occurring. Ensure that the feared
image and typical safety behaviors are clearly recorded on the worksheet. It is important
that the safety behaviors be clear and specific, so the client knows what she needs to
be focused on during the first phase of the experiment (e.g., while having a 5-minute
conversation I must keep my sunglasses on and my head down the whole time; I must
mentally rehearse everything I say before I say it; and I must ask lots of questions to keep
the spotlight off me by not having to say anything personal).
The client is now ready to engage in the social task for 5 minutes while using all
her safety behaviors. After completing the task, she can then rate her anxiety, self-­
consciousness, perceived observability of anxiety, and perceived social performance.
The second phase of the experiment involves repeating the same task, this time
under the condition of using no safety behaviors. Before doing this, encourage the client
to close her eyes and imagine herself engaging in the situation again without any safety
behaviors. Ask her to imagine this in as much detail as possible, taking note of what
she is doing, her posture, eye contact, what she is focusing her attention on, how she is
feeling in her body. Based on this image, the client clearly records what she will actu-
ally do instead of using safety behaviors, so she knows what to do in the second phase of
the experiment (e.g., while having the 5-minute conversation I will keep my head up,
shoulders back, and look at the other person the majority of the time; I will really listen
to what the other person is saying, and just allow my responses to naturally follow from
what they have said).
 Avoidance and Safety Behaviors 127

The client is now ready to engage in the social task for 5 minutes while using no
safety behaviors. After completing the task, she again completes ratings of anxiety, self-­
consciousness, perceived observability of anxiety, and perceived social performance. As
well as self-­ratings, where possible at the very end of the experiment, the client could
elicit feedback from the other party she was interacting with, getting their impression of
the impact safety behaviors had on the interaction. It can be very helpful within groups
for participants to ref lect on whether their conversational partner looked more or less
comfortable with or without their safety behaviors. Almost invariably clients say the
conversation f lowed better, the person seemed more engaged, and they could focus on
the content of the conversation when their conversational partner was not using safety
behaviors.
The final step is to debrief any discrepancies in ratings across the two conditions, and
from these observations draw some conclusions about what clients have learned about
the impact of safety behaviors. It is hoped that one of two outcomes occurs. Clients typi-
cally find that safety behaviors inhibit social performance, increase self-­consciousness,
prolong anxiety, and can generate the very outcome they are trying to avoid (i.e., a less
favorable evaluation from others because they seem disinterested or distracted during
social interactions when focused so much on their safety behaviors). This outcome usu-
ally facilitates a willingness to drop safety behaviors. While dropping safety behaviors
may have initially generated more anxiety during the experiment, clients may discover
that this increase in anxiety is short-lived, as they are better able to absorb themselves in
the social task at hand. Equally, if clients find little difference between the two condi-
tions, then safety behaviors can be abandoned in the knowledge that they bring no added
value.
If clients continue to perceive safety behaviors as helpful and of no detrimental
impact after the experiment, the case for dropping them in other behavioral experi-
ments still needs to be made. As a way of reducing the chance of an impasse between the
client and therapist, it can sometimes be helpful for therapists to express some surprise
about the possible value of using safety behaviors given the model that is being used to
guide treatment and past experiences with other clients. Therapists might say something
like “Well, this is very interesting to me. I’m now wondering whether safety behaviors
might actually be of some value. If so, the model we’re using to guide treatment might
be wrong, and I might need to start suggesting this to my other clients, and to start using
them myself in some situations. But before I do, how could we continue to gather evi-
dence to test out this possibility?” Therapist and client can then collaboratively develop
a range of additional behavioral experiments to repeatedly test the perceived benefits of
safety behaviors in different contexts. Therapists might also agree to conduct their own
behavioral experiments during the week and gather evidence to present feedback on in
therapy. They can offer a guarantee that if they both consistently find evidence for the
benefit of safety behaviors, then they will change the model and start using them more
often. To present this in a therapeutic manner, therapists need to maintain a stance of
genuine curiosity.
128 TREATMENT MODULES

Behavioral Experiment Hierarchies
Behavioral experiments (particularly standard future-­focused experiments and shame-­
attacking experiments) are typically graded to increase client engagement and confidence
in confronting difficult situations. Once clients are familiar with the behavioral experi-
ment process, a hierarchy of likely behavioral experiments of increasing difficulty is col-
laboratively devised. Developing a hierarchy ensures that each behavioral experiment,
which should still be thoroughly planned using Worksheet 7, the Behavioral Experiment
Record, is working toward an overall valued goal. The hierarchy provides an overall plan,
guide, or direction regarding a succession of behavioral experiments for clients to attempt.
Practically, it can be challenging to complete a hierarchy of social situations in a
stepwise manner, given that social interactions are not entirely controllable or predict-
able, and sometimes clients will be concerned that there is too big a “jump” between
steps on their hierarchy. It is not imperative that experiments always be completed in
a linear fashion. The critical aspect of a behavioral experiment is that there is a dis-
crepancy between the client’s expectancies and the actual outcome (prediction error).
Generally speaking, larger prediction errors lead to more powerful learning and better
long-term outcomes. Grading behavioral experiments, and even reductions in anxiety
during behavioral experiments, are not necessarily related to longer-­term outcomes. In
fact, if grading behavioral experiments, reduces the magnitude of the client’s prediction
error because he sees the outcome as being safer and more predictable, then learning and
long-term benefits may be reduced.
Nonetheless, the process of developing a hierarchy will help clients to plan very
specific tasks and will prime them to apply their behavioral experiment skills in a range
of situations. If clients come across situations that they could not imagine confronting at
this stage, the use of hierarchies allows them to at least start contemplating them for the
future. By the time they reach those steps, the situation will seem much more achievable.
There are four key steps involved in grading behavioral experiments to develop
a hierarchy or “stepladder.” These steps are outlined in Handout 8, Behavioral Experi-
ment Hierarchies, with sample hierarchies included for therapist and client reference. The
outcome of working through these four steps with clients can be recorded in their own
personal Behavioral Experiment Hierarchy (Worksheet 9).

Step 1
Start by helping clients identify an area of their life that they want to start working on.
Useful questions may be:

• “What would you like to be different?”

• “How would you like things to be?”
• “What would you like to be doing that you aren’t currently doing now?”
• “In what area of your life are you having difficulties that you would most like to
change?”
 Avoidance and Safety Behaviors 129

Common examples are meeting new people, socializing more, speaking in public,
initiating conversations, dating, and being assertive. There may be more than one area
clients wish to change, and this may mean that they will need to develop more than one
hierarchy. It is best to initially focus on one area of the client’s choosing. This decision
may be based on an area the client believes will be easiest to change, or the area that is
most important.

Step 2
Identify negative images of situations that ref lect the area of life clients want to change.
These images can be elicited by saying:

“Close your eyes and imagine yourself in this type of situation (e.g., meeting new
people), as if you are experiencing it right now. Where are you? What is happening?
What are you doing? What are others doing? What do you feel or sense?”

This image will tie all of the behavioral experiments together, as they will all pro-
vide opportunities to challenge it across a variety of contexts.

Step 3
Set a specific behavioral goal related to the area clients would like to change. This
involves specifying what they would like to be able to do (or not do) and provides an
end point to aim for. Again an imagery exercise can be used to assist clients in generat-
ing this goal.

“Close your eyes and imagine this type of situation (e.g., meeting new people) is no
longer a problem for you. Imagine that anxiety isn’t a problem. Shoot for the stars!
What would you be doing that you currently find extremely difficult? How would
you like it to be? Where are you? What is happening? What are you doing? What
are others doing? What do you feel or sense?”

Make sure there is consistency between the goal and life area chosen to work on, and
that the goal ref lects something of importance and value to clients.

Step 4
Brainstorm with clients a variety of situations around this theme that would give them
the opportunity to test their negative images and work toward their goal. Ensure clients
make a SUDS rating (0–10) for each experiment. The idea is to produce some relevant
experiments that generate mild anxiety (i.e., 3–4 out of 10) at the bottom of the hierar-
chy, some experiments that generate moderate anxiety (i.e., 5–7 out of 10) in the middle
of the hierarchy, and some experiments that generate high anxiety (i.e., 8–10 out of 10)
130 TREATMENT MODULES

at the top of the hierarchy. When developing the experiments, consider with clients
what would make it harder or easier for them to complete the experiment, so that they
can start to generate stepladders of social tasks that ref lect a range of difficulty. Useful
prompts for grading are:

• What are you going to do? (e.g., just say hello, or sustain a 10-minute conversa-
tion)
• Where will you do it? (e.g., How familiar or unfamiliar is the place?)
• When will you do it? (e.g., How busy or quiet will it be? What day and time?)
• Who will be involved? (e.g., How many people will be involved? How familiar or
unfamiliar are the people?)

By manipulating these variables, you can create behavioral experiment steps that are
harder or easier to complete.
Just as dropping safety behaviors is considered when planning specific behavioral
experiments, safety behaviors must also be considered when planning the broader behav-
ioral experiment hierarchy. There are two approaches clinicians can take in this regard.
The preferred approach is that clients use no safety behaviors within their hierarchy.
While clients may be able to accomplish harder steps with the use of safety behaviors
(e.g., accepting a party invitation if they can take a friend rather than going alone), drop-
ping safety behaviors in their hierarchy may mean they need to start with easier steps
(e.g., accepting an invitation to a friend’s house for dinner and going alone). Starting
lower on the hierarchy with no safety behaviors is preferred for all the reasons described
earlier, most notably that safety behaviors prevent clients from directly testing their
social fears, hence often making the behavioral experiment a less useful learning experi-
ence. However, if clients are unwilling to start any experiment without the use of safety
behaviors, then the progressive dropping of safety behaviors would need to be explicitly
incorporated into the steps of the hierarchy, so that the steps involve a gradual abandon-
ing of various safety behaviors (e.g., the first step is going to the gym with a friend, the
next step is going to the gym alone).

Tolerating Anxiety: Coping Imagery
Conducting behavioral experiments while dropping safety behaviors and working up
a hierarchy is the most anxiety-­provoking component of SAD treatment. However, it
is also the most crucial and effective component. Therefore, attention needs to be paid
to helping clients tolerate or “surf ” the anxiety that is likely to occur when conduct-
ing behavioral experiments. The idea of anxiety as something that is tolerable, rather
than something to be escaped from, will likely be foreign to most clients, and they will
require strategies to help them adopt this attitude. Just to clarify, when we use the word
“tolerate,” which can hold different meanings for different people, we mean fostering an
attitude of learning to cope with anxious feelings, rather than trying to get rid of them.
 Avoidance and Safety Behaviors 131

There are various methods a therapist could teach clients to assist their ability to
handle anxious feelings (e.g., helpful coping statements, f lash cards, mindfulness-­based
attention training, or focusing attention on the task at hand). Worksheet 6, the Imagery
Challenging Record, is also good preparation for engaging in behavioral experiments, as
clients can use this process to arrive at a more helpful or realistic image that increases their
willingness to engage in the challenging behavioral experiment situation. Regardless of
what methods are used, the aim is to help clients persist with behavioral experiments, even
in the face of emotional discomfort. We focus on one particular additional method, that
of developing metaphorical imagery, or the more client-­friendly term, “coping imagery.”

Client Rationale
The aim of coping imagery is to develop an individualized metaphorical image that
assists clients to cope with their anxiety during behavioral experiments. You might
introduce this concept by asking clients, “What is a metaphor?” In discussing this, you
can say, “A metaphor is a symbol/object/concept that represents our experiences or feel-
ings, as opposed to being something real or literal.” Perhaps normalize metaphors by
saying that we often talk or think in them without realizing it (e.g., “I felt like a fish out
of water”; “I was being put through the wringer”; “I nearly jumped out of my skin”).
Discuss the fact that putting our feelings into words can be hard and metaphors seem to
be a really good way of capturing how we are feeling emotionally. Also, metaphorical
images seem to connect to our feelings more strongly than words. The following imag-
ery exercise may provide an illustration of this concept.

Metaphorical Imagery Exercise
“Say to yourself a few times (in your mind) the word “hope,” “hope,” “hope”—
notice how that feels within you physically and emotionally . . . now close your eyes
and visualize something, someone, or somewhere that for you represents “hope” . . .
If nothing comes to mind immediately, that’s OK. Just sit with the idea of hope
for a while and see what emerges. Notice how that feels within you physically and
emotionally.”

Discuss any differences in emotional and physical experiences between the literal
word and the metaphorical image. Conclude that if metaphorical images can effectively
capture what we are feeling, and also elicit our feelings, then if we can develop a meta-
phorical image that represents us coping with our anxiety, this could be a helpful tool to
enable us to tolerate our anxious feelings during behavioral experiments.

Developing Coping Imagery
When developing an individualized coping image with clients, normalize that some
people find it hard at first, and the image they initially develop may not necessarily be
132 TREATMENT MODULES

the image they end up using in the long run. They can consider it a creative “work in
progress.” It can be useful to give clients some examples of coping images that past cli-
ents have used to represent coping with their anxiety. This can help give them a feel for
the sort of images that may be appropriate. Table 6.2 provides some of the coping images
our clients have developed over the years:

Coping Imagery Instructions
There are three phases to developing a coping image, which we have elaborated from
Hackmann and colleagues’ (2011, p. 154) guidelines on metaphorical imagery. The first
phase involves eliciting an anxious image, followed by developing a metaphorical image
to represent the activated anxious feelings, and then finally developing a coping image
by making appropriate changes to the metaphorical image. The following script can be
used as a guide to help clients through this three-stage process:

Eliciting an Anxious Image
“If you feel comfortable doing so, close your eyes, sitting comfortably . . . bring to
mind a situation in which you typically experience strong anxiety . . . try to visual-
ize a specific recent example of this situation . . . imagine this difficult situation as
if you are there right now, experiencing it firsthand . . . let’s explore this situation as
if it’s happening right now . . . ”
• “Where are you? What is going on? What can you see, hear, taste, smell or
touch?”
• “What are you thinking?”
• “What do you feel in your body? What sensations do you notice?”
• “What are you feeling emotionally?”

TABLE 6.2.  Client Examples of Coping Imagery

Anxious image Coping image
Drowning in a giant ocean wave Surfing the wave in to shore

Hiding in a dark cave Stepping out of the cave into the light of a beautiful sunny
garden

Being trapped under a cage A loved one lifting the cage and freeing me

A big rock weighing down on my chest Pushing the rock off my chest, standing up, and taking a
breath

A big red disgusting oozy mass Widening out my perspective to see it as a volcano that is just
part of a wider beautiful landscape

Being in a dark jungle with a tiger circling The jungle turns bright and sunny, and it is no longer a tiger
but my cat, which I am holding and petting
 Avoidance and Safety Behaviors 133

Eliciting a Metaphorical Image
“Having tuned in to how this situation makes you feel physically and emotionally, let
the image go and allow an image to arise that represents this feeling . . . let an image
arise that symbolizes how you feel . . . this may take some time . . . stay with it even
if it seems strange . . . you may or may not be in the image, it doesn’t matter as long
as it represents the anxiety you feel . . . if several images occur, pick the strongest.
“Now that you have an image that represents your anxiety . . . let’s explore it
using whatever senses seem most appropriate for the image. First . . . ”
• “How it looks . . . (notice the size, color, lighting, how it looks from different
angles or distances)”
• “Is there anything of note in terms of its texture, weight, temperature, the feel
of it to touch . . . ”
• “Any sounds of note . . . ”
• “Any smells or tastes of note . . . ”
• “What does this image mean about you or your anxiety? What is the image
trying to convey?”
• “How does the image make you feel emotionally? And what body sensations
go with that feeling?”

Eliciting a Coping Image (Changing the Metaphorical Image)

“Now, what would need to change in the image to make you feel better or resolve
the problem that is going on there? It may involve introducing some new action, or
person, or object, or seeing the image from a different vantage point or manipulat-
ing the image in some other way. Think about what is needed to change the image
for the better.
“Now that you know what needs to change, try to see these changes taking
place now. Find ways of making these changes happen in the image. It may take a
number of tries, but keep persisting until the problem in the image has a satisfactory
resolution.
“Now, notice how this new image makes you feel emotionally. And in your
body what sensations do you now notice, and where do you feel them? . . . When
you are ready you can let go of the image and open your eyes.”

Coping Imagery Debrief
Worksheet 10, Coping Imagery, provides a guide for debriefing and recording client learn-
ings from the exercise, as well as describing how to strengthen the image and apply it
in the future. The debrief should focus on how the coping image (i.e., the transformed
metaphorical image, not the initial metaphorical image) made clients feel emotionally
and physically, and what the coping image means about them and their anxiety. Gener-
ally, useful coping imagery will be associated with feelings of warmth, lightness, calm,
134 TREATMENT MODULES

and soothing, and clients often report experiencing these feelings in their chest region.
Meanings of the image will often relate to themes of strength, fortitude, persistence,
confidence, safety, security, or stability. If clients are not satisfied with the coping image
that arises, or the feelings and meanings derived from the image do not appear to serve
the purpose of coping with anxious feelings, feel free to rewind the image and try again.
It is important to discuss methods for strengthening this image so it becomes easily
retrievable from memory in high-­anxiety situations. This could simply involve regular
imaginal rehearsal of the image, or other methods such as creating or finding drawings,
pictures, music, poetry, or objects that represent the image. These can serve as reminders
of the image and may themselves become associated with the same feelings and meanings
that the coping image generates. For example, one client had his coping image of being
unshackled from handcuffs illustrated, and he then used illustration as the background
picture on his cell phone. The client reported using the image as a regular reminder of
the increasing freedom he felt from persevering with his behavioral experiments. Assist
clients to consider how they will apply the image to help them cope with behavioral
experiments. For instance, they could bring the image to mind prior to a behavioral
experiment, during a behavioral experiment if the urge to escape is present, or after a
behavioral experiment to self-­soothe back to baseline. Handout 9, Coping (Metaphorical)
Imagery, can be provided to clients as useful psychoeducation on the development and
use of coping imagery.

Coping Imagery: A Caution
Watch out for the misuse of coping imagery as a safety behavior, and ensure clients are
clear about when it is helpful to use coping imagery to persist with behavioral experi-
ments versus when it is unhelpful because it undermines learning from a behavioral
experiment. Using glimpses of the image to approach and fully engage with a difficult
situation is helpful. Needing to sustain the image and use it to avoid anxiety is problem-
atic. This distinction can be subtle at times, and assessing the attitude adopted by clients
when using coping imagery is important. Ensure clients’ intention is to use it as a tool
to tolerate anxiety, rather than as a safety behavior aimed at removing anxiety. Directly
asking clients why they are using the coping image may give you an insight into their
motives. Another option is to ask clients to rehearse out loud how they would use the
coping image when anxious (i.e., verbalizing their internal self-talk and imagery), or
when anxious in the presence of the therapist get them to report out loud how they are
using their coping image. The words they use, their tone and volume, and the rapidity of
their speech will give you some insight into whether they are using their coping image
to genuinely “ride the wave of anxiety” or whether they are using it to attempt to “get
the hell off the wave!”
The ultimate aim of coping imagery is to convey the sentiment “this is just anxiety,
just sensations—­I can cope with this.” This could obviously be provided to clients as a
helpful coping statement on a f lash card. However, coping imagery can be a nice short-
hand method of conveying this same meaning, yet in a far more emotionally evocative
 Avoidance and Safety Behaviors 135

way. It may be less cumbersome than a f lash card, more memorable and accessible than
having to spontaneously remember a series of coping statements, and ideally more emo-
tionally and physically impactful. Therefore, coping imagery can become a useful tool to
facilitate anxiety tolerance, and thus help clients to persist with the challenges of much-­
needed social behavior change.

Clinical Case: Behavioral Experiments

We just couldn’t stop at one clinical anecdote when it comes to behavioral experiments, as we have
shared some very memorable experiences with our clients! However, we don’t want the following clini-
cal anecdotes to misrepresent the nature of behavioral experiments undertaken in SAD treatment. Most
behavioral experiments conducted in treatment will involve engaging clients in fairly standard social
contexts in fairly conventional ways (e.g., walking into a busy shopping area to test the fear that every-
one will look at me, or saying hi to a work colleague to test the fear that I’ll saying the wrong name).
Shame-­attacking exercises usually form an essential minority of the behavioral experiments conducted
with clients. They are perhaps overrepresented in our clinical anecdotes because they tend to be so
memorable and powerful, both for clients and therapists.
The culmination of numerous standard and shame-­attacking behavioral experiments for one client
was skipping down a main café strip with a party hat on and blowing a whistle. It was amazing to see
the big smile on this client’s face and the sheer look of liberation as she truly discovered experientially
that “even if I do something that’s crazy and attracts attention, there is no real tangible negative cost.” In
fact, several bystanders who were unsure what it was all about cheered her on anyway. This freed her
from the “tightrope” of what is socially acceptable behavior, as she recognized that “if I can do this and
suffer no real tangible consequence, then I can handle usual everyday social interactions.”
Another client who had struggled over many group sessions to really engage with any of the strate-
gies either within or between sessions had a noticeable shift when he took part in a shame-­attacking
exercise of walking around a crowded place with toilet paper purposely hanging out the back of his
pants. He was depressed because of his social isolation and was caught in the trap of his depression
interfering with his engagement with social anxiety treatment. However, after many weeks with little
progress, this one experiment made a significant impression on him. It was the first time we had seen
him smile as he said, “No one seems to care what I do, so maybe I shouldn’t care so much either.”
The following story is especially for therapists who worry about behavioral experiments going
wrong (i.e., the client’s prediction coming true). In a group session where the clients and therapists were
embarking on a strange procession in single file through a public area, one client’s biggest fear was
that he would see someone he knew and be ridiculed. The client was a young male who reported that
many of his friends socialized in the area, so for him this feared situation was likely and highly costly.
From past experience the therapists were pretty confident that the likelihood of this occurring was
actually very slim, but a brief discussion followed about strategies for managing this situation should it
arise. Some group members suggested that he say the strange behavior in the group was part of an
acting course. Others suggested that he tell them that it was none of their business! Armed with these
potential responses the clients and therapists set off to complete the behavioral experiment. Well, what
do you know . . . the client did see a friend (another young male) who came up and asked, “What are
you doing?” During the debrief the therapists held their breath as they anticipated the outcome of the
conversation. The client reported that he was shocked to see his friend, and rather than lie he decided
136 TREATMENT MODULES

to tell him the truth, “I am doing a social anxiety course.” Again, the therapists held their breath. The
friend’s response was astounding to the client and to the whole group. His friend said, “I think I might
need to do something like that too.” This experience was pivotal for this client and provided an impor-
tant corrective experience for the whole group, including the therapists.
In another group therapy session, one of the shame-­attacking experiments we did as a group was
to walk down a public street with each of us dragging an object on a string as if we were taking it for a
walk. I (LS) had a paper coffee cup at the end of mine, some people had pens or toilet paper rolls. So,
we walked in a rough line with one cotherapist (PM) guiding the front, and me at the back. Being at the
back was interesting. People’s reactions to our group were initially a lack of attention, then eventual sur-
prise, and then curiosity. My colleague, being at the front, often went unnoticed, as people only tuned
in to this unusual behavior after several people walked past them with strange objects on strings. At
the end of the line another client and I therefore attracted the most interest and attention of all, none of
it malicious, all just genuine curiosity. The climax came when we were stopped by a bunch of foreign
tourists, not to ask what we were doing, but instead to ask if they could take a photo with us. The client
consented, and so we had our photo taken with about five other tourists, who all flashed big happy
smiles and peace signs, and were extremely grateful to us. They never bothered to ask what we were
doing or why. The client walked away exclaiming, “That was actually fun!” I have always wondered how
those tourists made sense of those pictures when they returned home.
 Avoidance and Safety Behaviors 137

THERAPY SUMMARY GUIDE: Avoidance and Safety Behaviors

Therapy Aim:  Identify avoidance and safety behaviors, and use behavioral
experimentation methods to reverse avoidance and drop safety behaviors. These
methods are intended to challenge and modify the negative social thoughts and images
that avoidance and safety behaviors serve to perpetuate.

Therapy Agenda Items:

Socialize clients to changing avoidance and safety behaviors:
]]
Identify avoidance and safety behaviors
\\
Normalize the function of avoidance and safety behaviors by linking them to the
\\
feared negative imagery these behaviors are designed to prevent
\\Highlight the maintaining role of avoidance and safety behaviors via Socratically
guided psychoeducation, including the vicious cycle of avoidance and anxiety and
positive cycle of approach and reduced anxiety
\\Discuss the impact of the Safety Behaviors Imagery Exercise
Develop strategies for coping with anxiety during behavioral experiments. Imagery
]]
Challenging is one method already available from Chapter 5, with another option
being the development of metaphorical coping imagery
Modify behavior to challenge cognitions via behavioral experiments:
]]
Introduce behavioral experiments with a focus on increasing client motivation
\\
Worksheet 7, Behavioral Experiment Record—review hypothetical examples, apply
\\
to client examples within therapy sessions (conducting the behavioral experiment
in session), plan and debrief experiments in session that are conducted by
clients outside session, and then have clients independently complete multiple
experiments as ongoing weekly homework
Develop a behavioral experiment hierarchy to guide the direction and planning of
\\
behavioral experiments over the course of treatment
Conduct a safety behaviors experiment, if necessary, to increase client
\\
commitment to dropping safety behaviors during behavioral experiments
As early as clients are willing, conduct shame-­attacking experiments to ensure the
\\
cost of social mishaps is tested during treatment

Therapy Materials:
Handouts
]]
Handout 4, The Cycle of Avoidance and Anxiety
\\
Handout 5, Safety Behaviors
\\
Handout 6, Behavioral Experiments—includes behavioral experiment record
\\
example
138 TREATMENT MODULES

Handout 7, Behavioral Experiment Menu

\\
Handout 8, Behavioral Experiment Hierarchies—including four behavioral
\\
experiment hierarchy examples
\\Handout 9, Coping (Metaphorical) Imagery
Worksheets
]]
\\Worksheet 7, Behavioral Experiment Record
\\Worksheet 8, Safety Behaviors Experiment
\\Worksheet 9, Behavioral Experiment Hierarchy
\\Worksheet 10, Coping Imagery
 CHAPTER 7

Negative Self‑Image

Therapist: What do you envision happening if you went to the party instead of
avoiding it?
Client: It would be a disaster!
Therapist: How so?
Client: Well, I wouldn’t know what to say, I wouldn’t be able to keep a conversa-
tion going, people will find me boring or annoying. They will think I am weird
because I look so anxious.
Therapist: Is there an image that comes to mind that captures the thought that
people are going to be bored or annoyed by you?
Client: I guess the other person’s eyes sort of glaze over; they look at their watch a
lot and search the room for someone else to talk to as an escape from me. They
make some weak excuse and walk away as soon as they can. They roll their eyes
and keep looking back at me as they talk to their “savior,” and you can just tell
that they are talking about me.
Therapist: What about the part where you said, “They will think I am weird
because I look so anxious”—how exactly would they be able to pick up on
your anxiety? What would they be seeing in you that would indicate you were
anxious?
Client: Well, I would be bright red in the face, sweating, shaking, I would “umm
and ahh” a lot, I would just look like a fool, so of course they will think “What’s
their problem?”
Therapist: That prediction of being bright red, sweating, shaking, does that ever
enter your mind like a photo or video of yourself looking that way?
Client: Sort of, I guess I am always conscious that my anxiety is pretty obvious.
139
140 TREATMENT MODULES

Therapist: It sounds like there are two kinds of negative social images you might
hold. Those that are about how others are reacting to you, and those that are
about how you are appearing to others, that is, how anxious you look and how
you are performing socially. So far we have mostly focused on challenging and
experimenting with images regarding other people’s reactions to you. I would
also like to turn our attention specifically to the negative self-image that you
hold, that picture of how you imagine you are appearing to others, and see if we
can challenge and experiment with this type of image too.
Client: But I am red, I am sweating and shaking, all that is true. It isn’t imagined.
Therapist: You are absolutely right. You are feeling anxious, and when we are
anxious we do feel all those symptoms in our body of things like f lushing,
sweating, shaking. But what I would like you to be curious about is whether
those symptoms are as observable to others as you think. So the issue is not
whether or not these symptoms are occurring, but are they as observable to
others as you think, and is the image you have of yourself completely accurate?

About This Module: Addressing Self‑Imagery in SAD

Clients with SAD often underestimate their social performance and overestimate the
observability of their anxiety. This is a form of emotional reasoning—“because I feel
anxious and I am very aware of it, everyone else must also be aware of it and I must
look like a fool.” Therapists can have similar biases about their clients. Therapists might
assume that because clients with SAD have typically been avoidant for some time they
must have a social skills deficit, either because they have not acquired appropriate skills
earlier in life or because of a lack of practice. Therapists may therefore share clients’ fears
of negative evaluation from others, assuming clients are not able to socialize in a con-
ventional manner. However, research and clinical experience suggest that a skills deficit
in SAD is not the norm, and that clients with SAD often have perfectly adequate social
skills and performance. The problem is usually that anxiety and safety behaviors inhibit
social skills. Once anxiety is successfully treated, our clients’ natural social skills often
become apparent.
Clients’ underestimation of performance and overestimation of the observability of
their anxiety often manifests cognitively via negative self-­imagery. Many clients will
hold a negative image from an “observer perspective,” that is, how they appear to oth-
ers, as if they were observing themselves through the other person’s eyes. This means
that when anticipating, participating in, or ref lecting on social occasions, clients’ nega-
tive social imagery may be intermixed with snippets that occur from a field perspective
(i.e., looking out at the situation through their own eyes to see other people’s reactions)
and snippets that occur from an observer perspective (i.e., seeing themselves from oth-
ers’ perspectives). The problem is that the self-image formed in the client’s “mind’s eye”
 Negative Self‑Image 141

is guided by internal cues (e.g., anxiety symptoms) and ambiguous external cues (e.g.,
seeing someone yawn or look away), rather than objective feedback. The self-image
can therefore be highly biased. This module covers the practicalities of identifying self-­
imagery and effectively engaging clients in the challenging behavioral experiments that
are required to correct biased self-­imagery, with a particular focus on using video feed-
back as a corrective tool.

Identifying Negative Self‑Images

Negative self-­images are a subset of negative social imagery and hence can be targeted
via similar challenging and experimentation principles that have already been discussed
in Chapters 5 and 6. When eliciting negative social images more broadly (see Chapter
5), which is usually done by asking clients to adopt a field perspective, it is likely that
they will spontaneously shift into an observer perspective, and therefore negative self-­
imagery will emerge. Thus, the prompt questions and Worksheet 5, Thought and Imagery
Record, already introduced for eliciting negative social images generally, will likely reveal
some negative self-­imagery too. However, if this spontaneous shift does not occur, then
clients may need more specific prompting to adopt an observer perspective:

“It is very common for people with social anxiety to have negative images not just of
people judging them and reacting to them negatively, but also of themselves appear-
ing in some way that will generate negative judgment from others. We will call this
a negative self-image, where you have a negative image of how you appear to others,
as if you were one of them observing yourself.
“When you are in a social situation and feeling anxious, how do you imagine
you look to others? How do you imagine you are performing? If I were there what
would I be noticing about you? [Client gives general examples.]
“Close your eyes and imagine being in [a social situation] as if you are there
right now experiencing it firsthand. This time take the perspective of the other
person looking at and observing you. What are they seeing? What are they noticing
about you? How are you appearing? How are you performing socially?”

As with any aspect of treatment, the rationale for targeting self-­imagery must be
clear to our clients. A convincing rationale is particularly important given that clients
typically find the main recommended experiment for modifying negative self–­imagery
(i.e., video feedback) very challenging. Before clients are likely to willingly engage in
video feedback they must first be convinced of the positive impact that challenging their
negative self-image will have on their treatment outcome. Handout 10, Self-Image: How
I Really Appear to Others, can be helpful to provide to clients as psychoeducation, and
the following are important points to discuss with clients to reinforce the rationale for
tackling negative self-­imagery.
142 TREATMENT MODULES

• Negative self-­imagery promotes self-­focused attention rather than task-­focused atten-

tion, which can reduce clients’ ability to fully engage in the social encounter and
negatively impact social performance.
• Negative self-­imagery increases perceived threat in social situations as it heightens
awareness of anxiety symptoms and exaggerates the presumption that these symp-
toms are obvious to others.
• More negative images follow from the self-image regarding negative evaluation from
others that will result from observable anxiety and poor performance.
• Negative self-­imagery increases the urge to avoid or escape if we perceive that the
image we are presenting to others is inadequate.

The following are potentially useful questions to Socratically elicit each point from
clients.

• “How do you think these negative images of yourself contribute to your social
anxiety?”
• “Does the image increase or decrease your self-­focused attention? What impact
does self-­focused attention have on you? What impact does it have on your anxi-
ety? What impact does it have on your social performance? Are you able to fully
participate in the social situation when this negative self-image is at the forefront
of your mind? If you can’t participate fully, then what happens? Do you find that
the image can be very distracting, increasing your awareness of your anxiety and
focusing your attention inward on trying to control the anxiety? Is it possible that
all of this takes attention away from the task and might interfere with your social
performance?”
• “In what ways might the negative self-image increase or decrease your sense of
social danger? If your negative self-image suggests that your anxiety symptoms are
noticeable, and you believe that others seeing your anxiety will lead to negative
evaluation, then what impact does the self-image have on your sense of danger in
social situations?”
• “What images do you have about how others will react to seeing your anxiety
or poor social performance? And how do you then see yourself reacting to this?
It sounds like the negative images about yourself can start to snowball into other
negative images.”
• “When you have these self-­images, are you more or less likely to stay in the social
situation? Are you more or less likely to want to go into similar social situations in
the future? How might this avoidance prevent you from ever testing your image
of the obviousness of your anxiety symptoms (i.e., the true likelihood of others
noticing)? Even if some people do notice your anxiety, how does avoidance pre-
vent you from directly testing how much this really needs to matter (i.e., the true
cost of others noticing)?
 Negative Self‑Image 143

Negative Self-Image
Image of obvious,
bright red blushing

Increased Perception Meaning

of Social Threat I look like an idiot
Feel even more anxious I will be criticized
(blushing, shaky, sweaty,
mind going blank)

Image of Others’ Reactions

Image of people laughing
and pointing at me

FIGURE 7.1.  The vicious cycle of negative self-­imagery and social threat.

In addition to discussion of these points, the vicious cycle diagram shown in Figure
7.1 can be drawn collaboratively with clients. The diagram illustrates how the negative
self-image leads to the beliefs that anxiety is obvious and performance is poor (e.g., I
look like an idiot), and that negative judgment and reactions from others will follow
(e.g., I will be criticized). These beliefs then lead to further negative imagery of other
people’s negative responses. The perception of social threat then escalates because nega-
tive evaluation seems even more likely, and so further anxiety is generated in response to
this threat. The anxiety symptoms that feature in the negative self-image then become
more intense, and are then presumed to be even more observable. This process strength-
ens the negative self-image and the cycle continues.

Modifying Negative Self‑Images
As with the negative images discussed in Chapters 5 and 6, negative self-­images can be
modified via challenging and experimentation methods. The role of the therapist is to
cast doubt on the accuracy of clients’ negative self-­images, cultivate a curiosity within
clients to discover how they truly appear when anxious, and provide opportunities to
gather this evidence.

Challenging Self‑Images
Many of the questions used for general imagery challenging in Chapter 5 can be applied
here to assist with identifying and challenging the accuracy of self-­images, and Worksheet
144 TREATMENT MODULES

6, the formal Imagery Challenging Record, could be used. The following concepts and dis-
putation questions may be particularly useful in helping clients to be more open to the
possibility that their negative self-­images may not be valid:

“Not only is the negative self-image unhelpful because it increases your social anxi-
ety [in the various ways previously outlined], it may also be unhelpful because we
know that many people who feel anxious in social situations do not have accurate
views about how they appear to others. It is possible that although you may feel anx-
ious, others cannot see this to the same degree that you feel it. In fact, most people
with social anxiety come across far better than they imagine they do. Overly nega-
tive images of your anxiety and social performance can therefore mislead you and
increase your perception of social threat.”
• “How do you know for sure that your self-image is accurate?”
• “How do you really know how you appear to others?”
• “How often do you get an objective picture or reliable feedback?”
• “What do you base your self-image on? Is this good, solid, reliable evidence?”
• “What evidence or experiences support your self-image being true?”
• “Have you had any experiences that show that this self-image is not com-
pletely true?”
• “Is your self-image based on unambiguous facts, or are you using emotional
reasoning (i.e., because I feel anxious therefore I must look anxious to others)?
What evidence do you really have?”
• “Is it possible that the symptoms you are concerned about may be less obvi-
ous than you think? Because they are happening within you, is it possible that
they seem magnified to you? To an outsider who is not specifically looking
for these things, is it possible that they may be less obvious and go unnoticed?”

Often clients will recognize that they have no clear evidence to support their nega-
tive self-image other than the anxiety they feel. If this is the case, it is important that they
realize they are jumping to the conclusion that an internal emotional and physiological
experience is very observable externally. It might be useful to question if they have ever
heard other people say “I was so nervous,” yet their perception was that the person didn’t
look nervous, or if they did it was quite minor and understandable given the task.
Sometimes clients will be able to recall experiences where people have noticed their
anxiety and commented. If this is the case, then it may be useful to place this feedback
within a broader context by asking the following:

• “How many times have you been anxious in your life, and how many comments
have you had, exactly?”
• “What specifically was the feedback you received? While your anxiety may at
times be noticeable to others, have you had reliable feedback about the intensity of
all the specific things you are concerned are noticeable?”
 Negative Self‑Image 145

• “Was it your anxiety symptoms or your safety behaviors that others were notic-
ing? If it was your safety behaviors, it sounds like using them might be increasing
the risk of negative evaluation. That’s interesting, what do you make of this?”
• “When someone has made a comment, then what? What happened next? What
was the true cost or consequence when someone noticed? Did you cope? How
could you cope?”
• “What does it say about the other person who would make a comment about
someone else feeling uncomfortable? What do you think other people would
think of their behavior?”
• “When you notice that someone is looking uncomfortable, how do you feel
toward them? Do you tend to be highly critical or more compassionate?”

