Psychoeducation

This chapter explains the tripartite model of anxiety: physiological arousal, behavioral disruption and avoidance, and distorted cognition. The interaction of these three components underlies the cognitive–behavioral therapy (CBT) model for this treatment. The material begins laying the groundwork for cognition as the precipitating event in a downward spiral and for avoidance as key in maintaining the problem. These concepts are important for helping clients understand the rationale for the primary components of treatment (cognitive restructuring and exposure both in and out of session). One goal of this chapter is to develop a common language to understand anxiety, which is helped by spending some time on each of the three components of anxiety to ensure that the client understands each component before moving on to their interaction.

Psychoeducation

The primary purpose of this chapter is to help the client understand his or her diagnosis in the context of normal and excessive social anxiety. The therapist helps the client gain an appreciation that cognitive–behavioral therapy (CBT) is effective and also provides a basic understanding of the nature of CBT, including the investment of effort and energy required. An important aspect is socialization to help the client to understand the need for his or her active participation, including making an emotional investment in change and participating in the many activities of therapy. The therapist works to enhance motivation for change and builds the therapeutic alliance.

Exposure and Cognitive Restructuring

Many individuals in treatment for social anxiety have some difficulty with casual conversations, even if it is not the primary focus of treatment. This chapter presents psychoeducational material about the importance of small talk in everyday life. The amount of in-session time spent will depend on how central this topic is to the specific client and how well the client is able to glean key points from the reading on their own. Two primary messages from this material are (a) casual conversations are the gateways to more significant relationships and (b) such conversations are, by definition, about inconsequential topics. Conversational situations are often the easiest exposures to design. They typically require few props, and a variety of circumstances can be easily staged. This chapter covers three typical automatic thoughts for conversations: not knowing what to say, not having anything interesting to say, and having poor conversational skills.

Exposure and Cognitive Restructuring

The first in-session exposure is a highlight of this therapy. (It is specified that exposure must occur no later than session 8 of treatment.) This is the first opportunity to fully integrate all of the therapeutic elements. Everything up to this point has been preparation for facing feared situations. Prior to the session, the therapist is instructed to review the client’s Fear and Avoidance Hierarchy and to determine what situation will likely be role-played. For the first exposure, simple, straightforward scenarios that require little “pretending” are the best. Although it is easy to skip setting an achievable behavioral goal to save time, this step is essential. Debriefing the exposure is often the most powerful portion of the intervention.

Cognitive Restructuring

This chapter introduces the idea of information-processing biases using the “amber-colored glasses” metaphor. Although information-processing biases are well established in the research literature, this is a difficult concept to communicate to socially anxious individuals. By describing the amber-colored glasses as a natural outcome of a particular combination of genetics, family environment, and important experiences, the therapist can indicate that the way in which the client processes information makes sense; it just may not be functional. The chapter also covers identification of automatic thoughts (ATs) and finding logical errors (the identification of thinking errors) in ATs. The notion of ATs is used extensively throughout treatment.

Additional Tools for Challenging Automatic Thoughts

Additional techniques to challenge automatic thoughts are presented in this chapter. These techniques include the “pie chart technique,” in which a pie chart can help clients examine catastrophic fears. The “continuum technique” can be used to help clients put possible negative outcomes in the proper perspective. The “me–not me” technique is intended to help therapists and clients maintain an awareness that anxiety in certain social situations is expected and even appropriate. The technique of “intentional physiological arousal induction” involves having the client engage in an activity like jogging in place or walking quickly up and down flights of stairs prior to engaging in an exposure. “Video feedback” is another potentially powerful intervention.

Exposure and Cognitive Restructuring

After the first in-session exposure, treatment enters a middle phase in which sessions (typically five to six in the recommended 16-session treatment program) revolve around the routine of in-session exposures and review and assignment of in vivo exposures for homework. Exposures are guided by the client’s Fear and Avoidance Hierarchy. For clients to benefit from this treatment, they must begin to engage in anxiety-provoking activities in their daily lives. It is essential that the therapist encourage this by carefully assigning and reviewing homework for in vivo exposure. At the beginning of each session, the therapist reviews the client’s completed Be Your Own Cognitive Therapist Worksheet and comments on aspects that show progress or use of cognitive restructuring skills. At a minimum, clients should engage in at least one in vivo exposure every week. As treatment progresses, this rate should increase if possible.

Cognitive Restructuring

This chapter builds on the first two steps of cognitive restructuring that were developed in chapter 5: (a) the identification of automatic thoughts (ATs) and the emotions they cause and (b) the identification of thinking errors. This chapter presents the remaining steps in cognitive restructuring: (c) challenging ATs by using disputing questions and (d) generating rational responses. The session opens with a review of the Social Anxiety Session Change Index and homework, and then each concept is covered. There is also a brief discussion in anticipation of the first exposure in the next session. The first in-session exposure is a key moment in treatment.

The Fear and Avoidance Hierarchy

In this chapter, the therapist and client continue to refine their understanding of the client’s three components of anxiety and develop a Fear and Avoidance Hierarchy. A Fear and Avoidance Hierarchy is a “top 10” list of situations in which the client experiences social anxiety. The greatest fear is in the number 1 position. Once the items are generated, each is rated for the level of anxiety it evokes and the likelihood that the person would avoid the situation if it were to occur in his or her life. There are four steps in constructing a Fear and Avoidance Hierarchy: (a) brainstorming, (b) discovering what makes a situation easier or harder and refining the client’s list of situations, (c) making ratings of fear and avoidance for each situation, and (d) rank ordering the situations. A hierarchy is meant to provide a good representation of situations that cause the client anxiety.

Psychoeducation

The primary purpose this chapter is to finish presentation to the client of the cognitive–behavioral therapy (CBT) model, with a discussion of the etiology and maintenance of social anxiety. Clients vary on how much they want to know about some of the details; however, nearly everyone asks about etiology at some point in treatment. This chapter includes the beginning of monitoring progress using the Social Anxiety Session Change Index (SASCI). From this point in therapy forward, at the beginning of each session, clients complete the SASCI. The chapter is an opportunity to reinforce the basics of the CBT model.