Introduction to Session Outlines for Managing Social ...

Introduction to Session Outlines for Managing Social Anxiety: A Cognitive-Behavioral Approach,

3rd edition Therapist Guide and Client Workbook

By Debra A. Hope, Richard G. Heimberg and Cynthia Turk

These outlines were developed to assist with the implementation of the treatment procedures as described in the

Managing Social Anxiety: A Cognitive-Behavioral Approach, 3rd edition published by Oxford University Press.

The outlines portray the treatment as it has been delivered in our clinics over the past several years, both for

participants in clinical trials and non-research clients. Therapists new to this approach can use the outlines to

guide sessions in order to closely follow the procedures that have been shown to have good clinical outcomes in

our published studies. We hope that these outlines will make the therapist guide and client workbook more user-

friendly for both the practicing clinician and clinical researcher. With this new edition, we have annotated the

outlines with Expert Tips to highlight key points based on our shared experience supervising hundreds of trainees

with this approach.

Therapists should be thoroughly familiar with the client workbook and therapist guide before implementing the

treatment. The outlines are meant to be carried into session so the therapist will not have to refer to the therapist

guide during session. Typically clients have their workbook in session for occasional reference. However, it is

best if both therapist and client can set the materials aside at times, especially during cognitive restructuring,

exposure and other occasions when important affective or cognitive processing are needed.

Note that all of the Forms and Worksheets from the Client Workbook and Therapist Guide are available for

download as PDFs here, at the Oxford University Press Treatments that Work website.

Debra A. Hope, Richard G. Heimberg, Cynthia L. TurkManaging Social Anxiety. © 2019 by Oxford University Press

Oxford Clinical Psychology | Oxford University Press

https://www.oxfordclinicalpsych.com/page/504/forms-and-worksheets

Updated: 11/2019

A Cognitive Behavioral Approach, 3rd edition Chapter 1 Session Outline

I. Set agenda for session

A. Social anxiety in client’s own words B. Chapter 1 in Client Workbook

1. Basic information about social anxiety 2. Information about how this treatment program works 3. Getting ready to start treatment

C. Any other matters that need to be handled for a given client

II. Social anxiety in client’s own words A. Ask client to speak about their social anxiety

A. What social anxiety means to them B. How social anxiety has affected their life

C. What they would like to change

III. Social anxiety (feeling nervous around other people) is

a normal part of life; illustrate with case vignette of normal

levels of social anxiety A. Vignette from Client Workbook: Jasmine is starting new job and

must make a presentation to the manager’s meeting

1. Anticipatory anxiety symptoms: questioning whether she

really wants promotion, “butterflies in stomach,” feeling

nervous, worried about making a good impression

2. Anxiety increases as begins presentation: heart beats

faster than normal, sees faces looking at her, stumbles over

words initially

3. Uses good coping statements

a) “I’m prepared.”

b) “No one expects me to be perfect on the first

day.”

Expert Tips

Give the client permission to speak briefly if that is all that feels comfortable. However brief, this will help the client to engage in the session and set out an early expectation that sessions should be interactive rather than coming only from the therapist.

Make this point early and often: Social anxiety is a normal part of life. Learning to manage the experience of anxiety is the goal, not getting rid of it.

Timeline: Typically one session Reading: Chapter 1 in Client Workbook Photocopies needed from Client Workbook:

Pros and Cons of Working on My Social Anxiety (Worksheet 1.1 in Client Workbook)

What Are My Values in Life, and How Does Social Anxiety Interfere? (Worksheet 1.2 in Client Workbook)

Physical Symptoms of Social Anxiety that I Experience (Worksheet 2.1 in Client Workbook)

Thoughts Related to an Anxiety-Provoking Situation (Worksheet 2.2 in Client Workbook)

Avoidance Behaviors Related to My Social Anxiety (Worksheet 2.3 in Client Workbook)



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4. As presentation continues, anxiety decreases as she notices

safety cues (e.g., everyone seems to be listening attentively)

5. Positive outcome after presentation

a) Jasmine wonders why she was so anxious before

presentation as it went well

b) Jasmine feels more optimistic about the job after

facing her fears

B. Jasmine’s experience is an example of social anxiety

1. Public speaking is a commonly feared situation

2. Jasmine’s symptoms are consistent with what people

typically report

3. Normal social anxiety is experienced by people in unfamiliar

or infrequently occurring situations

a) Speaking in front of a group

b) Meeting with a new boss or job interview

c) Going to a new class or job where you do not know

anyone

d) Getting to know a potential dating partner

C. Typically social anxiety is unpleasant but not unmanageable and

decreases quickly once the situation is faced

IV. Clinically severe social anxiety is different than normal

levels of social anxiety; illustrate with two case vignettes of

social anxiety disorder A. Vignette from Client Workbook: Cory is a 30-year-old man in his first

romantic relationship who is meeting his prospective in-laws for the

first time

1. Anticipatory anxiety

a) Started a week before the dinner and increased as

time approached

b) Tension and worry about the dinner dominated his

experience during the preceding week

c) Cancelled several previous dates because of

anticipatory anxiety

d) Worried about making a bad impression on Jodi’s

parents that would embarrass her and cause the

relationship to end

e) Anxiety interferes with concentration while driving

to restaurant

2. Anxiety severe as he meets Jodi’s parents and continues to

be a problem throughout dinner

a) Severe palpitations

b) Sweaty palms

c) Believes father is evaluating him negatively because

Expert Tips

It is easy to just read this

list to your client, but it is

more fruitful to engage

them in a dialogue in

which you and the client

generate a collaborative

list of situations in which

many people experience

a degree of social

anxiety.



Updated: 11/2019

he looks anxious

d) Trouble concentrating on conversation

e) Escapes before coffee and dessert by making

excuses

3. Later Jodi said that she thought the evening went well; her

parents noticed Cory’s anxiety but did not draw negative

conclusions

B. Vignette from Client Workbook: Eric is a 30-year-old man who

sought treatment for more severe levels of social anxiety.

1. Anxiety negatively affected many arenas of his life:

a) Went to college to avoid getting a job because the

school environment was more familiar.

b) Worked part-time at a library job because it did not

require contact with people.

c) After college, quit multiple part-time jobs because

the anxiety was intolerable.

d) Refused a promotion in his janitorial position

because it might increase his contact with people.

e) Had no friends.

2. His anxiety even made it difficult for him to seek treatment.

a) Difficulty talking on the phone.

b) Difficulty sitting in the waiting room.

c) Felt nervous around almost everyone.

d) Experienced heart pounding, shaky, and nauseous.

3. Severe social anxiety can have a widespread impact on

many important aspects of life, including education, jobs, and

relationships.