Behavioral Experiments for Negative Self‑Images

Challenging self-­images cognitively may not necessarily shift clients’ self-­imagery sig-
nificantly. However, the aim of this line of questioning is to start undermining the valid-
ity of self-­imagery, generate curiosity about alternative self-­images, and prepare clients
for behavioral experiments that will more reliably and powerfully test the accuracy of
their self-­images. Regardless of whether the self-­imagery challenging process has been
“successful,” therapists should move to questioning what would need to be done to
gain more valid information regarding their appearance by asking, “So how could we
go about getting a more accurate image of how you are coming across to others when
you’re feeling anxious?”

Feedback from Others
Clients might bring up the possibility of getting feedback from others. While a behav-
ioral experiment could achieve this, the problem is ensuring that the feedback is objec-
tive, constructive, and believable. Discuss with clients how they might obtain feedback
that meets these criteria. Clients would need to be able to identify who they trust to give
accurate and constructive feedback that is not unduly biased in a negative or positive
way. This might include friends, family, a boss, a tutor, or a job interview panel. Friends
and family could always be drawn on to give very general feedback (e.g., “do I look anx-
ious when I am talking to people I don’t know well?”), but more specific feedback will
have a greater impact. This would involve identifying a specific situation within which
clients will be observed and identifying beforehand the specific aspects of appearance
they are concerned about, so the person providing feedback can comment specifically on
each. Worksheet 7 (Behavioral Experiment Record), discussed in Chapter 6, could be used
to assist with planning the specific details of a feedback experiment.
Consideration should be given to whether to cue the observer in to the client’s
specific appearance concerns prior to the observation task. One option is not to tell the
observer the client’s appearance concerns and see if the observer notices them. If they
146 TREATMENT MODULES

go unnoticed and cannot be specifically identified, then this is important information

about the likelihood of the symptoms being noticed. The observer can then be prompted
retrospectively for feedback on the specific appearance concerns for further confirma-
tion. This approach is most naturalistic because people generally do not closely scruti-
nize others’ performance or appearance, and therefore the risk of minor symptoms being
magnified by excessive attentional focus is reduced.
However, if the client has strong concerns about a particular aspect of his appear-
ance and performance, it may be valuable for him to learn that even when someone was
specifically paying attention, the symptom wasn’t obvious or as intense as imagined. In
these instances, it may be helpful to ask the observer to focus on particular symptoms
before engaging in the task. After receiving feedback from others, as we do in all behav-
ioral experiments, this information is used to update the negative self-image into a more
helpful, realistic self-image.

Video Feedback
Using feedback from other people as a means of updating negative self-­images still runs
the risk of not providing objective and believable evidence. There is potential for clients
to dismiss positive feedback as being disingenuous. Instead, the therapist could encour-
age clients to consider the option of obtaining video feedback by asking questions like
“How could you find out once and for all, in a way that would be convincing to you,
how you come across when you’re feeling anxious, without having to rely on other
people’s feedback?”
Ideally clients will generate the idea of video feedback themselves, which the thera-
pist can endorse as a “great idea!” Video feedback offers clients the best opportunity to
gather objective evidence about their appearance that is most likely to be convincing to the
client. Video feedback experiments involve videotaping clients when they are anxious
and then having them repeatedly view this video in a strategic manner. The aim is for
clients to directly compare their self-image to the video image. The typical task used to
generate anxiety in group therapy is a 2-minute impromptu speech given in front of the
group. Therapists offer clients the option of giving the speech on a topic of their choos-
ing or a topic randomly chosen for them. After discussing the rationale for challenging
self-­images, if clients are willing, it might be preferable to move immediately to the
video feedback task prior to extensive thought and imagery challenging to maximize the
impact. The therapist must be careful to keep the thought and imagery challenging from
providing too much reassurance or removing any of the surprise the client might experi-
ence from observing the discrepancy between her self-image and video-­recorded image.
In individual therapy the same speech task could be used, and the therapist’s col-
leagues could be recruited as an audience. Having the therapist alone as an audience may
be enough to generate sufficient anxiety for some clients. The size of the audience is
unimportant, but the task must generate anxiety (a SUDSs rating of at least 5 out of 10).
Clients need to feel anxious when being taped, so they have the opportunity to observe
how they appear when in an anxious state. If they don’t feel anxious when being taped,
 Negative Self‑Image 147

the experiment is useless. If they report that the task is not anxiety provoking, question
what they could do to make it anxiety provoking, for example altering the type of task,
type of audience, number of people, length of time, and where the task is completed.
You may need to get creative! If clients are concerned because they will be anxious, the
therapist should respond with enthusiasm.

“Great! If you weren’t anxious it would be a waste of time. The whole purpose is
to feel anxious and to then observe once and for all how obvious those symptoms
really are.”

If clients still express reluctance it might be worth Socratically eliciting the potential
payoff from the task.

• “What would it be like, after all these years, to discover that although you might
feel anxious these symptoms are nowhere near as obvious as you thought they
were?”
• Why might this be useful to know?”
• What impact would this knowledge have on your ability to make genuine choices
about what you would like to do and not do in your life, without this unfair and
inaccurate negative self-image dictating these choices for you?”

Video Experiment Setup
Worksheet 11, the Speech Form, provides a useful guide through the steps involved in set-
ting and conducting a video feedback experiment. The Speech Form can be amended if
the task being used to elicit anxiety during videotaping is a different social task such as a
social interaction. Prior to the taping, clients are prompted to close their eyes and create
a mental image of how they think they will appear to others while giving the speech.
They then write a brief description or draw a picture of this image. Following this they
complete Worksheet 12, the Speech Rating Form, rating how anxious they predict they
will feel, how anxious they predict they will look, identifying any specific symptoms
they predict will be obvious based on the mental image they created, and rating how
observable they predict each symptom will be on the recording. Before embarking on
the task, it is important to remind clients to drop their usual safety behaviors because
these may also impair performance (e.g., looking down, not making eye contact, speak-
ing quietly, overrehearsing), increasing the likelihood of a more negative video image.
Alternatively, if their anxiety symptoms are not obvious on the tape, they might attribute
this to the use of their safety behaviors. In addition, clients should not use their coping
image prior to the task, again because the aim of the task is to be as anxious as possible.
As with all behavioral experiments, other than ensuring the experiment is clearly
planned, too much discussion beforehand can be a potential form of avoidance, so it
is usually helpful to get straight into the speech task. In a group setting we ask who is
prepared to go first and continue until all clients who have chosen to participate have
148 TREATMENT MODULES

completed a speech. If clients are reluctant to participate because they feel anxious,
remind them that the aim of the task is not to feel calm, but to purposely do a task that
makes them feel anxious so that they can test whether the video recording matches their
mental image of how they come across when anxious. If they think they will be most
anxious if they go last, then they can do this. If they think they will be most anxious
if they are first, then they should be encouraged to do this. As with all experiments,
you are not forcing clients to do something against their will, but rather providing the
opportunity to learn something new that may have a significant impact on how they see
themselves and hence how socially anxious they feel.
After completing their speech, clients then close their eyes and form a clear image of
how they think they came across during the speech, constructing an “internal video” of
how they think they will appear on the recording. They then write a brief description
or draw a picture of this image. Clients then revisit the Speech Rating Form, rating how
anxious they felt, how anxious they think they looked, and how observable they think
each previously identified symptom was.
On a practical note, obviously this exercise requires having access to a recording
device, and ideally some way of replaying the recording immediately after the task is
done. Replaying should be on a screen of sufficient size for the client to see themselves
clearly. Ideally, the recording should be in a format that the client can take away for
repeated viewing for homework.

Watching the Video
Now for the moment of truth, watching the video! The video is typically watched four
times (at least once in session and the other times for homework). The therapist may
decide that all four viewings should be done in his presence, if particular clients need
extensive prompting to facilitate viewing the recording in an unbiased manner. The
rationale for viewing the video on more than one occasion is that most people initially
dislike seeing themselves and hearing their voice on video, and this can adversely impact
perception. Clients often need to desensitize to this initial discomfort before they can
make objective judgments about what they are seeing. Watching the video is usually
anxiety provoking for clients and also for some therapists, with both parties concerned
that the self-image will be confirmed in the video feedback. It is important for therapists
to have some clear strategies for ensuring the video feedback is viewed in an unbiased
manner by clients, and that the experiment is a therapeutic experience.
Therapists may need to work hard to counteract attention and interpretation biases
during the video viewing. The following points are important to cover with clients prior
to watching the video, and may need to be reinforced during or after the viewing. Each
point assists in setting the tone for processing the video in a helpful manner:

•• Distinguish between how one feels versus how one looks. Ask clients to pay attention to
how they look in the video rather than how they felt during the speech (or are feeling
while watching themselves on video). Normalize the “yuck” factor we all get when
 Negative Self‑Image 149

watching ourselves on video, and request that they don’t let that interfere with being
able to objectively look at whether the video matches their original negative self-image.
Mention that viewing it four times is designed to help them put their emotions to the
side so they can look at the video more objectively.
•• Encourage maximum objectivity. Ask clients to watch the video as if watching a friend
or someone else they care about. Request that they observe the whole picture, rather
than homing in on a particular aspect they dislike. To do this they will need to make
sure they are not using safety behaviors such as hiding their face, averting their gaze, or
only intermittently looking at the video recording.
•• Identify unrealistic expectations. Preempt any double standards clients may hold for
themselves by encouraging them to apply the same expectations they would have of oth-
ers doing the task. Unrealistic expectations often involve the idea that they should not
say “um,” pause, stumble on any words, fidget, or move. Encourage them to consider
if their expectations of themselves are reasonable given the task demands. Are they rea-
sonable given their level of experience in public speaking or the impromptu nature of
the task? Would they be willing to abandon their double standards temporarily for the
purpose of this exercise, and rate themselves based on the standards they would apply to
others in the same situation?
•• Prepare for clients noticing negative aspects they hadn’t predicted. Decatastrophize any
aspect of their performance clients would like to change. Frame this as a learning oppor-
tunity. There may be things they want to improve with their public speaking, and this
is fine. Remind them that the aim is to test the predicted image of what they look like
when anxious, not to evaluate their public speaking ability, which is a skill that can be
developed. Request that they focus on discrepancies between the predicted image and
the actual image. Acknowledge that they will be good at finding things they don’t like,
but ask them to also look for things that were better than they expected.

Following the first viewing of the video, the Speech Rating Form should again be
completed, to gather ratings of how anxious they actually looked and how observable
each previously identified symptom was. Again, a new internal video of how they really
appeared should be brought to mind, and a brief description or picture drawn to repre-
sent this. The same is then done after watching the video three more times to see if their
perception changes with repeated viewing. When the final more realistic self-image is
recalled by the client, it can be inserted into a variety of contexts within the client’s life
within imagery to further consolidate and generalize the learning.

Video Experiment Debrief
The video feedback experiment should be debriefed and some helpful conclusions drawn
after the first viewing and again after the additional three viewings. Therapists should
focus on any discrepancies from early to later ratings, and hence any differences between
the negative self-image and the video image. Be aware of getting sidetracked by clients
150 TREATMENT MODULES

wanting to focus on anything they perceive as negative. Always try to redirect them to
discrepancies between the predicted image and predicted symptom ratings, as compared
to the actual image and actual obviousness of symptoms.
If the client’s unrealistic expectations become evident (e.g., you shouldn’t say “um”),
you might ask the following:

• “Are you watching yourself in the same way others would watch you in an inter-
action, or are you over scrutinizing/being critical/holding higher expectations/
looking for a specific symptom rather than taking in the whole person?”
• “How obvious do you think the symptom would be if you weren’t purposely
looking for it?”
• “If you saw someone else displaying [the symptom], what would you think? How
would you feel toward them?”
• “What would be acceptable if someone else was speaking (e.g., how many “um’s”
would be OK)?

The video could be watched again with the therapist, and the perceived “symptoms”
can be counted to see how they compare to what is acceptable for others.
If clients also hold unrealistically high expectations of what is acceptable for other
people, they may need to do some observational experiments watching everyday peo-
ple do a similar task (e.g., work colleagues presenting at meetings, the therapist doing
a videoed impromptu speech, wedding speeches, everyday people giving media inter-
views). Ensure the source of their observational experiments is not an experienced
public speaker. One of our clients compared his social performance to Barack Obama
and, perhaps unsurprisingly, believed he came up short every time! Another client
declared that she just wanted to speak like a newscaster, after which the therapist
encouraged the whole therapy group to have a conversation sounding like newscasters.
It became apparent very quickly that this rule generated some very awkward conversa-
tions.
If clients are harsh in their appraisals of themselves and you are working in a group
context, group feedback can be sought to challenge their appraisals. If you are working
in individual therapy, identifying other people in the client’s life (i.e., friends or family)
who could watch the video and provide fair and genuine feedback may be an option.
Alternatively, the therapist could provide feedback, or with client consent the therapist
could show the tape to colleagues and survey their feedback. However, as previously
discussed, the feedback needs to be considered by clients as objective, constructive, and
believable. If feedback is being sought from other people, then after watching the tape
they should make the same symptom ratings that the client has been completing.
The following questions are used in group therapy when drawing on other people’s
feedback to moderate clients’ harsh appraisals of their performance. These questions can
be adapted when feedback is sought from friends, family, the therapist, or the therapist’s
colleagues:
 Negative Self‑Image 151

• “How do you explain the difference between your observations of yourself versus
the group’s observations? Do you think they are just being nice? What could be
other reasons? Who’s likely to be more objective?”
• “If the rest of the group couldn’t pick it up (even though they were specifically
looking for signs of anxiety), would someone not looking for it notice?”
• “Do you think anyone else in the group has been harsh in how they have seen
themselves on the video? Is it possible that this might be happening for you too?”

If clients find the video feedback particularly helpful and meaningful because they
appear much better than they anticipated, then it is important that they develop and
regularly mentally rehearse a new self-image of how they really appear when anxious,
as a way of consolidating this learning. If these new self-­images are well practiced, then
clients will have a better chance of retrieving them from memory when they start to
question how they are coming across to others.
Some clients may find that video feedback has no impact on their negative self-
image, seemingly confirming what they already suspected. This may occur if clients
are unable to overcome their information-­processing biases when viewing the video.
For example, one client admitted watching the video while intoxicated and through a
window from a separate room. Clearly this was not an ideal strategy for obtaining an
objective impression.
The exercise might also have a limited impact if the video is objectively negative
(i.e., they do look anxious or don’t perform well). Such an occurrence is uncommon in
our experience, and not a reason not to show the client the video. Even if performance is
not of a high standard or some symptoms are present, the client’s self-image is typically
far more negative than the video image. Regardless of the reason for the video feedback
task being ineffective in challenging negative self-­imagery, therapists should not despair.
The following are some options for addressing this problem should it arise:

• “Regardless of whether the image is true, does holding this image help you in
your goal of being able to socialize more? What are the consequences of hanging
on to this image of yourself? What would be a more helpful image to develop that
might be more compatible with your goal of wanting to socialize more?”
• “Regardless of whether the image is true, let’s look at the cost. What does it mat-
ter if the symptoms of concern are present? You noticed them because you were
really attuned to them, which is different from other people noticing and caring.
What experiment could we do to find out how much others notice and how much
it really matters, even when the symptoms are really obvious?” This paves the way
for shame-­attacking experiments where symptoms are purposely exaggerated and
the consequence of this is observed (see Chapter 6).
• “Is it possible that the symptoms of concern may be more exaggerated in this
video task because you are not practiced at public speaking? I am wondering if it
would be the same in more general daily social interactions? How could we find
152 TREATMENT MODULES

out?” This could lead to experiments aimed at obtaining objective feedback from
trusted people in real-world situations (see the earlier section on feedback from
others).
• Reframe the video as an opportunity to improve, rather than the only goal being
to disprove the negative self-image. “What can you do about it? What specific
skills might you need to work on?” (e.g., making more eye contact, speaking in
a louder volume). The therapist and client can then begin working on these skills
in therapy. In addition, the client might acknowledge that many of the symptoms
noticed were actually safety behaviors, which provides a strong rationale for drop-
ping these in future social tasks.
• Given that social anxiety could be thought of as social perfectionism (i.e., demand-
ing that one be socially perfect), could this exercise be used as a good opportunity
to tolerate imperfection? “If you could tolerate not being socially perfect, what
would that be like for you? What consequences would follow?”

Cautions for Video Feedback
If clients have a current or past eating disorder, body dysmorphia, weight and shape
problems, or other body image issues, then you may need to consider whether video
feedback is still appropriate. The decision regarding whether to proceed should consider
how significant the negative self-image is in maintaining social anxiety, the likelihood
of the video task reinforcing or worsening appearance concerns, and whether clients
can separate concerns about the observability of their anxiety from other appearance
concerns. If clients have been able to successfully take part in mirror retraining, which is
recommended in the treatment of BDD (i.e., being able to more objectively describe and
view their image when using a mirror), then this is a good sign that they may be able to
engage in the video feedback task appropriately.
If the therapist has good evidence based on their observations of the client that the
negative self-image is accurate, then the therapist may decide not to proceed with video
feedback. However, therapists should make this decision with caution. Therapists might
predict that many socially anxious clients would perform poorly or show obvious anxi-
ety during the video task. However, it is often surprising how clients are able to rise to
the challenge when the task demands it. We have often been pleasantly surprised by cli-
ent performances during video feedback, in that most clients look like any person would
look when giving an impromptu speech, some nerves but nothing out of the ball park of
“normality.” In fact, we are frequently very entertained by our clients’ humor, knowl-
edge, and warmth when given the opportunity to present. Therapists need to be careful
not to get drawn into clients’ negative views of themselves, and in turn underestimate
clients’ capabilities and resilience. Anxiety symptoms are typically far more exaggerated
in clients’ self-­images than in reality. As already mentioned, even if clients’ negative
images are confirmed, video feedback will help them clearly identify specific behaviors
that they can actively work on.
 Negative Self‑Image 153

Clinical Case: Modifying Negative Self-­Imagery

One client was very preoccupied with the self-image of her jaw and face looking very tense whenever
she was anxious. She imagined looking very taut, unnatural, almost statue-­like. She believed this was
obvious to others, and as a result they would think she was crazy, mentally unstable, and dangerous.
In social settings, she would constantly touch her face and move her mouth in an attempt to relax
her jaw and would often keep her head down. It was actually these safety behaviors that were more
likely to generate negative judgment, rather than her jaw or facial appearance. A speech task was not
necessary to elicit her anxiety. Being videotaped in the therapist’s office doing nothing was enough to
elevate her anxiety sufficiently. The client was videotaped just sitting in the chair, and after a while she
was instructed to “amp up” the facial tension that she believed was so obvious. The therapist and client
then watched the video together. In true form, there were aspects of her appearance that she didn’t like
and initially honed in on. However, when the therapist encouraged her to instead focus on assessing
how the video image of her jaw matched the predicted self-image of her jaw, she laughed in disbelief,
saying “I don’t look like a statue, I don’t look how I imagined.” The client ceased touching her face and
the elaborate jaw movements thereafter.
154 TREATMENT MODULES

THERAPY SUMMARY GUIDE: Negative Self-Image

Therapy Aim:  Identify and modify negative self-­images, which typically ref lect
an overestimation of the observability of anxiety and an underestimation of social
performance.

Therapy Agenda Items:

Identify negative self-­images:
]]
Worksheet 5, Thought and Imagery Record, and general questions for identifying
\\
negative social thoughts and images outlined in Chapter 5 may reveal negative
self-­imagery
Prompt clients to adopt an observer perspective when eliciting negative social
\\
images
Provide a rationale for targeting negative self-­images:
]]
Have a Socratic discussion about negative self-­images promoting self-­focused
\\
attention, increasing perceived threat, eliciting further negative imagery, and
increasing avoidance
\\The vicious cycle diagram (i.e., Figure 7.1) can accompany this discussion
Modify negative self-­images:
]]
\\Worksheet 6, introduced in Chapter 5 (Imagery Challenging Record), can be used,
with additional disputation questions specific to challenging self-­imagery
\\Behavioral experiments:
ff Observer feedback is an option, but may not be ideal if clients cannot establish
an objective and believable feedback source.
ff Video feedback is preferred due to its objectivity. A video-­recorded impromptu
speech or social interaction can be used to elicit anxiety. Special attention must
be given to the way the experiment is set up, using Worksheet 1, the Speech
Form. to guide this process. Watching and debriefing the video also require
careful consideration and planning.

Therapy Materials:
Handouts
]]
Handout 10, Self-Image: How I Really Appear to Others
\\
Worksheets
]]
Worksheet 11, Speech Form
\\
Worksheet 12, Speech Rating Form
\\
 CHAPTER 8

Attention Biases

Therapist: You mentioned that walking down the street can be really anxiety
provoking. Have you ever noticed what you pay most attention to when you are
walking down the street?
Client: Not really, I’ve never thought about it.
Therapist: Let’s do it now together, if you’d be willing. We will just go outside
and walk along the street as you normally would do, but this time just notice
what your mind is homing in on . . . [Therapist and Client go out to the sur-
rounding streets and do the exercise, pause, and debrief on the street.] So what
did you notice your mind was focused on?
Client: Well, I was looking down most of the time.
Therapist: Yeah, I noticed that too. What was the purpose of looking down?
Client: Well, that way I don’t have to make eye contact with people, which would
be really awkward. They’d be able to tell I’m anxious just from the look on my
face.
Therapist: So, looking down is one of those safety behaviors we have spoken
about, trying to avoid your feared image of others noticing your anxiety if you
do make eye contact. I am also curious how looking down might make you
more inwardly focused. Did you notice if your mind was getting caught up in
things going on inside you?
Client: Yeah, I really noticed how uncomfortable I was feeling, how tight my
chest felt, how shaky my hands were, and how self-­conscious and awkward I felt
doing something as simple as walking. I was really focused on trying to not feel
those things, but it wasn’t working.
Therapist: When your mind focuses in on those symptoms and feelings, and
focuses hard on trying to get rid of them, what do you think happens?
155
156 TREATMENT MODULES

Client: Well, it probably makes them worse because I am paying so much attention
to them, but I can’t help it.
Therapist: Also, could you tell me anything about any of the sights that we went
past? Anything about the cafés or buildings? How many people or cars were out
and about on the street? Or how many trees or gardens we passed?
Client: No, I guess I wasn’t paying attention to any of those things.
Therapist: I am wondering if we could try the exercise again as we walk back to
the office, but this time just being aware when your gaze drops to the ground
and your mind goes inward, and instead purposely turning your attention to
what is going on around you, particularly looking for interesting things around
you that you haven’t noticed before. Would you be willing to approach the task
in this way just to see what it is like?
Client: Because you’re here I think I can try it. It would be harder if I was by
myself.
Therapist: That sounds like an expectation you have, and with more practice we
can see if that is really the case . . . [Therapist and Client continue the walking
exercise back to the office, the therapist prompting the client to verbalize what
enters her awareness and, if necessary, to redirect attention to external stimuli.
The debrief commences when back in the therapist’s office.] So, what did you
notice that time around?
Client: The ground was like a magnet. I kept wanting to look down, I didn’t real-
ize how much I did that. When I looked up it was difficult at first, but then I
would get drawn to something interesting and when that happened I think I felt
less self-­conscious for a moment.
Therapist: So being less self-­focused was difficult, but helpful in managing your
anxiety. Anything in particular you noticed out on the street that you hadn’t
before?
Client: One thing that stood out was that huge pink crane on the construction site
across the road. I can’t believe I have never noticed that before. Who doesn’t
notice a pink crane?!
Therapist: I wonder what other things you might miss out on, particularly in
social situations, when your attention is focused inward?

About This Module: Addressing Attention Biases in SAD

Human beings are hardwired to attend to threat. Attention is the “microscope of the
mind,” and when we are under genuine threat it is adaptive for this microscope to focus
on the threat to the exclusion of all else. All our attentional resources need to focus on
 Attention Biases 157

aspects of the situation that will increase our chances of survival at that moment. The
problem arises when attention is unduly drawn to, and maintained on, perceived rather
than real threats.
For socially anxious clients living in a social world, threat is almost everywhere.
Perceived threat is not only present in the external environment in the form of judgment
from others, but also internally. Anxious feelings and associated physical sensations are
perceived as threatening, as clients believe they are observable to others and hence will
increase the likelihood of negative evaluation.
Cognitive theory suggests that attention is directed toward information that is con-
gruent with an individual’s core beliefs. Attention is therefore biased by what we already
believe to be true about ourselves, others, and the world in general. We seek confirma-
tion of our beliefs, not objective information. Our attention gets hijacked by information
that fits with our existing knowledge, with any incongruent information that potentially
has the power to modify existing knowledge being overlooked. The information we
attend to then guides our interpretations and recall, and, in turn, ultimately shapes the
thoughts and images that occupy our stream of consciousness in any given situation.
Clients with SAD typically hold negative core beliefs about themselves as being
socially inept, inadequate, and unlikable. They also hold negative core beliefs about
others being generally critical, judgmental, hostile, and superior. Attention is guided
by these beliefs, and thus clients will tend to focus on internal and external evidence
(ambiguous or otherwise) of ineptitude, inadequacy, unlikability, criticism, judgment,
hostility, and inferiority. One client described this as a “GPS of the mind, which scans
and locks on to anything that alerts you to potential social danger.” Little attention is
paid to the social task at hand, which can adversely impact social performance. Excessive
self-focus makes it exceedingly difficult to keep up with the topic of conversations, let
alone actively contribute to the dialogue. Neutral and positive social feedback that has
the potential to undermine unhelpful core beliefs is largely ignored.
An important task of therapy is to assist clients with SAD to (1) recognize when
their attention is not deployed to the present social task but is instead focused on the
self or environment in unhelpful ways, and (2) rectify this attentional bias by purposely
redirecting attention back to the present social task. This module covers the practicalities
of effectively engaging clients in retraining their unhelpful attention biases, with the aim
of facilitating greater task-­focused attention when socializing. Doing this can not only
result in a reduction in perceived social threat and therefore reduced social anxiety but
can also enhance and enrich the social experience, and, dare we say, facilitate enjoyment
of that which was once feared.

Introducing Attention Biases
Introducing clients to the notion of self-, environment- and task-­focused attention can
simply be done by asking clients, “Where do you notice your attention is focused when
158 TREATMENT MODULES

you are in social situations?” If this question is too general, then experientially or ima-
ginally engage clients in a social situation and encourage them to notice where their
attention is focused. This self-­ref lection can then lead into a discussion of the concepts
of self-, environment- and task-­focused attention.

Self‑Focused Attention
Self-­focused attention refers to attention being deployed inwardly. The types of internal
experiences that might capture one’s attention when socially anxious can vary. Self-­
focused attention may relate to purely being caught up with negative internal experi-
ences, or strategizing how to stop negative internal or external experiences. Clients may
be focused on one particular internal experience or a myriad of internal experiences at
once, creating a sense of internal chaos. Attention might be captured by the emotional
experience itself (i.e., fear, anxiety, panic, self-­consciousness, embarrassment), physi-
cal sensations that accompany anxious feelings (e.g., sweating, shaking, blushing, heart
racing), or negative thoughts and images regarding one’s appearance, performance, or
negative evaluation from others. Attention could also be focused on intentionally moni-
toring one’s own performance, particularly what one is saying before, during or after
it has been said. People with SAD may also be acutely aware of the fact that they are
using safety behaviors and may be self-­critical or expect criticism from others as a con-
sequence.

Environment‑Focused Attention
The little attention that is left over is often focused on environmental threat, in the form
of scanning for signs of negative evaluation from others that confirm the clients’ nega-
tive social images. Ambiguous social cues such as frowns, yawning, a glance at a watch,
pauses in conversation, and laughter tend to lure the attention of the socially anxious
client. These ambiguous social cues are generally interpreted as signs of negative evalua-
tion, and hence provide fodder for further self-­focused attention as a means of trying to
reduce the perceived negative feedback.

Task‑Focused Attention
Our attentional capacity is finite, and so with self and environmental threats stealing the
show, attention to the “task at hand” suffers. During social interactions, the task at hand
will likely involve absorbing oneself in the moment, such as concentrating on the topic
of conversation, noticing common interests, allowing natural curiosity about what the
other person is saying to take over, and making links to one’s own experience that can
then be followed up in conversation. In observational situations (e.g., walking, eating,
writing, working in front of others) and performance situations (e.g., public speaking,
music or dance performances), the task at hand involves focusing on what is required
to complete and immerse oneself in the activity, including the sensory aspects. During
 Attention Biases 159

behavioral experiments, the task at hand will also involve directing attention to evidence
that may confirm or disconfirm negative thoughts and images.

The Competition for Attention: Self, Environment, and Task

Handout 11, Self-, Environment- and Task-­Focused Attention, provides useful psychoedu-
cation regarding the competition between these three potential attentional foci. These
concepts can also be visually illustrated to clients by collaboratively drawing and talking
through an attentional biases diagram similar to Figure 8.1.
Figure 8.1 shows that attention is mostly self-­focused on noticing internal emotional
experiences or monitoring safety behaviors, adopting an observer perspective of the self
and hence getting caught in negative self-­imagery, or being distracted by imagery of
others’ negative reactions. Any attention that can escape this rather enclosed self-­focused
system then moves to scanning the environment for social threat, either from the current
social companion or from further afield in the environment (e.g., other onlookers). Very
little attention is left over to focus on the task at hand of conversing with the current
social companion.

Environment-Focused
Attention
Ha ha!
Scan the room,
Great joke!
Self-Focused assume others are laughing at me
Attention
Negative
self-image
I’m looking
bright red

Observer
Negative thoughts perspective
and images How are others
Others are laughing seeing me?
at me

Anxiety and safety Task-Focused

behavior Attention
monitoring Little attention on
the task at hand

FIGURE 8.1.  Illustration of attentional biases: self-, environment-, and task-­focused attention.
160 TREATMENT MODULES

Impact of Attention Biases
Clients with SAD are usually readily able to recognize that when feeling socially anxious
they are not focused on the present task at hand (i.e., the conversation, walking, writing,
eating). It is important to normalize this attention bias:

“From an evolutionary perspective we are hardwired to pay attention to threat. In

cave-man times if there was a saber-­toothed tiger about to eat us, and we were pay-
ing attention to something else, then humans wouldn’t have lasted very long as a
species. Fast-­forward to now and the threat isn’t a saber-­toothed tiger but instead a
social situation; however, our attentional instincts are still the same: if we perceive
something is threatening, then of course we pay attention to it.”

After normalizing this cognitive process as useful in genuinely threatening situations,

clients must then be encouraged to recognize the detrimental impact of this attentional
bias when it comes to the maintenance of their social anxiety. Some clients will read-
ily recognize this, while others may at first believe that certain aspects of self- and
environment-­focused attention are helpful in reducing the likelihood of negative evalu-
ation, especially when attention is captured by strategizing about how to minimize
anxiety sensations or poor performance. First, ask clients, “How do you think self- and
environment-­focused attention could increase your social anxiety?” The following are
useful points to discuss:

“Distraction from the task at hand is a likely consequence when our attention is else-
where. In the case of a discussion, we are less able to contribute, speak naturally, and
come up with topics to discuss when we are preoccupied by things other than the
discussion we are having. We may miss cues from the other person that it is our turn
to speak. We may miss information offered by the other person that could be used
as leads for further comments and questions. As a result, we may be more likely to
draw mental blanks when it is our turn in conversation, which affects our social per-
formance. The very thing we are trying to prevent (i.e., a poor social performance)
may actually be more likely to occur when our attention is not task focused.
“Increased self-­consciousness will naturally follow from being more inwardly aware
of our anxiety. More negative self-­images will follow, ref lecting the things we don’t
like about what we are doing, feeling, and saying.
“We can miss positive and neutral feedback when we are so preoccupied with social
threat, which prevents us from gathering evidence that disconfirms our negative
social images. We are also more likely to misinterpret ambiguous feedback as evi-
dence that confirms our negative social images (e.g., a yawn means the other person
is bored rather than tired). This results in an overall negative recollection of the
social situation. The following computer analogy can also be useful in illustrating
the impact of this attentional bias on our recall: A computer can only remember
what we type into the keyboard. Our attention is like the keyboard. Anything that
isn’t attended to isn’t typed into our memory so it can be recalled later. So if we are
 Attention Biases 161

focusing on threatening information to the exclusion of positive feedback, then our

memory of social experiences will be biased toward remembering only the negative
aspects of the social situation.”

All of these side effects of self- and environment-­focused attention generate an

increased perception of social threat and therefore more anxiety.

Self‑ versus Task‑Focused Attention Experiment

While a verbal discussion of the negative consequences of not being task focused dur-
ing social interactions is useful, a more experiential method of illustrating these nega-
tive consequences may be more powerful. Clients need to be satisfied that self- and
environment-­focused attention is unhelpful when it comes to their social anxiety before
they are likely to abandon this as a protective strategy.
To experientially illustrate the helpfulness of task-­focused attention during social
interactions (or the unhelpfulness of self-­focused attention), it can be useful to do an
experiment that is very similar to the safety behaviors experiment described in Chapter
6. The experiment involves the client manipulating attention during a social task to con-
trast the impacts of self- versus task-­focused attention. In group therapy, as with the safety
behaviors experiment, the social task we use is a 5-minute conversation with another
group member, contrasting being self-­focused in the first conversation versus task focused
in the second conversation. In individual treatment, the conversation could be with the
therapist or the therapists’ colleagues. An alternative social task could be used, as long as
it can be completed twice to contrast the two attention conditions, and ideally it can be
done in the presence of the therapist rather than as a homework exercise. We find that
a conversational task is quite effective, as it usually becomes very clear that self-­focused
attention hinders social performance, and performance is very much valued by the client.
Worksheet 13, the Self- versus Task-­Focused Attention Experiment, can guide therapists
and clients through the steps of the experiment. Once the social task has been set, typi-
cally a conversation on a topic of the client’s choosing with a designated person (e.g., fel-
low group member, therapist, therapist’s colleague), clients are then given the instruction
to be self-­focused. For example:

“During the first conversation, I would like you to focus as much attention as pos-
sible on yourself. Notice how you are feeling, what thoughts or images are going
through your mind, body sensations you are experiencing, monitor carefully what
you are saying or doing. Devote as much attention as possible to yourself.”

Ask clients to list on the worksheet the types of things they will focus on so it is
very clear where they will place their attention during this first conversation. Allow 5
minutes for the conversation to take place, and once this is completed clients then rate
their anxiety, self-­consciousness, observability of their anxiety, and social performance
during the conversation.
162 TREATMENT MODULES

Prior to the second conversation, clients are given the instruction to be task focused.
For example:

“Now I would like you to engage in a second conversation with the same person, but
this time I would like you to focus as much attention as possible on the task at hand.
Focus on the topic of the conversation . . . what is being said, how it might relate
to your experience, sharing your experience. Really try to get to know the person.
Immerse yourself in the other person’s story and contribute as much as you can to
the topic. If your attention wanders, as best you can shift it back on to the topic of
the conversation and try and get yourself lost in the topic.”

Again, ask clients to list on the worksheet the types of things they will focus on.
As this condition of the experiment is more foreign to clients, imaginal rehearsal is
completed to prepare them to deploy their attention in this unfamiliar manner:

“Before starting this conversation, just close your eyes and imagine yourself being
able to focus almost all of your attention on the topic of the conversation. Imaging
yourself, from your own perspective, looking at the other person and devoting all
your attention to what they are saying. Also, notice that your own contributions to
the conversation are coming fairly naturally. You are able to focus your attention on
the topic, and this is freeing you up to contribute more to the conversation. If your
attention gets sidetracked momentarily, within the image just experience bringing
your attention back to the conversation, getting absorbed again in what is being
said. Notice what your posture is like as you are engaging in this conversation in a
comfortable and relaxed way. How does the other person look as they are appreciat-
ing the attention that you are devoting to them and the interest you are showing in
the conversation?”

Again, allow 5 minutes for the second conversation to take place, and once this is
completed clients again rate their anxiety, self-­consciousness, observability of their anxi-
ety, and social performance during the conversation.
The final step is to debrief any discrepancies in ratings across the two conditions,
and from these observations draw some conclusions about what clients have learned
about the impact of self- versus task-­focused attention. Typically, they acknowledge that
they felt more anxious and self-­conscious, perceived their anxiety to be more observable,
and perceived themselves to have performed more poorly when they were self-­focused.
If this does not occur, question what it was about being self-­focused that was more help-
ful. Hypothesize that the finding may have been an artifact of the task-­focused condition
being unfamiliar to the client, and hence a more challenging way to interact. Encour-
age curiosity about whether this finding would hold with more practice or repetition
of being task focused. For clients who recognize that task-­focused attention was more
helpful, therapists can suggest that even though they now know that being task focused
is a better way to approach social situations, they may still default to being self-­focused
 Attention Biases 163

because it is so automatic, involuntary, and habitual. This leads nicely into the rationale
for attention retraining as a means of assisting clients to acquire the skill of being task
focused more often.

Attention Retraining
Based on the previous groundwork, clients should now acknowledge that being task
focused is more beneficial for their social anxiety and social performance. They should
also be primed to understand that to get the most out of behavioral experiments they
need to approach social situations with an open mind, be present in the social task, and
be unbiased in the information they attend to. We hope they now realize that this is hard
to do when they are anxious and the default attentional bias to threat kicks in. Thus,
they need to adjust their default attention setting. We frame this as “attention retrain-
ing,” which is essentially a specifically focused form of mindfulness practice. Handout
12, Attention Retraining and Focusing, can provide useful psychoeducation about these
skills.