V. Compare and contrast normal and clinically severe

social anxiety as presented in the vignettes to illustrate that

social anxiety exists on a continuum of severity A. Differences in intensity of symptoms

B. Differences in duration of anticipatory anxiety

C. Differences in how much symptoms interfered with functioning

D. The important question is not whether someone experiences social

anxiety or not (most of us do), but how much and how often we

experience social anxiety

E. Social anxiety exists on a continuum of less severe to more severe

1. Contrast with a broken arm, which is an all-or-nothing

event

2. Re-examine all three scenarios by describing how the

anxiety could have been more or less severe in each set of

circumstances

Expert Tips

It is important to share Eric’s story with clients who are themselves on the severe end of the social anxiety continuum. It may help inoculate them against feeling like they are more severe than anyone else and, in that way, boost optimism just a bit. It is helpful in that context to mention that Eric did well in treatment.



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VI. Define social anxiety, social phobia, and social anxiety

disorder A. Social anxiety disorder vs. social phobia

1. Social anxiety disorder is new name for what has

traditionally been called social phobia—better reflects the

broad impact that social anxiety may have

B. DSM-5 definition of social anxiety disorder

1. Core features: fear of being negatively evaluated by others,

doing something humiliating or embarrassing in front of

others, others seeing one’s anxiety

2. Situations in which someone is concerned about what

others think vary widely; common situations include:

a) Public speaking

b) Conversations with unfamiliar people

c) Dating

d) Being assertive

e) Eating or drinking in front of other people

f) Being the center of attention

g) Talking with supervisors or other authority figures

h) Urinating in a public bathroom (usually only men)

i) Intimate sexual situations

j) Using social media

3. Regardless of the specific situation, persons with social

anxiety disorder share a common fear that other people will

think poorly of them

4. Other criteria

a) Realizing that the fear is excessive

b) Avoiding the situations that cause anxiety or

enduring them despite high levels of anxiety

c) Social anxiety disorder must interfere with the

person’s life in important ways

5. If social anxiety is a problem, even if one does not

technically meet criteria for the disorder, this treatment is

probably appropriate

VII. Help client consider how his/her concerns could be

described as social anxiety, social anxiety disorder, and/or

social phobia A. Compare how client’s experience relates to vignettes

B. Watch for any doubts that social anxiety describes what client is

experiencing

1. Separate doubts about whether treatment can be

successful from agreement with therapist on

conceptualization of the presenting problem

Expert Tips

More or less time can be spent on discussion of social anxiety disorder as a diagnosis. Some clients find it reassuring that their problems have an “official” name. Others can be dislike being stigmatized with a “mental illness.” Similarly, therapists tend to emphasis or not DSM diagnoses. It is not central to the treatment to meet criteria for social anxiety disorder per se or to include a diagnosis in the overall case conceptualization. Almost participants in our studies have met official diagnostic criteria, in our clinical work we have seen subclinical social anxiety respond well to this approach. Thus, we have titled the Client Workbook Managing Social Anxiety, not Managing Social Anxiety Disorder.



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2. Do not move on until some level of agreement that client is

experiencing social anxiety

VIII. Evidence for effectiveness of the treatment program A. No guarantees but research suggests that CBT is helpful for most

people with social anxiety disorder

B. Research data

1. Comparison of this treatment to educational-supportive

group therapy

a) 12 weeks of group treatment

b) 75% of clients in cognitive-behavioral treatment

classified as “improvers,” indicating major

improvement in symptoms and sub-clinical severity of

social anxiety and avoidance

c) Greater percentage of “improvers” than in credible

educational-supportive group treatment

d) Six month post-treatment follow-up – most judged

to be improved

e) At 5-year follow-up, still doing well and better than

educational-supportive group treatment

2. Dozens of other studies from around the world with

hundreds of clients found CBT to be very helpful for social

anxiety

3. Overall, in Heimberg, Hope, and colleagues’ research,

about 80% of the participants who complete treatment are

classified as “improvers” or “responders” (similar percentages

in group versus individual treatment)

C. In 2013, the National Institute for Health and Care Excellence

(NICE) in the UK endorsed this treatment program as one of only two

supported CBT treatment models in the world.

IX. Discussion of clients’ motivation for change A. Pros and cons for changing and staying the same

1. Reasons that you want your life to be different

2. Reasons you might have for not changing might get in the

way of making progress in treatment

B. Worksheet 1.1 Pros and Cons of Working on My Social Anxiety

1. List the Pros and Cons of working on social anxiety

a) How is social anxiety interfering in your life or

keeping you from doing the things you want to do?

b) What obstacles might there be to following

through with treatment or being successful at it?

Expert Tips

See Chapter 1 of the Therapist Guide for additional studies of individual and group CBT for social anxiety disorder. Share with clients who seem to be particularly interested, otherwise move on.

The Pros and Cons exercise will be most useful if it is an interactive exchange between client and therapist. Ask a lot of questions and make a few suggestions to get (or keep) the client going.

It is important to empathically acknowledge the difficulty of change and the client’s perceptions of barriers to change.

Encourage the client to think about friendships, romantic relationships, family relationships, spirituality, health, community involvement, education, and occupation.



Updated: 11/2019

X. Focusing the discussion on clients’ values A. Reasons that you want your life to be different

1. What the client’s life may be like in 5 or 10 years if steps

are not taken to change now

2. What the client could have in his or her life (i.e., personal,

family, work) if social anxiety were no longer standing in the

way

B. Worksheet 1.2 What Are My Values in Life, and How Does Social

Anxiety Interfere?

1. What are the things in life I most value? What do I want my

life to stand for in the areas most important to me?

2. How have I made choices consistent with my social anxiety

rather than consistent with these values?

3. What things will I need to start doing to live a life more

consistent with my most important values?

XI. How clients can get the most out of this program A. Seriously invest in change

1. Personal change is hard work

2. Need to set aside time several times a week to work on

social anxiety

3. Need to make an emotional investment by being willing to

experience anxiety

4. Share slogan: Invest Anxiety in a Calmer Future

5. Need to make an emotional investment by being honest

with self and therapist and thoughts and fears

B. Do the exercises carefully and practice procedures frequently

C. Persevere!

1. Keep working even if the benefits are not immediately

apparent; small improvements lead to larger ones

D. Avoid “disqualifying the positive” as socially anxious individuals are

often their own worst critics

E. Be willing to try new ways and give up old ways of dealing with

social anxiety

1. Must be willing to give up drugs or alcohol to help control

your anxiety

2. Must be willing to give up PRN (“as needed”) prescription

medication for anxiety when doing exposures

F. Emphasize that whether this program works for a given client is

under his/her control. If clients commit the time and energy, they are

likely to see benefits.

Expert Tips

Novice therapists may tend to lecture about how to get the most out of this treatment program. Making the discussion more interactive by drawing in examples from the client’s experience can be helpful. It is balance of making clear the client has control by fully engaging in the treatment vs. overwhelming them as being fully responsible for change.



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XII. Overview of This Treatment Program A. Continue education about social anxiety, its components, and where it comes from

B. Learn to analyze your anxiety and understand what it is about different situations that makes you

anxious

C. Learn cognitive restructuring skills to help manage your anxiety

D. Gradually begin to practice situations that are difficult, starting within session and with easier situations

first

E. Learn to apply cognitive restructuring skills to manage anxiety in feared situations

F. Consolidate gains and prepare to finish treatment with the therapist

XIII. Assign Homework: A. Review Chapter 1 and read Chapter 2

1. In general, it will be most helpful for you if you have read the relevant chapter before you meet

with your therapist.

B. Complete the following forms from Chapter 2

1. Physical Symptoms of Social Anxiety that I Experience (Worksheet 2.1 in Client Workbook)

2. Thoughts Related to an Anxiety-Provoking Situation (Worksheet 2.2 in Client Workbook)

3. Avoidance Behaviors Related to My Social Anxiety (Worksheet 2.3 in Client Workbook)

C. Leave Worksheets 2.4 and 2.5 alone for now. We’ll ask you to complete those after your next session

with your therapist.



Updated: 11/2019

Therapist Guide for Managing Social Anxiety: A Cognitive Behavioral Approach, 3rd edition

Chapter 2 Session Outline

I. Agenda Setting and Review of Homework A. Developing a common language to talk about social anxiety B. Answer questions client may have from previous session C. Reiterate the importance of commitment between sessions

1. Did client complete reading assignment? 2. Did client complete (attempt) assigned forms?

D. Homework will be reviewed as work through session material

II. Developing a common language to understand anxiety: The three components of anxiety

III. A. Physiological Component – feelings in the body when one is anxious

1. Review Table 2.1 in Client Workbook for list of physiological symptoms

2. Symptoms may occur for reasons other than anxiety a) Physically dangerous situation; symptoms may be helpful as your body gears up to fight the danger or run away b) Nausea may be the result of a spicy meal! c) Symptoms may indicate a medical problem under some circumstances

(1) Chest pain can mean a heart problem, stomach distress can mean an ulcer, etc. (2) If symptoms occur only when frightened or worried about something, then probably part of anxiety, not a physical problem or disease

3. Panic attacks a) One third of the general population and 50% of

Expert Tips

Strive to make this session interactive, focusing on the concepts as they apply to the client’s personal experience, as this will facilitate the therapeutic alliance.

Helping clients to understand the three components of anxiety will help to make their anxiety less mysterious and potentially more manageable.


Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook) Worksheet for Reactions to Starting This Treatment Program (Worksheet 2.5 in Client

Workbook)

Where Did My Social Anxiety Come From? (Worksheet 3.1 in Client Workbook) Photocopies needed from Therapist Guide:

Rationale for exposure: Patterns of anxiety response when exposed to a feared situation (Figure 2.A in the Therapist Guide)

Rationale for exposure: Patterns of anxiety response over repeated exposures to a feared situation (Figure 2.B in the Therapist Guide)



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people with social anxiety disorder have experienced a panic attack b) Symptoms that come on quickly and peak within 10-15 minutes

(1) Intensity of symptoms can be frightening, and people often worry they are losing their mind or having a heart attack

c) If client has panic attacks and they occur most frequently in social situations, then this treatment should be helpful

4. Review client’s physical symptoms using Worksheet 2.1 in the Client Workbook.

B. The cognitive component of anxiety

1. “Cognitive” is psychologists’ word for thoughts or thinking 2. Using Worksheet 2.2 in the Client Workbook, elicit and review client’s thoughts during the same situations used to elicit physiological symptoms 3. Socially anxious people usually just accept thoughts without questioning whether they are true or realistic

a) However, thoughts may represent our worst fears rather than what actually happens b) Learning to think differently in situations that make you anxious is an important step toward learning to manage your social anxiety

C. The behavioral component of anxiety 1. The behavioral component has two parts

a) What a person does in the anxiety-provoking situation, for example:

(1) Poor eye contact (2) Shuffling feet (3) Nervous gestures

b) Avoidance of anxiety-provoking situations (1) Can be complete avoidance (not attending a party) or more subtle avoidance (attending the party but only talking with familiar people) (2) Safety behavior: a form of subtle avoidance that includes anything the person feels they must do to survive an anxiety- provoking situation

(a) gripping a glass tightly so hand tremors are not visible (b) wearing a shirt that will not show perspiration (c) avoiding certain conversation topics

(3) Avoidance decreases anxiety in the short term

(a) Decrease in anxiety when escaping an anxiety-provoking situation

Expert Tips

Occasionally clients have difficulty identifying their thoughts. If the problem persists, consult the several places in the Therapist Guide where this is addressed, especially Chapters 5 and 8.



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reinforces the avoidance (b) Becomes more likely that the person will avoid similar situations in the future

(4) Avoidance is a poor long-term solution for coping with anxiety

(a) Guilt, frustration, and other negative feelings typically occur when one avoids an anxiety-provoking situation (b) Avoidance can greatly interfere with functioning (c) Avoidance keeps a socially anxious person from getting over their anxiety and finding out whether they would be able to cope if the situation had not been avoided (d) Avoidance leads to missed opportunities, activities that the person never started, as well as those that were escaped

2. Examine the client’s avoidance behavior using Worksheet 2.3 in the Client Workbook

a) Several different types of avoidance behavior: (1) Total avoidance (2) Escape (3) Missed opportunities (4) Safety behaviors

b) How did the client feel after engaging in these avoidance behaviors? c) How was the client’s avoidance behavior inconsistent with their goals and values?

IV.The interaction of the physiological, cognitive, and behavioral components

A. The three components interact; change in one causes increases or decreases in the others B. Downward spiral of anxiety – illustrate interaction of components with a case vignette

1. Cathy is a clerical worker who has not received an expected raise despite good evaluations 2. Decides to speak with supervisor about a raise at the end of a meeting about another matter 3. Anticipatory anxiety – follow downward spiral in Figure 2.4 in Client Workbook

a) Cognitive: “Something must be wrong with my work, or they would give me a raise” b) Physiological: Tightness in stomach, shoulder and back muscles are tense

Expert Tips

The downward spiral of anxiety may not always be quite so linear as it appears in the example of Cathy. Multiple components may be simultaneously activated. A symptom of one component can elicit a range of symptoms from other components, and this will likely differ from

one client to another.

For the purposes of this treatment, all anxiety is considered to start with a negative thought.