Rationale for Attention Retraining
The following discussion can be useful to orient clients to attention retraining:

“Before we can focus our attention on the task at hand in social situations, we need to
increase our general awareness of what our attention is focused on at any given time,
and our ability to flexibly redirect our attention. We are often oblivious to where our
attention is, and it can often be a very automatic, involuntary, unconscious process.
It also may not occur to us that we can become more deliberate about where we
deploy our attention.
“The strategy we use to increase our attentional awareness and f lexibility, mak-
ing it more deliberate, voluntary and conscious, is called attention retraining. This
process involves paying attention to the present moment and ‘coming to our senses.’
This means focusing on what we can see, hear, feel, touch, and taste in the ‘here
and now,’ using our senses as ‘anchors’ to the present. We start by doing this with
nonsocial activities that are not anxiety provoking (e.g., doing the dishes, hang-
ing the laundry, eating, showering, sitting, walking, breathing), so that eventually
we can apply the skill in social situations, helping us to be more task focused when
socializing.
“You can think of it this way: before an athlete can use a muscle for its intended
purpose (e.g., a big race), the muscle needs to be strengthened (e.g., training in the
gym). We use this as a metaphor for attention retraining. Your attention keeps get-
ting locked on social threat, so your attentional muscle needs to be strengthened
generally (i.e., with nonsocial activities), which will enable you to use it the way you
want (i.e., to be task focused in social situations).”
164 TREATMENT MODULES

Clients are then guided through some attention retraining exercises within the
therapy session to get a more practical understanding of attention retraining. In session,
we typically use short exercises involving attention to breath (see Box 8.1) and sitting
(see Box 8.2). We then encourage clients to adopt this same “coming to their senses”
approach multiple times daily in all manner of nonsocial tasks as a homework exercise,
encouraging them to use Worksheet 14, Attention Retraining Record, to monitor their
practice. We are not necessarily wedded to a particular mindfulness exercise, as long as

BOX 8.1.  Attention Retraining Exercise: Breath

“If you feel comfortable doing so, I would like you to close your eyes and sit comfortably in
your chair, with your hands resting on your lap or on the arms of the chair. Sitting up in a
dignified way with your head comfortably balanced and feet resting on the floor. [pause]
Now I would like you to begin by directing your attention to your breath. Just noticing the
sensations associated with inhaling and exhaling, without trying to alter your breath. [pause]
Observe the entry point of the air into your nose. How does it feel to be drawing air into your
body through your nostrils? Does it tickle? Is it numb? Can you start to become aware of the
sensations within your nasal cavity that are meeting the new air as it arrives? [pause] Start
to follow the path your breath makes all the way down into your windpipe and into the bot-
tom of your lungs . . . and then follow the path of the air from the bottom of your lungs out
through your trachea, nasal cavity, and back into the environment . . . allow yourself to follow
the path of your breath. [pause] Now becoming aware of the sensations of the muscles in
your stomach and chest expanding as you breathe in to the point where they choose to start
expelling the air, and contracting and relaxing as they let the air go. [pause] Notice how your
whole body feels as you continue to inhale and exhale . . .
“Should your mind wander, that’s OK. That’s what minds do. Just congratulate yourself
for noticing . . . perhaps make a mental note . . . “mind wandering” . . . and then shift your
attention back to your breath. [pause] It doesn’t matter how many times your mind wanders
away from your breath, it is the noticing that is important, and you can just shift your attention
back to the sensations of breathing whenever you need to. [pause] If you start to notice any
uncomfortable sensations, emotions, thoughts, or images that are distracting you, as best
you can, try and make space for them, allow them to be there alongside your breath . . . can
you allow them to be as they are for a little while without trying to change them? Allow these
experiences to be there, and then when you are ready, without any urgency, guide your
attention back to the sensations of the breath. [pause 1 minute] OK, as we end our attention
retraining on the breath, when you are ready, open your eyes, bringing your focus back to
the room.”

Debrief: “What did you experience during the exercise? What did you notice or learn about
your attention? How much of your attention was on the task at hand (i.e., the breath)? Were
you able to catch your mind wandering? How did you know it was wandering? Where did it
wander to? What did you do when you noticed this? What impact did that have? When you
were focusing on the present moment, how much attention was left over for thinking about
other things?”

Make sure that clients do not see the purpose of the exercise as having to maintain 100%
focus on their breath. Frustration is a sure sign that this is their aim. Remind them that the
point is to be aware of where their attention is, including when it wanders.
 Attention Biases 165

BOX 8.2.  Attention Retraining Exercise: Sitting

“We are going to do another attention retraining exercise to demonstrate that we can apply
the skill to different activities. I would now like you again to close your eyes if you feel com-
fortable to do so, and again sit comfortably in your chair. I would like you to direct your atten-
tion to the sensations of the chair pushing against your body. Starting with the back of the
chair. Noticing the portions of your back that are in contact with the chair and the portions
that are not. How does it feel on your back? Is it hard, soft, supportive, uncomfortable . . .
just notice these sensations. [pause] Now focus on the part of the chair pushing up against
your bottom. How does this feel? What sensations are you noticing? [pause] Now shift your
attention down to the parts of your feet that are making contact with the ground. How does
the ground pushing up against you feel on the soles of your feet? [pause] OK, we are going
to end the attention retraining exercise here, so at your leisure, feel free to come back to the
room and open your eyes.”

Debrief in a similar manner to the breathing exercise.

the aim of the exercise is the same. That is, developing an awareness of where attention
is, choosing to shift attention to present-­moment experience, noticing when the mind
has inevitably wandered away, and gently and nonjudgmentally redirecting it back to the
intended focus. We frequently use the phrase “catch and bring it back” when orienting
clients to this aim. We emphasize that the goal is not to be 100% focused on the present
moment, but instead to catch where our attention is and bring it back to the task at hand,
no matter how many times redirection is required.
Many treatments use various mindfulness-­ based practices. Most will introduce
mindfulness in their own manner with their own rationale and aim, which may well be
different from the rationale and aim used in this treatment. The emphasis when using
mindfulness exercises in this treatment is on general attentional awareness (i.e., attention
as conscious) and choice regarding attentional deployment (i.e., attention as deliberate).
Above all, the aim in this case is not to achieve general relaxation or a generally present-­
focused mindset, but to ultimately help clients to be able to focus their attention away
from social threat and onto the social task at hand.

Attention Retraining: A Caution
Attention retraining is not to be used as a safety behavior. Be aware of the potential for
some clients to misuse attention retraining as a means of focusing attention away from
perceived threat, as a form of distraction or cognitive avoidance of social situations. They
may be physically in the social interaction but may use attention retraining exercises to
mentally be elsewhere. An example of this is clients doing attention retraining on their
breath during social interactions. Using attention retraining in this manner will inhibit
clients from challenging their negative social images, as they will miss the opportu-
nity to gather contrary evidence that might be available in the situation because their
166 TREATMENT MODULES

attention is mostly directed internally (i.e., on their breath). Instead, attention retrain-
ing is a means of strengthening attentional awareness, so that when clients are in social
situations they can pay attention to more helpful aspects of the situation (e.g., neutral
and positive aspects), rather than only focusing on threatening or negative aspects of the
situation. As a guideline, clients should always be seeking to deploy their attention on
the task at hand. The conversation, rather than the client’s breath, would be the task at
hand when socializing. It may be helpful to focus on the breath before and after a social
situation as a way of tolerating anxiety and settling back to baseline, but not as a form of
avoidance. Attention retraining exercises should therefore typically only be completed
on nonsocial tasks when the client is not feeling anxious.

Attention Focusing
Once clients have begun to understand and practice their attention retraining exercises,
this skill can be extended by introducing the idea of “attention focusing.” Clients do not
need to be experts in attention retraining before moving to attention focusing. In fact,
these skills can often be introduced back to back in one session or across two sessions,
providing the client understands the value of regular attention retraining practice in
facilitating attention focusing.

Rationale for Attention Focusing
Picking up the athlete metaphor again can be a helpful way of introducing attention
focusing:

“So, initially we focused on strengthening your attention muscle generally using

nonsocial activities (i.e., becoming aware of attention and being able to move it).
With attention focusing, you then use your attention muscle for a specific purpose
(i.e., being task focused during social interactions). To extend the athlete metaphor,
we have done the training in the gym and now it is time to use those muscles in the
big race for which all that hard training was intended.”

Attention focusing is essentially encouraging clients to deliberately practice shifting

attention to the task at hand during social encounters. This can be phrased as “getting
lost in the conversation” or “getting out of your head and into the situation.” Clients are
encouraged to develop a new habit when socializing. As soon as they become aware that
their attention is focused on themselves or the environment in an unhelpful way, or they
recognize that their attention is not on the present social task, this is a cue to reorient
their attention back to the task at hand. In social interaction situations, it is clear that the
task at hand is the topic of conversation.
 Attention Biases 167

What Is the Task at Hand in Observation Situations?

The task at hand is a little less clear in situations when the person might be observed
rather than engaged in a social interaction (e.g., eating in public, shopping, walking in
a public place). In line with the attention-­retraining exercises, it might be tempting for
clients to focus solely on the sensory aspects of eating, shopping, or walking. However,
deploying their attention in this way could deprive them of the opportunity to gather
positive or neutral information about other people’s behavior. For example, if clients are
focused on the feeling of pressure in their feet as they walk down the street, they may
miss out on observing that the other people walking by are generally too preoccupied
with themselves to be paying any attention to what they are doing.
When trying to work out with a client what the task at hand is, and hence where
attention needs to be focused, behavioral experiments should be prioritized. Behavioral
experiments will require attention to be deployed in the service of collecting evidence
for and against negative thoughts and images, rather than being tuned to self or environ-
mental threat. During a behavioral experiment, the task at hand is objective evidence
gathering, and clients need to use their attention “muscle” to do this. So for the client
who finds walking down the street challenging, the task is to do this activity and pay
attention in an objective way to whether other people’s actual reactions match the client’s
predicted negative image. Once the negative thoughts and images have been adequately
modified (e.g., <5% belief ), clients often report doing these social activities “without
thinking,” which is a great sign that the anxiety has reduced and new approach behav-
iors are becoming automatic. At this stage, it might then be appropriate to apply atten-
tion retraining exercises to fully immerse oneself in the sensory experience of walking
down the street. However, until then, objective evidence gathering must take prece-
dence. Worksheet 7, The Behavioral Experiment Record, has a prompt in the “Evidence to
Observe” column for clarifying where attention needs to be focused during behavioral
experiments.

Attention‑Focusing Exercises
To facilitate attention focusing, when this is first introduced clients are asked to choose
a specific social interaction that they will participate in as a homework task, and to
purposely approach the interaction with the explicit intention of being task focused. To
encourage this deliberate attentional focus, clients are aware that following the interac-
tion (as soon as is practicable) they will be required to write as much content as they
can remember from the social interaction on Worksheet 15, the Task-­Focused Attention
Exercise. This exercise encourages clients to prioritize focusing as much of their attention
as possible on the content of the conversation, to the exclusion of self- and environment-­
focused attention.
Attention focusing can also be practiced in role plays between client and therapist.
The client and therapist could have a conversation with the explicit intention of the
168 TREATMENT MODULES

client noticing when self-­focused attention is occurring and redirecting attention back to
the conversation as quickly as possible. Clients can signal with their fingers the number
of times they need to redirect attention back to the conversation, so as not to disrupt
the conversational f low. Another option is that the therapist could hold two cards, one
with the words “self-­focused attention” and the other with “task-­focused attention.”
The therapist can hold up each card in turn to signal to the client to switch attention as
demanded. This may give clients practice with attention redirection.
All the attention exercises are designed to increase client perception that attention
is something that can be deliberately manipulated to either the benefit or detriment of
their social anxiety. While being more task focused can reduce social anxiety, likewise
clients find that as their social anxiety diminishes they usually observe that their atten-
tion is naturally more f lexible and that the “threat-­seeking GPS” is no longer switched
on in social situations.

Clinical Case: Attention Retraining

One client was obviously highly anxious while conducting one of the group behavioral experiments,
which involved walking down a main street in single file and performing silly tasks (e.g., pretending to
be airplanes, skipping). Her head was down and her eyes fixed on the ground throughout the whole
experiment. While other group members progressively became braver with their actions, as they dis-
covered just how hard it was to capture anyone’s attention, this client’s affect did not shift. During the
debrief she reported feeling highly anxious and embarrassed about what the group had just done. The
other group members gently challenged her beliefs that other people had noticed or cared what the
group had done based on what they had observed. However, the client appeared unable to accom-
modate this information on an emotional level and the experiment was sadly unsuccessful for her. This
example highlights self-­focused attention as a critical maintainer of social anxiety. This client’s negative
thoughts and images could not be effectively challenged while her safety behavior of looking down was
in operation. This in turn promoted strong self-­focused attention, which negatively biased her process-
ing of the event. In group situations, it is not always possible to titrate exposures to everyone’s needs,
and fortunately this is rarely a problem. In this instance, having noticed the client’s inability to drop her
safety behaviors and broaden her attention, the therapist had the option of interrupting the experiment
and completing another experiment with this client. Observation of the group completing the task may
also have allowed for vicarious learning, without her own anxiety overwhelming her ability to be task
focused. In individual therapy, the therapist may have spent more time developing the client’s attention
retraining and focusing skills prior to conducting behavioral experiments.
 Attention Biases 169

THERAPY SUMMARY GUIDE: Attention Biases

Therapy Aim:  Increase awareness of attention biases to self and environmental threat,
and develop the capacity to be task focused in social situations.

Therapy Agenda Items:

Introduce attention biases:
]]
Encourage clients to self-­ref lect on their attentional focus in social situations
\\
generally, or prompt clients to be more aware of their attention deployment
during specific in vivo or imaginal social situations
\\Discuss self-, environment-, and task-­focused attention, and use Figure 8.1 to
illustrate the competition between these biases
\\Normalize attentional bias to threat
\\Socratic discussion of the negative impacts of self- and environment- focused
attention in SAD, including distraction, self-­consciousness, and missing feedback
\\Conduct the self- versus task-­focused attention experiment
Attention Retraining:
]]
\\Introduce attention retraining exercises using nonsocial tasks
\\Complete attention retraining exercises in session, such as the breathing and
sitting exercises
\\Use Worksheet 14, Attention Retraining Record, to self-­monitor daily practice
Attention Focusing:
]]
\\Encourage clients to be task focused in all social tasks, clarifying what this means
for interaction versus observation situations
\\Worksheet 7, the Behavioral Experiment Record, prompts for explicit consideration
of attentional focus during behavioral experiments
\\Worksheet 15, Task-­Focused Attention Exercise, can be used initially to encourage
task-­focused attention in social interactions

Therapy Materials:
Handouts
]]
Handout 11, Self-, Environment-, and Task-­Focused Attention
\\
Handout 12, Attention Retraining and Focusing
\\
Worksheets
]]
Worksheet 13, Self- versus Task-­Focused Attention Experiment
\\
Worksheet 14, Attention Retraining Record
\\
Worksheet 15, Task-­Focused Attention Exercise
\\
 CHAPTER 9

Negative Core Beliefs

Client: I picture all eyes are on me. People are sneering, frowning, judging.
Therapist: Judging you how?
Client: That I’m . . . not good enough.
Therapist: In what way “not good enough”?
Client: In every way . . . looks, intelligence, personality, social skills, money, you
name it.
Therapist: That idea of not being “good enough,” is that something you experi-
ence just in this situation, or does it pop up in other situations too?
Client: I always feel like I’m not good enough.
Therapist: It might sound like a funny question, but for you what is bad about
“not being good enough,” what will “not being good enough” lead to?
Client: Well, if you aren’t good enough people aren’t going to want to know you,
and people will sense that you are inferior and find ways to expose and humili-
ate you.
Therapist: Do you believe all people will do these things all the time?
Client: I know that sounds a bit over the top, but I still feel like most people are
like that, aside from my closest family. Everyone just seems better than me,
more together than me.
Therapist: It sounds like you have two types of what we call “negative core beliefs”
at play that drive all your specific negative social images that arise in specific
social situations. One core belief relates to how you generally see yourself as a
person, and this is captured by that idea “I am not good enough.” The other
belief relates to how you generally see most other people, and this is captured by
170
 Negative Core Beliefs 171

the idea “Others are better than me, and will reject me or expose and humiliate
me.” These two beliefs kind of play off one another. Not being good enough
leads to the expectation that others will be negative toward you, and the expec-
tation that others will be negative toward you just confirms the idea of not being
good enough.
Client: But “not being good enough” is such a part of me, I don’t think it is some-
thing that will ever change.
Therapist: Many of us have these sorts of negative core beliefs, so I hope you
don’t think you are alone in this. These beliefs usually develop from how we
have made sense of certain experiences we had during our life. What can hap-
pen with core beliefs is once an idea is established, which often happens when
we are quite young—so like a child’s understanding of the world—our mind
then keeps focusing on things that seem consistent with the belief and our mind
ignores things that don’t match the belief. So, over time the belief grows very
strong.
Client: So how do you change a belief that is that strong and feels so true?
Therapist: Rather than try to tackle the belief head on, our best strategy is to start
with your behavior. What I mean is putting yourself in the position to have new
social experiences that don’t fit your beliefs of “not being good enough” or oth-
ers being “rejecting and unkind,” and of course paying close attention to these
experiences. It would be interesting to see if over time by doing this you start
to see these beliefs as outdated and then feel ready to update them. Think of the
beliefs as having initially started out the size of a mouse. But they have been fed
over the years by your mind paying so much attention to every possible negative
social experience or every minute f law within you, so these beliefs are now the
size of some huge beast. Maybe what we can do is not try to fight or tackle the
beast because that probably wouldn’t work, but instead we could just stop feed-
ing it for now. Perhaps we could start feeding an alternative more helpful belief,
and over time this could grow. If we do this, over time the old belief might start
to diminish in strength until it is just in the background, whereas the new, more
helpful and fair belief will increase in strength and become the new lens through
which you see yourself and others.

About This Module: Addressing Negative Core Beliefs in SAD

Negative core beliefs are negatively valenced, global, overgeneralized, fundamental, cen-
tral, pervasive, long-­standing “truths” of how we see ourselves, others, and the world.
Negative core beliefs are generally framed as simple, inf lexible absolute facts, such as “I
am unlikable,” “others are critical,” or “the world is dangerous.” Core beliefs generally
lead to the development of certain rigid rules for how to live one’s life and assumptions of
what one can expect in life, given the “truth” of the core beliefs. For example, if I hold
172 TREATMENT MODULES

core beliefs that “I am unlikable” and “others are critical,” then I might understandably
develop the rule that “I must not get close to other people” and the assumption that
“if I get close to others, they won’t like what they see and will reject me.” These rules
and assumptions therefore help me negotiate life and protect me in the context of my
core beliefs. In this treatment, we focus most explicitly on negative core beliefs, given
that they underpin subsequent rules and assumptions. However, explicitly eliciting and
addressing rules and assumptions is still a valid treatment pursuit, particularly for clients
with chronic low self-­esteem and personality pathology such as avoidant personality
disorder.
Negative core beliefs are generally formed by the processing of early or later life
experiences (e.g., parenting received, parent modeling, bullying, abuse, criticism,
humiliation, ostracism, limited achievements, relationship breakdown), which is inf lu-
enced by genetic and temperamental factors. As already discussed in Chapter 8 (“Atten-
tion Biases”), our attention and interpretive processes are guided by our core beliefs, so
that core beliefs become self-­perpetuating. That is, our core beliefs guide what we pay
attention to and how we interpret sensory input, such that we attend to and interpret
the world in a manner that mostly confirms our core beliefs. This leaves our core beliefs
firmly in place to then bias the processing of subsequent sensory inputs.
The most prominent negative core beliefs in SAD center on themes of the self as
defective and others as rejecting, hostile, or superior. Table 9.1 provides some common
examples of negative core beliefs prominent in SAD, most of which are overgeneralized
conclusions about the self or others. Some clients will also hold problematic core beliefs
that relate to societal conventions and intolerance of anxiety, which can also maintain
SAD.
This module first reviews more traditional cognitive-­behavioral approaches to elic-
iting and modifying negative core beliefs. These approaches are still valid and useful.
However, the greater focus of this module, and indeed this treatment, is on imagery-­
based methods for eliciting and modifying negative core beliefs. The practicalities of

TABLE 9.1.  Typical Core Beliefs in SAD

Domain Core belief examples
Self: I am . . . worthless; inadequate; incompetent; unlikable; not good enough; inferior;
boring; weak; socially inept; different; weird; not like others; not normal; a
loser; stupid; a failure

Others: Others are . . . critical; judgmental; scrutinizing; rejecting; ostracizing; mean; hostile;
aggressive; bullies; superior; better; confident; calm; strong

World: Society . . . has strict social rules; demands social perfection; requires good social skills to be
successful in life; dictates that there is a right and wrong thing to say and do in
social situations; does not tolerate people being different

Emotions: Anxiety is . . . bad; a sign of weakness; unbearable; abnormal; something to be hidden; a sign
of being weird or mentally unstable
 Negative Core Beliefs 173

engaging clients with and effectively applying imagery rescripting and positive imagery
are a particular focus. Behavioral action planning to consolidate core belief changes
accomplished via these imagery-­based strategies is also outlined.

Traditional Approaches to Addressing Negative Core Beliefs

How Do We Change Negative Core Beliefs?
Negative core beliefs can be changed by genuinely and actively attending to, interpret-
ing, encoding, and recalling experiences that are inconsistent with them. An accumula-
tion of disconfirming experiences over time will eventually require accommodation of
the new information, leading to the development of new balanced core beliefs that better
ref lect reality in the here and now.
To gather these new experiences, clients need to do two things:

1. Approach (instead of avoid) situations that provide opportunities to gather dis-

confirmatory evidence, and
2. Be open, realistic, and balanced in their thinking and imagery about the situa-
tion.

Do these two requirements for core belief change sound familiar? Essentially this
is what we have already been doing so far in treatment (i.e., behavioral experiments,
imagery challenging, and task-­focused attention). Accumulating these new positive and
neutral experiences, as well as learning how to manage negative experiences in a bal-
anced way, will “chip away at” and undermine negative core beliefs over time, leaving
room for more balanced core beliefs. This gradual and cumulative pathway to core belief
change necessitates that it is the last factor addressed in treatment. By the time treatment
begins to explicitly target core beliefs, clients should already have accumulated a range
of experiences that contradict and compete with their negative core beliefs.
While acquiring new experiences is crucial for core belief change, reframing past
experiences upon which negative core beliefs are based can also be therapeutic. This
process will generally involve assisting clients to understand that past negative experi-
ences, or a lack of positive experiences, were not necessarily their fault or ref lective of
personal defects. It is also important for clients to understand that these past experiences
are relatively isolated to particular people, places, or times, rather than ref lecting how all
people are likely to behave toward them now. This reunderstanding of the past can be
very useful in weakening the foundation upon which negative core beliefs rest.

A Word of Caution
Explicitly highlighting and working with negative core beliefs can be confronting for
some clients, as having greater awareness of the negative ways in which they perceive
174 TREATMENT MODULES

themselves at their very core can be distressing and leave them feeling vulnerable. While
explicitly addressing negative core beliefs late in treatment makes strategic sense for
the reasons previously outlined, it also places clients in a better position to cope with
any distress that is elicited. Later in treatment the therapeutic alliance should be strong.
Clients will likely trust their therapist, have experienced success with previous strate-
gies that were also challenging, and therefore be ready to undertake this next challenge.
The work they have done will hopefully have already weakened their negative core
beliefs, perhaps reducing the intensity of conviction with which they are held. Clients
will likely also have acquired meta-­learning (e.g., thoughts/images are not facts), that
will stand them in good stead to approach their core beliefs with a more detached and
curious attitude. Clients will also have acquired emotion regulation skills via strategies
already developed in treatment (e.g., imagery challenging, coping imagery, attention
training). If high distress is elicited from core belief work, normalize this and encour-
age the application of these previously learned strategies, as well as the addition of self-­
soothing behavioral strategies.

Identifying Negative Core Beliefs

Traditional CBT methods of eliciting and adjusting negative core beliefs often start with
the “downward arrow technique.” CBT therapists will be familiar with this question-
ing method of starting with negative automatic thoughts or images available in client
thought records and then exploring the deeper meanings and implications of these by
asking “If this [thought/image] were true, what would this say or mean about you?”
This continued chain of questioning elicits the meaning implications of a situation-­
specific cognition to the deeper core character of the person. An example of how to
elicit core beliefs about self and others is provided below.

Therapist: So, when you were in the lunchroom at work, what was going through
your mind?
Client: Jason must be regretting the decision to have lunch right now because now
he’s stuck with me!
Therapist: OK, I wonder if this thought is related to any core beliefs about your-
self or others. Shall we see if we can find out?
Client: Sure. How do we do that?
Therapist: We can use the downward arrow technique. This involves starting
with a specific negative thought or image you have in a specific social situa-
tion you find anxiety provoking, and then asking the same question until we
uncover a broad negative belief about yourself or others. Let’s start with core
beliefs about yourself. The question we ask is “If it is true that Jason is regretting
being stuck with you, what would it say or mean about you?”
Client: Well, that I’m boring.
 Negative Core Beliefs 175

Therapist: OK, so one core belief might be that you are boring. Let’s see if we
can go any further. If it is true that you are boring, what would that say or mean
about you?
Client: That I’m a loser.
Therapist: Ok, if it is true that you are a loser, what might this say or mean about
you?
Client: That I’ll always be alone.
Therapist: OK, so the thought that Jason is regretting being in the lunchroom
with you might stem from the core beliefs that you are boring, a loser, and
will always be alone. If you believed you were no more boring than most other
people and that you weren’t a loser, would you still think Jason doesn’t want to
have lunch with you?
Client: No, I don’t think so.
Therapist: OK, so the negative thought about Jason does seem to stem from these
core beliefs about yourself. Now, let’s see if there are also any core beliefs about
other people at play here. To uncover core beliefs about other people we just
change the question slightly to “If this were true, what would this say or mean
about other people?” So if it were true that Jason regretted being with you, what
would this say or mean about other people?
Client: Well, I don’t think it is very nice to be that judgmental. But I don’t think
that is just about Jason. I think everyone is like that.
Therapist: OK, so one of your core beliefs about other people is that they are
judgmental. If you hold this core belief about others, then it makes sense that
you would expect Jason to be sitting there having negative thoughts about you.
If, on the other hand, you believed that most people are usually kind and accept-
ing, you would probably be unlikely to expect negative evaluation from others
and you might feel more comfortable. Does that make sense?

Once a core belief has been uncovered via this method, its validity can be ques-
tioned. The broad impact of the negative core belief across a variety of domains in
the client’s life is then considered (e.g., family, friendships, relationships, work, leisure,
health/self-care). The aim is to assist clients to recognize the unhelpfulness of the core
belief (i.e., it is getting in the way of the life they want) and prepare them for what needs
to be done to address it.

Evidence against Negative Core Beliefs

The next step is to develop alternative conclusions that are more helpful in contextual-
izing and depersonalizing the experiences that have informed negative core beliefs. The
therapist assists clients to specifically look for evidence against core beliefs. The aim is
176 TREATMENT MODULES

to alter clients’ attentional biases by setting the task of purposely collecting evidence
or experiences that show their core belief is not 100% true all the time. This involves
recording historical “evidence against”‘ their core belief, such as positive treatment by
others, positive social experiences, personal achievements, and positive personal quali-
ties. Clients are also encouraged to become more attuned to present “evidence against”
their core beliefs daily. For instance, they might be encouraged to record one small thing
they do or experience each day that contradicts their core belief, such as positive behav-
ioral experiment outcomes, positive feedback from others, completing a task on time,
doing something considerate for others, and attending to daily responsibilities.

Formulating New Core Beliefs

The next step is to formulate a new balanced core belief that better fits the accumulated
evidence. CBT has traditionally made a strong case for promoting balanced, believable,
and realistic thinking, rather than positive thinking. With this in mind, the therapist
might be tempted to guide clients to very modest, moderate core belief statements (e.g.,
“I am unlikable” might become “Some people will like me some of the time and some
people won’t, but that is OK and probably says more about them than me”). Christine
Padesky’s writing in this area gives the therapist some food for thought when consider-
ing new core beliefs. Padesky (1994) writes that negative core beliefs tend to be short,
basic absolute statements (e.g., I am unacceptable, worthless, unlikable), and as such they
tend to pack quite a punch. Padesky advocates that new core beliefs should be positive
versions of the same absolute statements (e.g., I am acceptable, worthwhile, likable). But
does this approach still fit with the CBT stance of realistic rather than positive thinking?
Padesky (and we) would say yes! Padesky (1994) writes that negative absolutes are
usually more extreme as they imply total absence (e.g., if I am unlikable, then there
is absolutely nothing likable about me), whereas positive absolutes are less extreme by
nature as they imply that a quality is present but not necessarily perfect (e.g., if I am
likable, then I am able to be liked by others, but not necessarily everyone will like me).
Therefore, when assisting clients to develop new balanced core beliefs, we would recom-
mend that therapists don’t shy away from positive statements. The guiding principles to
keep in mind are that new core beliefs need to be:

1. Potentially believable to clients. We say “potentially” because they are unlikely

to be believable at first, before experiences generated by behavior change have
accumulated sufficiently to strengthen them;
2. Reasonable ref lections of reality. That is, new core beliefs should not overstate
the positive in an unrealistic way (e.g., “I am inferior” to “I am superior”); and
3. Framed in clients’ own words, so they can eventually take ownership of these
new beliefs.

It may be useful for therapists to keep in mind that longer, more moderate core belief
statements may lack emotional “punch.”
 Negative Core Beliefs 177

Putting New Core Beliefs into Action

Once new balanced core beliefs have been developed, the final step is to put them into
action across various life domains. This involves assisting clients to find specific ways of
“acting as if ” their new core beliefs were true. Useful questions include:

• “If you believed you were [insert the new core belief, e.g., likable], what would
you be doing differently when it comes to family?”
• “What about your friendships?”
• “What would you be doing differently in terms of your romantic relationships?”
• “What about your work, career, or studies?”
• “How would you be spending your leisure time?”
• “What might you be doing to take care of your health and well-being?”

These questions help clients to understand that the new, more helpful core beliefs
will be optimally strengthened and consolidated if comprehensive changes are made
across all valued aspects of their lives. The actions identified need to be very concrete
and specific, and may need to be graded. The rationale for this approach, which some
people describe as “fake it till you make it,” rests on the idea that behaving in this new
manner places clients in a better position to have new positive and neutral life experi-
ences that will strength the new balanced core beliefs over time.
We all know life is not always smooth sailing and at times certain people can be
judgmental or mean. At these times clients are then encouraged to make sense of the
experience in a helpful way that doesn’t undermine new core beliefs. For example, the
negative experience could be seen as the exception rather than the rule, and factors other
than core personal defectiveness or an overgeneralized view of others being critical can
be considered.
Essentially the end point of working on core belief change is to engage clients in
ongoing, unlimited behavioral experiments that are about testing the validity of their
new balanced core beliefs. As such this can be framed as a “work in progress” that con-
tinues even when formal therapy sessions have finished. This final stage of therapy is
about helping clients to modify the way they live their lives so they accumulate experi-
ences that support their new balanced core beliefs and chip away at their old negative
core beliefs over time. Core belief modification is not a quick fix. Core beliefs are
strongly entrenched, so it will take time and plenty of new experiences to strengthen
new, more helpful and adaptive ones.

Difficulties with Traditional CBT Approaches

The approaches just mentioned are useful for many clients, but a common complaint
when working in this manner is the disconnect between logic and emotion (e.g., “Logi-
cally I can see that when I was bullied at school it wasn’t about me personally, that kids
can be cruel if they sense anyone is a bit different. But I still feel like it was my fault, that
178 TREATMENT MODULES

there was/is something wrong with me”). Imagery-­based strategies may be particularly
valuable in these instances due to the emotional bridge they can facilitate. In this treat-
ment, we favor using imagery to address negative core beliefs, and we do this in two
specific ways:

1. Imagery rescripting involves using imagery to reexperience, in new ways, past nega-
tive events that significantly contributed to the development of negative core
beliefs. Imaginally reexperiencing these events and attaching benign or positive
meanings to them serves to undermine negative core beliefs.
2. Positive imagery involves clients imagining how they would like to be in cer-
tain situations and using this ideal image to assist in the identification of new
balanced core beliefs. Positive imagery then provides direction for the specific
actions required to strengthen these new beliefs.

Imagery Rescripting to Undermine Negative Core Beliefs

What Is Imagery Rescripting?
Imagery rescripting can be used as a broad term that refers to rewriting or transforming
problematic images. It can be applied to memories of events or other images that are not
based on actual experiences (e.g., intrusive images, nightmares). In this treatment for
SAD, imagery rescripting is applied to memories that are consistent with clients’ nega-
tive core beliefs, and as such support them (Hackmann et al., 2011). In other words, the
strategy is applied to address images of past events that have significantly contributed to
how clients see themselves, others, and the world now.
Slightly different methods can be used to facilitate imagery rescripting. The method
used in this treatment is informed by the work of Arnoud Arntz (Arntz, 2011; Arntz &
Weertman, 1999), whose method of imagery rescripting was first developed for work-
ing with personality disorders and complex trauma, and has more recently been applied
to posttraumatic stress disorder, depression, eating disorders, and SAD (Stopa, 2011). In
SAD, researchers have applied imagery rescripting alone (Reimer & Moscovitch, 2015;
Wild, Hackmann, & Clark, 2007, 2008) or as part of a treatment package (Clark et al.,
2003; McEvoy & Saulsman, 2014; McEvoy et al., 2015), with positive outcomes. Read-
ers interested in using imagery rescripting with clients are encouraged to read further in
this area, particularly Hackmann and colleagues (2011) and the special issue of Cognitive
and Behavioral Practice (2011, Volume 18, Issue 4).
The aim of imagery rescripting is important to remember because at first glance it
can seem fanciful or like “playing pretend.” The purpose of imagery rescripting is the
generation of a new competing image of a recalled negative event, with the new image rep-
resenting more functional meanings and affect than the initial memory image. With this in
mind, the content of the new image that emerges from the rescripting process does not
really matter. It is fine for the new image to seem fanciful or unrealistic when viewing
 Negative Core Beliefs 179

it from a literal perspective. What matters is that the new image represents a new more
helpful perspective about the event in terms of its implications about the self or other
people, and hence more positive feelings are attached to the image. We must remember
that memories are constructions that have been extensively filtered through personal
biases and then edited and manipulated through similar biases over time. Therefore,
whether they are an exact replication of some “external truth” is not especially impor-
tant. What is important is the meaning that memories have for clients and the extent to
which clients believe them or “feel” them to be true and relevant to now.
The theoretical framework for imagery rescripting is Brewin’s (2006) “retrieval com-
petition theory” as already mentioned in previous chapters. During imagery rescripting
we are creating a new image representation of a past event that needs to effectively com-
pete with the old negative image of the event, and hopefully win the retrieval competi-
tion. From this perspective, fanciful images may be effective because they are likely to be
quite distinctive and memorable, hence increasing their chances of retrieval supremacy.
During imagery rescripting we are not removing the original memory. Instead we are
creating a new image, which is an alternative elaboration of the old memory. The new
image considers the wider context of time, place, person, or circumstance and intro-
duces a more helpful perspective regarding the past event. Think back to the logic ver-
sus emotion disconnect that some clients complain about during thought challenging.
The new image developed via imagery rescripting should capture the logical meaning
that clients may concede is true during verbally based discussions of the event with the
therapist. However, because by its very nature the image is more emotionally evocative,
it may be better able to bridge the gap between logic and emotion, creating a synchrony
between the two. Consequently, imagery-­based reframes of past experiences that sup-
port negative core beliefs should have a greater emotional impact for clients.

Introducing Imagery Rescripting
The Rationale
The most common question asked by therapists new to rescripting is “How do I explain
this to clients?” Clinicians can be concerned that it will seem to clients like we are try-
ing to pretend that a bad thing didn’t happen. Clinicians may even have firsthand expe-
rience of clients discounting the strategy because “that isn’t how it happened in reality”
or “that couldn’t happen in reality so what is the point?” The rationale presented to
clients is crucial so that they are on board with the true purpose, which will be lost if we
just launch into using imagery rescripting without adequate preparation. Below are the
types of concepts we have found useful in orienting clients to effective engagement with
imagery rescripting, and they have been reiterated in Handout 13, Past Imagery Rescript-
ing, as psychoeducation for clients:

“So far we have been working on negative images of the present or future (i.e., pic-
tures of ourselves or others’ reactions in a current or upcoming social situation). We
180 TREATMENT MODULES

are now going to move on to the final bubble in the model—core beliefs (i.e., how
we generally see ourselves, others, the world), which tend to be inf luenced by nega-
tive social images from the past (or memories).
“It is common for people with social anxiety to report memories of early nega-
tive social experiences that impact what they expect in social situations now. When
we have had some negative social experiences in our past we can get ‘stuck’ in our
memories, so that they can recur as echoes of the past, haunting us, and shaping the
negative social images we have in the here and now.
“Memories we may have of other events tend to feel like they are firmly in the
past and probably rarely rear their head. In social anxiety, negative social memories
we may intellectually know are in the past may still feel emotionally relevant to today.
“Now, we can’t change that these negative experiences happened. It is awful
that you had to go through them in the first place. What is also awful is that these
experiences keep affecting your life, coloring and tainting what you expect in social
situations now.
“Using a technique we call imagery rescripting, we have the opportunity to go
back in our imagination to experience the past event from a new perspective. We
can do things we couldn’t do at the time, but that in an ideal world we would have
liked to have done with no limitations. Doing this seems to have the effect of repro-
cessing the event in a way that can be helpful for changing its meaning and putting
the memory back in its place—as a bad thing that happened in the past with little
relevance to the here and now. As we work on these past images, we can learn that
these memories don’t ref lect on ourselves, others, and the world today as we previ-
ously thought, that the memory is outdated (specific to a past time, place, or person),
and doesn’t need to dictate what we expect and how we live our lives now.”

PHOTO METAPHOR

“These memories are like a bad photo we have been carrying around in our front
pocket and looking at all the time. We can’t rip up the photo, but processing these
memories can help us to put them in a photo album on the shelf as mementos from
the past, rather than carrying them with us now. This can change the way we feel
about these past events and their impact on how we see ourselves, others and the
world now.
“Working on the past memory image can be upsetting in the short term, though
worthwhile in the long run. This idea of short-term pain for long-term gain has
been a theme that runs through everything that you have done in treatment so far.”