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c) Behavioral: Knocks stack of files off desk due to

distraction of anxiety d) Cognitive: “I’m so incompetent! No wonder they won’t give me a raise” e) Physiological: Heart starts to beat faster, ache in back of neck f) Behavioral: Cannot sit still, keeps jumping out of seat to do something g) Cognitive: “If I deserved a raise, I would have one” and “Asking for a raise is too ‘pushy’”

4. Anxiety in the meeting with supervisor a) Physiological: Shortness of breath, shaking hands b) Cognitive: “She’ll laugh when I ask for a raise…” c) Behavioral: Foot tapping

d) Physiological: Pounding heart e) Cognitive: “I’m too nervous to talk with her. I won’t do it right and I’ll get fired.” f) Behavioral: Leaves meeting without asking for a raise g) Physiological: Heart rate decreases, muscles relax h) Cognitive: “I’m such a loser! I don’t deserve a raise anyway.” i) Avoidance leads to negative outcome

(1) Feel frustrated, angry, sad, depressed, etc. (2) Still does not have the deserved raise

D. Goal of treatment: 1. First, learn to recognize downward spiral of anxiety 2. Second, gain tools to learn how to interrupt the downward spiral

V.Rationale for 3 components of treatment (systematic graduated exposure, cognitive restructuring, and homework assignments)

A. Systematic Graduated Exposure 1. Overcoming fears means one must eventually face them, i.e., exposure 2. Graduated exposure means starting with easier situations and working up to harder ones (starting at the shallow end of the pool) 3. In-session exposures are a unique aspect of this treatment program

a) Opportunity to try new things in a controlled environment b) Provide an opportunity to get feedback that is unlikely to occur in real life c) Can work on situations that are feared but unlikely to happen in real life

4. Three ways exposure is helpful in overcoming social anxiety a) Exposure allows rehearsal of behavioral skills

Expert Tips

As you introduce systematic graduated exposure to clients, it may be prudent to emphasize that exposure exercises will not begin for a number of weeks. In the meantime, the client will learn skills that will help them manage their anxiety experience in exposures.



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b) Exposure provides an opportunity to test dysfunctional beliefs

c) Physical symptoms level off and decrease over time (1) A normal process – our bodies are not “built” to maintain high arousal (2) Clients may not have experienced this because they did not stay in feared situation long enough (3) Eventually clients will learn to trust the process and realize the anxiety will decrease if they stay in the situation

(a) Introduce graph in Figure 2.A of the Therapist Guide, drawing graph for client

i. Introduce X and Y axis of the graph ii. Draw line representing client's belief (that anxiety will continue increasing) iii. Draw vertical line representing escape then anxiety pattern when escape occurs iv. Draw line illustrating what is likely to happen v. Help client see that avoidance, such as Cathy chose, keeps one from finding out what happens to anxiety

(4) Arousal also lessens with repeated practice in the same situation

(a) Introduce graph in Figure 2.B of the Therapist Guide, drawing graph for client

i. Introduce X and Y axis of the graph ii. Draw line representing initial exposures iii. Draw line representing middle exposures iv. Draw line representing later exposures v. Emphasize the importance of entering the same feared situation repeatedly

B. Cognitive Restructuring 1. A set of procedures that attacks dysfunctional thinking by systematically analyzing anxiety-related self-statements

a) Cognitive restructuring is not replacing bad thoughts with positive thoughts or stating

Expert Tips

Clients may also not have realized the lessening of physiological symptoms over time because they are engaging in negative thinking that keeps the threat level continuously high or because they are better at detecting danger cues than safety signals. These points might be useful for clients who push back on the idea that arousal should decrease over time. This is one of the reasons that exposure and cognitive restructuring work well together.



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affirmations b) Cognitive restructuring techniques involve testing

beliefs, assumptions, and expectations and see if they really make sense or are helpful

2. Cognitive restructuring helps decrease physiological arousal by making a more realistic assessment of the danger in a situation 3. Cognitive restructuring helps the behavioral component of social anxiety in two ways

a) Less dysfunctional thinking will leave more cognitive capacity to handle the complexities of social interaction b) Changing dysfunctional beliefs will decrease avoidance

(1) This leads to more opportunity for more positive experiences (2) Positive experiences will further change dysfunctional thoughts

C. Homework Assignments 1. Homework transfers what is being learned in therapy sessions to the person’s daily life 2. Assignments include

a) Initially reading or monitoring some aspect of client’s anxiety or behavior b) Later assignments involve graduated exposure to feared situations outside of the session combined with cognitive restructuring

3. Three important aspects of homework a) Assignments are negotiated between therapist and client so client should be honest about what he/she believes can or will be done b) Homework does not need to be done perfectly to be successful if a good effort has been made c) It is essential to do the cognitive restructuring exercises, not just the exposures, to get the full benefit of the experience

VI. Assign Homework: A. Complete Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook)

1. If necessary, explain how to use form 2. If anxiety-provoking situation does not arise, imagine a recent experience with social anxiety and complete the form

B. Complete Worksheet for Reactions to Starting This Treatment Program (Worksheet 2.5 in Client Workbook) C. Read Chapter 3 of Client Workbook D. Complete Where Did My Social Anxiety Come From? (Worksheet3.1 in Client Workbook)

Expert Tips

Building a good rationale for homework is essential for clients to be successful in this treatment. Early homework assignments for reading or self-monitoring help build a good habit of homework completion for later assignments to engage in therapeutic exposure on their own.



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I. Review homework A. Assure that client can identify the three components of anxiety in his/her own experience B. Address any problems with compliance or completion of the homework C. If assignment not done, do so in session before continuing on D. Review Worksheet 2.5 Reactions to Treatment in the Client Workbook

1. A few doubts are normal 2. Address more significant doubts by reviewing relevant material in the first two chapters of the Client Workbook.

II. Biopsychosocial etiology of social anxiety A. Genetics

1. Two lines of supporting efforts a) Somewhat greater concordance for social anxiety disorder in monozygotic twins compared to dizygotic twins b) Jerome Kagan’s work on “behavioral inhibition to the unfamiliar”

(1) Some very young infants withdraw rather than explore unfamiliar people and objects

c) At 7 years of age, 75% still display behavioral inhibition; 75% of non-inhibited infants still not displaying behavioral inhibition d) By early adolescence, many of the youth with behavioral inhibition met criteria for social anxiety disorder. e) Because behavior pattern starts so young and continues, thought to be related to genetics

2. A genetic component in the etiology of social anxiety does not mean it is not amenable to cognitive-behavioral treatment

a) Concordance is not close to 100% in monozygotic twins (24% vs 15% in dizygotic twins – leaves much

Expert Tips

See Chapter 3 of the

Therapist Guide for tips

on how to handle clients

who are skeptical on

Worksheet 2.5.

It is easy for novice

therapists to turn this

session into a lecture

because the material

seems academic. Look

for ways to make it

conversational or

emphasize relating it

their experience. For

example, Do you know

how some little children

are very shy and some

seem to just be born to

talk to everyone? is a

good opening for Kagan’s

work.

Spending more time on

the environmental

factors than genetics

helps emphasize how

clients’ learn from

experience, consistent

with this treatment

approach.


Social Anxiety Session Change Index (SASCI)

Weekly Social Anxiety Session Change (SASCI) Graph

Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook)

Brainstorming My Fear and Avoidance Hierarchy (Worksheet 4.1 in the Client Workbook)



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room for environmental effects)

b) 25% of behaviorally inhibited infants were not shy at age 7 c) This suggests a “genetic predisposition” not a “genetic blueprint” d) Other factors are also important in the development of social anxiety

B. Influence of early family environment on the development of social anxiety

1. We learn about ourselves and the world from our families a) Can people be trusted? b) How does the world operate? c) Are events predictable or unpredictable? d) Do we control events or are we at the whim of fate or powerful other people?

2. Research shows families of people with social anxiety disorder tend not to socialize with other families, even compared to the families of agoraphobics 3. Parental social anxiety can be communicated to the child through display of anxiety symptoms or modeling avoidance behavior 4. Parents may not encourage a shy child to enter feared social situations and thus prevent them from learning to face and overcome their fears 5. Parents of socially anxious individuals tend to use shame to discipline their children or communicate that it is important to worry about what others think of one’s behavior or appearance

C. Important experiences may contribute to the development of social anxiety

1. A child or adolescent who is “different” in some way may be more likely to develop social anxiety, e.g., as a result of teasing for stuttering as a child 2. Man from working class background who became extremely anxious at wedding to daughter of wealthy parents and began to worry others would discover he “didn’t belong” or did not deserve his social and professional position 3. Having a panic attack or a situation where you became extremely anxious.

D. Genetics, family environment and important life experiences probably interact to cause social anxiety disorder in a given person

1. Not all factors equally important for everyone 2. Inherited tendency to be shy combines with experiences in the family and other life experiences to lead to particular ways of viewing the world and other people and, eventually, socially anxiety

E. Important factors in the client’s experience 1. Discuss the client’s responses to Where Did My Social Anxiety Come From? (Worksheet 3.1 in Client Workbook)

Expert Tips

Occasionally clients have

a lot of emotion,

including anger, regret or

shame, when talking

about their family or life

experiences. Using good

active listening skills can

help explore this

material. This

exploration should be

balanced with the

knowledge that such

discussions will be much

more fruitful later in the

context of cognitive

restructuring or core

belief work when the

client has the skills to use

this processing to make

changes.



Updated: 11/2019

2. Genetics, family environment, and important experiences 3. Pie chart graphing the relative contributions of each element in the client’s experience of social anxiety.

4. Everyone’s pie chart will look different. F. Emphasize the ways that social anxiety appears to have been learned

1. Summary of the causes of social anxiety. 2. Social anxiety disorder seems to result from a combination of an inherited tendency to be anxious and withdrawn from new situations that then interacts with certain types of experiences early in life

III. Introduce the SASCI A. Introduce idea of monitoring progress from week to week

A. Helps make sure client is making expected progress B. Helps to look at progress if feeling discouraged C. Explain SASCI, have client complete it and graph it.

IV. Homework 1. Complete Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook) 2. Read Chapter 4 of Client Workbook 3. Complete Brainstorming My Fear and Avoidance Hierarchy

(Worksheet 4.1) 4. Review the first three chapters of the Client Workbook, as needed

Expert Tips

Many therapists have the

SASCI available as clients

enter their office or clinic

so it can be completed in

the waiting room.

Make sure the client

understands that the

SASCI items relate to

how they were doing

before they started

treatment. It looks at

change from baseline

each week.

Pay attention to the

situations and thoughts

clients are recording on

Worksheet 2.4 each

week. This information is

very helpful for

construction of the Fear

and Avoidance Hierarchy

(Chapter 4) and cognitive

restructuring (Chapters 5

and 6).



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I. Review homework

A. Administer the SASCI and graph the ratings B. Assure that client can identify the three components of anxiety in his/her own experience C. Address any problems with compliance or completion of the homework D. Let client know that the SUDS Anchor Points and Brainstorming for Your Fear and Avoidance Hierarchy homework will be reviewed as we progress through the session.

II. Develop an Individualized Fear and Avoidance Hierarchy

A. Define and explain rationale 1. It is a rank ordered list of situations that evoke social anxiety 2. Rationale

a) Used to understand what makes a situation more or less anxiety-provoking

b) Helps guide selection of therapeutic exposures c) Used to assess progress in treatment

B. Step 1: Brainstorming 1. Refer to Worksheet 4.1 in Client Workbook, which client should have completed for homework, to begin generating situations that might appear on the hierarchy 2. Situations can describe a specific event (“attending high

school reunion”) or a more general category of social event (e.g., “conversations with strangers”)

3. Include situations that evoke mild, moderate, and severe anxiety 4. Emphasize situations that the client would like to address in

treatment

Expert Tips When reviewing homework for consider the following: Note any patterns in automatic thoughts across sessions. Gently inquire about a few thoughts underlying one or two superficial automatic thoughts and add any newly generated thoughts to the list (e.g. “What is bad about other people noticing you blush? What does blushing mean?”) If avoidance behaviors occurred, point out that avoidance is not surprising, given the automatic thoughts that the client was experiencing; also compassionately point out the longer term cost of avoidance (e.g., missed opportunities, feeling bad later). If the situation turned out better than expected, point out the contrast between that outcome and the automatic thoughts.



Weekly Social Anxiety Session Change (SASCI) Graph Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook)

Brainstorming for Your Fear and Avoidance Hierarchy (Worksheet 4.1 in Client Workbook)

SUDS Anchor Points

Practice Taking Off the Amber Color Glasses (Worksheet 5.1 in Client Workbook) Photocopies needed from Therapist Manual:

Fear and Avoidance Hierarchy (Worksheet 4.A in Therapist Manual)



Updated: 11/2019

C. Step 2: Discovering the Dimensions that Make a Situation Easier or Harder

1. Examine the list to identify situational dimensions that increase or decrease the difficulty 2. For items important to the client’s treatment goals, it can be worth asking if there are things that make that situation easier or harder and subdividing items as appropriate.