The Three Phases of Imagery Rescripting

After the rationale has been presented, it is important to give clients clear expectations
about what will take place during the imagery exercise, so they are prepared to fully
 Negative Core Beliefs 181

engage in the process. You don’t want clients to be distracted by wondering what will
come next or how long it will take while doing the imagery exercise. Inform them that
there are three phases to the imagery exercise, and the time for each will depend on
how involved the situation is that they are imagining and how long it takes them to run
through the situation in their mind’s eye. The three phases are as follows and should be
brief ly described to clients:

• Phase 1: Imaginally reexperiencing the event at the age it occurred as if it were

occurring right now.
• Phase 2: Imaginally reexperiencing the event at their current age, watching their
younger self going through the experience and intervening in any way they wish
to protect and care for the younger self.
• Phase 3: Imaginally reexperiencing the event at the age it occurred, but this time
experiencing their older self intervening and asking the older self for anything else
they need.

Spend time discussing the idea of the older self being intervening within the image.
Remind clients that they will be manipulating a past image, and so it is essentially creat-
ing a fantasy. The technique will involve imaging aspects of the situation that didn’t and/
or couldn’t have happened in reality, but that they might have liked to have happened.
Again, be clear that we are not pretending this awful thing did not happen. We can’t
change the event, but we can change the meaning of the event. Changing the meaning
can, in turn, change associated feelings and reduce the relevance of the past event to
life in the here and now. It can be very useful to give examples of how the intervention
doesn’t have to conform to reality, so clients realize there are no limits on what they can
do (e.g., shrinking the bully to the size of a mouse; getting on a dragon and f lying away
to a village of people who are kind and caring).

Prepare for Distress Tolerance
Therapists should also explain that as they work on the image the therapist will try
to remain in the background, simply asking prompting questions, and will not offer
comfort unless distress becomes extreme and overwhelming. Therapists should reas-
sure clients by saying, “I don’t anticipate this will happen, I just like to cover all bases.
If this happens you can just open your eyes, and then we can use your coping image or
attention retraining exercises to deal with those feelings.” It can be useful to predeter-
mine the client’s preferred distress tolerance strategy. This is particularly important if
applying imagery rescripting in a group context. To our knowledge, we are the first to
have used imagery rescripting in a group therapy setting. Prior to commencing imagery
rescripting in group therapy, we ask each group member to nominate their preferred
distress tolerance strategy, such as focusing on their breathing, connecting with their
five senses in the present moment, or engaging with the specific content of their coping
182 TREATMENT MODULES

image. Therapists write down each client’s preferred strategy so it can be easily referred
to should a client’s distress need to be contained within a group environment. So far in
our experience no client has needed assistance to use a distress tolerance strategy. It may
be that the process of nominating a strategy is enough to create a sense of safety in the
group so that clients are more willing and able to endure the emotions activated by the
technique.

Imagery Rescripting Preparation
Select a Memory to Rescript
Clients with SAD will often easily be able to identify key negative social memories from
the past that relate to their social anxiety today. Bullying, embarrassment, criticism, and
humiliation, often in their school years, are the most common memories that emerge as
significant in SAD. If clients can’t readily identify a relevant memory, then ask them to
imagine being in a situation where they feel socially anxious, connecting with socially
anxious thoughts, images, feelings, and urges. Once they are connected with this expe-
rience then ask, “When in your life do you first remember feeling this same way?”
This emotional bridge technique can be very useful for identifying memories of
relevance (Hackmann et al., 2011). Once a memory has been selected it is recorded in
Worksheet 16, Past Imagery Rescripting, which assists with working through the remain-
der of the imagery rescripting process.

Elicit the Meaning of the Memory

Once a memory is selected, the meaning of the memory to the client must be identi-
fied. There are two ways to do this. The first approach is via verbal discussion prior to
completing the imagery rescripting exercise. Therapists can simply ask clients what the
experience meant to them.

• “From the experience, what did you conclude about yourself as a person?”
• “What did you conclude about what other people are generally like?”
• “What did you conclude about what the world is generally like?”

When eliciting meanings, the therapist can also question the significance or impor-
tance of the image per se to identify any metacognitive beliefs relevant to the memory:

• “Does this image seem important in some way, rather than just being a picture of
the past?”
• “Does the image seem powerful or scary in any way?”
• “Does it seem like an important image to hold on to for some reason?”
• “Does it help you in some way to hold the image close, rather than lose it to the
recesses of your mind like other memories from long ago have been lost?”
 Negative Core Beliefs 183

Some clients may see the memory as helpful if they believe that remembering the
event keeps them vigilant and hence safe from it reoccurring or prepares them for the
worst. Some clients might fear bringing the memory to mind, as they perceive it as
being too powerful at eliciting emotion or undermining coping (e.g., “the memory is
too overwhelming, I won’t be able to cope or function if I think about it, I’ll have a
breakdown”).
If verbal discussion of the meaning of the memory is not fruitful, then you could
save the sorts of questions above and ask them at the end of Phase 1 within the imagery
exercise when they have relived the experience. While they still have their eyes closed
and before moving to Phase 2, their emotions related to the event should still be active,
which indicates that core beliefs are likely to be activated and more accessible. Phrasing
the questions in the following way may be more relevant:

• “How are you seeing yourself?” or “What is this image/event saying about you?”
• “How are you seeing others?” or “What is this image/event saying about others?”
• “How are you seeing the world?” or “What is this image/event saying about the
world?”
• “Does the image itself seem important in some way, either in a bad way or in a
helpful way? Is there something bad about holding on to it? Is there something
helpful about holding on to it?”

Whichever method is used to elicit the meaning of the past event, this should then
be recorded in Worksheet 16, Past Imagery Rescripting. The strength of belief in each core
belief can also be rated (i.e., “Belief before rescripting”).

Identify the “Older You” Perspective

Before engaging in imagery rescripting, clients are encouraged to think about what they
know about the situation now that they may not have known at the time, and record this
“older you” perspective on Worksheet 16. Therapists may say something like:

“The older, more compassionate ‘adult you’ may know things now that you didn’t
know then. These things you’ve learned since the event may have been useful for
you to have been aware of at the time of the upsetting event. Although the event
may still be emotionally painful to think about, you may be able to understand the
situation differently now.
“For instance, if I had been bullied at school I might now have a different per-
spective compared to when it happened. At the time, I might have assumed this
occurred because I was unlikable and a loser. Although I still feel sad about it, I can
now see logically that although there were differences between me and the bully,
his bullying behavior had less to do with me and more to do with his personality or
insecurities. I simply did not deserve this treatment and no child deserves this treat-
ment. Any child who bullies another child is behaving badly, and it need not ref lect
184 TREATMENT MODULES

on the bullied child’s character, likability, or worth. In fact, in hindsight we may be

able to see that there were aspects of ourselves that were very likable at that time. We
might be able to see these things as an adult, but we didn’t know them as a child.”

If clients have difficulty generating a more helpful perspective on the situation, ide-
ally one that depersonalizes the negative event, the following questions may be helpful.

• “If a friend had been through a similar experience, what advice would you give
them?”
• “If you were observing a child go through that same experience right now, what
would you think about the situation and the child?”

It can also be useful to brainstorm ideas for ways the older self can intervene before
the imagery rescripting exercise is undertaken. This will reduce the likelihood of clients
getting stuck when they get to the most distressing point in the image and not know-
ing what to do. This process also provides the therapist with an opportunity to assess
whether clients have the internal resources to intervene in the rescript, or whether the
therapist will need to be more active and make suggestions. It can also serve as another
reminder to clients that there are no limits on what they can do with the image. This
doesn’t mean that they must use the ideas generated in verbal discussion during the
imagery exercise, but it may help them to be both creative and determined when taking
care of the younger self within the image. A key ingredient in the intervention is that
the younger self experiences what was emotionally needed at the time of the event in
the third phase. The intervention should facilitate a sense of mastery and safety first (e.g.,
stopping the bullying or bad treatment, power being removed from the perpetrator,
increasing one’s own power), followed by experiencing soothing and compassion (e.g.,
experiencing kindness, warmth, and comfort from another). Ideally the rescript should
end with the younger self engaging in some form of happy play or comforting activity
with a sense of moving past the event.

Imagery Rescripting Guide
The scripts outlined in Box 9.1 provide an example of how imagery rescripting is con-
ducted. These scripts were designed for a group treatment setting specifically and are
used verbatim in this context. In an individual treatment setting they are only intended
as a guide.

Imagery Rescripting in Individual versus Group Treatment

There are some key differences in conducting imagery rescripting in individual com-
pared to group treatment. In group treatment clients select the memory to be rescripted
and discuss the “older you” perspective and ways of intervening in pairs. Therapists can
circulate and observe these discussions to ensure that the memories being worked on are
 Negative Core Beliefs 185

BOX 9.1.  Imagery Rescripting Guide

Phase 1: Imagining the event from the perspective of the “younger you”
“Closing your eyes now, sitting comfortably, I would like you to imagine being back in the past situation
you have identified, being the age you were when it occurred, and imagine it as vividly as you can from
beginning to end, as if you are there experiencing it firsthand right now. Looking through the younger
you’s eyes . . . What is happening? Who is there? What can you see (hear, smell, taste, feel)? . . . How
are you feeling emotionally? How does your body feel—what sensations do you notice? What are you
thinking? What is this event meaning to you? What happens next? Take your time to run the image to
its conclusion. When you have finished briefly raise your hand and then wait in silence. [Allow up to 10
minutes, although most clients will complete the task within 5 minutes.]”

Note: The Phase 1 script is only applicable if the event is not highly traumatic. If this were the case,
the whole event does not need to be imagined. With traumatic memories, the image only needs to be
taken to the point the client knows the traumatic event is going to happen and emotion is activated. At this
point the image would switch to the therapist intervening (see the chapter section on trauma memories
for more information).

Phase 2: Imagining the event from the perspective of the “compassionate older you”
offering support to the “younger you”
“Now, go back to the start of the memory. Run through the image again from start to finish, but this time
from the perspective of the ‘older, compassionate you’ at the age you are now, watching the ‘younger
you’ going through the experience. As you look through the older you’s eyes and observe the ‘younger
you’ going through the situation, what are you feeling? What are you thinking? What do you want to do
to help them? What needs to be done? What does the younger you need? . . . Now do it, intervene and
do those things . . . What are you saying and doing? [pause] Make eye contact with the younger you
and move closer. What else do you want to do? What else does the younger you need? Keep interven-
ing until you feel satisfied you’ve done all that is needed. I will now give you some time to do this. Briefly
raise your hand when done and wait quietly with eyes closed.”

Phase 3: Imagining the event from the perspective of the “younger you” but with the
“compassionate older you” intervening and offering all the support needed
“Now, again let’s rewind going back to the start of the image. Now run through the image again from
start to finish, but this time from the perspective of the ‘younger you’ receiving the support of the ‘older,
compassionate you.’ Looking through the younger you’s eyes, pay close attention to how you feel as
the ‘older, compassionate you’ is intervening. What are they doing and how does that make you feel?
[pause] Make eye contact with the ‘older you’ as you receive their support. [pause] Once you have
received all their support, pay attention to what else you need from the older you and ask for it. Continue
asking the older you for what you need until you feel safe and comfortable. I will now give you some time
to do this. Briefly raise your hand when done and wait quietly with eyes closed.
“As you keep this image in mind, notice what the event means to you now . . .
“What is this image saying about you?
“What is this image saying about others?
“What is this image saying about the world?
“How important does the original image seem now?
“Just note how you are feeling as you think about the event now. Notice how you feel and where you
feel it in your body. When you are ready you can open your eyes.”
186 TREATMENT MODULES

not too traumatic to rescript within the group context and to assess each client’s capacity
to intervene. The three scripts are read verbatim, and aside from the therapist talking,
the exercise is done in silence. As each phase will take different durations for each per-
son, the script gives the instruction that when clients are finished with each phase they
can brief ly raise their hand to let the therapist know they have finished and then wait
in silence until everyone has completed the phase. After each phase clients open their
eyes and make the relevant emotion and body ratings on Worksheet 16, Past Imagery
Rescripting, before closing their eyes again to participate in the next phase. After Phase
3 they record any new conclusions regarding the self, others, world, or the image itself,
the strength of belief they have in each of these new conclusions (0 = completely untrue,
10 = completely true), and how they generally feel about the past event now. This is
also when they rerate their strength of belief in their initial core beliefs (i.e., “Belief after
rescripting”). As a group we then debrief participants’ experiences, ref lecting particu-
larly on quantitative and qualitative shifts in emotion and meaning across the phases, and
their new conclusions about the event and its meaning.
The exercise is more interactive and f lexible in individual treatment because clients
can verbally respond to the therapist’s prompt questions and therapists can adjust the
process to account for individual needs. Thus, the scripts are only a guide for individual
therapy. The circular questioning guide in Table 9.2 can be useful to assist therapists
through the process of imagery rescripting in a more f lexible way in individual treat-
ment. Once the scene has been set regarding the specific rescripting phase (i.e., whether
the client is taking the perspective of the younger or older self ), the therapist can then
use questions f lexibly to first elicit a description of the situation, followed by emotional
and body experiences, cognitions, and then behavioral actions. Behavioral actions in
Phase 1 refer to those that actually occurred in the event, either enacted by the client
or others involved in the situation. Behavioral actions in Phases 2 and 3 refer to those
desired by the older and younger self respectively. The questioning then circles back to
the start again, with an update on the situation, and so on.

TABLE 9.2.  Imagery Rescripting Circular Questioning Guide

Focus Phase 1 Phase 2 Phase 3
Situation What is happening?

Emotion/body How are you feeling? Where do you feel it?

Cognition What are you thinking?

Behavior/action What are you doing? What do you want to do? What do you need?
What are others doing? Do it Ask for it

Repeat questions—what’s happening now?

Note. Based on Arntz (2011).

 Negative Core Beliefs 187

In individual treatment, rather than having clients open their eyes at the end of
each phase to make relevant emotion and body ratings on Worksheet 16, the therapist is
already eliciting this information during the circular questioning process and can record
it on the client’s behalf. In this way, there is no need for breaks between the three phases,
unless in the therapist’s clinical judgment this would be worthwhile, for example if each
phase is lengthy and the client is losing focus. As with group treatment, at the end of the
process it is important to debrief the client’s experience and ref lect on the emotion and
meaning shifts that have occurred. Ref lect on whether clients’ feelings are now more
consistent with their logical understanding of the situation and assess any shift in the
current relevance of the image. This should be followed up over subsequent weeks by
asking clients to periodically ref lect on how they feel about the event now. Particularly
focus on the correction of meaning distortions that are relevant to clients’ negative core
beliefs, such as coming to understand that the negative event wasn’t their fault, wasn’t
about their personal worth, and was the exception, not the rule of how other people and
the world operate. By working through this process, clients can also make metacognitive
shifts regarding the broader importance of distressing memories, such as these insights
from previous clients following imagery rescripting: “the meaning of memories is mal-
leable,” “you can change your perspective on anything,” and “I don’t need to be scared
of my memories.”
The process of imagery rescripting can be challenging and exhausting for clients.
Ideally a comprehensive debrief will occur immediately afterward to consolidate the
new learning. However, sometimes clients feel somewhat dazed and tired after the exer-
cise and find it difficult to elaborate on their learning immediately afterward. On these
occasions, it can sometimes be fruitful to keep the debrief relatively short and revisit their
experience and shifts in meaning in more detail at the next session. The therapist needs
to ensure that the client is emotionally contained and safe before completing the session,
which may require some grounding exercises or casual conversation before the client is
sufficiently settled. The therapist might encourage clients to bring their new image (i.e.,
the Phase 3 image) to mind several times over the intervening week between sessions, or
if helpful meaning and emotion shifts have not been achieved during the initial exercise,
then the exercise may need to be repeated in the next session, with the client imagining
a different rewrite of the memory that may be more effective. However, in our experi-
ence, if a satisfactory rescript has occurred in session, rescripting the same event is not
typically necessary for meaning and emotion shifts to be consolidated.

Other Imagery Rescripting Tips

Multiple Memories
If there are multiple memories, allow clients to choose one they wish to start on. Grad-
ing the memories in terms of distress is not essential, unless clients wish to adopt this
approach. If there are multiple memories that are similar in meaning, working effectively
188 TREATMENT MODULES

on one or two memories will often generalize to seeing other significant memories in a
different light.

Trauma Memories
In group therapy we encourage clients to work with a past negative social experience to
rescript. Should clients attribute their social anxiety to a highly traumatic experience
(e.g., sexual abuse, physical violence, torture), we would recommend that rescripting of
this nature be undertaken in individual and not group therapy. With highly traumatic
experiences, clients may be at risk of dissociating or may need more assistance from the
therapist with the rescripting process. For example, if clients find it difficult to adopt a
more compassionate perspective, the therapist may need to take a far more active role in
intervening in the image rather than relying on the client’s older self being the interven-
ing figure. These issues obviously cannot be accommodated within a group setting. It is
important to note that with highly traumatic experiences clients do not need to relive
horrific trauma in Phase 1 for rescripting to be effective. In these circumstances, clients
only need to imaginally reexperience the event up to the point where they know the
traumatic incident is about to occur, and hence the associated emotion is activated. At
that point the therapist would step into the image and be the intervening figure, protect-
ing the client, and actively providing the safety and comfort required. Again, readers are
encouraged to read Hackman and colleagues (2011) and Arntz (2011) for further infor-
mation on rescripting under these circumstances.

What about Aggressive or Violent Imagery?

Clients will sometimes want to include violence in their imagery, for example, envis-
aging the bully being bullied or clients seeing themselves enacting violent revenge.
Therapists sometimes feel uneasy about facilitating vengeful and violent impulses in their
clients in case they are encouraged to act them out in real life. Arntz (2012) suggests
that the desire for revenge can be common and natural, and that articulating, accept-
ing, and learning to tolerate this desire during rescripting may reduce the likelihood
of acting it out. Studies investigating the impact of violent imagery have found that
safe-place imagery (leaving the situation and entering a positive and safe situation) has
a more positive impact on reducing angry emotions and increasing positive emotions
compared to imagery rescripting with or without revenge (Seebauer, Froß, Dubaschny,
Schönberger, & Jacob, 2014). Interestingly, rescripting with revenge did not help or hin-
der the rescripting process compared to rescripting without revenge. Other studies have
also found that revenge imagery has not increased the risk of aggressive actions (Arntz,
Tiesema, & Kindt, 2007). It is important to note that there have been very few studies of
violent imagery in clinical samples. Caution may also be required in forensic settings or
with clients who have a history of violence or aggression. Needless to say, people with
SAD do not typically fit this profile. If revenge is enacted in fantasy during imagery
 Negative Core Beliefs 189

rescripting, Arntz (2011) suggests that therapists then pay close attention to other needs
the client has regarding feeling comforted, supported, and safe.

Imagery Rescripting Summary
Consistent with traditional CBT strategies, imagery rescripting is essentially a method
of trying to re-­understand “evidence for” negative core beliefs in a new way that under-
mines them. When the older self tells the bully off, or shrinks him, or lassos him, or
sends him to jail, and then people come and support the younger self, telling him it is
OK, that they aren’t to blame, putting their arm around him, hugging him, asking him
to come play on the swings or go for an ice cream—what message do these imagined
actions convey? “The bully was the problem, not me.” “They were in the wrong, not
me.” “People are on my side.” “People are kind.” “I am not weak and defective.” “I am
strong and likable.”
Imagery rescripting brings a new perspective to a negative event that can be more
emotionally evocative than a purely verbal reinterpretation of the event. For therapists
new to this process, who may be unsure if the way the image has been rescripted is
“right,” remember that it is just an image that can be played with. Remember it is the
meaning of the image that is important. If the meaning and feelings attached to the
new image seem appropriate and helpful to both the client and therapist, then it is likely
to be helpful for emotional processing of the event. Remember, it is an image, so you
can always rewind it and try something else if initial attempts fail to yield demonstrable
emotional shifts.

Positive Imagery to Construct New Core Beliefs

The use of positive imagery for the construction of new balanced core beliefs comes
from Padesky and Mooney’s (2005, cited in Hackmann et al., 2011) “Old System/New
System” approach, and particularly their method of “New System” construction. This
approach was developed for working with personality disorders, with the aim of helping
to address the chronic long-­standing interpersonal difficulties these clients face. Mooney
and Padesky (2000) are strong advocates of constructing new core beliefs, rather than
only challenging the old ones. This is a collaborative creative process between therapist
and client that involves the exploration of new possibilities of how the client would like
to be in life. Imagery is a particularly useful tool for starting to develop “new ways of
being” (Hackmann et al., 2011, p. 181), as essentially clients are encouraged to vividly
imagine an alternative, more ideal way of operating in the world. Clients’ imagery then
provides clues as to the new core beliefs that are required to operate in the desired man-
ner. At first it is OK for clients not to believe the alternative self they are envisioning or
the new core beliefs their imagery represents. Following Padesky and Mooney’s “New
System” approach, behavior change becomes the primary means of strengthening new
190 TREATMENT MODULES

beliefs. Positive imagery is simply recruited in the construction of new core beliefs, and
action planning (i.e., behavioral experiments) is used to strengthen new core beliefs.

Introducing Positive Imagery
It is critical that clients be provided with a strong rationale for using positive imagery so
that they can fully engage with the process, otherwise it may be interpreted as “pie in
the sky wishful thinking.” We have found the following concepts useful in socializing
clients to this method:

“The imagery work done so far has been about uncovering negative images (past,
present, and future) that maintain social anxiety, and finding ways to manipulate
or change these images by testing their validity through various experiments. Our
focus has mostly been on chipping away and breaking down these negative images.
“However, it is equally important to construct positive images. We have already
seen the power of imagery in terms of its inf luence on emotions and actions. Just as
negative images inf luence negative emotions and actions, equally, positive images
can promote positive emotions and actions. Developing positive images of how you
would ideally like things to be in your life can give us clues about new core beliefs
you might like to start developing.
“Hopefully the behavioral experiments and past imagery rescripting have shown
you that the old negative core beliefs are outdated. For example, experiments as an
adult have shown that others and the world generally aren’t as critical and hostile as
first believed, or that you are more socially adept than you’ve given yourself credit
for. So it is time for a core belief update.
“The positive images we develop can help us construct these new core beliefs. It
is OK and normal if you don’t initially believe any of the positive images we gener-
ate. We will find ways to strengthen your belief in these positive images over time
through the way you act and live your life.”

Positive Imagery Guide
There are seven steps involved in developing positive imagery to construct new core
beliefs, and these can be divided into three aims: identifying new core beliefs, general-
izing new core beliefs, and consolidating new core beliefs. Worksheet 17, Constructing
New Core Beliefs, and the accompanying Handout 14, Constructing New Core Beliefs, can
assist the therapist and client through the seven steps. When the positive imagery exer-
cises are completed in a group setting, we pause after each of the three sections to take
some time to fill in the worksheet and debrief clients’ experiences before moving to the
next section. In individual treatment, this process can be more f lexible and at the discre-
tion of the therapist. The therapist can often fill in the details required on Worksheet
17 from the client’s responses during the imagery exercise. However, the therapist will
likely choose to pause and have the client open her eyes at certain points, as the imagery
 Negative Core Beliefs 191

exercise would be very lengthy if all seven steps were done without a break. Below we
provide a script for working through the seven steps that has been elaborated from the
ideas of Padesky and Mooney’s “New System” approach (Hackmann et al., 2011, p. 190;
Mooney & Padesky, 2000; Padesky, 2011). This script is delivered verbatim in a group
setting and is used as a f lexible guide in individual treatment.

Identifying New Core Beliefs

STEP 1: ELICIT A DIFFICULT SITUATION

“If you feel comfortable doing so, close your eyes, sitting comfortably . . . bring to
mind a situation in which you have typically experienced strong social anxiety . . .
(raise your hand when you have a clear situation in mind).”

STEP 2: IMAGINE A NEW WAY OF OPERATING

“Without changing anything about the situation itself, how would you like to be? How
would you like to handle the situation? Experience being that way now. What are
you doing? [pause] What kind of expression do you have on your face? [pause] How
are you holding your body posture? [pause] What self-talk is going through your
mind? [pause] Experience being this way now . . . [pause] When you are operating
in this way how do you feel? How does that feel in your body? Where do you feel
it?”

STEP 3: NEW CORE BELIEF IMPLICATIONS

“When operating in this new way, how do you see yourself ? [pause] How do you see
others? [pause] How do you see the world? [pause]”

The typical experiences this part of the exercise elicits are visions of the self as
calm, at ease, interacting and participating socially, contributing to discussions freely,
others engaging with the client positively, the client smiling and standing in a relaxed,
engaged, and confident posture with head held high and shoulders back. From these
actions, clients can typically infer new core beliefs about the self as socially adept, good
enough, adequate, worthwhile, competent, interesting, confident, strong, likable, and
so on. Others are seen as equals, welcoming, kind, nonjudgmental, and interested. The
world is seen as safe, with f lexible social conventions.

Generalizing New Core Beliefs

STEP 4: DIFFERENT LIFE DOMAINS

“Let’s reestablish the new positive image again. Closing your eyes again, sitting com-
fortably . . . bring to mind the same situation as before, seeing yourself operating in
192 TREATMENT MODULES

this new more positive mode, operating from your new core beliefs (raise your hand
when you have this in mind). Now imagine bringing this new way of operating into
other situations.”
• “Think about your current relationships . . . bring an image of a friend, partner,
or acquaintance to mind . . . if no one is coming to mind, imagine that you
are starting to establish a relationship . . . keep in mind your new core beliefs
about yourself, others, and the world . . . maintain these new core beliefs as
you develop the image in your mind’s eye . . . what would you and the other
person be doing to ref lect these positive core beliefs ? . . . again being aware
of your expression, posture, and how it all feels within you . . . [pause] Make
a note of how things are different, what you are doing, how you are feeling,
where you notice those feelings in your body . . . [pause]”
• “Now think about your family. Bring to mind a vivid image of how things would
be different if you were operating from your new, more positive core beliefs.
[pause]”
• “Now move on to what you would be doing differently with your work, stud-
ies, or daily responsibilities if you were operating from your new core beliefs.
How would you be approaching these situations? [pause]”
• “Now bring to mind an image of your leisure time or hobbies, or other ways
that you would spend your time if you were operating in this new system of
more positive core beliefs. What would you be doing and how does that feel?
[pause]”
• “Finally, bring to mind an image of how your lifestyle might be different
when it comes to health and general well-being? If you were operating from your
new core beliefs, what would you be doing to take care of your health, well-
being and self-care? [pause]”

The typical experiences this part of the exercise elicits are seeing oneself more
engaged, interactive, and participating in all domains of life, rather than avoiding or
being disconnected. Clients envision more positive relationships with current friends,
relatives, and partners, or the development of a new social network or intimate relation-
ship. They see themselves involved in desired work or study and being able to progress
in these areas. They see themselves attending to the responsibilities of daily living inde-
pendently, taking up new hobbies and interests, and taking care of their physical health.
In general, the vision is of a much improved quality of life when operating from their
new core beliefs.

STEP 5: “STORMY WEATHER”

“Unfortunately, life doesn’t always go according to plan and we can hit ‘stormy
weather.’ It is important to prepare for these times. Continuing with your eyes
closed, I would like you to imagine a social situation that doesn’t go so well, for
 Negative Core Beliefs 193

example where you thought you offended someone, or you thought someone didn’t
like you, or you made a mistake (raise your hand when you have this in mind).
“Now remembering your new core beliefs about how you see yourself, other
people, and the world . . . if this were to occur, how could you handle this? What
would you need to do? Experience yourself doing it. What would you need to say
to yourself? Say these things to yourself now, adopting the body posture and facial
expression that would go with this. How do you feel within yourself when you react
in this manner? What does that feel like in your body?”

This part of the exercise is about building new core beliefs that are strong enough to
accommodate and be resilient to setbacks, rather than reverting to enacting the old nega-
tive core beliefs at the first sign of trouble. Generally, clients envision themselves staying
calm, depersonalizing the experience, letting it go, and moving on.

Consolidate the New Core Belief

STEP 6: EVIDENCE FOR

“Think of a past occasion where you did something that exemplifies your new core
belief. This may be the recent past, perhaps as part of this treatment, or further
into the past. Now close your eyes again and visualize this past occasion . . . stay
with this image, experiencing yourself in the situation as if it were now . . . what’s
happening . . . how do you feel? How does your body feel? Spend a few moments
reexperiencing this event.”

This process is equivalent to what is done in traditional CBT, looking for evidence
that supports the new core beliefs. However, by having the client imaginally reexperi-
ence the evidence and sit with the feelings this generates it aims to make the evidence
more emotionally powerful, memorable, and convincing. This step also instills hope that
the new core beliefs may not be “pie in the sky” ideals when clients glimpse evidence of
having operated in this way before. Given all the work they have done earlier in treat-
ment, clients may be closer than they think to transitioning to a set of new core beliefs.
They may not be building something from scratch, but instead gradually increasing the
amount of time or circumstances within which they operate in this new way.

STEP 7: ICONS

“When you imagine operating in this way, what ‘icons’ come to mind? [you can give
a brief personal example] Are there particular songs, images, movies, characters,
fairy tales, stories, people, animals, or scenes from nature that represent this way of
operating for you? For you, is there something that captures the spirit of your new,
more positive core beliefs? If nothing immediately comes to mind that’s OK, just
give yourself some time for an image to emerge [pause].
194 TREATMENT MODULES

“If you have an icon in mind, spend a moment noticing how you feel in your
body when you bring this icon to mind. [pause] Consider for a moment how this
icon could be used to help you stay in this new way of operating. [pause]
“You can now start broadening your attention back to the room and, when you
are ready, open your eyes.”

Clients have used icons such as Superman, Wonder Woman, Yoda, a sunset, and a
wild horse to represent the spirit of their new core beliefs. Clients are only limited by
their creativity. The main aim is to see if clients can develop a shorthand way of stimu-
lating the same mindset and feelings that are linked with their new core beliefs. The icon
can then be used as a means of kick-­starting the new core belief system when they need
some assistance. Clients can then elaborate or strengthen their icons by mentally rehears-
ing the icon image or finding other mediums that reinforce the icon (i.e., painting,
drawing, photos, pictures, songs, objects, pendants). The idea is to make the icon easily
accessible and effective in stimulating the new core belief system and emotions, particu-
larly when faced with challenging situations where clients may be tempted to revert to
cognitive, emotional, and behavioral cycles ref lecting their old negative core beliefs.
For example, one client walked into a party with the theme music of Star Wars play-
ing in his mind’s ear. This served the purpose of activating the new core belief system
(by representing the system and elicit feelings linked to the system), giving him the
boost he needed to hold his head high, shoulders back, smile, and approach someone to
have a conversation. Doing this meant he was operating consistently with his new core
beliefs that “I am competent and others are kind.” Other clients might choose to use
their new “core belief song” as a ring tone, which will serve as a regular reminder to
approach phone conversations in a manner consistent with their new core beliefs.

Action Planning to Strengthen New Core Beliefs

During the positive imagery exercise, and particularly in Step 4 when generalizing new
core beliefs to different life domains, clients will have envisioned some specific activities
they would be doing differently if they were operating consistently with their new, more
balanced core beliefs (e.g., enjoying family gatherings, spending time with new friends,
attending a course of study, going to the gym to exercise). These visions of an alternative
life offer ideas about what actions clients will need to engage in over the long term to
reinforce and strengthen the newly constructed core beliefs. The actions clients need to
take across various aspects of their lives may be similar to what they have already been
doing in treatment with their behavioral experiments. In practice, strengthening new
core beliefs may therefore mean doing more of the same. However, the intention will
be not only to challenge their negative social images, but also to test the validity of their
new balanced core beliefs.
It is useful to socialize clients to the need to act consistently with their new core beliefs
as a means by which to gradually strengthen their conviction in the new core beliefs.
 Negative Core Beliefs 195

“We know that the best way to build conviction in your new core beliefs is to live
your life ‘as if ’ they were true. Some call it ‘fake it till you make it,’ and what we
know is that changing our behavior is the most powerful way to change our beliefs.
Behavioral experiments are a prime example of that. So if you start operating, act-
ing, behaving in a way that is consistent with your system of new balanced core
beliefs, usually your confidence in the new beliefs will catch up.”

Worksheet 18, the New Core Belief Action Plan, is then used for collaboratively plan-
ning the specifics of operating within clients’ new core belief system. This involves
identifying a target for change in each life domain, such as participating in family events,
starting a course of study, being assertive at work, making new friends, starting an art
class, and so on. A specific plan of action is then devised for how to meet this target,
and a time frame is placed on when specific actions will be taken to increase the likeli-
hood that the plan will become a reality. A target for change may require more than one
action to achieve change, and the actions required are likely to be ongoing over time.
This means that clients don’t just operate from their new core beliefs in isolated cases
but must ensure they are consistently operating from their new core beliefs over time.
For example, if the target for change is being more assertive at work, there may be sev-
eral action steps such as saying no to unreasonable requests, delegating tasks to others,
making requests of others, providing constructive feedback where necessary, and raising
problems with the boss. Each of these tasks will need to be done multiple times as the
opportunity arises. As clients become more familiar with completing their action plans,
the structured planning of these behavioral changes may not need to be so formal. Tar-
gets for change should be thought of as something that is typically never “achieved” per
se, but something one is always working toward.
The idea is for clients to treat each planned action as a behavioral experiment. How-
ever, by this point in therapy the experiments generally won’t have to be planned as rig-
orously, using Worksheet 7, the Behavioral Experiment Record, as was required for behavior
changes early on in therapy. Over time with an accumulation of many behavioral exper-
iments over many life domains, clients’ new core beliefs will mostly be supported. The
action plan is a road map that guides clients to live their lives in a manner that provides
them with many opportunities to strengthen their new set of balanced core beliefs. With
time, these new core beliefs will more consistently govern clients’ social expectations
and how they operate in the world, hence facilitating recovery from SAD.

Clinical Case: Modifying Negative Core Beliefs

During imagery rescripting one client reexperienced being back in early primary school. There was no
one specific memory for this person—­the image was a conglomeration of the bullying and rejection
she received from her peers at the time. It featured being laughed at, being left out of games, being
called “weirdo” when she tried to join in on group activities in the playground, and a lot of time spent
on the swings alone. As an adult, and when in “safe” company, this client was quite brash and had a
great sense of humor. She was generally really fun to work with in therapy. It appeared in her imaginal
196 TREATMENT MODULES

recount of primary school that her sophisticated sense of humor was present from a young age. She
reexperienced the teachers laughing at her jokes, but her peers sitting dumbfounded. These sorts of
experiences just reinforced her overall core beliefs that she was “different,” “weird,” and “didn’t belong.”
During the rescripting process her older self visited her in the school grounds and sat next to her on
the swings. The older self gave advice like “who would want to be like those boring jerks, they are all
sheep.” The older self spoke about how being different was a good thing, something she might even
value later in life, seeing her differences as a sign that she was funny, intelligent, creative, unique, and
special. The older self gave comfort to the younger self by putting her arm around her and pushing her
on the swing. She then brought into the image a person she met later in high school who ended up
being a fabulous friend. Imagining that they had met earlier allowed the younger self to experience the
sense of belonging and kinship she needed. At the end of the imagery rescripting exercise when the
client opened her eyes the first words out of her mouth were an exuberant “I was an awesome kid!” This
was an important step in her developing a new core belief about herself, which she phrased as “I am
different and that is an awesome thing to be.”
 Negative Core Beliefs 197

THERAPY SUMMARY GUIDE: Negative Core Beliefs

Therapy Aim:  Identify and undermine negative core beliefs typically regarding self
as defective and others as judgmental, and construct new balanced core beliefs and
positive actions to strengthen these new core beliefs.

Therapy Agenda Items:

Traditional CBT methods for identifying and modifying core beliefs can be used;
]]
however, this SAD treatment places a strong emphasis on imagery rescripting,
positive imagery, and action planning as the main methods for achieving the same
aim.
Imagery Rescripting:
]]
Introduce clients to imagery rescripting by presenting a rationale, explaining the
\\
three phases, and preparing for distress tolerance
\\Use Worksheet 16, Past Imagery Rescripting, to guide the entire process:
ff Prepare for imagery rescripting by selecting a memory, eliciting its meaning,
and identifying the “older-you” perspective
ff Complete imagery rescripting by following the three-phase imagery rescripting
guide and/or circular questioning guide
ff Debrief shifts in meaning and affect regarding the memory
Positive Imagery:
]]
\\Introduce clients to positive imagery by presenting a rationale
\\Use the positive imagery guide and Worksheet 17, Constructing New Core Beliefs, to
guide the process:
ff Identify new core beliefs by imagining how clients would like to be in difficult
situations and extrapolating new core beliefs
ff Generalize new core beliefs to different life domains and difficult situations
(i.e., “stormy weather”)
ff Consolidate new core beliefs by reexperiencing past confirmatory evidence and
developing an icon to activate the new core belief system
Action Planning:
]]
Use Worksheet 18, New Core Belief Action Plan, to plan specific behavior changes
\\
across life domains that will likely strengthen the new core beliefs over time
198 TREATMENT MODULES

Therapy Materials:
Handouts
]]
Handout 13, Past Imagery Rescripting
\\
Handout 14, Constructing New Core Beliefs
\\
Worksheets
]]
Worksheet 16, Past Imagery Rescripting
\\
Worksheet 17, Constructing New Core Beliefs
\\
Worksheet 18, New Core Belief Action Plan
\\
 C H A P T E R 10

Maintenance and Relapse Prevention

Therapist: Let’s review your initial goal that you set for treatment “to be less
socially anxious so that I can accept and initiate invitations with friends, join a
sporting club, and speak up in work meetings.” How much do you feel you have
progressed with that goal?
Client: Well, I am doing all of those things. I am going out more with friends, and
I have started playing basketball, and I make a point of saying at least one thing
in work meetings each week.
Therapist: It sounds like you have achieved your goal then?
Client: Yeah, I have.
Therapist: That being the case, maybe we should start talking about how we
might know we were coming to the end of treatment. I guess one sign would
be achieving the goal you had set at the start.
Client: Yes, but I still don’t feel confident in all situations, and coming here is good
for helping me plan my behavioral experiments for the week. I am not sure how
I would go without that.
Therapist: It is natural to be a bit cautious about the idea of ending treatment.
But let’s start to look at other signs that might tell us if you are ready to move
to the “winding down” phase of therapy. I wonder what other signs we might
look for to make this decision together. I am also wondering about what things
we could put in place to help you feel more confident about finishing treatment
when the time comes.