D. Step 3: Rate each situation for fear it evokes and the likelihood of avoidance

1. Explain fear (SUDS) ratings a) Wolpe and Lazarus’ Subjective Units of Discomfort Scale (SUDS) b) 0-100 scale, higher numbers indicate more discomfort or anxiety c) Subjectively define ratings of 0, 25, 50, 75, and 100 by identifying a situation that matches each description and recording it in Client Workbook if the client has not already done so

(1) 0 = No anxiety. Not necessarily happy but calm and relaxed (2) 25 = Alert but able to cope. A little “hyped up” (3) 50 = Anxiety is bothersome, some difficulty concentrating but still coping (4) 75 = extreme discomfort, thoughts of avoiding or escaping (5) 100 = worst anxiety has experienced or can imagine experiencing

2. Explain avoidance ratings on 0 – 100 scale with higher numbers indicating greater avoidance

a) Rating avoidance behavior, not emotions

b) Virtually all situations can be avoided, although sometimes cost is high (e.g., loss of job) c) Subtle avoidance occurs if parts of a situation are avoided and should lead to higher avoidance ratings (e.g., attending a party but only talking with familiar people)

3. Complete SUDS and avoidance ratings for each situation 4. If all hierarchy items produce high anxiety (e.g., 85 and above), create a couple additional items that produce moderate anxiety (i.e., SUDS of around 50)

E. Step 4: Rank Ordering the Situations 1. Rank order braining storming list with 1= most difficult (i.e.,

highest SUDS rating) 2. For items with the same SUDS, the situation with more avoidance is ranked higher 3. Rank ordering may reveal the need to subdivide some situations or change SUDS and/or the avoidance rating originally assigned.

Expert Tips

The well-prepared therapist

would have reviewed the

intake information, prior

goals and values work, and

previous homework

assignments prior to

session. In doing so, the

therapist would have

additional items ready to

add to the list of social

situations if the client gets

stuck or forgets about a

situation previously noted

as important.

For clients with generalized

social fears, it is often

helpful to include aspects

of many conversations such

as sharing personal

information, giving a

complement, stating an

opinion, expressing a

feeling, and so on rather

than just listing

“conversations.”

Briefly asking why a certain

dimension is more anxiety-

provoking aids case

conceptualization. That is,

we would expect the

client’s idiosyncratic belief

system (e.g., that men are

more critical than women

or that women are more

critical than men) to be

reflected in what makes

situations more or less

anxiety-provoking.

Additionally, this

conceptualization helps the

therapist predict how

anxious the client will

become in response to

various exposures.

Expert Tips

Sometimes a client will have difficulty making a rating for a certain item and say “It depends.” Clarify what “it depends” on, and then break the single item into one or more items for rating.



Updated: 11/2019

4. Transfer hierarchy situations to Worksheet 4.A from the Therapist Manual.

III. Homework A. Complete Monitoring the Three Components of Social Anxiety (Worksheet 2.4 in Client Workbook) B. Read Chapter 5 of Client Workbook C. Complete Practice Taking Off the Amber Color Glasses (Worksheet 5.1 in Client Workbook) D. Review the first three chapters of the Client Workbook, as needed.



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I. Review Homework and SASCI A. Assure that client can identify the three components of anxiety in his/her own experience B. Address any problems with compliance or completion of the homework C. Graph ratings from SASCI.

II. Illustrate the importance of cognition in social anxiety using parallel case vignettes with different outcomes depending upon thoughts about the events

A. Jerry recently moved to town to start a new job, interested in meeting new people and finding a woman to date

1. Set up neutral circumstances a) Arrives home from work and see attractive woman getting her mail, apparently having just arrived home from work as well b) Recognizes her as a next door neighbor but has never spoken with her c) Says hello, introduces himself, indicates he has just moved in d) She looks up from her mail briefly and says hello, then continues sorting through her mail

2. Jerry’s thoughts that will discourage further attempts to initiate a conversation

a) “She doesn’t want to talk with me.” b) “I’m bothering her.” c) “She thinks I’m weird or something.” d) “I’m so inept that I made a bad first impression just saying hello.”

3. Jerry’s emotional and behavioral responses to these negative thoughts

a) Feels anxious and uncomfortable b) Escapes the situation

4. Outcome of escape a) Anger - “She wouldn’t even talk to me.”


Social Anxiety Session Change Index (SASCI) Weekly Social Anxiety Session Change Graph (same copy as used last session)

List of thinking errors (Table 5.1 in Client Workbook

Monitoring Your Automatic Thoughts (Worksheet 5.2 in Client Workbook)

Expert Tips

The parallel scenarios with Jerry and Rich represent a core idea in this treatment approach – the importance of thoughts, rather than situations, in determining emotional and behavioral responses.



Updated: 11/2019

Expert Tips

b) Depression – “I’ll never meet anyone.”

B. Same neutral circumstances for Rich, except his thoughts in response to her initial brief hello are more positive

1. Rich’s functional/positive thoughts are equally valid based on the circumstances

a) “She must be expecting something important in the mail.” b) “Maybe she is tired from work. I’ll have to try a little harder.” c) “She is pretty dressed up. I’ll have to ask her about where she works.” d) “She might be a little hesitant to talk with a man she does not know.”

2. Emotional and behavioral outcome for Rich’s more positive thoughts

a) Makes another attempt at the conversation by commenting on the weather and asking if it is typical b) His attempt is met by further conversation on her part c) Ends with invitation for further contact d) Rich feels pleased about having made an acquaintance that could develop into something further

III. The relationship between events, thoughts, and feelings A. Use Figure 5.1 in the Client Workbook to develop the concept that

the concept that thoughts, beliefs and interpretations determine the emotional impact of an event, not the event itself, using the Jerry and Rich vignette.

1. Event/situation = woman’s lack of response 2. Thoughts, Beliefs and Interpretations =

a) Jerry’s belief was that she did not want to continue the conversation b) Rich’s belief was that she probably would want to continue the conversation but was temporarily distracted or tired

3. Feelings and Behavior = a) Jerry continued to be alone and felt angry and depressed b) Rich was excited about the beginnings of a possible friendship

B. It is not the events themselves that make a person anxious but how one interprets the events C. People with social anxiety become anxious, not because of the situation itself, but because of what they believe about the situation, the other person, or themselves

Expert Tips

It is helpful to draw Figure 5.1 together on the white board to re-emphasize the key points after reviewing the parallel scenarios.

It is helpful to draw out Figure 5.2 together on a white board if one is available to walk through the example together.



Updated: 11/2019

IV. Amber-Colored Glasses Metaphor for Dysfunctional Thinking Patterns – Figure 5.2 in the Client Workbook.

A. Explain the metaphor a. “Seeing the world through rose-colored glasses” means

seeing everything in a positive light.

i. Glasses act as a filter that only lets in positive things and negative information gets screened out.

ii. Neutral events are seen as positive. b. Socially anxious people act like they have amber-colored

glasses i. Amber is caution in traffic lights

ii. Amber-colored glasses are searching for threat or danger

1. Negative information is highlighted 2. Neutral information is seen as

threatening 3. Positive or safety information is screened

out. iii. One goal of treatment is to learn to take off

amber-colored glasses and see social situations as they really are.

B. Review vignette of Shemika who feared conversations. a. Shemika is fearful of conversations, especially not

knowing what to say and being unable to break silences. b. Across several in-session exposures, Shemika indicated

she had not performed well because of long pauses that were not obvious to the therapist.

c. In next conversation, roleplaying talking with a neighbor, therapist timed the pauses and found the longest was 4 sec and both speakers broke the silence even though Shemika believed the pauses to be a minute.

d. Amber-colored glasses (belief that she was not good at conversation and monitoring of pauses) distorted her perception of the conversation.

e. With practice, Shemika learned more accurately observe what was happening, e.g., taking off amber-colored glasses.

C. Practice Taking Off Amber-Colored Glasses Worksheet 5.1 in the Client Workbook

a. If client has completed Worksheet 5.1 before the session, review it together to check that they understand the concept and able to generate both anxious and non- anxious examples.

b. If client has not already attempted Worksheet 5.1, complete it together in session.

D. Consider how others might respond if they could see the negative thoughts in Worksheet 5.1

a. Other person might be sympathetic or reassuring if they

Expert Tips

The purpose of Worksheet 5.1 is to reinforce the idea that different interpretations are possible of the same event, leading to different reactions. This process can also help increase cognitive flexibility as clients practice taking different perspectives.

At this point, it is acceptable if clients do not believe the non- anxious options they are generating. Also, some clients may not experience anxiety in some of these examples so the reaction without the amber-colored glasses would be likely for them. This is especially helpful in illustrating how much the interpretation matters. Very anxious clients may have difficulty generating non-anxious responses so the therapist may need to offer suggestions to get the process started.



Updated: 11/2019

Expert Tips

knew about a socially anxious person’s anxious thoughts. b. Client might believe other person would judge them

negatively but most people have had moments of social anxiety themselves and can be empathetic.

V. Automatic thoughts a. Introduce concept of Automatic Thoughts (ATs) – “negative or irrational thoughts about oneself, the world, or the future.” 1. Socially anxious people have ATs that underlie their social anxiety 2. Learning to change ATs decreases anxiety

1. It is not about replacing negative thoughts with positive thoughts such as with affirmations. 2. Trying to suppress ATs makes them even more persistent, according to research on thought suppression 3. Goal will be to learn to question ATs to see if they are true or helpful

b. First step of cognitive restructuring is identifying ATs and the emotions they cause

i. Review thoughts from the Monitoring the Three Components of Social Anxiety (Figure 2.4 in Client Workbook) completed over the last few weeks

ii. How many “negative or irrational thoughts about oneself, the world, or the future” are listed?

iii. Often begin with “I’m…,” “I’m going to…,” or “He/she will think…”

iv. Look for thoughts that have a lot of emotion in them or contain emotional words or emotionally laden labels.

VI. Thinking Errors a. Thinking Errors are what make ATs “irrational”

1. “Irrational” means something is illogical or does not make sense when the AT is considered objectively 2. Some patterns in logical errors have been identified and these appear on the List of Thinking Errors in Table 5.1 of the Client Workbook.

b. Review List of Thinking Errors in Table 5.1 of the Client Workbook 1. Give examples of thoughts that exemplify each Thinking

Error

2. Many ATs may contain more than one thinking error 3. Clients who personally identify with several Thinking Errors

are not more severely impaired than others 4. Note that some thoughts are not illogical but are still

unhelpful as defined by the last item on the list of Thinking Errors

c. Practice identifying Thinking Errors with a case vignette (Beth) 1. Beth’s ATs that made her feel anxious and hopeless about getting the job

Expert Tips

In the past, cognitive restructuring often highlighted the role of cognition and ignored the role of affect. It is helpful to consistently tie ATs to the emotional consequences for two reasons. First, ATs without significant emotional consequences are probably not the ones that should be the focus of treatment. Secondly, seeing the relationship between ATs and emotions helps the client build confidence that changing ATs can be helpful.



Updated: 11/2019

a) “I must make a good first impression or they won’t hire me.”

(1) Should Statement (2) All-or-Nothing Thinking (3) Fortune Telling

b) “They are going to think I don’t have enough experience.”

(1) Mind Reading (2) Disqualifying the Positive (3) Fortune Telling

c) “I’ll never find another job as perfect as this one would be.”

(1) Catastrophizing (2) All-or-Nothing Thinking

d. Practice identifying Thinking Errors in the client’s ATs recorded for homework on the “Cognitive Component” column of the Monitoring the Three Components of Anxiety form (Worksheet 2.4 in the Client Workbook).

VII. Assign Homework a. Using form in Worksheet 5.2 in the Client Workbook (Monitoring My Automatic Thoughts), identify ATs in a situation that arises during the week and the emotions they evoke

i. Try to come up with at least five thoughts. ii. Rate on a 0-100 scale how strongly you believe the idea

that is expressed in the thought iii. Indicate what emotion(s) you were feeling in the situation. iv. Complete sheet when cognitions are fresh

1. When anticipating a situation 2. As soon after a situation occurs as possible

v.If no situations arise, imagine one that occurred in the past and record ATs and emotions

b. Read Chapter 6 in Client Workbook

Expert Tips

It is easier to categorize thoughts that are declarative statements. In other words, what does she think of me? or I wonder what she thinks of me is difficult to work with now and in future cognitive restructuring. Gently work with the client to get to underlying thoughts that are making these anxiety-provoking such as She thinks I’m weird or She’s noticing me blush.

Most clients are able to identify their thoughts by this point in treatment. If a client continues to have difficulty giving specific thoughts, see the material in Chapter 5 of the Therapist Guide for troubleshooting tips.



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I. Review homework

A. Administer the SASCI and graph the ratings B. Check in regarding whether the client completed Monitoring My Automatic Thoughts (Worksheet 5.2) as homework

1. If completed, let client know that it will be discussed later in the session 2. If not completed, have the client complete it now

II. Explain challenging ATs using Disputing Questions A. Review steps in cognitive restructuring so far

1. Identifying ATs and the emotions they cause

2. Identifying Thinking Errors in the ATs 3. Next step is to use the Disputing Questions to ask and answer questions to challenge the logical errors in the ATs

B. Becoming a scientist who analyzes the ATs 1. Analyze what ATs mean and determine whether they are logical 2. Conduct experiments to see if the ATs are true

C. Disputing Questions (Figure 6.1 in the Client Workbook) 1. These all-purpose questions can be used to challenge ATs but do not hesitate to deviate from this list

2. Use Disputing Questions by putting ATs in the blank 3. Emphasize that it is essential to answer the question. It is the answers to the questions that matter.