199
200 TREATMENT MODULES

About This Module: Completing Treatment

The duration of SAD treatment is going to vary between clients depending on pretreat-
ment symptom severity and speed of skill acquisition. As already discussed, in group
therapy the treatment outlined in Chapters 4–9 is completed in 12 weekly 2-hour ses-
sions, with a subsequent 1-month follow-­up session. In individual therapy the length of
treatment can be f lexible depending on client needs. This module covers what to look
for in clients to determine when treatment should move into the completion phase. In
addition, this module outlines the topics that should be covered and how to address each
topic, with the aim of preparing clients to maintain their therapy gains and be resilient
to social anxiety setbacks to prevent relapse.

When Are Clients Ready to Complete Treatment?

A sign that treatment can move into the completion phase is when clients are actively
and independently engaging in behavioral experiments, and through this process there
is a reduction in their perceived social threat. This should mean that while certain situ-
ations may still trigger social anxiety, the intensity is reduced, experimentation rather
than avoidance now follows, and the threshold for trigger situations is now set higher.
A sure sign that therapy is nearing its end is when sessions become repetitive in
nature. For example, sessions may start to focus mainly on setting and debriefing
between-­session behavioral experiments, the planning may not need to be as meticulous
as it was early in treatment (i.e., clients are well aware of how to approach social situa-
tions, where to place their attention, and what safety behaviors to drop), and the conclu-
sions from behavioral experiments are becoming repetitive (e.g., “no one is looking,”
“no one is judging,” “the situation went well,” “I was able to participate and socialize,”
“when I screwed up it wasn’t a big deal, I was able to move on from that moment rather
than getting stuck in it”).
Another sure sign that treatment is coming to a natural conclusion is when clients are
doing things they want to be doing in life without social anxiety holding them back. For
example, they can regularly attend and participate in study or work, can go to a sporting
or hobby group they have always wanted to be a part of, they are engaging more with
family and friends, and they are establishing some new friendships or relationships. The
end point of therapy is not indicated by the absence of anxiety in social settings, but
instead the client should be well along the trajectory of living a life that is not dictated
by a fear of negative evaluation from others. If clients can do this, then their anxiety will
likely continue to diminish over time, and when their anxiety inevitably spikes at times,
as it does for all of us, they will be well practiced in knowing how to handle this.
 Maintenance and Relapse Prevention 201

How to Complete Treatment
As treatment starts to wind down, it may be useful to begin spacing sessions further
apart, moving from weekly sessions to fortnightly or monthly sessions. Scheduling fol-
low-­up sessions at 1-, 3-, or 6-month intervals may also be useful for some clients who
lack the confidence that they can maintain or continue their progress without therapist
assistance. Follow-­up intervals can provide clients with the opportunity to discover for
themselves that they can cope independently, and can be framed as behavioral experi-
ments. The therapist might encourage clients by saying:

“I believe you can do this on your own because it has been you doing the hard work
all along. This treatment has been all about training you to become your own thera-
pist. Maybe the follow-­up period can be like a behavioral experiment, giving you
the opportunity to gather evidence and prove this to yourself, so that you believe it
too.”

The focus of sessions in the completion phase of therapy should be to review treat-
ment content, review client progress, facilitate maintenance of client gains, plan for
preventing relapse, address any therapy termination concerns clients may have, and look
forward to the future ahead. This can typically be achieved in two sessions and can be
reiterated in follow-­up sessions if they have been scheduled.

Reviewing Treatment
When reviewing treatment, therapists might return to Worksheet 1, My Model of Social
Anxiety, which they completed at the beginning of treatment, and Socratically elicit the
main treatment strategies that have been used to address each component of the model.
The following treatment components should be reviewed, and clients encouraged to
ref lect on the components that were most helpful to them. These components can be
referred to as their “skills toolbox” and are described in Handout 15, Skills Toolbox.
The main treatment components include:

• Imagery monitoring and challenging

• Coping imagery to facilitate engaging in behavioral experiments
• Behavioral experiments to reverse avoidance
• Behavioral experiment hierarchies
• Dropping safety behaviors
• Video feedback to correct a negative self-image
• Attention retraining and focusing to facilitate task-­focused attention during
behavioral experiments
• Imagery rescripting to change the meaning of past events linked to negative core
beliefs
• Positive imagery and action planning to generate new core beliefs
202 TREATMENT MODULES

Reviewing Progress
Worksheet 19, Your Progress, can be used as a way of focusing discussion on the progress
and gains clients have made during treatment. The worksheet encourages clients to con-
sider the following:

• “In what situations are you managing your social anxiety better?”
• “What changes have you made in your life? What things have you done that you
had not done before (or not done for a long time)?”
• “What was the most important thing that you learned in treatment that has con-
tributed to reducing your anxiety in social situations?”
• “What new skills learned in treatment are you using regularly?”
• “What skills do you think you would benefit from using more often?”
• “What specific situations do you need to confront to overcome remaining anxiet-
ies?”
• “What specific goals can you set to help you address these remaining anxieties?”

Readministration of Worksheet 2, the Personal Fear and Avoidance List, and debrief-
ing changes from pre- to posttreatment are also recommended as a method of review-
ing progress and determining any future priorities for change. Areas that have changed
should be reinforced and those that have not changed can be discussed. Therapist and
client can consider together the reasons why change has not occurred (e.g., no behav-
ioral experiments have been conducted in this specific domain, or safety behaviors are
still in place and are inhibiting change), and they can specifically target the area by
designing relevant behavioral experiment hierarchies and/or action plans. Obviously,
readministration of any psychometric pretreatment measures would occur at this time.
This will provide an objective indicator of treatment outcome, and appropriate feedback
should be provided to the client.

Maintaining Gains
The last four questions of Worksheet 19, Your Progress, can also stimulate discussion
regarding what clients need to keep doing to maintain and further their progress when
formal treatment has finished. Therapists should convey the message that “just because
the formal therapy sessions have finished does not mean that the therapy has finished.
Therapy and its benefits can be ongoing when you continue to apply the skills you
have learned in day-to-day life.” Worksheet 18, New Core Belief Action Plan, previously
completed to strengthen new core beliefs, and any ongoing behavioral experiment hier-
archies clients are still working on (see Worksheet 9 and Chapter 6) can facilitate main-
tenance, giving clients a plan for what specific tasks need to be done to stay on track and
progress even further.
 Maintenance and Relapse Prevention 203

The development, maintenance, and treatment of psychological difficulties can be

complex. However, in our experience, the main therapy concepts and strategies that
will work for clients, and a plan for continuing to apply these in daily life, should be as
simple as possible—­in fact, simple enough to fit onto a single sheet of paper and/or a
3″ × 5″ f lash card. In lieu of ongoing therapy sessions, this brief summary of key lessons
from therapy can then serve as a reminder for clients and as a prompt to check in on
their progress. If the concepts and strategies learned in therapy are many, vast, complex,
and not easily accessible, then the likelihood of sustained application of therapy skills by
clients may be compromised.

Preventing Relapse
Recovery from SAD can be a “rocky road.” Therapists should explain to clients that
the road to recovery is rarely smooth, and there are usually some ups and downs along
the way. Sometimes drawing a graph showing the typical peaks and troughs of progress
can help to convey this “two steps forward, one step back” message. This message is not
intended to be pessimistic, but to normalize setbacks and develop realistic expectations
regarding change:

“Setbacks are normal, the important thing is how we respond to these setbacks. If
we think in unhelpful ways like ‘I’m back at square one’ we will probably start to
fall back into old habits of avoiding social situations and reverting back to old safety
behaviors. Instead, if we try to learn something from the experience and see it as the
ideal opportunity to practice our therapy skills to help overcome the setback, this
will build our resilience. Not feeling socially anxious is not the only sign that we
have overcome our social anxiety. Feeling socially anxious, coping with those feel-
ings, and not having those feelings stop us from doing what we want to do in life is
an equally important sign of social anxiety recovery.”

Worksheet 20, Dealing with Setbacks, encourages clients to consider potential triggers
for setbacks (i.e., When are setbacks in my social anxiety more likely to occur? In what
types of circumstances do I tend to have a setback?) and consider early warning signs
of setbacks (How do I know when I have had a setback in my social anxiety? Are there
any emotional, thinking, behavioral, or physical signals?). With this awareness in mind,
clients are then encouraged to consider how they will respond to setbacks by developing
a cognitive action plan (i.e., What do I need to focus on and remind myself of when a
social anxiety setback occurs?) and behavioral action plan (i.e., What do I need to do
when a social anxiety setback occurs?). If follow-­up sessions have been scheduled, be
sure to prompt clients on whether they have had to use their action plans during the
follow-­up period, the impact or outcome of this, and whether their action plans require
revising.
204 TREATMENT MODULES

Addressing Termination Issues
Clients can have mixed feelings about ending therapy. Some may feel ready to move on,
some may be glad to move on, and others may find it a loss and be worried about their
independent coping abilities. It is important to ensure attention is given to how clients
are feeling about completing therapy, so that if they do have fears about therapy termi-
nation, you have the opportunity to address them. The spacing of sessions and follow-
­up sessions can allay some concerns. For those who are concerned, it may be useful to
use Worksheet 6, the Imagery Challenging Record, to uncover negative images regarding
therapy termination, and allow clients to use the skills they have acquired to challenge
this image and develop a more helpful image of life beyond therapy.

Looking Forward to the Future

It is within the spirit of the imagery-­based approach to end therapy with a final imag-
ery exercise that encourages clients to look to the future with optimism. The following
script can be used to facilitate this.

“Closing your eyes, I would like you to consider the question of how you will be
heading forward from here. Spend a few minutes imagining yourself at some point
in the future, continuing to operate consistently with what you have learned in
treatment, operating consistently with your new core beliefs and action plans.
“Where are you? What are you doing? What are you thinking? What is your
facial expression and body posture like? How do you feel? Where do you feel this
in your body? I will give you a few moments to explore this image looking into the
future . . .
“When you are ready you can let go of the image and open your eyes.”

In individual therapy, therapists can ask clients to describe what they are imagin-
ing during the exercise. In group therapy, the therapist can elicit descriptions afterward.
Take some time to debrief the exercise by asking clients about the main features of
their future-­oriented imagery. Clients will usually envision a life that they desire—­
participating in study, work, or hobbies, having meaningful friendships, engaging in
family events, having a partner, having a family, and so on. They may acknowledge that
SAD had previously robbed them of this kind of life. However, through the courage
they have demonstrated by participating and persisting with this treatment, this type of
life may now be accessible to them, if not immediately, then as a future no longer outside
the realms of possibility. As therapist and client end their journey together, both can be
satisfied that the short-term pain has been worth the long-term future gain of a life well
lived.
 Maintenance and Relapse Prevention 205

Clinical Case: Completing Treatment

For one of our clients, completing university study had always been a struggle due to his social anxiety.
Historically, he would begin study and inevitably withdraw at assignment or exam time when he started
to miss classes and therefore fall behind in his work. Going back to school had therefore been highly
anxiety provoking, with images of past “breakdowns” and “quitting” in his mind. He was very concerned
that his social anxiety would get the better of him and history would be repeated yet again. On this
occasion, compared to his previous attempts at returning to college, he was undertaking treatment at
the same time and hence was well prepared for the challenge. He was now aware of his negative social
images and able to challenge these, he saw attendance at classes as continual behavioral experi-
ments, and he was now naturally dropping safety behaviors and being more task focused in these
environments. A sign that we were coming to the end of treatment was his ability to continue meeting his
university commitments even during times of anxiety “flare-ups.” Our sessions were beginning to feel
repetitive, and we seemed to have less to cover and would finish the session early. I clearly remember
him saying to me, “This time is different from all those previous times I couldn’t deal with college, I have
different skills now that I didn’t have then.” It wasn’t so much what he said, but the way he said it that
struck me. I reminded him that during the imagery challenging we had been doing earlier in therapy to
prepare for his return to college, this statement had appeared almost verbatim in his Contrary Evidence
column to counter his negative image that “returning to university would be just like all the other times.”
However, compared to earlier in therapy, I heard a confidence, conviction, and certainty in his voice
when he said these words. It was not just the wonderful cognitive and behavioral changes he had made
that indicated he was ready to end treatment, but his tone of voice, body language, and attitude when
reflecting on those changes gave us both confidence that formal therapy was no longer necessary.
206 TREATMENT MODULES

THERAPY SUMMARY GUIDE: Maintenance and Relapse Prevention

Therapy Aim:  Complete therapy ensuring clients are: (1) clear and confident regarding
what they need to keep doing to maintain and further their gains, and (2) prepared for
responding to setbacks to prevent SAD relapse.

Therapy Agenda Items:

Review treatment:
]]
Map treatment strategies onto clients’ previously completed Worksheet 1, My
\\
Model of Social Anxiety
\\Complete handout 15, Skills Toolbox, to summarize the treatment components
Review clients’ progress:
]]
\\Refer to Worksheet 19, Your Progress
\\Readminister Worksheet 2, Personal Fear and Avoidance List, and provide feedback
on changes
\\Readminister any relevant psychometric measures and provide feedback on
changes.
Facilitate maintenance of gains:
]]
Use relevant questions on Worksheet 19, Your Progress
\\
Ensure that previously completed Worksheet 18, New Core Belief Action Plan, and/
\\
or any uncompleted behavioral experiment hierarchies (Worksheet 9) are clear
and can serve as guides to continued behavior change over time
Simplify on one page or a f lash card in clients’ own words the most helpful
\\
concepts and strategies from treatment that they will continue to apply regularly
Prevent relapse:
]]
Normalize setbacks
\\
Use Worksheet 20, Dealing with Setbacks, to plan a response
\\
Address termination concerns where necessary:
]]
Schedule follow-­up sessions
\\
Use imagery challenging skills
\\

Close treatment on an optimistic note with the Looking Forward to the Future
]]
Imagery Exercise
 Maintenance and Relapse Prevention 207

Therapy Materials:
Handouts
]]
Handout 15, Skills Toolbox
\\
Worksheets
]]
Worksheet 19, Your Progress
\\
Worksheet 20, Dealing with Setbacks
\\
 APPENDIX

Reproducible Worksheets
and Handouts
WORKSHEETS
Worksheet 1.  My Model of Social Anxiety 211
Worksheet 2.  Personal Fear and Avoidance List 212
Worksheet 3.  Looking Forward 213
Worksheet 4.  Thought/Image–Feeling Connection 214
Worksheet 5.  Thought and Imagery Record 215
Worksheet 6.  Imagery Challenging Record 216
Worksheet 7.  Behavioral Experiment Record 217
Worksheet 8.  Safety Behaviors Experiment 218
Worksheet 9.  Behavioral Experiment Hierarchy 219
Worksheet 10.  Coping Imagery 220
Worksheet 11.  Speech Form 221
Worksheet 12.  Speech Rating Form 223
Worksheet 13.  Self- versus Task-Focused Attention Experiment 224
Worksheet 14.  Attention Retraining Record 225
Worksheet 15.  Task-Focused Attention Exercise 226
Worksheet 16.  Past Imagery Rescripting 227
Worksheet 17.  Constructing New Core Beliefs 228
Worksheet 18.  New Core Belief Action Plan 231
Worksheet 19.  Your Progress 233
Worksheet 20.  Dealing with Setbacks 234

209
 HANDOUTS
Handout 1.  What Is Social Anxiety Disorder? 235
Handout 2.  Recording Thoughts and Images 243
Handout 3.  Challenging Negative Thoughts and Images 245
Handout 4.  The Cycle of Avoidance and Anxiety 247
Handout 5.  Safety Behaviors 249
Handout 6.  Behavioral Experiments 251
Handout 7.  Behavioral Experiment Menu 253
Handout 8.  Behavioral Experiment Hierarchies 254
Handout 9.  Coping (Metaphorical) Imagery 259
Handout 10.  Self-Image: How I Really Appear to Others 260
Handout 11.  Self-, Environment-, and Task-Focused Attention 261
Handout 12.  Attention Retraining and Focusing 262
Handout 13.  Past Imagery Rescripting 264
Handout 14.  Constructing New Core Beliefs 266
Handout 15.  Skills Toolbox 269

210
 WORKSHEET 1

My Model of Social Anxiety

Avoidance
Safety
behaviors

Negative social
Triggers thoughts and images Fear Response

Perception of Social Threat

Probability Cost
How likely is it that my What are the consequences

211
fears will come true? of my fears coming true?

Negative Images of how

core beliefs I appear to others

Self- and
environment-focused
attention

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright © 2018 The Guilford Press. Permission to
photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download additional copies of
this material (see the box at the end of the table of contents).
 WORKSHEET 2

Personal Fear and Avoidance List

Name: 

1.  List up to 10 of your most feared social situations.

2.  Rate your level of anxiety in each situation on a scale from 0 (no anxiety) to 10 (panic).
3.  Rate how much you avoid the situation (due to your anxiety) from 0 (never avoid) to 10 (always
avoid).

Start of Treatment End of Treatment

Anxiety Avoidance Anxiety Avoidance
Situation (0–10) (0–10) (0–10) (0–10)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

212
 WORKSHEET 3

Looking Forward
1.  Close your eyes and imagine what your life would be like if your social anxiety did not change and
you continued along the same path you are currently traveling. What would your life look like in 10
years’ time? Write down what life would be like.

2.  Now close your eyes and imagine how your life might be in 10 years’ time if you make changes in
your life and overcome your social anxiety. Write down what life would be like.

3.  What kinds of things might get in the way of making the life changes necessary to overcome your
social anxiety? What sorts of issues might act as obstacles or roadblocks for you?

4.  The positive aspects of changing to a life without social anxiety are pretty obvious, but what about
the negative aspects? Is there anything that you stand to lose by changing?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

213
 WORKSHEET 4

Thought/Image–Feeling Connection
Thoughts/Images

Feeling
Angry

Thoughts/Images

Situation/Event Feeling
(Trigger) Anxious
Friend is late
meeting me
at a café

Thoughts/Images

Feeling
Sad/depressed

Thoughts/Images

Feeling
Neutral

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

214
 WORKSHEET 5

Thought and Imagery Record

Trigger/Situation Thoughts Visual Image Sensations Emotion
What is happening? What thoughts are going What specific images arise What sensations are part of How did I feel?
Where am I? through my mind? from these thoughts about the image (body, taste, smell, SUDS 0–10?
the situation? sound)?

215
From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright © 2018 The Guilford Press. Permission to
photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download additional copies of
this material (see the box at the end of the table of contents).
 WORKSHEET 6

Imagery Challenging Record

1. Trigger 2. Negative Image 3. Emotion 4. Contrary Evidence 5. Realistic Probability 6. Helpful Image 8. Rerate
Situation What visual images/ How do I feel? What evidence do I have and Consequences Describe as a picture the Emotion
What was/is thoughts are going How intensely that does not support these How likely is it that my most realistic outcome and/or Describe and rate
happening? through my mind? (SUDS 0–10)? thoughts/images? negative thoughts/images a more helpful image. emotions during
Where am I? Body sensations, taste, Alternative ways to view are accurate? helpful image
smell, touch, sound? the situation? If something bad happened, (SUDS 0–10).
then so what? Would it really
be that bad? Would I cope?

216
7. Visualize the helpful image as if it were actually occurring now.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright © 2018 The Guilford Press. Permission to
photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download additional copies of
this material (see the box at the end of the table of contents).
 WORKSHEET 7

Behavioral Experiment Record

Negative Image SUDS Experiment Evidence to Observe Results Conclusion
Describe your prediction. ( /10) Specifically, what could you Specifically, what do you What happened? What clear What conclusion follows from
Specifically, what do you How anxious do to test this image? need to look for to confirm or evidence did you collect? your results?
envision happening? do you feel? Safety behaviors to drop? disconfirm your image? Stick to unambiguous facts.
Where to focus attention?

217
Close eyes and update image based on results and conclusions.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright © 2018 The Guilford Press. Permission to
photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download additional copies of
this material (see the box at the end of the table of contents).
 WORKSHEET 8

Safety Behaviors Experiment

Situation: 

Image(s) of the worst possible outcome in this situation (describe in words or pictures):

My safety behaviors in this situation are: 

With safety How self-conscious did How anxious did I appear How good was my social
behaviors How anxious did I feel? I feel? to others? performance?

Rating (0–10)

What I will do instead of using safety behaviors: 

Without safety How self-conscious did How anxious did I appear How good was my social
behaviors How anxious did I feel? I feel? to others? performance?

Rating (0–10)

Conclusion—What did I learn about safety behaviors? 

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

218
 WORKSHEET 9

Behavioral Experiment Hierarchy

Area for change: 

Image(s) in these situations (describe in words or pictures):

SUDS
Goal: (  /10)

TIP: When thinking about the steps, consider what would make it harder or easier for you to complete
the experiment. What will you do? Where will you do it? When will you do it? Who is there? By
manipulating these variables you can create harder or easier steps.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

219
 W O R K S H E E T 10

Coping Imagery
Describe in detail (in words or pictures) your coping image.

How vivid is this image (circle)?

Not at all vivid Moderately vivid Like seeing a movie/photo
1 2 3 4 5 6 7 8 9 10

How do you feel emotionally when you hold this image?

How do you feel physically when you hold this image?

Meaning of image: What does this image mean about you or your anxiety? What is the image trying to
convey to you?

How can you strengthen this image?

How can you use this image to help manage your anxiety in the future?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

220
 W O R K S H E E T 11

Speech Form
Before the speech:
 1. Task: 
  2. Topic of your choosing: 
(Note: Make sure the topic will create at least 5/10 anxiety for you.)
  3. For 2 minutes create a mental image of how you think you will appear to others as you are giving
the speech. Write a brief description or draw a picture of this image.

  4. How clearly were you able to see yourself in the image (0 = not at all vivid, 10 = extremely vivid)?

  5. Complete the first column of the Speech Rating Form (pre-speech). Rate each item to reflect how
you think you will perform on the 5-point scale.

After the speech, but before watching the recording:

  6. Now that you have completed the speech task, close your eyes and form a clear image of how you
think you came across during the speech. Do your best to construct an “internal video” of how you
think you will appear on the recording. Write a brief description or draw a picture of this image.

  7. How clearly were you able to see yourself in the image (0 = not at all vivid, 10 = extremely vivid)?

  8. Now predict what you will see in the recording by completing the second column of the Speech
Rating Form (post-speech).

Review of the Recording

Before watching the recording we need to be clear about the difference between how you felt while
giving the speech (and how you feel watching it) and how you look. You need to pay attention to how
you look rather than how you felt. Try watching as if you were viewing a friend or someone else you
cared about.
   Now watch the recording once.
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

221
 Speech Form  (page 2 of 2)
After watching the recording once:
  9. Rerate yourself using the third column on the Speech Rating Form.
10. Do your best to construct an “internal video” of how you actually look on the recording. Write a brief
description or draw a picture of this image.

11. How clearly were you able to see yourself in the image (0 = not at all vivid, 10 = extremely vivid)?

After watching the recording four times:

12. Rerate yourself using the fourth column on the Speech Rating Form.
13. Do your best to construct an “internal video” of how you actually look on the recording. Write a brief
description or draw a picture of this image.

14. How clearly were you able to see yourself in the image (0 = not at all vivid, 10 = extremely vivid)?

15. Conclusions: Make a note of what you learned from this task. What do you notice when you
compare your ratings? What does this tell you about the accuracy of your initial image? How
could this new information help to reduce your “perception of social threat” in the future? Within
imagery, take a few moments to see yourself completing upcoming speech tasks or engaging in
conversations in a way that is consistent with this new self-image.

222
 W O R K S H E E T 12

Speech Rating Form

Use the “Pre-speech” column to rate how anxious you think you will feel and look while giving the
speech. Then list the specific symptoms you believe will be obvious and rate how much you think they
will show on the recording. In the remaining columns, rate your anxiety and observable symptoms after
giving the speech and then after watching the recording.
Not at all Mild Moderate High Extreme
0 1 2 3 4 5 6 7 8 9 10

After After
watching watching
Pre- Post- recording recording
speech speech once four times
How anxious will/did I feel? (0–10)
How anxious will/did I look? (0–10)
Below list your anxiety symptoms (e.g., blushing, shaking, mind going blank) and rate how obvious
you think they will be/are on the recording. (0–10)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

223
 W O R K S H E E T 13

Self- versus Task-Focused Attention Experiment

1. Experiment situation: Having a conversation with . . .
2. Self-focused attention: List what you pay attention to when you are self-focused.

3. Conversation with self-focused attention

4. Rate yourself.
How anxious did you How self-conscious How anxious did you How good was your
feel? did you feel? appear to others? social performance?
Rating
(0–10)

5. Task-focused attention: List what you pay attention to when you are task focused.

6. Imagine yourself being task focused during the conversation.

7. Complete the conversation with task-focused attention.
8. Rate yourself.
How anxious did you How self-conscious How anxious did you How good was your
feel? did you feel? appear to others? social performance?
Rating
(0–10)

9. Conclusions: What was the impact of self- versus task-focused attention?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

224
 W O R K S H E E T 14

Attention Retraining Record

Date/ Attentional Task Concentration
Time (e.g., breath, walking, eating, sitting) Duration Level (0–10) Comments

225
From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright © 2018 The Guilford Press. Permission to
photocopy this material is granted to purchasers of this book for personal use or use with clients (see copyright page for details). Purchasers can download additional copies of
this material (see the box at the end of the table of contents).
 W O R K S H E E T 15

Task-Focused Attention Exercise

Practice task-focused attention during at least one social interaction this week. Devote as much of
your attention as possible to the task at hand. Below there is space for you to recall the content of the
conversation in as much detail as you can. Knowing that you are planning to recall these details may
help you to continue reorienting your attention back to the content of the conversation.
Date: 
Situation/interaction: 
Anxiety level (0–10): 

Details of interaction (especially content of conversation)

Self-focused attention:     %

Environment-focused attention:     %
Task-focused attention:     %

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

226
 W O R K S H E E T 16

Past Imagery Rescripting

Past image: Describe a past distressing situation. (What happened? When did it happen? Where did it happen? Who was
there?) Note. If you can’t think of a specific event, describe your earliest memory of feeling the way you do in social situations.

Belief before rescripting Belief after rescripting

Meaning of the experience and image: 0 = completely untrue, 0= completely untrue,
What meaning did you take from this experience? 10 = completely true 10 = completely true

I am . . .

Others are . . .

The world is . . .

The image is . . .

Perspective of the “older” you: What do you know now that would have been helpful to know at the time of the event?
Logically, what do you know now? If a friend experienced the same situation, what perspective might you offer him or her?

After Phase 1: Imagining the event from the perspective of the “younger you”

What emotions are you feeling? Where in your body are you feeling them? How strong is the emotion?
0 = none, 10 = strongest ever

After Phase 2: Imagining the event from the perspective of the “compassionate older you” offering support to the
“younger you”

What emotions are you feeling? Where in your body are you feeling them? How strong is the emotion?
0 = none, 10 = strongest ever

After Phase 3: Imagining the event from the perspective of the “younger you,” but with the “compassionate older you”
intervening and offering all the support you need

What emotions are you feeling? Where in your body are you feeling them? How strong is the emotion?
0 = none, 10 = strongest ever

Strength of belief
0 = completely untrue,
Conclusions What did you learn from this? 10 = completely true

I am . . .

Others are . . .

The world is . . .

The image is . . .

How do you feel when you think about the event now?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

227
 W O R K S H E E T 17

Constructing New Core Beliefs

1. A situation in which I have typically experienced strong social anxiety is . . .

2a. How would I like to be in social situations . . . ?

Actions

Expression on my face

Body posture

Self-talk

2b. How would that feel? (emotionally, physically)

Emotions

Sensations in my body

3. When operating in this new way . . .

I see myself as

I see others as

I see the world as

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

228
 Constructing New Core Beliefs  (page 2 of 3)
4. When I see myself, others, and the world in this way, what do I see myself doing (or not
doing) in the following areas of my life? (Be very specific.)
My relationships

My family life

Work/study

Leisure/hobbies

Health/well-being

Other important aspects of my life

5. When I see myself, others, and the world in these more positive and helpful ways, if I were to
hit “stormy weather” (e.g., something bad does happen), how would I like to respond?
Actions

Self-talk

Body posture

Expression on my face

Emotions

Sensations in my body

For a few minutes imagine myself being this way . . .

(continued)

229
 Constructing New Core Beliefs  (page 3 of 3)
6. A past occasion when I did something that exemplifies my new core beliefs was . . .

Now spend a few minutes visualizing this occasion.

7. When I imagine operating in this way, what “icons” come to mind? Are there particular songs,
images, movies, characters, fairy tales, stories, people, animals, or scenes from nature that
represent this way of operating? Is there something that really captures the spirit of my new, more
positive core beliefs?
How do I feel in my body after bringing this icon to mind?

How could this icon be used to inspire or motivate me to continue operating within the new system
of more positive core beliefs?

230
 W O R K S H E E T 18

New Core Belief Action Plan

EXAMPLE:
New core beliefs
(self, others, world) Life domain Target for change Specific actions Time frame
Self: likable Work Be more assertive Ask boss for a meeting Tomorrow
Others: caring, at work to say that I need
supportive more help

World: safe

Self: likable Relationships Initiate more Invite work colleague Ask Thursday if
Others: friendly social outings for coffee at lunchtime colleague wants
to meet for
World: safe
coffee on Friday

My New Core Beliefs

Self:

Others:

World:

Life domain Target for change Specific actions Time frame

My relationships

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

231
 New Core Belief Action Plan  (page 2 of 2)
Life domain Target for change Specific actions Time frame
My family life

Work/study/
career

My leisure/
hobbies

My health/
well-being

Other important
areas of my life

232
 W O R K S H E E T 19

Your Progress
1. In what situations are you managing your social anxiety better?

2. What changes have you made in your life? What things have you done that you had not done before
(or not done for a long time)?

3. What was the most important thing that you learned in treatment that contributed to reducing your
anxiety in social situations?

4. What new skills are you using regularly?

††Imagery monitoring
††Imagery challenging
††Coping imagery
††Behavioral experiments
††A structured behavioral experiment hierarchy
††Dropping safety behaviors
††Recalling an accurate self-image (even when anxious)
††Attention retraining
††Attention focusing
††Rescripting past images
††Action planning to strengthen your new core beliefs

5. What skills do you think you would benefit from using more often?

6. What specific situations do you need to confront to overcome remaining anxieties?

7. What specific goals can you set to help you combat these remaining anxieties?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

233
 WORKSHEET 20

Dealing with Setbacks

Setbacks are normal; it is how I respond to setbacks that is most important.

My Triggers (When are setbacks in my social anxiety more likely to occur? In what types of
circumstances do I tend to have a setback?)

My Warning Signs (How do I know when I have had a setback in my social anxiety? Are there any
emotional, thinking, behavioral, or physical signals?)

ACTION PLAN:
What do I need to focus on and remind myself What do I need to do when a social anxiety
when a social anxiety setback occurs? setback occurs?

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee. Copyright
© 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for personal use or use
with clients (see copyright page for details). Purchasers can download additional copies of this material (see the box at the end
of the table of contents).

234
 HANDOUT 1

What Is Social Anxiety Disorder?

Everyone experiences anxiety from time to time, but when anxiety debilitates someone in impor-
tant ways (e.g., work, social life, relationships), then he or she may be experiencing an anxiety
disorder. Although you might feel alone in your struggle with anxiety, the reality is that anxiety
disorders are very common. In fact, around 1 in 5 people will experience an anxiety disor-
der in the course of a lifetime.
Anxiety disorders do not discriminate, and they can affect any kind of person at any stage
in of life. People can suffer from anxiety disorders regardless of their circumstances, youthful or
elderly, male or female, wealthy or poor. So remember, you are not alone. In fact, you’re not even
very unusual!
“Social anxiety” is used to describe anxiety that occurs in response to social situations. The
anxiety may occur before, during, or after the social situations, and quite often at all three time
points. Of course, most people feel anxious about some social situations, such as public speaking
and job interviews. Worrying about whether the speech or interview will go well, or what other
people will think, is quite common. Most people will also feel relieved when it is over. For some
people, however, the anxiety may be so distressing that they avoid the situation at all costs.
In clinical practice, the term “social anxiety disorder” or “social phobia” is used to describe
intense, long-standing, and debilitating fear of social situations. Often people with social anxiety
disorder (or SAD) will avoid social situations if they can. They worry that they will be embarrassed
or humiliated in some way and that they will be evaluated negatively or criticized by other people.
SAD is one of the most common anxiety disorders. Although the prevalence differs in different
countries, around 8–16% of people are likely to meet criteria for the disorder in their lifetimes.
Half of all people who experience SAD will develop the disorder by the age of 13 years. Many
people report always being shy or socially anxious. Unfortunately, SAD is often a chronic disorder
that does not disappear without treatment and people usually suffer for many years before seeking
help. The good news is that treatment can be very effective at helping people to better
manage their anxiety.
People with SAD may fear most social situations or one or two specific situations. Therefore,
just as with any other problem, people with SAD can vary in the range and severity of their dif-
ficulties.

WHAT CAUSES SAD?

There is no single or simple answer to the question of what causes SAD. Contributing factors are
many, and they can vary for different individuals. However, some important factors have been
identified that can increase someone’s chance of developing SAD. These factors can be divided
into biological and psychological causes.
Biological factors such as a family history of anxiety disorders or depression increase your
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

235
 What Is Social Anxiety Disorder?  (page 2 of 8)
chances of having an anxiety disorder. The more family members you have who suffer with anxi-
ety or depression, and the closer they are to you genetically, the more likely you are to develop an
anxiety disorder. We are also born with our own temperaments, which may be inherited to some
degree. Many people with SAD report that they were shy or inhibited as very young children.
While most children will grow out of early shyness, if they are shyer and more timid than their
peers, this also increases their chances of developing SAD later in life.
Having a biological vulnerability does not necessarily mean that someone will develop an
anxiety disorder. It also may depend on the lifestyle of the person, the types of life stressors they
have encountered, and their early learning. Many people with SAD report experiencing bully-
ing or abuse during their childhood or adolescence. Some report having one or two particularly
distressing social experiences that have stuck in their minds, while others report experiencing
regular criticism early in life. Some report that their families did not socialize much during their
childhood, so they did not have the opportunity to develop confidence in their ability to develop
relationships with others.
Ultimately it probably takes a combination of biological, temperamental, and social factors for
someone to develop SAD. The good news is that regardless of the causes of your SAD, effective
treatment is available.

WHAT KEEPS SAD GOING?

The diagram on the last page of this handout (based on Worksheet 1) illustrates the model of SAD
that will be used to guide your treatment. On the left there is a shaded box labeled triggers, which
includes a range of social situations that can trigger a perception of social threat. Our perception
of social threat is basically how strongly we believe that a “social catastrophe” will occur. This
perception is divided into two parts: probability and cost. The probability refers to how likely our
fears are to happen. If we believe our fears are highly likely to come true, then our fear response is
more likely to be triggered. The cost refers to how bad we believe it will be if our fears do come
true. For example, if you believe it is very likely that you will appear nervous and make a mis-
take when delivering a presentation (high probability), and that if this does happen you will be
criticized or humiliated by others (high cost), then you are likely to feel very anxious about the
presentation.
Once the perception of social threat is triggered (i.e., perceived social danger is high) you will
experience a strong fear response. This usually results in physical symptoms such as:

• Trembling or shaking
• Blushing
• Pounding heart
• Mind going blank
• Nausea
• Sweating
• Overbreathing or hyperventilation
• Difficulty concentrating
• Urge to escape
(continued)

236
 What Is Social Anxiety Disorder?  (page 3 of 8)
These symptoms are part of the fight-or-f light response, the body’s protective mechanism. If
we are under real threat (e.g., a robber) our body must ready itself to fight or f lee from the threat.
As a result, we get a surge of adrenaline and our respiration rate increases (to get more oxygen to
the body), we sweat (to cool the body), our muscles tense (to prepare for fighting or f leeing), our
heart rate increases (to pump more blood around the body), our attention narrows and focuses on
the threat (so that we aren’t distracted from dealing with the threat), and so on. As you can see, all
these changes are designed to help us deal with the threat.
In most social situations we can’t simply fight or run away at top speed, so we aren’t able to use
all the extra resources (e.g., adrenaline, oxygen) in our body. As a consequence, we subjectively
experience these bodily changes as intense anxiety. Some people may also experience a “freeze”
fear response, which is again part of our survival instinct and designed to provide another means
of protecting ourselves when we can’t fight or f lee.
So the shaded areas of the model explain the link between the triggers, the perception of social
danger (probability and cost), and the fear response. The question is, what maintains the percep-
tion of social danger? This is where the bubbles around the model come in.

NEGATIVE SOCIAL THOUGHTS AND IMAGES

Most people, when they are upset, have upsetting things going through their minds. Sometimes
they are in the form of thoughts or words, and sometimes in the form of pictures or feelings in
the body. These images may initially be vague or fuzzy, or they might be as clear as if you were
watching a movie. They may be about past, present, or future social situations.
Images may involve multiple senses. We may see a visual image as if it is a film. We may hear
sounds or verbalizations. We may associate touch, taste, or other physical or behavioral reactions
with the image, as if we were in the actual situation.
Let’s demonstrate. Close your eyes and imagine biting into a lemon and sucking out as much
juice as you can. What reactions do you notice? Can you see the lemon wedge as you put it to your
mouth? Can you imagine how it feels in your hand? Can you taste the lemon? How does your
mouth respond to the taste? Do you notice an urge to take another bite, or an urge to screw up
your mouth and spit it out?
People can have images before, during, and after social events. Just like the lemon, these
images may have a powerful impact on multiple senses and ultimately on our emotions. Common
social anxiety images may include:

• Saying something stupid and others laughing

• Other people talking about me behind my back
• Seeing myself trembling, shaking, and looking as bright red as a beet
• Seeing myself sitting away from the crowd, or not contributing
• Imagining other people looking at me as if I am very odd

(continued)

237
 What Is Social Anxiety Disorder?  (page 4 of 8)
Although negative thoughts are very common, we will be focusing more on negative social
images in this treatment. If you notice negative thoughts, you will be encouraged to try and trans-
form the thoughts into images. The main reasons for this are that images (1) are more specific,
(2) are more strongly linked to emotion, and (3) become less scary when we don’t avoid them.

Images are often more specific than thoughts.

Many of the negative thoughts people have when they are socially anxious are catastrophic,
abstract, and overgeneralized. By abstract and overgeneralized, we mean that they tend to refer
to something bad happening in general or to some general negative label. For example, if you are
asked about what you think will happen in a particular social situation, an overgeneralized thought
might be “I will look like an idiot” or “they will think I am an idiot.” The problem is that when
we make such a general statement, it is unclear exactly what we mean. Specifically, what does
looking like an “idiot” actually mean? Our fears remain quite vague, which makes it difficult to
find ways to challenge, test, and change our fears.
Imagery forces you to be really specific about what you fear socially, which is important for
effective treatment. So if instead you were asked to close your eyes and describe what you see hap-
pening in the same social situation, you might say, “I see myself shaking, stuttering, bright red,
having nothing to say” (which is more specific than “looking like an idiot”) or “I see others laugh-
ing at me, criticizing me, turning away and avoiding speaking to me” (which is more specific than
“they will think I am an idiot”).
The more specific and detailed you are about what concerns you the most socially, the better
position you are in to be able to target your concerns. We now have testable fears we can work
with (i.e., did you actually shake, stutter, go bright red, have nothing to say, did others actually
laugh, criticize, turn away and avoid you).

Images are more strongly linked to emotion.

Research has shown that images have a very strong association with the parts of the brain that
generate emotions, including anxiety. In fact, imagining something either positive or negative
generates much more emotion within us than merely thinking about that same thing. So think-
ing in images can have a more powerful impact on our emotions (in either a negative or positive
direction) than merely thinking in words. Given that we are trying to overcome the emotion of
anxiety in social settings, we need to work in the “mode” most likely to impact that emotion (i.e.,
imagery rather than words).
The reason images are more strongly linked to our emotions is that images can be as power-
ful as the real thing. Research has also shown that many of the same brain pathways are involved
in imagining something and actually doing it. So imagining something can have the same impact
on our brain and body as if the thing we imagined were real and actually happening to us. For
social anxiety, an image of being rejected prior to socializing can elicit the same feelings as actual
rejection and hence stop you from socializing. Conversely, an image of being socially competent
can elicit the same feelings as actual social competence and make you more inclined to socialize.

(continued)

238
 What Is Social Anxiety Disorder?  (page 5 of 8)
Running images on past their worst point can make them less scary.
It is likely that when you have a negative social image pop into your head, you dwell on the
worst part of it for a little bit, then when it becomes too distressing you suppress it, trying to push
the image out of your mind. However, research shows that thought suppression often backfires,
making you think even more about the thing you don’t want to think about. So you kind of get
stuck in the worst part of the image as you think about it, then suppress it, think about it, then
suppress it, and so on. Overall this keeps your anxiety and concerns about the situation very high.
The alternative is to think about the negative social image fully from beginning to end, rather than
suppressing it. By doing this you won’t get stuck at the worst point. Instead you can run it on past
this point and see what you discover about yourself and other people. It is likely that when you
take this approach, your anxiety and concerns will be more like a wave, subsiding when you allow
yourself to move past the worst point.

AVOIDANCE
In order to stop feeling anxious, most people with social anxiety try to avoid social situations,
including:
• Interacting in groups/going to parties
• Initiating and maintaining conversations
• Meeting new people/dating
• Public speaking
• Being watched while writing, eating, or drinking
• Being assertive with others
• Using public toilets

People with social anxiety might also try to avoid the negative imagery. They may use cogni-
tive and/or behavioral avoidance strategies.

Cognitive avoidance may include:

• Distracting yourself from the images
• Suppressing the images (actively trying to push them out of your mind)
• Criticizing yourself for having the thoughts in the first place
• Worrying or ruminating about the situation (research shows that repetitively thinking about
the situation in words helps us to avoid having as many distressing negative images)
• Thinking about ways of escaping the situation or image

Behavioral avoidance may include:

• Escaping from the situation, or avoiding it in the first place, to avoid the negative images
• Using subtle avoidance behaviors to try and prevent our images from coming true (e.g.,
avoiding eye contact, not contributing to conversations, only speaking with “safe” people).
These are called “safety behaviors” (see below for more detail).
(continued)

239
 What Is Social Anxiety Disorder?  (page 6 of 8)
Avoidance makes sense in the short term because it may provide some relief from the anxiety.
However, the relief is only temporary because the underlying perception of social threat is never
directly tested, challenged, and modified. As a consequence, the social fear maintains indefinitely.
In fact, avoidance usually results in increasing anxiety in more and more situations as people learn
that they cannot cope with social situations. Avoidance also causes a lot of practical problems and
interference in people’s lives.

SAFETY BEHAVIORS

Sometimes it is not possible to completely avoid social situations. In these cases, socially anxious
people often use “safety” behaviors to help them feel more comfortable. Safety behaviors are any
things you do within social situations to try and prevent your fears from coming true. Common
safety behaviors include:

• Using alcohol or drugs

• Not making eye contact
• Not contributing to discussions/meetings
• Wearing inconspicuous clothes
• Asking a lot of questions so you don’t need to disclose personal information
• Making excuses to leave early
• Covering up your anxiety symptoms in some way (e.g., using makeup to cover blushing)
• Perfectionistic behaviors such as overpreparation for presentations/meetings
• Carrying or taking antianxiety medications “when needed”
• Only talking to specific “safe” people

We might feel like these “tricks of the trade” are helping to reduce our anxiety and prevent
social catastrophes, but in fact they just stop us from learning that our fears are less likely to happen
than we think (probability) and less catastrophic when they do happen (cost). If a social situation
goes well it doesn’t seem to make a difference to our social anxiety because we attribute the success
to our safety behavior, rather than learning that the situation itself is safe and we can cope socially.
Safety behaviors can actually make things worse because they can cause us to become more self-
focused and appear less engaged in the social situation.

IMAGE OF HOW I APPEAR TO OTHERS

Close your eyes and see if you can create a mental image of how you think you appear to other
people when you are feeling socially anxious. Most people with social anxiety imagine that they
are performing very badly and that this is blatantly obvious to other people. In our “mind’s eye”
we may see ourselves blushing bright red, shaking, trembling, looking away, sweating, and stum-
bling over our words. However, we know that many people who feel anxious in social situations
do not have accurate views about how they appear to others. It is very likely that although you
(continued)

240
 What Is Social Anxiety Disorder?  (page 7 of 8)
may feel anxious, others cannot see this. In fact, most people with social anxiety come across far
better than they think they do. Inaccurate and overly negative images of your social performance
can therefore mislead you and increase your perception of social threat.

SELF- AND ENVIRONMENT-FOCUSED ATTENTION

People with social anxiety focus their attention in ways that increase their anxiety in social situa-
tions. In particular, socially anxious people focus most of their attention on themselves, including
their physical symptoms of social anxiety and their negative thoughts and images (self-focused
attention). They may also look around their environment for any evidence that they are in fact
being negatively evaluated (e.g., people laughing in another part of the room, anyone looking in
my direction; environment-focused attention). When most of our attention is directed toward
ourselves and/or looking for threats in our environment, very little attention is left over to focus
on the “task at hand” (task-focused attention). The effects of this are to increase self-consciousness
and anxiety, and it interferes with social performance because you are not focusing on what you
are trying to do (e.g., maintain a conversation).

CORE BELIEFS

The final “bubble” in the model refers to core beliefs. Many people with SAD recall early life
events (childhood, adolescence, early adulthood) that were associated with significant social anxi-
ety. There may be one or two situations, or many early experiences, that you identify as substan-
tially contributing to your social anxiety. These early experiences may be associated with impor-
tant meanings about ourselves, others, and the world in general (i.e., core beliefs), which then
manifest as negative images in the here and now. For example, if I was bullied I may have formed
core beliefs such as “I am unlikable” or “I am inferior.” I might also have come to believe that
“others are hostile or critical.” As a consequence, when I think about entering a social situation
now, I envision my “inferiority” as being obvious and I expect to be criticized by others. Core
beliefs are not necessarily conscious thoughts, but are more like unwritten rules or assumptions
through which people interpret what is happening around them. They can act like filters that
guide our images and expectations in the here and now.
All of the bubbles in this model work together to cause you to feel anxious and uncomfortable
in social situations. So you can see that social anxiety has a mix of factors maintaining the problem.
The good news is that the components of this model can also work for us because making a change
in any one of the bubbles can f low through to the others.
The treatment you are undertaking will help you to make changes in each bubble within the
model of social anxiety.

(continued)

241
 What Is Social Anxiety Disorder?  (page 8 of 8)
MODEL OF SOCIAL ANXIETY
Avoidance
Safety
(e.g., parties, lunchroom, behaviors
making phone calls)
(e.g., use alcohol,
Negative social don’t speak, don’t disclose
Triggers thoughts and images personal information, Fear Response
no eye contact)
(e.g., parties, (e.g., making a fool of myself, (e.g., blushing,
meetings, being laughed at shaking,
classes, and criticized) heart racing,
walking down trembling,
the street, sweating,
public toilets, Perception of Social Threat urge to flee)
eating in front

242
Probability Cost
of others)
How likely is it that my What are the consequences
fears will come true? of my fears coming true?

Negative Images of how

core beliefs I appear to others

(e.g., memories of being Self- and (e.g., “red as a beet,”

bullied mean I’m environment-focused shaking, voice quavering)
unlikable, inferior) attention
(e.g., vigilant to anxiety
symptoms, looking
for “threat”)
 HANDOUT 2

Recording Thoughts and Images

Most people have thoughts and/or “pictures” or images going through their minds before, during,
and after anxiety-provoking social situations. Some people also hear the sounds of people’s voices;
experience the body in various ways, like feeling small and fragile or feeling stuck in a box; or
experience imaginary tastes or smells. These images may initially be vague or fuzzy and may not
seem to make sense, but they may still turn out to be the worth tuning in to.
You may be very aware of such thoughts and imagery, or you may not. During this treatment
you will be encouraged to start “tuning in” to thoughts and images going through your mind
when you feel anxious. These thoughts and images may be of past experiences or about what is
happening during a social interaction, or they may ref lect future expectations.
You are encouraged to increase your awareness of various elements of your thoughts and
images, which are outlined in the Thought and Imagery Record (Worksheet 5). Use this form to keep
track of your imagery.
If you are having difficulty noticing your thoughts and imagery during the week, practice
closing your eyes and thinking back to a past social situation in which you felt anxious. Don’t
start with the most anxiety-provoking social experience. The Subjective Units of Distress Scale
(SUDS) can help you to monitor the intensity of your anxiety, with a SUDS of 10 being the most
severe social anxiety you’ve ever experienced, 7–8 being high, 5 being moderate, 2–3 being mild,
and 0 being no anxiety at all (see the scale below). A good place to start is by recalling a past situ-
ation with a SUDS rating of around 5/10. Imagine the social situation as vividly as possible and
complete a Thought and Imagery Record for this situation. An example is provided on the next page.

SUDS = SUBJECTIVE UNITS OF DISTRESS SCALE

No anxiety Mild Moderate High Extreme anxiety
0 1 2 3 4 5 6 7 8 9 10

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

243
 Recording Thoughts and Images  (page 2 of 2)
THOUGHT AND IMAGERY RECORD—EXAMPLE

Trigger/Situation Thoughts Visual Image Sensations Emotion

What is happening? What thoughts are going What specific images arise What sensations are part of How did I feel?
Where am I? through my mind? from these thoughts about the image (body, taste, smell, SUDS 0–10?
the situation? sound)?
I’m about to go into the I hate being the center of Everyone stares at me as I I get this sensation of being Anxious and
lunchroom at work. attention, my colleagues will walk in. in the heat of a bright embarrassed
think I’m a loser and that spotlight.
I’m really boring. I sit down, they are all 8/10
interacting loudly with each My body feels really jittery
other and small.

I’m not saying anything. I can hear the other people

244
talking and laughing loudly.
They deliberately ignore me.
I can almost smell the coffee
and toast in the lunchroom.
 HANDOUT 3

Challenging Negative Thoughts and Images

So far you have been “tuning in” to your negative thoughts and images when you feel socially anxious.
It is now time to start scrutinizing these negative thoughts and images. Effective challenging of anxious
thoughts and images involves eight steps. The Imagery Challenging Record (Worksheet 6) can help to guide
you through this process. An example is provided on the next page.
Step 1: Trigger Situation: What is the situation? Where am I? Brief ly describe what was (past event) or is
(present event) happening and who is there.
Step 2: Negative Image: Describe the negative visual images going through your mind. Also describe other
senses in the image (i.e., sounds, body/touch sensations, tastes, smells). If thoughts in the form of words are
the most prominent thing on your mind, close your eyes and see what picture represents those thoughts.
Step 3: Emotion: Describe the emotions you are feeling and indicate their intensity using SUDS ratings.
Step 4: Contrary Evidence: Look for contrary evidence and consider alternative images and thoughts.
It is easy to fall into the trap of only recognizing or remembering experiences that confirm our fears,
while ignoring contrary experiences. The best way to counteract this bias or “filter” is to think about evi-
dence that does not support your negative images. The types of questions you can ask yourself are:
• Have I had any experiences that show that this image is not completely true all of the time?
• Are there any small things that contradict my image that I might be ignoring?
• Have I been in this type of situation before? What happened? Is there anything different between this situation
and previous ones? What have I learned from prior experiences that could help me now?
• Is my image based on facts, or am I “mind reading”? What evidence do I really have?
• Am I jumping to conclusions that are not completely justified by the evidence?
• If someone who loves me knew I was having this image, what would they say to me? What evidence would they
point out that would suggest that my image was not 100% true?
• Are there other ways of looking at this situation?
• What are all the possible explanations in this situation? Are there any alternatives to mine?
• What’s the best that could happen?
• What’s the worst that could happen? What’s so bad about that? Could I cope with this? Would life go on? What
could I do that would help?
• Will this still bother me in 1 week/month/year?
• If the roles were reversed, how might I judge the situation/other person?
• Regardless of whether the image is true, is it helpful to think this way? What are the negative consequences of
thinking this way? What would be a more helpful way to think or a more helpful image to hold?
Step 5: Realistic Probability and Consequences: Given the contrary evidence and alternative perspectives, now
consider the most realistic probability and consequences. What is the most likely outcome? What are the
most likely consequences?
Step 6 Helpful Image: Describe the most realistic outcome and/or a more helpful image.
Step 7: Now spend a few moments visualizing this helpful image.
Step 8: Describe and rate the strength of your emotions as you visualized the new helpful image.
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

245
 Challenging Negative Thoughts and Images  (page 2 of 2)
IMAGERY CHALLENGING RECORD—EXAMPLE
1. Trigger 2. Negative Image 3. Emotion 4. Contrary Evidence 5. Realistic Probability 6. Helpful Image 8. Rerate
Situation What visual images/ How do I feel? What evidence do I have and Consequences Describe as a picture the Emotion
What was/is thoughts are going How intensely that does not support these How likely is it that my most realistic outcome and/or Describe and rate
happening? through my mind? (SUDS 0–10)? thoughts/images? negative thoughts/images a more helpful image. emotions during
Where am I? Body sensations, taste, Alternative ways to view are accurate? helpful image
smell, touch, sound? the situation? If something bad happened, (SUDS 0–10).
then so what? Would it really
be that bad? Would I cope?

I’m about to Everyone will stare at Anxious and People don’t always look up It is likely (50%) that some A couple of people glance Still a bit anxious
go into the me as I walk in. embarrassed whenever I enter a room. people will look at me, but as I walk in the room (5/10), but not
lunchroom at not everyone. It is unlikely and then go back to their embarrassed
work. They will all interact 8/10 I am often quiet and don’t they will actually stare (i.e., conversation. (2/10)
with each other, but I say anything unless someone look longer than 3 seconds)
won’t say anything. asks me a question, but not I sit at the table and a
always. It is very likely (90%) that couple of people say hi. I

246
They will deliberately I will be quiet and not say listen to the conversation.
ignore me. Sometimes people do make anything unless I’m spoken
small talk with me. to. One person asks me a
Bright spotlight. question.
It would be pretty rude to It is possible (30%) that
I feel Jittery, small. just stare at someone who someone will try to speak I focus on eating my lunch,
had just walked in. with me. and making the effort
I hear their loud to talk and ask them a
voices. If they don’t include me If some people do look at me question back.
it might be because they I will feel uncomfortable, but
I can smell the are caught up in the then they will probably just My colleagues are mostly
lunchroom. conversation they are go back to what they are friendly and are just
already having. doing. interested in whatever
conversation is going on.
If no-one speaks to me
7. Visualize the helpful image as if it were actually occurring now.

then I will just read my The times I am silent are OK

magazine. by everyone.

My colleagues are unlikely

to ignore me in a rude or
critical way.
 HANDOUT 4

The Cycle of Avoidance and Anxiety

People with social anxiety often rely on avoidance as a way to minimize their anxiety. On the one
hand, avoidance seems like a very sensible strategy. Anyone who had very negative expectations
about social situations would want to avoid them. This makes perfect sense. On the other hand,
avoidance is one of the main reasons that social anxiety persists. In fact, social anxiety is likely to
persist indefinitely until social fears are directly tested.

WHAT’S THE PROBLEM WITH AVOIDANCE?

Although in the short term avoidance may help us to feel safer and less anxious, in the longer term
avoidance keeps us anxious for a number of reasons.

1. We never get to test our negative images. When we avoid a social situation we are assuming that
our negative images are accurate ref lections of reality. However, avoidance never gives us
an opportunity to directly test our fears. If we did, we might discover that our images are
actually inaccurate. We might learn that in fact our fears rarely come true and instead that
things often turn out pretty well. We might also find that even if social experiences don’t
go according to plan sometimes, we can cope with this as well. So avoidance prevents us
from getting an accurate impression of the true probability and cost of our fears coming
true.
2. We never get opportunities for positive experiences. As long as we avoid social situations, we have
no chance of having positive social experiences that would motivate us to engage more
socially over time.
3. Loss of self-esteem. Because people with social anxiety aren’t doing what they would really
like to do (i.e., have more satisfying relationships) they tend to be very self-critical and can
have low self-esteem. They may ruminate a lot about aspects of life that are passing them
by, which leaves them more vulnerable to further anxiety and depressed mood. In fact,
people with social anxiety can often use their avoidance as just another reason to criticize
themselves.
4. Avoidance and anxiety can generalize. As we avoid and lose confidence in one area of our
lives (e.g., relationships with peers), our anxiety can start to generalize to more and more
domains of life (e.g., work, family relationships).

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

247
 The Cycle of Avoidance and Anxiety  (page 2 of 2)
For all these reasons, it is crucial that the cycle of avoidance and increasing anxiety
is broken. Behavioral experiments are a very effective way of achieving this.

Negative social images

Never test negative images

Miss out on positive experiences Anxiety
More self-critical
Start feeling anxious in more situations

Avoidance

248
 HANDOUT 5

Safety Behaviors
It is very difficult to completely avoid all social situations. However, when people with social
anxiety can’t avoid social situations they often rely on more subtle forms of avoidance called safety
behaviors. Safety behaviors are used in an attempt to prevent feared predictions from coming true
and to feel more comfortable in social situations. Examples of common safety behaviors include:

Safety Behavior Function: Why Use It?

No/limited eye contact To avoid drawing attention to myself
To avoid seeing negative reactions from others
Alcohol/drugs I don’t believe I can interact with other people without it
I think my anxiety will overwhelm me without it
Don’t contribute to conversations I believe I’ll say something stupid and be criticized
Something bad will happen if I’m the focus of attention
Rehearse/plan what I’m about to say To make sure it isn’t stupid
To make sure I don’t stumble over my words
Wear inconspicuous clothes To avoid drawing attention to myself
Wear makeup To cover blushing

List some of your safety behaviors.

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

249
 Safety Behaviors  (page 2 of 2)
SO WHAT IS THE PROBLEM WITH SAFETY BEHAVIORS?

While safety behaviors may help people to feel safer in the short term, unfortunately they serve to
maintain social anxiety in the longer term because . . .

1. Safety behaviors stop us from directly testing our fears. Although we haven’t avoided the situ-
ation completely, by using our safety behaviors we are not directly testing our fears. For
instance, if I attend a work meeting but don’t contribute, I never get to test my image of
“saying something stupid and other people laughing or looking confused at my answers.”
When the next meeting comes along the same image will come to mind and again I will be
gripped by fear. If I directly tested my fear by making a comment in the meeting I would
have an opportunity to discover that my negative image was inaccurate. After I test the
image numerous times and find that it does not come true then the negative image can be
seen for what it is—just an image that does not ref lect reality. It will have less emotional
impact, and it will no longer need to dictate what I do.
2. Safety behaviors can become “self-fulfilling prophecies.” Safety behaviors can actually cause the
outcomes we are trying to prevent by using them. For instance, if I use alcohol because
otherwise I don’t believe that I could interact with people, I might find myself overindulg-
ing at times and acting in ways that result in negative evaluation from others (e.g., drunken
behavior). So the “safety behavior” has increased the chances of negative evaluation rather
than reduced it. Similarly, my boss might get more frustrated with me for not contributing
to meetings than if I did contribute from time to time.
3. If our fears don’t come true we mistakenly “thank” the safety behavior. If we use our safety behav-
iors and our fears don’t come true, we might believe that the safety behaviors “prevented”
this from happening. As a result we can become very dependent upon our safety behaviors
and start to feel even more anxious if they can’t be used (e.g., no alcohol available, not given
time to overprepare for meetings). The truth may be that our fears wouldn’t have come
true even without the safety behavior, but we never discover this as long as we continue
relying on them.
4. Safety behaviors increase our self-focused attention. Safety behaviors often involve people scruti-
nizing themselves (what they are doing, how they are doing it, monitoring their thoughts),
which can be very distracting. Self-focused attention hijacks attention from the task at hand
(e.g., the conversation), which can make it even more difficult to keep up with conversa-
tions and contribute.

So, as you can see, safety behaviors may not in fact help to reduce our anxiety in the longer
term. If your anxiety remains high after repeatedly confronting a social situation, chances are you
are using safety behaviors that are preventing you from directly testing your fears.

250
 HANDOUT 6

Behavioral Experiments
Just like a scientist using an experiment to test a prediction, behavioral experiments are designed
to test our negative images or beliefs about social situations. Behavioral experiments provide a
structured way of systematically and directly testing our fears once and for all.
There are a number of steps to conducting a behavioral experiment that enable us to learn as
much as possible from social experiences. Use the Behavioral Experiment Record (Worksheet 7) to
help you with the process of planning your experiment and collecting the results. An example is
provided on the next page.

Step 1: Negative Image: Identify a social situation that triggers anxiety for you and bring to mind an
image of what you think will happen in this situation. Write a description (in words or pictures) of
this image. What are you seeing happen? What are other people doing? How are they responding
to you? How will they respond to you in the future as a consequence? What are you doing? How
does the image start and end?

Step 2: SUDS: Rate the intensity of your anxiety about this situation (0 = no anxiety, 10 = maxi-
mum anxiety).

Step 3: Experiment: Plan your experiment. What could you do to find out how accurate this image
is? How could you create a situation that would enable you to test the accuracy of this image?

Step 4: Evidence to Observe: What evidence would you need to look for to confirm or disconfirm
the accuracy of your image? This evidence must be unambiguous (i.e., clear, observable, objec-
tive evidence). Would the evidence hold up in a court of law, or would the judge “throw it out of
court” because it was subjective/speculative?

Step 5: Do the Experiment.

Step 6: Results: Note the results. Specifically, what evidence (for and against your negative image)
did you observe?

Step 7: Conclusion: Develop some conclusions. What do the results tell you about your initial nega-
tive image?

Step 8: Update Imagery. Close your eyes and spend a few minutes now re-creating the image in your
mind, but this time incorporating what you learned from your experiment. How is your experi-
ence of this image different from your initial negative image? How does this new image make you
feel?
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

251
 Behavioral Experiments  (page 2 of 2)
BEHAVIORAL EXPERIMENT RECORD—EXAMPLE
Negative Image SUDS Experiment Evidence to Observe Results Conclusion
Describe your prediction. ( /10) Specifically, what could you Specifically, what do you What happened? What clear What conclusion follows from
Specifically, what do you How anxious do to test this image? need to look for to confirm or evidence did you collect? your results?
envision happening? do you feel? Safety behaviors to drop? disconfirm your image? Stick to unambiguous facts.
Where to focus attention?

I walk into the 9/10 Go into the lunchroom when Can I finish a sentence I made one comment and My image wasn’t accurate
lunchroom and my two colleagues are there. without stumbling? Do my they agreed. I couldn’t see this time.
colleagues ask me a colleagues listen? Do they any sign of confusion. I felt
question that I can’t Instead of not speaking and stop and look confused or anxious but was able to finish I need to keep testing it.
answer. I hesitate, looking down pretending does the conversation just my sentence. There was no
stumble over my words, I am reading, look up and continue? evidence that they didn’t My negative image was
and feel an adrenaline make a contribution to their understand my point or that telling me that my work
rush. I can’t finish my conversation. they were being critical. colleagues were going to act
sentence, my colleagues like bullies, but that wasn’t
look very confused, the case.

252
and I get up and leave
abruptly.
Close eyes and update image based on results and conclusions.
 HANDOUT 7

Behavioral Experiment Menu

Many behavioral experiments are designed to test the likelihood/probability of our fears occur-
ring, and by now you might be recognizing that your fears are much less likely to come true than
you initially thought. But how about the cost/consequences, should they come true?
We are now going to test, once and for all, the true cost of drawing attention to ourselves.
How much does it really need to matter?
The activities from the list below can be completed as behavioral experiments. Select a task
that you find anxiety provoking and complete the first four steps of a Behavioral Experiment Record
(Worksheet 7). Complete the rest of the record after doing the experiments.

 1. Devise three questions you could ask people about their anxiety in social situations. Then
approach shoppers and ask them to participate in a brief survey about social anxiety.
 2. Look upward and point to the sky for 5 minutes.
 3. Pretend to be a street performer and sing a song on a busy street corner.
 4. Walk around with a sign on your back proclaiming your support for a sports team.
 5. Sit down in a busy café or fast-food outlet and sing happy birthday to yourself . . . then repeat.
 6. Walk around with a party hat and a whistle.
 7. Skip down the street.
 8. Yell “hey” at people and wave.
 9. Dance down the street with the most humorous moves you can think of.
10. Take a piece of fruit or other item “for a walk” on a piece of string.
11. Walk down the street with your sweater or shirt on back to front and inside out.
12. Walk down the street with toilet paper hanging out of the back of your pants.
13. Approach strangers and give them a compliment
14. Approach strangers and ask them for the time, preferably while wearing a watch.
15. Go to a shop and buy something, then immediately ask to return it.
16. Ask a salesperson in a shop for help and deliberately look nervous.
17. Deliberately spill a drink while by yourself in a restaurant.
18. Go to a bookshop and ask an employee to help you find a book about social anxiety.
19. Go to a small clothing boutique and try on some expensive clothes that you have no intention
of buying.
20. Go into a drug store or supermarket and ask a clerk for a packet of colored condoms.
21. At the supermarket ask an employee where an item is when you’re right in front of it.
22. Deliberately drop an item while waiting in line at the supermarket.
23. Without giving a reason, ask people in front of you in a line if you can go ahead of them.
24. Strike up a conversation with people at the checkout and tell them something personal about
yourself.
25. Do something in public and simulate the anxiety symptoms you are concerned about (e.g.,
shaking, blushing, sweating, trembling, stumbling over words).

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

253
 HANDOUT 8

Behavioral Experiment Hierarchies

A behavioral experiment hierarchy is a tool for planning behavioral experiments in increasing
order of difficulty. Experiments that generate mild anxiety (say, around 3–4 out of 10) will be at
the bottom of the hierarchy, those that generate moderate anxiety (5–7 out of 10) will be in the
middle, and those that generate high anxiety (8–10 out of 10) will be at the top. The basic process
is to:

1. Identify an area for change. What would you like to be different? Or in what area of your life
are you having difficulties that you would most like to change?
2. Identify your negative image of what you predict will happen in this situation or area of your
life. What are you worried may happen? What image do you have of this situation?
3. Design as many experiments as possible that will help you test this predicted image.
4. Place these experiments in order of difficulty using the Behavioral Experiment Hierarchy (Work-
sheet 9).

HOW TO COME UP WITH DIFFERENT STEPS ON YOUR HIERARCHY

Try and think about what makes social situations more or less difficult for you. Ask yourself the
following questions:

• What am I doing?
• Where am I doing it? How familiar/unfamiliar is the place?
• When am I doing it?
• Who is there? How many people are there? How familiar/unfamiliar are the people?

As you consider these questions, you may be able to manipulate these variables to make a task
more or less challenging. For instance, I might feel more anxious if there are more people around.
So walking down the street at quieter times of the day might be ranked around the bottom of my
hierarchy and walking down the street at busier times of day might be closer to the top.
Write down what variables make you feel more or less anxious (e.g., number of people, gender
of other person, formal or informal situations):

Now use these variables to design your behavioral experiment hierarchy

(see Worksheet 9). Some examples to get you thinking are on the following pages.
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

254
 Behavioral Experiment Hierarchies  (page 2 of 5)
BEHAVIORAL EXPERIMENT HIERARCHY—EXAMPLE 1
Area for change:  Increase my social network

Image(s) in these situations (describe in words or pictures):

I have nothing to say. I am stumbling over my words or not saying anything. People are criticizing
me for being boring or they are laughing at me. They don’t want to speak to me any further.

SUDS
Goal:  Join a sports team (  /10)
Go to a social function with teammates. 10

Sign up to join the team. Attend training and speak to a couple of my teammates. 9

Attend one training session, just to watch. Introduce myself to the coach. 8

Phone the local soccer club and find out information about the team. Ask at least three 7
questions.

Initiate a conversation with someone before a class. Ask two questions and say one thing 6
about myself. Speak to the same person briefly after the class.

Sit next to the person again in the next class and ask her a question. 5

Say one thing to the person I sit next to in class. 4

Initiate a conversation with my neighbor (1–2 minutes). 3

(continued)

255
 Behavioral Experiment Hierarchies  (page 3 of 5)
BEHAVIORAL EXPERIMENT HIERARCHY—EXAMPLE 2
Area for change:  Be more assertive

Image(s) in these situations (describe in words or pictures):

Others are getting hostile toward me for saying no or expressing my own opinion. They are being
critical, dismissive, and rude. They turn away from me, not wanting anything to do with me. I
can’t handle the feeling of others not liking me.

SUDS
Goal:  Express my own opinion/be able to disagree (  /10)
Ask my boss for a raise. 10

Tell my colleague that I cannot help her with her project until next week. 9

Complain to a waiter about the food at a restaurant. 8/9

When someone makes a suggestion (e.g., restaurant/activity), provide an alternative 8

suggestion.

Suggest a particular restaurant for dinner with friends/family. 7

Buy something at a large chain store, then take it back and ask for a refund right away. 6

Catch the bus and pay the driver with a $50 bill. 5

Try something on in a large chain clothing store and don’t buy it. 4

Walk past a salesperson at the store and say “No, thanks” immediately without stopping. 3

(continued)

256
 Behavioral Experiment Hierarchies  (page 4 of 5)
BEHAVIORAL EXPERIMENT HIERARCHY—EXAMPLE 3
Area for change:  Feel more comfortable being the center of attention

Image(s) in these situations (describe in words or pictures):

I am blushing, stumbling over my words, and my mind is blank. I don’t make any sense. People
can see how anxious I am. They are smirking and whispering among themselves about me.

SUDS
Goal:  Make a speech at my sister’s wedding (  /10)
Give a presentation at the main work meeting with all colleagues. 10

Make a brief presentation at a small work meeting. 9

Practice my speech in front of my partner and sister. 8

Make at least one contribution to a work meeting. 8

Meet with my boss alone to make a suggestion for change. 7

Intentionally be the last one to enter the room for a meeting. 6

Wear a brightly colored shirt to work. 5

Walk down the street without sunglasses on. 4

Speak on the phone within earshot of a colleague. 3

(continued)

257
 Behavioral Experiment Hierarchies  (page 5 of 5)
BEHAVIORAL EXPERIMENT HIERARCHY—EXAMPLE 4
Area for change:  Initiate conversations more often

Image(s) in these situations (describe in words or pictures):

I don’t know what to say. I feel awkward. I am silent. I blurt out stupid comments that don’t
make sense to break the silence. The other person is looking at me with a weird expression on his
or her face.

SUDS
Goal:  Initiate a conversation with someone I’m very physically attracted to (  /10)
Try to maintain a longer (5–10 min) conversation with a friend at college who I am 10
moderately physically attracted to.

Initiate a short conversation with a friend at college who I am moderately physically 9

attracted to.

Initiate a short conversation with a friend at college about a controversial topic (e.g., 8
politics, religion).

Initiate a short conversation with a friend about a sports team he follows, and then say 8
that I root for a different team and why I think they are better.

Say hi to someone who is sitting next to me on the bus, then ask how her day is going. 7

Initiate a short conversation with a friend at college. Disclose one thing about myself (e.g., 6
an opinion on something).

Speak to my housemate over dinner. Ask at least three questions. 5

Tell a checkout clerk one thing about my day. 4

Ask a checkout clerk how his day is going. 3

258
 HANDOUT 9

Coping (Metaphorical) Imagery

Metaphors are symbols/objects that represent our experiences or feelings (as opposed to being real or lit-
eral). We often talk and think in metaphors without realizing it (“being put through the wringer” “like a
caged animal,” “deer in the headlights,” “my back to the wall”).
Putting our feelings into words can be hard, and metaphors seem to be a really good way of capturing
how we are feeling emotionally. Also, metaphorical images seem to connect to our feelings more strongly
than words.
Developing a metaphorical (or coping) image that represents your anxiety can help you to see your
anxiety from a different perspective, which can help you persevere through difficult experiences and
develop confidence in your ability to pursue your goals.
Some examples of coping images include:

Anxious Image Coping Image

Anxiety as a giant ocean wave I am drowning in Surfing the wave in to shore
Anxiety is like hiding in a dark cave I am stepping out of the cave into the light of a
beautiful sunny garden
My anxiety is like being trapped under a cage A loved one lifting the cage up and freeing me
My anxiety feels like a big rock weighing down on Pushing the rock off my chest, standing up, and
my chest taking a breath

Developing an image that represents your anxiety can give you an opportunity to allow a coping
image to arise that symbolizes or represents the feeling of coping. It can take time and it may feel strange,
that’s OK.
Developing a coping image involves doing the following . . .
Let an image arise in your mind that represents your anxiety. Take some time to pay attention to
what it is like (e.g., size, color, lighting, how it looks from different angles, texture, weight, smells, sounds,
tastes). Consider what this image means about you or your anxiety. What meaning is the image trying to
convey?
Consider what would need to be different in the anxious image for you to feel better or to resolve the
problem that is going on in the image. What needs to change in the image? It may involve introducing some
new action, or new person, or new object, or seeing the image from a different vantage point that allows
other things to enter it. Think about what is needed to change the image for the better.
Now that you know what needs to change, try to see these changes taking place now. Find ways of
making these changes happen in the image. It may take a number of tries, but keep persisting until the
problem in the image has a satisfactory resolution.
Notice how the new image (which we will call your coping image) makes you feel emotionally.
What sensations do you notice in your body?

Try to bring this new coping image to mind when you are confronting anxiety-provoking
situations. Notice the impact it has on how you feel and your ability to persevere as you con-
front your anxiety and pursue your goals.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

259
 H A N D O U T 10

Self-Image: How I Really Appear to Others

Research has shown that socially anxious people underestimate their social performance relative to
others. This is because people who are socially anxious base their judgments on how they are feel-
ing, rather than how they are actually performing. This is called “emotional reasoning,” whereby
the person has decided that “because I feel anxious I must look anxious.”
If the image we have of ourselves is very negative, this will increase our percep-
tion of social threat. For instance, if I feel warmth in my cheeks and notice that I am shaking
and sweating, I might imagine “in my mind’s eye” that my face is as bright as a beet, I am shaking
like a leaf, and sweating profusely. The image I have is that these symptoms are highly obvious to
everyone around me, which may lead me to expect negative evaluation from others.
But what if our symptoms aren’t anywhere near as obvious to others as we think
they are? What if we find that in fact many of the symptoms you thought were obvious are actu-
ally very mild (or unnoticeable) from other people’s perspective (the observer perspective)? What
impact would that have on your expectations of negative evaluation?
You can obtain feedback in a number of ways. If you are getting feedback from other people,
it is important to choose someone you can trust who will give you honest and balanced feedback
(i.e., not overly positive or negative). It will also be helpful if you ask for feedback that directly
addresses your specific concerns/fears (e.g., “do I sweat profusely when I socialize?”). You should
therefore identify in as clear and detailed a manner as possible the features of your performance you
are concerned about beforehand and have a trusted person observe you socially and give feedback
on these areas of concern.
As a way of illustrating the power of feedback, and how self-perceptions can sometimes be
inaccurate, we can also set up an experiment where you watch and evaluate a video of yourself
giving an impromptu speech, which is something that makes most people anxious. We need you
to be anxious, so we can then compare what you see on the video to your initial judgments of how
obvious you imagine your anxiety symptoms are to others. It is therefore important that you try
and make these judgments as objective as possible. It may be helpful to watch the video a number
of times first to reduce that initial self-consciousness or “yuk” reaction. You may also want to try
and watch it as if it is someone else on the video. Would you be making the same judgments if it
were someone else (e.g., someone you cared for or respected) doing exactly the same thing? The
idea is to be fair and balanced about your self-evaluations.
It is important to also have reasonable expectations. Perhaps you have avoided giving speeches
for many years. Either way, giving an impromptu speech is likely to be challenging for most peo-
ple. Remember, the aim is not to evaluate your public speaking ability (which is a skill that can be
developed), but to see how you really look when you are anxious, and whether your anxiety is as
obvious as you have always imagined.
If you do notice something that you would prefer to change, try to think about it as a learning
experience. At least you know about it now and you can work on that in the future. Our goal is to
have a realistic image of ourselves, not an unrealistically positive or negative one.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

260
 H A N D O U T 11

Self-, Environment-, and Task-Focused Attention

Most people with social anxiety notice that most of their attention is self-focused. They might be focus-
ing on their physical sensations of anxiety, negative thoughts/images, their use of safety behaviors, and/or
judgments about what they are saying or doing.
At the same time they might also scrutinize the environment for social threats. For example, you
might be looking around for people who are laughing at you or could potentially be criticizing you.
We all have a limited attention span—we simply cannot take in all the information around us, so we
must select what we are going to focus on. Our attention is like the keyboard on a computer—the com-
puter can only “attend to” what we are typing. The computer can therefore only encode and remember
what is typed into it. Similarly, our brains can only encode and remember what we attend to. Now, if most
of our attention is focused on ourselves and on potential threats in the environment, then that’s what we
will remember most from our social experiences (i.e., how awful it felt and any sign of “threat” from the
environment). We will miss positive feedback from others—it won’t be noticed or remembered.
The problem is that if we are too self-focused and environment focused it doesn’t leave much attention
left over to focus on the task at hand. The pie chart below illustrates the proportion of our attention that is
usually self-focused, environment focused, and task focused when feeling socially anxious.

Task-Focused Attention
(e.g., topic of the conversation, 10%
what I am actually doing) Self-Focused Attention
70% (physical symptoms, negative
20% thoughts/images, behavior, etc.)
Environment-Focused Attention
(looking for signs of “social threat,”
e.g., people laughing, looking)

Self- and environment-focused attention maintains social anxiety by . . .

1. Distracting us from the task at hand: When we are self- and environment focused we are less able to pay
attention to what is being said in conversations and less able to come up with our own contributions.
This can have a negative impact on the quality of our conversations.
2. Increasing the perception of threat: If we are always looking for threat in the environment, this can increase
our sense that something bad will happen.
3. Missing nonthreatening feedback: The little bit of attention that is left over to focus on the task at hand may
not capture any positive feedback we get from the other person. Instead, our impression is skewed by
what we are noticing about ourselves (thoughts, feelings, behavior) and the environment (e.g., what
other people in the room are doing). Our memory of the social situation will therefore also be nega-
tively skewed.
4. Making us more likely to misinterpret ambiguous feedback: If we are looking for social threat, we may be more
likely to misinterpret ambiguous feedback from others. For example, if I start a conversation looking
for signs that I am boring, then I am more likely to interpret someone yawning (ambiguous behavior)
as proof that the person is bored. I’m unlikely to think that perhaps she is just tired.

The goal then is to become aware of when we are being too self- and environment focused
and, as best we can, redirect our attention back to the task at hand.

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

261
 H A N D O U T 12

Attention Retraining and Focusing

The pie chart below illustrates the proportion of our attention that we would ideally place on the
task at hand (i.e., at least 80%) so that we can immerse ourselves in helpful aspects of the social
experience rather than focus on perceived threat.

Self-Focused Attention
(physical symptoms, negative
thoughts/images, behavior, etc.)
10% Task-Focused Attention
80% (e.g., topic of the conversation,
Environment-Focused Attention 10% what I am actually doing)
(looking for signs of “social threat,”
e.g., people laughing, looking)

ATTENTION RETRAINING

Before we can direct our attention to the task at hand we need to increase our awareness of where
our attention is in the first place. When we are feeling anxious, research has shown that we will
search for threat. If you think about it, if there is a real threat it is a good thing that we become very
focused on the threat, so that we can do something to protect ourselves. However, when social
anxiety is excessive we become too threat focused (i.e., self- and environment focused), which
affects our ability to focus on the task at hand.
Attention retraining involves paying attention to the present moment by “coming to our
senses.” By this we mean deliberately choosing to notice what we can see, hear, smell, taste, and
touch right now. We can train our attention at any time of day, regardless of what we are doing.
For example, we can attend to:
• The breath • Sensations of water on body during a shower
• Sensations while walking • Feel of the water and plates while washing dishes
• Taste/smells of food/drink • Sensations of the chair on your body as you sit
• Sensations of water on body while • Sounds while walking in the park
swimming

When you try to maintain your attention on the present moment you will notice that your
mind will wander—you might start to think about the future, the past, or something else that
captures your attention. This is OK. This is what minds do. The task is to notice when your mind
wanders and gently escort it back to the task at hand (i.e., whatever it is that you are choosing to
focus on).

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

262
 Attention Retraining and Focusing  (page 2 of 2)
Practice attention retraining exercises multiple times throughout the day. Think of it as
strengthening a muscle. If you were an athlete, you would train your muscles every day so that
they were ready when you really needed them during competition. Attention retraining is like
strengthening your ability to (1) be aware of what you are focusing on, (2) notice when your
attention wanders, and (3) shift it back to the task at hand. Once you have practiced these skills on
nonsocial tasks you will be better equipped to use them within social situations.
One of the advantages of being more present focused is that it is virtually impossible to be
present focused and be worrying at the same time.

ATTENTION FOCUSING

Attention focusing involves taking all the skills you have learned from attention retraining and
using them to direct your attention more constructively in social situations. The aim is to try to
maximize task-focused attention, that is, directed attention toward the behavior required in any
specific situation. In social interactions this will mainly involve your attention being focused on
really listening to what other people are saying when they are speaking, and then switching focus
onto your own message when it is your turn in conversation. This is not easy, and like other skills,
it requires regular practice.

263
 H A N D O U T 13

Past Imagery Rescripting

So far we have been working on negative images of the present or future (i.e., pictures of ourselves
or others’ reactions in a current or upcoming social situation). We are now going to move on to
the final bubble in the model—core beliefs (i.e., how we generally see ourselves, others, and the
world), which tend to be inf luenced by negative social images from the past (or memories).
It is common for people with social anxiety to report memories of early negative social expe-
riences that impact what they expect in social situations now. When we have had some negative
social experiences in our past we can get “stuck” in our memories, so that they can recur as echoes
of the past, haunting us and shaping the negative social images we have in the here and now.
Memories we may have of other events tend to feel like they are firmly in the past, and prob-
ably rarely rear their heads. In social anxiety, negative social memories we may intellectually know
are in the past may still feel very relevant to today emotionally.
Now, we can’t change the fact that these negative experiences happened. It is awful that you
had to go through them in the first place. What is also awful is that these experiences keep affect-
ing your life, coloring and tainting what you expect in social situations now.
Using a technique we call imagery rescripting, we have the opportunity to go back in our
imagination to experience the past event from a new perspective. We can do things we couldn’t do
at the time but that in an ideal world with no limitations we would have liked to have done. While
initially this may seem a bit like “make-believe” or just a “fantasy,” doing this seems to have the
effect of reprocessing the event in a way that can be helpful for changing its meaning and putting the
memory back in its place—as a bad thing that happened in the past with little relevance to the here and now. As
we work on these past images, we can learn that these memories don’t ref lect on ourselves, others,
and the world today, as we previously thought, that they are outdated (specific to a past time, place,
or person), and that they don’t need to dictate what we expect and how we live our lives now.
Think of these memories as being like a bad photo we have been carrying around in our front
pocket and looking at all the time. We can’t rip up the photo, but processing these memories can
help us to put them in a photo album on the shelf as mementos from the past, rather than carrying
them with us now. This can change the way we feel about these past events and their impact on
how we see ourselves, others, and the world now.

IDENTIFYING PAST IMAGERY

The first step to working on past imagery is to try and recall an early social experience that you
believe may have shaped some of the images you now have when feeling socially anxious. For
some people it may be instances of bullying or of being criticized, embarrassed, or humiliated.
If no clear examples are coming to mind, that’s OK. Think back to when in your life you first
remember having the same sorts of thoughts, feelings, and sensory experiences that are present
when you feel socially anxious.
(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

264
 Past Imagery Rescripting  (page 2 of 2)
If you are aware of multiple images, then choose one that is meaningful to you. You might
decide to choose the most distressing one first, or you might choose a less distressing one to start
with. The choice is yours.

PERSPECTIVE OF THE “OLDER, COMPASSIONATE YOU”

Once you have an image from the past, think about what you know about the situation now that
you may not have known at the time it happened. The older, more compassionate “adult you” may
know things that you didn’t know then. These things you’ve learned since may have been useful
for you to have been aware of at the time of the upsetting event. Although the event may still be
emotionally painful to think about, you may be able to understand the situation differently now.
For example, if I was bullied at school I might have initially assumed it was because I was
unlikable and worthless. However, as a compassionate adult I can see that the bullying had less to
do with me and more to do with the bully’s insecurity. I simply did not deserve the bullying, no
child deserves it. Any child who bullies another child is behaving poorly, and it does not ref lect
on the bullied child’s character, likability, or worth. In fact, I may be able to see now that I had
qualities that were very likable at the time of the bullying.

RESCRIPTING THE PAST IMAGE

Now that we have an image and a new perspective about the image, we can start to rescript or
update it. There are three stages to this process, and you can keep track of your experiences in each
stage by using Worksheet 16, Past Imagery Rescripting. The three phases are:

Phase 1: Imagining the event at the age you were when it occurred as if it were occurring right
now.
Phase 2: Rewinding and imagining the event at your current age, watching the younger you going
through the experience and intervening in any way you wish in order to protect and care for your-
self. You can do anything you like, there are no limits!
Phase 3: Rewind for the last time and imagine the event again at the age you were when it
occurred, but this time experiencing the older you intervening and also asking the older you for
anything else you need to make you feel safe, secure, calm, and content.

CONCLUSION
The way we have made sense of past negative events has shaped the negative core beliefs we hold
today about ourselves, other people, and the world generally. Using imagery rescripting to create a
“fantasy” of how we would have liked things to be can help us understand these negative events in
a new, more helpful way, changing their meaning for the better. This can then help to undermine
our negative core beliefs, paving the way for letting them go and developing new balanced core
beliefs.

265
 H A N D O U T 14

Constructing New Core Beliefs

The imagery work done so far has been about uncovering negative images that fuel your social
anxiety and finding ways to manipulate or modify these images. Chipping away at, modifying,
and updating these negative images is very important for changing the way you feel about social
situations.
However, it is equally important that you build up more helpful, constructive, positive, and
balanced images. We have already seen that images are powerfully linked to our emotional reac-
tions. Just as your negative images are associated with negative emotions and actions, more positive
images can promote more positive emotions and actions.
Developing positive images of how we would ideally like things to be in our life can give us
clues for what new core beliefs we might want to start developing. Remember, core beliefs are the
essence of how we generally see ourselves, other people, and the world around us, and these global
views that we hold play a central role in our social anxiety. Hopefully all the behavioral experi-
ments you’ve done have shown you that your old negative core beliefs might be a little outdated.
So, it might be time for a core belief update, and building positive imagery can be a way to start
this process. Below we guide you through the sections of Worksheet 17, Constructing New Core
Beliefs.

Sections 1–3: Generating More Positive Imagery

1. You can start the process of generating more positive imagery by bringing to mind a situ-
ation in which you have typically experienced strong social anxiety.
2. Without changing anything about the situation itself, consider how you would like to be
within the situation.
What would you be doing? Specifically, what would that look like? What kind of expression
would you have on your face? How would you be holding your body? How would you be talking
to yourself? Take a few moments to visualize being this way . . .
As you are visualizing being the way you want it to be, how does that feel? How does it feel
in your body? Where do you feel it?
3. When you are operating this way, how do you see yourself? Others? The world?
For now you may not fully believe any of these new core beliefs and positive images, but
that’s OK. We will find ways to strengthen your belief in these positive images over time via your
actions.

Section 4: Road-Testing Your New Core Beliefs in Different Life Domains

Our core beliefs can affect our images, behavior, and feelings in many important areas of our lives.
Now that you have identified some new, more positive core beliefs, consider how you might “act

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

266
 Constructing New Core Beliefs  (page 2 of 3)
as if ” these new core beliefs were true in your life more generally. If you were “acting as if ” your
new more positive core beliefs were true, what would you be doing (or not doing) in these areas
of your life?
• Current relationships (friends, partners)
• Your family (e.g., parents, siblings, children)
• Work, school, career
• Daily responsibilities
• Leisure, hobbies
• Health, well-being, self-care
• Other ways you would be spending your time (or not spending your time)

Your new core beliefs might be associated with doing more of something (e.g., making more
phone calls to friends or family) or less of something (relying less on alcohol in social situations).
Spend some time imagining yourself operating consistently with your new core beliefs in each of
these areas of your life. Write these changes down because they will be used as the basis for your
Action Plans later.

Section 5: “Stormy Weather”

Sometimes social situations do not go as planned. In fact, we all encounter some very challenging
social situations from time to time (e.g., we unintentionally offend someone, someone does not
like us for some reason, we make a mistake). Consider what you can do to maintain the new way
you would like things to be in difficult times like these. If you were acting in accordance with your
new core beliefs, how would you manage these situations? What would you need to do? What
would you need to say to yourself? Spend some time imagining yourself responding in these ways
to a difficult social situation. See yourself adopting the body posture and facial expression that
would go with this. How do you feel within yourself when you react in this manner?

Section 6: Identifying “Evidence For”

Bring to mind a past occasion when you did something that exemplifies your new core beliefs and
spend a few moments visualizing this occasion.

Section 7: Identifying an “Icon”

When you imagine operating in this way, what icons come to mind? Are there particular songs,
images, movies, characters, fairy tales, stories, people, animals, or scenes from nature that represent
this way of operating for you? Is there something that really captures the spirit of your new, more
positive core beliefs? If nothing springs to mind, give yourself time for an image to emerge.
Consider for a moment how this icon could be used to help you stay in this new mode of
being, which is consistent with your new, more positive, more helpful core beliefs. How could you
strengthen the icon and be reminded of it when you need it?
One way you could use your new core belief icon is to prepare for anxiety-provoking situ-
ations. Before you approach a social situation, elicit an image of the situation in your mind and
(continued)

267
 Constructing New Core Beliefs  (page 3 of 3)
bring your icon to mind and see yourself operating from your new core belief. Notice what you
are doing and, as best you can, adopt the posture and facial expression that goes with that image.
Notice how this feels emotionally. Notice how you feel in your body and where you feel it.
Remember your icon and your new core beliefs about yourself, other people, and the world before
you enter the situation.
Another time to use your icon might be during or after a challenging anxiety-provoking
social situation. Bring your icon to mind and remember your new core beliefs to help you handle
the situation and your feelings.

Action Planning
The best way to build conviction in your new core beliefs is to live your life as if they are true.
Some call it “faking it till you make it.” Changing our behavior is the most powerful way to
change our beliefs—behavioral experiments are a prime example of that. So if you start operating,
acting, and behaving in a way that is consistent with your system of new balanced core beliefs, your
confidence in the new beliefs will catch up.
The positive images you uncovered for different domains of your life in Section 4 of Work-
sheet 17 can be used to give you some ideas about how to live your life as if you believed your new
core beliefs. You can now take these ideas and use them in Worksheet 18, the New Core Belief Action
Plan, to help you plan a “road map” of specific actions that will lead you to build belief in your new
positive core beliefs over time. In many ways it is like continuing to do behavioral experiments in
lots of areas of your life, but by this time the experiments may not need to be planned as formally
as earlier in treatment, and this time they might be more about strengthening positive images of
yourself than discrediting negative ones.

268
 H A N D O U T 15

Skills Toolbox
Congratulations on making it to the end of treatment. Change is very challenging, but hopefully you have
found the hard work well worth it. We have covered a range of tools you can use, which are summarized
below.
Consider how helpful each of these tools has been for you and commit to applying them regularly. If
you continue to apply your new skills you will continue to improve.

Tools
Imagery monitoring
Starting to become more aware of your negative social images was the first step toward being able to
work with this imagery during treatment. You may have been very aware of your imagery at the start of
treatment, or you may have had to work hard to generate imagery that ref lected your anxious thoughts
or feelings. Research has shown that imagery has very powerful links to emotions, so we have focused
on working with imagery rather than working only with thoughts.
Imagery challenging
You learned that your initial negative social images may just be images rather than facts. You learned
how to start looking for contrary evidence that does not fit your images, and we started to consider
alternative, more helpful or realistic images.
Coping imagery
You learned how to develop coping imagery to help you see your anxiety from a different perspective.
We elicited an image that ref lects your anxiety and then manipulated it so that it was more benign or
positive, or demonstrated coping behavior. Bringing this coping image to mind can help you persevere
through difficult experiences and develop confidence in your ability to pursue your goals.
Behavioral experiments
You learned that avoiding images and situations that trigger anxiety stops you from directly testing your
negative images and therefore keeps your social anxiety going. Behavioral experiments encourage us
to be curious about our fears rather than avoid them. Behavioral experiments were used to directly test
your negative images. They involved:
• Being very specific about your predictions (using imagery)
• Planning how you could test the predicted negative image
• Carefully considering what evidence you needed to observe to support or disconfirm your
predicted image
• Doing the experiment
• Ref lecting on the results
• Drawing conclusions based on the results.
• Updating your image to better ref lect what you had learned from the experiment
Developing a behavioral experiment hierarchy helped ensure that your behavioral experiments were
working toward a valued goal.

(continued)

From Imagery-Enhanced CBT for Social Anxiety Disorder by Peter M. McEvoy, Lisa M. Saulsman, and Ronald M. Rapee.
Copyright © 2018 The Guilford Press. Permission to photocopy this material is granted to purchasers of this book for per-
sonal use or use with clients (see copyright page for details). Purchasers can download additional copies of this material (see
the box at the end of the table of contents).

269
 Skills Toolbox  (page 2 of 2)
Behavioral experiments typically show us that our negative images are less likely to come true than
we think, and that even when aspects of our negative images do occur we can cope. Shame-attacking
experiments in particular show us that even when we do something unusual socially, the consequences
are not as catastrophic as we expect. In fact, it can be hard to draw people’s attention, and when we do,
no costly consequence occurs.
Dropping safety behaviors
We use safety behaviors to prevent our fears from coming true, or so we think! You learned that safety
behaviors actually keep anxiety going because they are just more subtle forms of avoidance. They also
keep us self-focused, can create negative evaluation rather than prevent it, and ultimately stop us from
directly testing our fears. If things go well, we conclude that the safety behavior saved us . . . rather
than learning that our fears were just less likely to come true than we thought. You have learned the
importance of dropping your safety behaviors generally, and particularly during behavioral experiments.
Video feedback
You recorded yourself giving a speech, an exercise designed to reveal if your self-image was accurate
or not. You discovered that even when we are highly anxious our symptoms are not as obvious as we
think. You learned that when we are anxious we don’t need to be so focused on other people noticing
our anxiety.
Attention retraining and focusing
You learned that when your attention is focused on yourself or on looking for threats in the
environment you cannot be very focused on the task at hand. Self- and environment-focused attention
just distracts us from the task (e.g., conversation), which is then likely to affect our memory of the
social situation in three ways. First, we are only likely to remember negative aspects of the situation
(e.g., how anxious I was feeling) because that’s what we were most focused on. Second, we are likely
to miss positive aspects of the situation that would challenge our fears (e.g., positive feedback from
others). Third, it is going to be much more difficult to keep up with the task at hand (e.g., topic of
the conversation) because we are so distracted with ourselves. You learned how to be more aware
and deliberate with your attention generally (attention retraining), and particularly how to shift your
attention back to the social task at hand (attention focusing).
Past imagery rescripting
You learned that images from past negative social experiences can contribute to the images and anxiety
you are currently experiencing. You learned how to take a more compassionate approach to your early
experiences by revisiting those experiences (1) as they originally occurred, (2) with your older and
more compassionate self intervening to help and support your younger self, and (3) as your younger self
receiving support from your older self. The aim of rescripting past images is to put them in context and
to reexamine the meanings we took from the initial events, when we didn’t have the same perspective
that we do now. Doing this can help chip away at our negative core beliefs, which often arise from these
past negative social experiences.
Positive imagery and action planning
You learned how to generate more positive imagery of how you would ideally like to be socially, which
ref lects more positive core beliefs about yourself that can be applied across various domains of life (e.g.,
relationships, work, family). You also learned how to turn this positive imagery into action plans so that
you could continue to act in accordance with these new core beliefs to build strength in these beliefs
over time. We also identified an “icon” that can represent and trigger your new, more positive way of
operating within the world.

270
 References

Acarturk, C., Cuijpers, P., van Straten, A., & de Graaf, face-to-face cognitive behavior therapy for psychiatric
R. (2009). Psychological treatment of social anxiety and somatic disorders: A systematic review and meta-­
disorder: A meta-­ a nalysis. Psychological Medicine, 39, analysis. World Psychiatry, 13, 288–295.
241–254. Andrews, G., Cuijpers, P., Craske, M. G., McEvoy, P., &
Aderka, I. M. (2009). Factors affecting treatment efficacy Titov, N. (2010). Computer therapy for the anxiety and
in social phobia: The use of video feedback and indi- depressive disorders is effective, acceptable and practical
vidual vs. group formats. Journal of Anxiety Disorders, 23, health care: A meta-­a nalysis. PLOS ONE, 5, e13196.
12–17. Arnberg, F. K., Linton, S. J., Hultcrantz, M., Heintz, E.,
Alden, L. E., & Taylor, C. T. (2004). Interpersonal pro- & Jonsson, U. (2014). Internet-­delivered psychological
cesses in social phobia. Clinical Psychology Review, 24, treatments for mood and anxiety disorders: A systematic
857–882. review of their efficacy, safety, and cost-­effectiveness.
American Psychiatric Association. (1980). Diagnostic and PLOS ONE, 9, e98118.
statistical manual of mental disorders (3rd ed.). Washing- Arntz, A. (2011). Imagery rescripting for personality dis-
ton, DC: Author. orders. Cognitive and Behavioral Practice, 19, 466–481.
American Psychiatric Association. (1987). Diagnostic and Arntz, A. (2012). Imagery rescripting as a therapeutic
statistical manual of mental disorders (3rd ed., rev.). Wash- technique: Review of clinical trials, basic studies, and
ington, DC: Author. research agenda. Journal of Experimental Psychopathology,
American Psychiatric Association. (1994). Diagnostic and 3, 189–208.
statistical manual of mental disorders (4th ed.). Washing- Arntz, A., Tiesema, M., & Kindt, M. (2007). Treatment
ton, DC: Author. of PTSD: A comparison of imaginal exposure with and
American Psychiatric Association. (2000). Diagnostic and without imagery rescripting. Journal of Behavior Therapy
statistical manual of mental disorders (4th ed., text rev.). and Experimental Psychiatry, 38, 345–370.
Washington, DC: Author. Arntz, A., & Weertman, A. (1999). Treatment of child-
American Psychiatric Association. (2013). Diagnostic and hood memories: Theory and practice. Behaviour Research
statistical manual of mental disorders (5th ed.). Arlington, and Therapy, 37, 715–740.
VA: Author. Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender
Amir, N., Najmi, S., & Morrison, A. S. (2012). Image differences in social anxiety disorder: A review. Clinical
generation in individuals with generalized social pho- Psychology Review, 56, 1–12.
bia. Cognitive Therapy and Research, 36, 537–547. Beck, A. T., & Dozois, D. J. (2011). Cognitive therapy:
Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., Current status and future directions. Annual Review of
& Hedman, E. (2014). Guided Internet-­ based vs. Medicine, 62, 397–409.

271
272 References

Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (1979). treatment of social phobia: Systematic review and
Cognitive therapy of depression. New York: Guilford Press. meta-­a nalysis. Neuropsychiatric Disease and Treatment, 8,
Beidel, D. C., Alfano, C. A., Kof ler, M. J., Rao, P. A., 203–215.
Scharfstein, L., & Sarver, N. W. (2014). The impact Carleton, R. N., Collimore, K. C., Asmundson, G. J.,
of social skills training for social anxiety disorder: A McCabe, R. E., Rowa, K., & Antony, M. M. (2009).
randomized controlled trial. Journal of Anxiety Disorders, Refining and validating the Social Interaction Anxiety
28, 908–918. Scale and the Social Phobia Scale. Depression and Anxi-
Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psy- ety, 26, E71–E81.
chopathology of childhood social phobia. Journal of the Carleton, R. N., Thibodeau, M. A., Weeks, J. W., Teale
American Academy of Child and Adolescent Psychiatry, 38, Sapach, M. J., McEvoy, P. M., Horswill, S. C., et al.
643–650. (2014). Comparing short forms of the Social Interac-
Bennett-­Levy, J., Butler, G., Fennell, M., Hackmann, A., tion Anxiety Scale and the Social Phobia Scale. Psycho-
Mueller, M., & Westbrook, D. (2004). Oxford guide to logical Assessment, 26, 1116–1126.
behavioural experiments in cognitive therapy. New York: Carroll, J. S. (1978). The effect of imagining an event on
Oxford University Press. expectations for the event: An interpretation in terms
Blanco, C., Heimberg, R. G., Schneier, F. R., Fresco, D. of the availability heuristic. Journal of Experimental Social
M., Chen, H., Turk, C. L., et al. (2010). A placebo-­ Psychology, 14, 88–96.
controlled trial of phenelzine, cognitive behavioral Carver, C. S., & Scheier, M. F. (1978). The self-­focusing
group therapy, and their combination for social anxiety effects of dispositional self-­consciousness, mirror pres-
disorder. Archives of General Psychiatry, 67, 286–295. ence, and audience presence. Journal of Personality and
Boden, M. T., John, O. P., Goldin, P. R., Werner, K., Social Psychology, 36, 324–332.
Heimberg, R. G., & Gross, J. J. (2012). The role of mal- Chiupka, C. A., Moscovitch, D. A., & Bielak, T. (2012).
adaptive beliefs in cognitive-­behavioral therapy: Evi- In vivo activation of anticipatory vs. post-event auto-
dence from social anxiety disorder. Behaviour Research biographical images and memories in social anxiety.
and Therapy, 50, 287–291. Journal of Social and Clinical Psychology, 31, 783–809.
Boettcher, J., Carlbring, P., Renneberg, B., & Berger, T. Clark, D. M. (2001). A cognitive perspective on social
(2013). Internet-­based interventions for social anxiety phobia. In W. R. Crozier & L. E. Alden (Eds.), Interna-
disorder: An overview. Verhaltenstherapie, 23, 160–168. tional handbook of social anxiety (pp. 405–430). Chiches-
Borkovec, T. D. (1994). The nature, functions, and origins ter, UK: Wiley.
of worry. In G. C. L. Davey & F. Tallis (Eds.), Worrying: Clark, D. M., Ehlers, A., Hackmann, A., McManus, F.,
Perspectives on theory, assessment, and treatment (pp. 5–33). Fennell, M., Grey, N., et al. (2006). Cognitive therapy
New York: Wiley. versus exposure and applied relaxation in social phobia:
Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoid- A randomized controlled trial. Journal of Consulting and
ance theory of worry and generalized anxiety disorder. Clinical Psychology, 74, 568–578.
In R. G. Heimberg, C. L. Turk, & D. S. Menin (Eds.), Clark, D. M., Ehlers, A., McManus, F., Hackmann, A.,
Generalized anxiety disorder: Advances in research and prac- Fennell, M., Campbell, H., et al. (2003). Cognitive
tice (pp. 77–108). New York: Guilford Press. therapy versus f luoxetine in generalized social phobia:
Brewin, C. R. (2006). Understanding cognitive behav- A randomized placebo-­controlled trial. Journal of Con-
iour therapy: A retrieval competition account. Behav- sulting and Clinical Psychology, 71, 1058–1067.
iour Research and Therapy, 44, 765–784. Clark, D. M., & Wells, A. (1995). A cognitive model of
Brown, T. A., & Barlow, D. H. (2014). Anxiety and Related social phobia. In R. G. Heimberg, M. R. Liebowitz, D.
Disorders Interview Schedule for DSM-5 (ADIS-5)—Adult A. Hope, & F. R. Schneier (Eds.), Social phobia: Diag-
Version. New York: Oxford University Press. nosis, assessment and treatment (pp. 69–93). New York:
Burstein, M., He, J.-P., Kattan, G., Albano, A. M., Ave- Guilford Press.
nevoli, S., & Merikangas, K. R. (2011). Social phobia Clark, G. I., & Egan, S. J. (2015). The Socratic Method
and subtypes in the National Comorbidity Survey—­ in cognitive behavioural therapy: A narrative review.
Adolescent Supplement: Prevalence, correlates, and Cognitive Therapy and Research, 39, 863–879.
comorbidity. Journal of the American Academy of Child and Clauss, J. A., & Blackford, J. U. (2012). Behavioral inhibi-
Adolescent Psychiatry, 50, 870–880. tion and risk for developing social anxiety disorder: A
Cain, S. (2012). Quiet: The power of introverts in a world that meta-­a nalytic study. Journal of the American Academy of
can’t stop talking. New York: Crown. Child and Adolescent Psychiatry, 51, 1066–1075.
Canton, J., Scott, K. M., & Glue, P. (2012). Optimal Coles, M. E., Turk, C. L., Heimberg, R. G., & Fresco, D.
 References 273

M. (2001). Effects of varying levels of anxiety within etiology and treatment (pp. 3–24). New York: Guilford
social situations: Relationship to memory perspective Press.
and attributions in social phobia. Behaviour Research and Foa, E. B., & Kozak, M. J. (1986). Emotional processing of
Therapy, 39, 651–665. fear: Exposure to corrective information. Psychological
Cox, B. J., Turnbull, D. L., Robinson, J. A., Grant, B. F., Bulletin, 99, 20–35.
& Stein, M. B. (2011). The effect of Avoidant Personal- Furmark, T. (2002). Social phobia: Overview of commu-
ity Disorder on the persistence of Generalized Social nity surveys. Acta Psychiatrica Scandinavica, 105, 84–93.
Anxiety Disorder in the general population: Results Furmark, T., Tillfors, M., Stattin, H., Ekselius, L., &
from a longitudinal, nationally representative mental Fredrikson, M. (2000). Social phobia subtypes in the
health survey. Depression and Anxiety, 28, 250–255. general population revealed by cluster analysis. Psycho-
Craske, M. G., Treanor, M., Conway, C., Zbozinek, T., logical Medicine, 30, 1335–1344.
& Vervliet, B. (2014). Maximizing exposure therapy: Fyer, A. J., Mannuzza, S., Chapman, T. F., Martin, L. Y.,
An inhibitory learning approach. Behaviour Research and & Klein, D. F. (1995). Specificity in familial aggrega-
Therapy, 58, 10–23. tion of phobic disorders. Archives of General Psychiatry,
Cuming, S., Rapee, R. M., Kemp, N., Abbott, M. J., 52, 564–573.
Peters, L., & Gaston, J. E. (2009). A self-­report mea- Gaston, J. E., Abbott, M. J., Rapee, R. M., & Neary, S. A.
sure of subtle avoidance and safety behaviors relevant to (2006). Do empirically supported treatments generalize
social anxiety: Development and psychometric proper- to private practice?: A benchmark study of a cognitive-­
ties. Journal of Anxiety Disorders, 23, 879–883. behavioural group treatment programme for social
Davidson, J. R., Hughes, D. L., George, L. K., & Blazer, phobia. British Journal of Clinical Psychology, 45, 33–48.
D. G. (1993). The epidemiology of social phobia: Find- Gilbert, P. (2001). Evolution and social anxiety: The role
ings from the Duke Epidemiological Catchment Area of attraction, social competition, and social hierarchies.
Study. Psychological Medicine, 23, 709–718. Psychiatric Clinics of North America, 24, 723–751.
Demyttenaere, K., Bruffaerts, R., Posada-­Villa, J., Gas- Gilbert, P. (2009). Introducing compassion-­focused ther-
quet, I., Kovess, V., Lepine, J. P., et al. (2004). Preva- apy. Advances in Psychiatric Treatment, 15, 199–208.
lence, severity, and unmet need for treatment of men- Glass, C. R., Merluzzi, T. V., Biever, J. L., & Larsen, K. H.
tal disorders in the World Health Organization World (1982). Cognitive assessment of social anxiety: Devel-
Mental Health Surveys. Journal of the American Medical opment and validation of a self-­ statement question-
Association, 291, 2581–2590. naire. Cognitive Therapy and Research, 6, 37–55.
DeWit, D. J., Ogborne, A., Offord, D. R., & MacDon- Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F.,
ald, K. (1999). Antecedents of the risk of recovery from Heimberg, R., & Gross, J. J. (2016). Group CBT versus
DSM-III-R social phobia. Psychological Medicine, 29, MBSR for social anxiety disorder: A randomized con-
569–582. trolled trial. Journal of Consulting and Clinical Psychology,
Edwards, D. (2007). Restructuring implicational mean- 84, 427–437.
ing through memory-­based imagery: Some historical Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou,
notes. Journal of Behavior Therapy and Experimental Psy- S. P., Goldstein, R. B., et al. (2005). The epidemiology
chiatry, 38, 306–316. of social anxiety disorder in the United States: Results
Fenigstein, A., Seheier, M. E., & Buss, A. H. (1975). from the National Epidemiologic Survey on Alcohol
Public and private self-­consciousness: Assessment and and Related Conditions. Journal of Clinical Psychiatry,
theory. Journal of Consulting and Clinical Psychology, 43, 66, 1351–1361.
522–527. Hackmann, A., Bennett-­Levy, J., & Holmes, E. A. (2011).
Fergus, T. A., Valentiner, D. P., McGrath, P. B., Gier-­ Oxford guide to imagery in cognitive therapy. Oxford, UK:
Lonsway, S. L., & Kim, H. S. (2012). Short forms of the Oxford University Press.
Social Interaction Anxiety Scale and the Social Phobia Hackmann, A., Clark, D. M., & McManus, F. (2000).
Scale. Journal of Personality Assessment, 94, 310–320. Recurrent images and early memories in social phobia.
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, Behaviour Research and Therapy, 38, 601–610.
R. L. (2016). Structured Clinical Interview for DSM-5 Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing
Disorders—­Clinician Version (SCID-5-CV). Arlington, yourself through others’ eyes: A study of spontaneously
VA: American Psychiatric Association. occurring images in social phobia. Behavioural and Cog-
Foa, E. B., Huppert, J. D., & Cahill, S. P. (2006). Emo- nitive Psychotherapy, 26, 3–12.
tional processing theory: An update. In B. O. Roth- Harvey, A. G., Clark, D. M., Ehlers, A., & Rapee, R. M.
baum (Ed.), Pathological anxiety: Emotional processing in (2000). Social anxiety and self-­impression: Cognitive
274 References

preparation enhances the beneficial effects of video of cognitive-­behavioral therapy for anxiety disorders
feedback following a stressful social task. Behaviour on quality of life: A meta-­a nalysis. Journal of Consulting
Research and Therapy, 38, 1183–1192. and Clinical Psychology, 82, 375–391.
Haug, T. T., Blomhoff, S., Hellstrøm, K., Holme, I., Holmes, E. A., Lang, T. J., & Shah, D. M. (2009). Devel-
Humble, M., Madsbu, H. P., et al. (2003). Exposure oping interpretation bias modification as a “cognitive
therapy and sertraline in social phobia: 1-year follow- vaccine” for depressed mood: Imagining positive events
­up of a randomised controlled trial. British Journal of makes you feel better than thinking about them ver-
Psychiatry, 182, 312–318. bally. Journal of Abnormal Psychology, 118, 76–88.
Heimberg, R. G., Brozovich, F. A., & Rapee, R. M. Holmes, E. A., & Mathews, A. (2005). Mental imagery
(2010). A cognitive-­behavioral model of social anxiety and emotion: A special relationship? Emotion, 5, 489–
disorder. In S. G. Hofmann & P. M. DiBartolo (Eds.), 497.
Social anxiety: Clinical, developmental, and social perspectives Holmes, E. A., & Mathews, A. (2010). Mental imagery
(2nd ed., pp. 395–422). New York: Academic Press. in emotion and emotional disorders. Clinical Psychology
Heimberg, R. G., Brozovich, F. A., & Rapee, R. M. Review, 30, 349–362.
(2014). A cognitive-­behavioral model of social anxiety Hook, J. N., & Valentiner, D. P. (2002). Are specific and
disorder. In S. G. Hofmann & P. M. DiBartolo (Eds.), generalized social phobias qualitatively distinct? Clinical
Social anxiety: Clinical, developmental, and social perspec- Psychology: Science and Practice, 9, 379–395.
tives (3rd ed., pp. 705–728). Waltham, MA: Academic Kashdan, T. B. (2007). Social anxiety spectrum and
Press. diminished positive experiences: Theoretical synthesis
Heimberg, R. G., Mueller, G. P., Holt, C. S., Hope, D. and meta-­a nalysis. Clinical Psychology Review, 27, 348–
A., & Liebowitz, M. R. (1992). Assessment of anxiety 365.
in social interaction and being observed by others: The Keller, M. B. (2003). The lifelong course of social anxiety
Social Interaction Anxiety Scale and the Social Phobia disorder: A clinical perspective. Acta Psychiatrica Scandi-
Scale. Behavior Therapy, 23, 53–73. navica, 108(Suppl. 417), 85–94.
Hinrichsen, H., & Clark, D. M. (2003). Anticipatory pro- Kendler, K. S., Aggen, S. H., Knudsen, G. P., Røysamb,
cessing in social anxiety: Two pilot studies. Journal of E., Neale, M. C., & Reichborn-­Kjennerud, T. (2011).
Behavior Therapy and Experimental Psychiatry, 34, 205– The structure of genetic and environmental risk fac-
218. tors for syndromal and subsyndromal common DSM-
Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. IV axis I and all axis II disorders. American Journal of
(2003). Self-­images play a causal role in social phobia. Psychiatry, 168, 29–39.
Behaviour Research and Therapy, 41, 909–921. Kennerley, H. (2007). Socratic method. Oxford, UK: Oxford
Hirsch, C. R., Mathews, A., Clark, D. M., Williams, R., Cognitive Therapy Centre.
& Morrison, J. A. (2006). The causal role of negative Kessler, R. C., Avenevoli, S., Costello, E. J., Georgiades,
imagery in social anxiety: A test in confident public K., Green, J. G., Gruber, M. J., et al. (2012). Preva-
speakers. Journal of Behavior Therapy and Experimental lence, persistence, and sociodemographic correlates of
Psychiatry, 37, 159–170. DSM-IV disorders in the National Comorbidity Sur-
Hirsch, C. R., Meynen, T., & Clark, D. M. (2004). Nega- vey Replication Adolescent Supplement. Archives of
tive self-­imagery in social anxiety contaminates social General Psychiatry, 69, 372–380.
interactions. Memory, 12, 496–506. Kessler, R. C., Berglund, P., Demler, O., Jin, R., Meri-
Hofmann, S. G., & DiBartolo, P. M. (2000). An instru- kangas, K. R., & Walters, E. E. (2005). Lifetime preva-
ment to assess self-­statements during public speaking: lence and age-of-onset distributions of DSM-IV disor-
Scale development and preliminary psychometric prop- ders in the National Comorbidity Survey Replication.
erties. Behavior Therapy, 31, 499–515. Archives of General Psychiatry, 62, 593–602.
Hofmann, S. G., Newman, M. G., Ehlers, A., & Roth, Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky,
W. T. (1995). Psychophysiological differences between A. M., & Wittchen, H. U. (2012). Twelve-­month and
subgroups of social phobia. Journal of Abnormal Psychol- lifetime prevalence and lifetime morbid risk of anxiety
ogy, 104, 224–231. and mood disorders in the United States. International
Hofmann, S. G., & Suvak, M. (2006). Treatment attrition Journal of Methods in Psychiatric Research, 21, 169–184.
during group therapy for social phobia. Journal of Anxi- Kessler, R. C., Stein, M. B., & Berglund, P. (1998). Social
ety Disorders, 20, 961–972. phobia subtypes in the National Comorbidity Survey.
Hofmann, S. G., Wu, J. Q., & Boettcher, H. (2014). Effect American Journal of Psychiatry, 155, 613–619.
 References 275

Kosslyn, S. M. (1994). Image and brain: The resolution of the Witzlenben, I., Schroeder, B., et al. (2005). Who
imagery debate. Cambridge, MA: MIT Press. comes, who stays, who profits?: Predicting refusal,
Kosslyn, S. M., Ganis, G., & Thompson, W. L. (2001). dropout, success, and relapse in a short intervention for
Neural foundations of imagery. Nature Reviews Neurosci- social phobia. Psychotherapy Research, 15, 210–225.
ence, 2, 635–642. Makkar, S. R., & Grisham, J. R. (2011). Social anxiety and
Kupper, N., & Denollet, J. (2012). Social anxiety in the the effects of negative self-­imagery on emotion, cogni-
general population: Introducing abbreviated versions of tion, and post-event processing. Behaviour Research and
SIAS and SPS. Journal of Affective Disorders, 136, 90–98. Therapy, 49, 654–664.
Lang, P. J. (1979). A bio-­informational theory of emo- Marks, D. F. (1973). Visual imagery differences in the
tional imagery. Psychophysiology, 16, 495–512. recall of pictures. British Journal of Psychology, 64, 17–24.
Laposa, J. M., & Rector, N. A. (2011). A prospective Mathers, C., Vos, T., & Stevenson, C. (1999). Burden of dis-
examination of predictors of post-event processing ease and injury in Australia (Cat. No. PHE 17). Canberra:
following videotaped exposures in group cognitive Australian Institute of Health and Welfare.
behavioural therapy for individuals with social phobia. Mattick, R. P., & Clarke, J. C. (1998). Development and
Journal of Anxiety Disorders, 25, 568–573. validation of measures of social phobia scrutiny fear and
Laposa, J. M., & Rector, N. A. (2016). Can I really do social interaction anxiety. Behaviour Research and Ther-
this?: An examination of anticipatory event processing apy, 36, 455–470.
in social anxiety disorder. Journal of Cognitive Psychother- Mayo-­Wilson, E., Dias, S., Mavranezouli, I., Kew, K.,
apy, 30, 94–104. Clark, D. M., Ades, A. E., et al. (2014). Psychologi-
Lecrubier, Y., Sheehan, D. V., Weiller, E., Amorim, P., cal and pharmacological interventions for social anxi-
Bonora, I., Harnett-­Sheehan, K., et al. (1997). The Mini ety disorder in adults: A systematic review and network
International Neuropsychiatric Interview (MINI): A meta-­a nalysis. Lancet Psychiatry, 1, 368–376.
short diagnostic structured interview: Reliability and McEvoy, P. M. (2007). Effectiveness of cognitive behav-
validity according to the CIDI. European Psychiatry, 12, ioural group therapy for social phobia in a community
232–241. clinic: A benchmarking study. Behaviour Research and
Levine, B., Svoboda, E., Hay, J. F., Winocur, G., & Mosco- Therapy, 45, 3030–3040.
vitch, M. (2002). Aging and autobiographical memory: McEvoy, P. M., Erceg-Hurn, D. M., Saulsman, L. M.,
Dissociating episodic from semantic retrieval. Psychol- & Thibodeau, M. A. (2015). Imagery enhancements
ogy and Aging, 17, 677–689. increase the effectiveness of cognitive behavioural
Libby, L. K., Shaeffer, E. M., Eibach, R. P., & Slemmer, group therapy for social anxiety disorder: A bench-
J. A. (2007). Picture yourself at the polls: Visual per- marking study. Behaviour Research and Therapy, 65,
spective in mental imagery affects self-­perception and 42–51.
behavior. Psychological Science, 18, 199–203. McEvoy, P. M., Grove, R., & Slade, T. (2011). Epidemi-
Lieb, R., Wittchen, H. U., Hof ler, M., Fuetsch, M., Stein, ology of anxiety disorders in the Australian general
M. B., & Merikangas, K. R. (2000). Parental psycho- population: Findings of the 2007 Australian National
pathology, parenting styles, and the risk of social phobia Survey of Mental Health and Wellbeing. Australian and
in offspring: A prospective-­ longitudinal community New Zealand Journal of Psychiatry, 45, 957–967.
study. Archives of General Psychiatry, 57, 859–866. McEvoy, P. M., Nathan, P., Rapee, R. M., & Campbell,
Liebowitz, M. R. (1987). Social phobia. Modern Problems of B. N. C. (2012). Cognitive behavioural group therapy
Pharmacopsychiatry, 22, 141–173. for social phobia: Evidence of transportability to com-
Liebowitz, M. R., Heimberg, R. G., Schneier, F. R., munity clinics. Behaviour Research and Therapy, 50,
Hope, D. A., Davies, S., Holt, C. S., et al. (1999). 258–265.
Cognitive-­behavioral group therapy versus phenelzine McEvoy, P. M., & Saulsman, L. M. (2014). Imagery-­
in social phobia: Long-term outcome. Depression and enhanced cognitive behavioural group therapy for
Anxiety, 10, 89–98. social anxiety disorder: A pilot study. Behaviour Research
Lincoln, T. M., Rief, W., Hahlweg, K., Frank, M., von and Therapy, 55, 1–6.
Witzlenben, I., Schroeder, B., et al. (2003). Effective- McEvoy, P. M., Thibodeau, M. A., & Asmundson, G. J.
ness of an empirically supported treatment for social (2014). Trait repetitive negative thinking: A brief trans-
phobia in the field. Behaviour Research and Therapy, 41, diagnostic assessment. Journal of Experimental Psychopa-
1251–1269. thology, 5, 382–398.
Lincoln, T. M., Rief, W., Hahlweg, K., Frank, M., von McLeod, B. D., Wood, J. J., & Weisz, J. R. (2007).
276 References

Examining the association between parenting and personality. Paper presented at the 5th International
childhood anxiety: A meta-­a nalysis. Clinical Psychology Congress of Cognitive Psychotherapy, Gotenburg,
Review, 27, 155–172. Sweden.
Mooney, K. A., & Padesky, C. A. (2000). Applying client Peters, L. (2000). Discriminant validity of the Social Pho-
creativity to recurrent problems: Constructing possi- bia and Anxiety Inventory (SPAI), the Social Phobia
bilities and tolerating doubt. Journal of Cognitive Psycho- Scale (SPS) and the Social Interaction Anxiety Scale
therapy, 14, 149–161. (SIAS). Behaviour Research and Therapy, 38, 943–950.
Mörtberg, E., Clark, D. M., Sundin, O., & Åberg Wist- Peters, L., Sunderland, M., Andrews, G., Rapee, R. M.,
edt, A. (2007). Intensive group cognitive treatment and & Mattick, R. P. (2012). Development of a short form
individual cognitive therapy vs. treatment as usual in Social Interaction Anxiety (SIAS) and Social Phobia
social phobia: A randomized controlled trial. Acta Psy- Scale (SPS) using nonparametric item response theory:
chiatrica Scandinavica, 115, 142–154. The SIAS-6 and the SPS-6. Psychological Assessment, 24,
Moscovitch, D. A. (2009). What is the core fear in social 66–76.
phobia?: A new model to facilitate individualized case Pictet, A. (2014). Looking on the bright side in social
conceptualization and treatment. Cognitive and Behav- anxiety: The potential benefit of promoting positive
ioral Practice, 16, 123–134. mental imagery. Frontiers in Human Neuroscience, 8, 43.
Moscovitch, D. A., Gavric, D. L., Merrifield, C., Bielak, Pictet, A., Coughtrey, A. E., Mathews, A., & Holmes, E.
T., & Moscovitch, M. (2011). Retrieval properties of A. (2011). Fishing for happiness: The effects of positive
negative vs. positive mental images and autobiographi- imagery on interpretation bias and a behavioral task.
cal memories in social anxiety: Outcomes with a new Behaviour Research and Therapy, 49, 885–891.
measure. Behaviour Research and Therapy, 49, 505–517. Powers, M. B., Sigmarsson, S. R., & Emmelkamp, P. M.
National Institute for Health and Care Excellence. (2013). G. (2008). A meta-­ a nalytic review of psychological
Social anxiety disorder: Recognition, assessment and treat- treatments for social anxiety disorder. International Jour-
ment (Clinical guideline no. CG159). Manchester, UK: nal of Cognitive Therapy, 2, 94–113.
Author. Rachman, S., Grüter-­A ndrew, J., & Shafran, R. (2000).
Ng, A. S., Abbott, M. J., & Hunt, C. (2014). The effect of Post-event processing in social anxiety. Behaviour
self-­imagery on symptoms and processes in social anxi- Research and Therapy, 38, 611–617.
ety: A systematic review. Clinical Psychology Review, 34, Rapee, R. (1995). Descriptive psychopathology of social
620–633. phobia. In R. G. Heimberg, M. R. Leibowitz, D. A.
Norton, A. R., Abbott, M. J., Norberg, M. M., & Hunt, Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis,
C. (2015). A systematic review of mindfulness and assessment, and treatment (pp. 41–66). New York: Guil-
acceptance-­based treatments for social anxiety disorder. ford Press.
Journal of Clinical Psychology, 71, 283–301. Rapee, R. M. (2014). Preschool environment and tem-
Öst, L. G. (2014). The efficacy of Acceptance and Com- perament as predictors of social and nonsocial anxiety
mitment Therapy: An updated systematic review and disorders in middle adolescence. Journal of the American
meta-­a nalysis. Behaviour Research and Therapy, 61, 105– Academy of Child and Adolescent Psychiatry, 53, 320–328.
121. Rapee, R. M., Gaston, J. E., & Abbott, M. J. (2009). Test-
Padesky, C. A. (1993, September). Socratic questioning: ing the efficacy of theoretically derived improvements
Changing minds or guiding discovery? Paper presented at in the treatment of social phobia. Journal of Consulting
the European Congress of Behavioural and Cognitive and Clinical Psychology, 77, 317–327.
Therapies, London. Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-­
Padesky, C. A. (1994). Schema change processes in cog- behavioral model of anxiety in social phobia. Behaviour
nitive therapy. Clinical Psychology and Psychotherapy, 1, Research and Therapy, 35, 741–756.
267–278. Rapee, R. M., & Lim, L. (1992). Discrepancy between
Padesky, C. A. (2011, October). Simplifying personality dis- self- and observer ratings of performance in social pho-
order treatment: A new paradigm for CBT. Workshop pre- bics. Journal of Abnormal Psychology, 101, 728–731.
sented at the 34th Australian Association for Cognitive Rapee, R. M., & Spence, S. H. (2004). The etiology of
Behaviour Therapy (AACBT) National Conference, social phobia: Empirical evidence and an initial model.
Sydney, Australia. Clinical Psychology Review, 24, 737–767.
Padesky, C. A., & Mooney, K. A. (2005, May). Cogni- Reimer, S. G., & Moscovitch, D. A. (2015). The impact
tive therapy for personality disorders: Constructing a new of imagery rescripting on memory appraisals and core
 References 277

beliefs in social anxiety disorder. Behaviour Research and social anxiety disorder: An evidence-­ based model.
Therapy, 75, 48–59. Behaviour Research and Therapy, 86, 50–67.
Reisberg, D., Pearson, D. G., & Kosslyn, S. M. (2003). Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W.,
Intuitions and introspections about imagery: The role & Clark, D. M. (2003). Cognitive therapy for social
of imagery experience in shaping an investigator’s theo- phobia: Individual versus group treatment. Behaviour
retical views. Applied Cognitive Psychology, 17, 147–160. Research and Therapy, 41, 991–1007.
Rodebaugh, T. L. (2009). Hiding the self and social anxi- Stapinski, L. A., Rapee, R. M., Sannibale, C., Teesson,
ety: The Core Extrusion Schema measure. Cognitive M., Haber, P. S., & Baillie, A. J. (2015). The clinical
Therapy and Research, 33, 90. and theoretical basis for integrated cognitive behavioral
Rodebaugh, T. L., Woods, C. M., Thissen, D. M., Heim- treatment of comorbid social anxiety and alcohol use
berg, R. G., Chambless, D. L., & Rapee, R. M. (2004). disorders. Cognitive and Behavioral Practice, 22, 504–521.
More information from fewer questions: The factor Stein, M. B., & Deutsch, R. (2003). In search of social
structure and item properties of the original and brief phobia subtypes: Similarity of feared social situations.
Fear of Negative Evaluation Scale. Psychological Assess- Depression and Anxiety, 17, 94–97.
ment, 16, 169–181. Stein, M. B., Torgrud, L. J., & Walker, J. R. (2000). Social
Salkovskis, P. M. (1991). The importance of behaviour phobia symptoms, subtypes, and severity: Findings
in the maintenance of anxiety and panic: A cognitive from a community survey. Archives of General Psychiatry,
account. Behavioural and Cognitive Psychotherapy, 19, 57, 1046–1052.
6–19. Stopa, L. (2011). Imagery rescripting across disorders: A
Salkovskis, P. M. (Ed.). (1996). Frontiers of cognitive therapy. practical guide. Cognitive and Behavioral Practice, 18,
New York: Guilford Press. 421–423.
Saulsman, L. M., & Page, A. C. (2004). The five-­factor Stopa, L., Brown, M. A., & Hirsch, C. (2012). The effects
model and personality disorder empirical literature: A of repeated imagery practice on self-­concept, anxiety
meta-­a nalytic review. Clinical Psychology Review, 23, and performance in socially anxious participants. Jour-
1055–1085. nal of Experimental Psychopathology, 3, 223–242.
Scaini, S., Belotti, R., & Ogliari, A. (2014). Genetic and Stopa, L., & Jenkins, A. (2007). Images of the self in social
environmental contributions to social anxiety across anxiety: Effects on the retrieval of autobiographical
different ages: A meta-­a nalytic approach to twin data. memories. Journal of Behavior Therapy and Experimental
Journal of Anxiety Disorders, 28, 650–656. Psychiatry, 38, 459–473.
Scheier, M. F., & Carver, C. S. (1985). The Self-­ Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N.
Consciousness Scale: A revised version for use with A., & Lydiard, R. B. (2003). The Social Thoughts and
general populations. Journal of Applied Social Psychology, Beliefs Scale: A new inventory for assessing cognitions
15, 687–699. in social phobia. Psychological Assessment, 15, 384–391.
Seebauer, L., Froß, S., Dubaschny, L., Schönberger, M., & Vassilopoulos, S. (2005). Social anxiety and the effects
Jacob, G. A. (2014). Is it dangerous to fantasize revenge of engaging in mental imagery. Cognitive Therapy and
in imagery exercises?: An experimental study. Journal of Research, 29, 261–277.
Behavior Therapy and Experimental Psychiatry, 45, 20–25. Vriends, N., Bolt, O. C., & Kunz, S. M. (2014). Social
Shamir-­ Essakow, G., Ungerer, J. A., & Rapee, R. M. anxiety disorder, a lifelong disorder?: A review of the
(2005). Attachment, behavioral inhibition, and anxiety spontaneous remission and its predictors. Acta Psychiat-
in preschool children. Journal of Abnormal Child Psychol- rica Scandinavica, 130, 109–122.
ogy, 33, 131–143. Watson, D., & Friend, R. (1969). Measurement of social-­
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim, evaluative anxiety. Journal of Consulting and Clinical Psy-
P., Janavs, J., Weiller, E., et al. (1998). The Mini-­ chology, 33, 448–457.
International Neuropsychiatric Interview (M.I.N.I.): Watson, D., Gamez, W., & Simms, L. J. (2005). Basic
The development and validation of a structured diag- dimensions of temperament and their relation to anxi-
nostic psychiatric interview for DSM-IV and ICD-10. ety and depression: A symptom-­based perspective. Jour-
Journal of Clinical Psychiatry, 59, 22–33. nal of Research in Personality, 39, 46–66.
Skocic, S., Jackson, H., & Hulbert, C. (2015). Beyond Weeks, J. W. (2015). Replication and extension of a hier-
DSM-5: An alternative approach to assessing Social archical model of social anxiety and depression: Fear
Anxiety Disorder. Depression and Anxiety, 30, 8–15. of positive evaluation as a key unique factor in social
Spence, S. H., & Rapee, R. M. (2016). The etiology of anxiety. Cognitive Behaviour Therapy, 44, 103–116.
278 References

Weeks, J. W., & Heimberg, R. G. (2012). Positivity Wild, J., Hackmann, A., & Clark, D. M. (2008). Rescript-
impairments: Pervasive and impairing (yet nonpromi- ing early memories linked to negative images in social
nent?) features of social anxiety disorder. Cognitive phobia: A pilot study. Behavior Therapy, 39, 47–56.
Behaviour Therapy, 41, 79–82. Wittchen, H. U., Stein, M. B., & Kessler, R. C. (1999).
Weeks, J. W., Heimberg, R. G., Fresco, D. M., Hart, T. Social fears and social phobia in a community sample
A., Turk, C. L., Schneier, F. R., et al. (2005). Empiri- of adolescents and young adults: Prevalence, risk factors
cal validation and psychometric evaluation of the Brief and co-­morbidity. Psychological Medicine, 29, 309–323.
Fear of Negative Evaluation Scale in patients with social Wong, J., Gordon, E. A., & Heimberg, R. G. (2014).
anxiety disorder. Psychological Assessment, 17, 179–190. Cognitive-­behavioral models of social anxiety disor-
Weeks, J. W., Heimberg, R. G., Rodebaugh, T. L., Goldin, der. In J. W. Weeks (Ed.), The Wiley–­Blackwell hand-
P. R., & Gross, J. J. (2012). Psychometric evaluation of book of social anxiety disorder (pp. 1–23). Chichester, UK:
the Fear of Positive Evaluation Scale in patients with Wiley–­Blackwell.
social anxiety disorder. Psychological Assessment, 24, Wong, Q. J. J., Gregory, B., & McLellan, L. F. (2016). A
301–312. review of scales to measure social anxiety disorder in
Weeks, J. W., Heimberg, R. G., Rodebaugh, T. L., & Nor- clinical and epidemiological studies. Current Psychiatry
ton, P. J. (2008). Exploring the relationship between Reports, 18, 1–15.
fear of positive evaluation and social anxiety. Journal of Wong, Q. J., & Moulds, M. L. (2009). Impact of rumi-
Anxiety Disorders, 22, 386–400. nation versus distraction on anxiety and maladaptive
Weeks, J. W., & Howell, A. N. (2012). The bivalent fear of beliefs in socially anxious individuals. Behaviour
self-­
evaluation model of social anxiety: Further integrating Research and Therapy, 47, 861–867.
findings on fears of positive and negative evaluation. Wong, Q. J., Moulds, M. L., & Rapee, R. M. (2014). Vali-
Cognitive Behaviour Therapy, 41, 83–95 dation of the self-­beliefs related to social anxiety scale:
Wells, A. (1997). Cognitive therapy of anxiety disorders: A prac- A replication and extension. Assessment, 21, 300–311.
tice manual and conceptual guide. Chichester, UK: Wiley. Wong, Q. J., & Rapee, R. M. (2016). The aetiology and
Wells, A., Clark, D. M., & Ahmad, S. (1998). How do I maintenance of social anxiety disorder: A synthesis of
look with my mind’s eye?: Perspective taking in social complementary theoretical models and formulation of a
phobic imagery. Behaviour Research and Therapy, 36, new integrated model. Journal of Affective Disorders, 203,
631–634. 84–100.
Wild, J., & Clark, D. M. (2011). Imagery rescripting of Woody, S. R., Chambless, D. L., & Glass, C. R. (1997).
early traumatic memories in social phobia. Cognitive and Self-­focused attention in the treatment of social phobia.
Behavioral Practice, 18, 433e443. Behaviour Research and Therapy, 35, 117–129.
Wild, J., Hackmann, A., & Clark, D. M. (2007). When the Yonkers, K. A., Dyck, I. R., & Keller, M. B. (2001). An
present visits the past: Updating traumatic memories in eight-year longitudinal comparison of clinical course
social phobia. Journal of Behavior Therapy and Experimen- and characteristics of social phobia among men and
tal Psychiatry, 38, 386–401. women. Psychiatric Services, 52, 637–643.
 Index

Abuse, SAD risk and, 10, 236 therapy summary guide, 169 for negative self-imagery, 35–36,
Affective functioning, image processing treatment case example, 155–156 145–153
and, 28–29, 81–83, 238 treatment goals, 157 past-oriented, 125
Agoraphobia, 12 Attention focusing, 36–37, 166–168, process, 34, 117–120
Anticipation, in SAD, 17, 18–19, 98 263 safety, 125–127
Anticipatory Event Processing Avoidance self- versus task-focused attention,
Questionnaire, 67 assessment, 65–66, 68–69 161–163
Anticipatory Social Behaviors cycle of anxiety and, 108–110, shame-attacking, 122–125
Questionnaire, 67 247–248 standard future-focused, 121
Anxiety Disorders Interview Schedule, highlighting consequences of, therapist anxiety in use of, 47,
65 107–111 116–117, 125
Assessment and diagnosis identifying, 103–104 in treatment of SAD, 34, 99,
case formulation example, 70–71 identifying function of, 105–107 113–114
comorbid conditions, 10–11, 12 introducing client to concept of, types of, 121–122
diagnostic criteria, 6–7 62–63, 102–103 use of coping imagery in, 130–135
differential diagnosis, 7, 11–13 of negative thoughts and images, Beliefs and assumptions, in SAD
generalized versus specific SAD, 88–90 assessment, 69–70
14–15 in SAD, 12, 21, 103, 113, 239–240 as treatment target, 37–38
identifying anxiety triggers, 59, 61, safety behaviors, 17–18, 21 See also Negative core beliefs
104 social skills and, 13, 18 Benzodiazepines, 23
identifying feedback loops, 59–60 therapy summary guide, 137–138 Body dysmorphic disorder, 12, 152
identifying negative self-images, 141, as treatment target, 34–35 Brain Input and Output Exercise,
142 Avoidance theory, 29 82–83
measures, 64–70 Avoidant personality disorder, 12, 15 Brief Fear of Negative Evaluation Scale,
sociocultural context, 7, 8 66–67
Attachment, 10 Bandwidth metaphor, 123 Bullying, 10, 236
Attention biases, 6 Behavioral experiments
clinical significance, 156, 160–161 case examples, 135–136, 252 Case formulation
competition among, 159 hierarchy, 128–130, 254–258 example, 70–71, 72
introducing concepts of, 157–163 imagery enhancements for, 120–121 individualized case formulation,
retraining, 36–37, 163–166, 168, introducing, 114–116, 251–252 70–71, 72
262–263 menu, 253 measures to aid, 64–70
self- versus task-focused attention to modify avoidance and safety psychoeducation about SAD, 59–61
experiment, 161–163 behaviors, 103 treatment model, 61–64

279
280 Index

Causality, 9, 235–236 Gender differences in SAD risk, 7–8 homework in, 58

cognitive-behavioral models, Generalized SAD, 14 indications, 47–48
17–20 Genetics, 9, 236 individual therapy with, 6, 38–40
imagery-enhanced CBT model, 32 Group therapy, 6 introducing client to, 51–52
role of negative self-imagery, 26 client selection, 48 key maintaining factors, 6, 20–22,
Chocolate Cake Imagery Exercise, effectiveness, 22–23 30–31, 32, 62–64
81–82 group size, 41 maintenance and relapse prevention,
Cognitive-behavioral therapy imagery rescripting in, 181–182, 202–205, 269–270
addressing negative core beliefs in, 184–186 mechanism of change, 29–30, 48
173–178 treatment structure, 40–46, 200 model of SAD, 32, 235–242
effectiveness in treating SAD, video experiments in, 147–148, modifying avoidance and safety
22–26 150–151 behaviors, 102–120
enhanced, 24–26 outcomes evaluation, 46
models of SAD, 16–20 Habituation, 25 rationale, 25–26, 31
See also Imagery-enhanced CBT Handouts, 210 rationale for imagery work in,
Cognitive restructuring, 93, 224–225 1.  What is Social Anxiety Disorder?, 80–84
Cognitive therapy, 23 235–242 session structure, 58–59, 201
Comorbid conditions, 10–11, 12 2.  Recording Thoughts and Images, socializing clients to work with
treatment considerations, 47–48 243–244 imagery in, 78–80
Consequences, 94–95 3.  Challenging Negative Thoughts and therapist qualifications, 46–47
Contrary evidence, 94, 99 Images, 93, 245–246 treatment goals, 40, 60
Coping imagery, 34–35, 130–136, 4.  Cycle of Avoidance and Anxiety, treatment targets, 26–28, 32–38
259 247–248 to undermine negative core beliefs,
Course of SAD, 235 5.  Safety Behaviors, 249–250 178–189
age of onset, 7, 13 6.  Behavioral Experiments, 117, use of Socratic method in, 57–58
case examples, 3–5, 15 251–252 working with negative thoughts and
disability patterns and rates, 9 7.  Behavioral Experiment Menu, 253 images, 85–100
help-seeking, 9 8.  Behavioral Experiment Hierarchies, See also Behavioral experiments;
remission patterns and rates, 8 128, 254–258 Group therapy
Cultural differences, 7, 8 9.  Coping (Metaphorical) Imagery, 259 Imagery rescripting, 38, 264–265
10.  Self-Image: How I Really Appear circular questioning guide, 186
Depression, SAD and to Others, 141, 260 debrief, 187
comorbidity, 10–11, 13 11.  Self-, Environment- and Task- defining characteristics, 178
differential diagnosis, 7 Focused Attention, 159, 261 in groups, 181–182, 184–186
treatment considerations, 47 12.  Attention Retraining and Focusing, guide, 184, 185
Diagnostic and Statistical Manual of Mental 262–263 individual therapy, 186–187
Disorders, 7, 14, 16 13.  Past Imagery Rescripting, 264–265 with multiple memories, 187–188
Differential diagnosis, 7, 11–13 14.  Constructing New Core Beliefs, 190, orienting clients to, 179–181
Distraction, 160 266–268 phases of, 180–181
15.  Skills Toolbox, 201, 269–270 preparation for, 182–184
Eating disorders, 152 Helpful images, 95–100 therapeutic goals, 178–179, 189
Emotion, image processing and, 28–29, Homework, 58 with traumatic memory, 188
81–83, 238 Hope, 55 use of violent or aggressive imagery
Emotional processing theory, 29, 30 House Imagery Exercise, 78–79 in, 188–189
Environment-focused attention, 69, Impact of Safety Behaviors Imagery
158, 261 Icons, in constructing new core beliefs, Exercise, 111–113
Exposure therapy, 22–23, 24–25, 193–194, 267–268 Inhibitory learning theory, 84
83–84 Imagery-enhanced CBT Internet-based treatment delivery, 24
assessment measures, 64–70 Interpersonal psychotherapy, 23, 24
Family factors, 9, 10 case formulation example, 70–71 Interpersonal relations
Fear of negative evaluation, 66–67 client expectations and understanding assessment, 65–66
Fear of Negative Evaluation Scale, 66 of, 55–56, 59–64, 73–74 avoidance behaviors in, 104
Fear of positive evaluation, 67, 85 collaborative nature of, 56–57 feedback processing, 18
Felt sense, 78–79 completing treatment, 200–201 social skills of persons with SAD,
Fight-or-f light response, 32, 62, 237 duration, 200 13, 18
Focus of Attention Questionnaire, 69 effectiveness, 31
Free Association Exercise, 80 emotional amplification in, 28–29 Liebowitz Social Anxiety Scale, 68–69
 Index 281

Maintaining factors, 6, 20–22, 30–31, behavioral experiments to challenge, SAD. See Social anxiety disorder
32, 62–64 113–120 Safety behaviors, 17–18, 21
Memory challenging and modifying, 91–100, assessment, 69
eliciting meaning of, 182–183 245–246 attention retraining contraindicated
retrieval competition theory, 29, 30, client understanding of, 62, 63–64 for, 165–166
120–121, 179 cognitive-behavioral models of SAD, behavioral experiments, 118–119,
See also Imagery rescripting 17–20 125–127
Metaphorical images, 98, 131, 133, 259 facilitating, 85–87 client understanding of, 63, 249–250
Mindfulness-based therapies, 23, 24 as maintaining factor in SAD, 20–21, clinical significance of, 103, 113, 240
attention retraining, 164–165 62, 237–239 highlighting consequences of,
MINI International Neuropsychiatric negative core beliefs and, 77 107–111
Assessment, 65 record of, 87–88 identifying, 103–104
Monoamine oxidase inhibitors, 23–24 socializing clients to work with identifying function of, 105–107
images, 78–80, 84–85 introducing client to concept of,
National Institute for Health and Care strategies for enhancing access, 88–91 102–103
Excellence, 24 therapy summary guide, 101 misuse of coping imagery as,
Negative core beliefs, 37–38 as treatment target, 26–28, 32–34, 134–135
attention bias and, 157 37–38, 76–77 range of, 104
in avoidant personality disorder, 12 using imagery to identify thoughts, 91 self-focused attention and, 111
case example of intervention with, using thoughts to identify imagery, as self-fulfilling, 110
170–171, 195–196 90–91 therapy summary guide, 137–138
caution in working with, 173–174 See also Negative core beliefs; as treatment target, 35
collecting evidence against, 175–176 Negative self-imagery use of imagery to understand and
examples, 172 Neuroticism, 9 modify, 111–113
formation of, 172 Schizoid personality disorder, 12–13
formulating new, 38, 173, 176–177 “Older You” perspective, 183–184 Selective serotonin reuptake inhibitors,
identifying, 69–70, 174–175 Old System/New System approach, 38, 23–24
introducing client to concept of, 189–190 Self-Beliefs Related to Social Anxiety
63–64 Outcome prediction, 47–48 Scale, 70
in maintenance of SAD, 17–18, 19, Outcomes evaluation, 46, 65–66 Self-Consciousness Scale, 69
20, 30–31, 37, 171–173, 241 Self-focused attention, 17, 18, 22, 159
positive imagery to construct new Panic disorder, SAD versus, 11–12 assessment, 69
core belief, 38, 189–195, 266–268 Performance Questionnaire, 67 introducing concept of, 157–158,
rationale for imagery-enhanced CBT Performance SAD, 14 241, 261
for, 177–178 Personality and temperament, SAD risk safety behaviors and, 111
reinforcement of, 37 and, 9 versus task-focused attention
rescripting to undermine, 178–189, Pharmacotherapy, 23–24 experiment, 161–163
264–265 Positive thoughts and images, 28 as treatment target, 36–37
therapy summary guide, 197–198 to construct new core belief, Self-help interventions, 23–24
treatment goals, 40, 71 189–195, 266–268 Self-perception
as treatment target, 21, 77 Post-Event Processing Questionnaire, 67 client understanding of, 63, 260
Negative self-imagery Probability, 94–95 in maintenance of SAD, 19–20, 21
behavioral experiments, 145–152 Psychodynamic psychotherapy, 23–24 positive imagery deficits, 28
challenging, 40, 140, 143–145 Psychoeducation, 59–61 as treatment target, 26–28, 31, 35–36
effect on social performance, 27 Public speaking, 14–15, 67 See also Negative self-imagery
identifying, 141, 142 Self-Statements during Public Speaking
in maintenance of SAD, 6, 17, 19, 20, Relapse prevention, 40, 203, 269–270 Scale, 67
26, 28, 35–36, 37, 140–141 case example, 199, 205 Serotonin–norepinephrine reuptake
rationale for targeting, 71, 141–142 therapy summary guide, 206–207 inhibitors, 23–24
therapy summary guide, 154 Remission, 8 Session guide
vicious cycle of, 143 Repetitive Thinking Questionnaire, 67 group treatment, 40–46
See also Negative core beliefs; Rescripting, 264–265. See Imagery individual treatment, 38–40
Negative thoughts and images rescripting Session structure, 58–59
Negative thoughts and images Retrieval competition theory, 29, 30, Setbacks in therapy, 56
abstract and overgeneralized nature 120–121, 179 Shame-attacking behavioral
of, 80–81, 238 Role play, attention focusing in, experiments, 122–125
assessment, 66–67, 69–70 167–168 Shyness, 14
282 Index

Social anxiety disorder (SAD) Subjective Unites of Distress Scale, 243 Waterloo Images and Memories
avoidance in, 12, 21, 239–240 Substance use and abuse, 11, 47–48 Interview, 68
causes, 9, 235–236 Subtle Avoidance Frequency Worksheets, 209
comorbidity, 10–11 Examination, 69 1.  My Model of Social Anxiety, 64, 72,
core characteristics, 6–7, 14, 235, 211
236–237 Task at hand focus, 166–167 2.  Personal Fear and Avoidance List, 65,
epidemiology, 7 Task-focused attention, 158–159, 70, 202, 212
handout to enhance client 161–163, 261 3.  Looking Forward, 71–73, 213
understanding of, 235–242 Therapeutic alliance 4.  Thought/Image–Feeling Connection,
identifying and modifying negative beginning treatment, 52–57 84–85, 214
self-imagery in, 141–145 in behavioral experiments, 115–116 5.  Thought and Imagery Record, 87–88,
negative self-imagery in, 140–141 for work with negative core beliefs, 141, 215
negative social thoughts and images 174 6.  Imagery Challenging Record, 91–100,
in, 20–21, 62, 237–239 Therapist qualities, 46–47 125, 131, 143–144, 204, 216
risk factors, 7–8, 9–10, 236 Thought/Image–Feeling Connection 7.  Behavioral Experiment Record, 117,
safety behaviors in, 103, 113, 240 Exercise, 84 123–124, 128, 145, 217
social skills of persons with, 13, 18, Tightrope metaphor, 123 8.  Safety Behaviors Experiment, 126,
140 Trauma memory, 188 218
subtypes, 14–15 Treatment 9.  Behavioral Experiment Hierarchy,
See also Assessment and diagnosis; of avoidant personality disorder, 12 128, 219
Course of SAD; Imagery- cognitive-behavioral models, 16–20 10.  Coping Imagery, 133, 220
enhanced CBT comorbidity considerations, 11 11.  Speech Form, 147–148, 149,
Social Interaction Anxiety Scale, 65–66 effectiveness, 22–26 221–222
Social Interaction Phobia Scale, 66 goals, 13, 15 12.  Speech Rating Form, 147, 223
Social Interaction Self-Statement Test, target, 26 13.  Self- versus Task-Focused Attention
67 of threat perceptions, 21 Experiment, 161–163, 224
Social phobia, 235 See also Cognitive-behavioral 14.  Attention Retraining Record, 164,
Social Phobia Scale, 65–66 therapy; Imagery-enhanced CBT 225
Social skills training, 23–24 15.  Task-Focused Attention, 167, 226
treatment goals, 60 Video-feedback experiments, 36 16.  Past Imagery Rescripting, 182, 183,
Social Thoughts and Beliefs Scale, 70 cautions in use of, 152 186, 227
Socratic method, 57–58 debriefing, 149–152 17.  Constructing New Core Beliefs, 190,
Specific SAD, 14 goals, 146–147 228–230
Spontaneous Use of Imagery Scale, 68 for negative self-imagery, 141, 18.  New Core Belief Action Plan, 195,
Stress management, 24–25 146–153 202, 231–232
Structured Clinical Interview for watching video, 148–149 19.  Your Progress, 202, 233
DSM-5, 65 Vividness of Visual Imagery 20.  Dealing with Setbacks, 203, 234
Structured interviews, 64–65 Questionnaire, 68 Worry, 29
 ebook
THE GUILFORD PRESS