D. Practice using Disputing Questions for the case of Beth 1. Help client challenge the three ATs used for the Thinking Errors exercise with Beth from Chapter 5 in the Client Workbook 2. Follow through with several Disputing Questions and answers with one thought until a more rational, adaptive point of view is reached 3. Point out how emotions change as thinking becomes more

Timeline: Typically one to two sessions Reading: Chapter 6 in Client Workbook Photocopies needed from Client Workbook:


Weekly Social Anxiety Session Change (SASCI) Graph

Monitoring My Automatic Thoughts (Worksheet 5.2 in Client Workbook)

List of Thinking Errors (Table 5.1 in Client Workbook)

Disputing Questions (Figure 6.1 in Client Workbook)

Practice Using Anxious Self/Coping Self Dialogue (Worksheet 6.1 in Client Workbook)

Cognitive Restructuring Practice (Worksheet 6.2 in Client Workbook)

Expert Tips

Instead of using the case of

Beth to practice using

disputing questions for the

first time, the therapist may

present a situation from

their own history (e.g., a

job interview, a

professional presentation)

to generate ATs. The client

labels the thinking errors

and then poses disputing

questions. The therapist

models providing rational

answers. These answers are

written down and

contrasted with the original

ATs. This same scenario is

used for developing a

rational response. The

therapist shows that

anxiety is a normal part of

the human experience and

models coping

appropriately with it

through this exercise.



Updated: 11/2019

adaptive

E. Practice using Disputing Questions for homework ATs 1. Use Practice Using Anxious Self/Coping Self Dialogue worksheet (Figure 6.1 in Client Workbook) to guide challenge of 2-3 ATs from homework 2. Follow through with several Disputing Questions and answers with one thought until a more rational, adaptive point of view is reached 3. Note that some answers to Disputing Questions contain their own ATs that need to be challenged 4. Point out how emotions change as thinking becomes more adaptive 5. Assure that the Disputing Question is answered, not just asked

III. Explain using Rational Responses in cognitive restructuring A. Review steps in cognitive restructuring so far

1. Identifying ATs and the emotions they cause 2. Identifying Thinking Errors in the ATs 3. Use Disputing Questions to ask and answer questions to challenge the logical errors in the ATs 4. Next step is to develop a Rational Response to combat the ATs when they occur

B. Rational Response is a coping statement that summarizes the dialogue with the Disputing Questions

1. Use Rational Responses to respond to ATs when they occur in anxiety-provoking situations 2. Qualities of a good Rational Response

a) Positive (or at least neutral) view of the situation or symptoms b) Short c) Realistic, not overly positive

3. Do not need to believe the Rational Response at first, but if the client keeps an open mind, it will help chip away at anxious beliefs 4. Examples

a) does not equal . b) “The worst that can happen is , and I can live with that.” c) “The worst that can happen is , and that is unlikely.” d) Reasonable goals such as “I only have to say hello.” e) Permission to show anxiety or make mistakes “It is OK to .”

5. Practice developing Rational Responses for ATs from vignette 6. Practice developing Rational Responses for homework ATs

Expert Tips

When a client answers a

disputing question with

an AT, it is helpful for the

therapist to explicitly

label that new thought

as an AT. The client may

then ask a disputing

question of this new AT

or return to the original

one. In either case, the

client takes the lead on

asking the disputing

questions and answering

them. The therapist may

also need to gently

remind the client that

the purpose of the

exercise is to give

consideration to

alternative perspectives.

However, it is not

necessary for the client

to believe the alternative

perspectives 100% at this

point.



Updated: 11/2019

IV. Assign Homework: A. Practice the first 4 steps of cognitive restructuring using Worksheet 6.2 in Client Workbook (Cognitive Restructuring Practice).

1. List several ATs and emotions for an anxiety-provoking situation during the week 2. Identify Thinking Errors for all ATs 3. Pick 1-2 ATs and do Anxious Self/Coping Self dialogue using Disputing Questions 4. Summarize key points from Anxious Self/Coping Self Dialogue 5. Develop 1-2 Rational Responses 6. If no situations arise, imagine one from the past

B. Read Chapter 7 in Client Workbook if in-session exposures are to

begin in the following session. If a second session is devoted to this material, withhold the assignment of that reading for a week.

V. Anticipation of Exposure Next Session A. Inform client that the next session will include an exposure in the session

1. Exposure is graduated so it will not be the highest situation on the Fear and Avoidance Hierarchy 2. Will use cognitive restructuring skills before, during, and after to help cope with anxiety 3. Moving to exposure is a sign that treatment is “on schedule” and that the client is making appropriate progress

B. Address anticipatory anxiety about exposure 1. Acknowledge that anticipatory anxiety is normal 2. Encourage coping with anticipatory anxiety about the exposure through the use of cognitive restructuring skills 3. Emphasize the need to attend next session as it is easy to avoid

Expert Tips

There is a careful balance of letting clients know that exposure is coming but also not frightening clients so they avoid the next session. If they seem especially alarmed, it is useful to spend a few minutes in cognitive restructuring to help them cope during the week. They can continue to practice on their own as well. Also, therapists should be careful not to promise a certain situation will be used for the first exposure. It is helpful to maintain as much flexibility as possible depending on what their level of anxiety in the next session. Also, too specific of a commitment can cause the highly anxious client to spend the week overly focused on the situation or even developing a rationale of why they do not need to practice that situation.



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I. Review Homework and SASCI A. Graph ratings from SASCI B. Review homework

1. Briefly discuss the Cognitive Restructuring Practice (Worksheet 6.2 in Client Workbook). 2. Ask the client briefly about what from the reading was of particular interest and/or about questions (do not review in detail)

II. Briefly revisit rationale for exposures A. Exposures will proceed in a graduated fashion

a. Easier situations to harder b. In session exposures first, then real life situations

B. How therapeutic exposure is helpful a. Practice

i. You will have a chance to do things that you might not have done much, which will make doing them again later easier

ii. You will get feedback on how you did iii. You may get suggestions for how you might

improve if that is relevant b. Identification of ATs: Your most powerful ATs may only be

accessible in the middle of an anxiety-provoking situation c. Testing ATs: Going through situations to see if ATs are

accurate

III. Complete first in-session exposure A. Briefly outline situation with client and have him/her imagine it

briefly a. Should be a situation from the 40 – 60 SUDS range

Timeline: One 90-minute session Readings from Client Workbook: Chapter 7 Photocopies needed from Client Workbook:

Social Anxiety Session Change Index (SASCI) (Worksheet 3.3 in Client Workbook) Weekly Social Anxiety Session Change Graph (same copy as used last session)



Be Your Own Cognitive Therapist (BYOCT) Worksheet (Worksheet 7.1 in Client Workbook) Photocopies needed from Therapist Guide:

Form for Recording Key Information During In-Session Exposures That Can Serve as Session Progress Note (Figure 7.B in the Therapist Guide)

Expert Tips

In clinical settings where it is impossible to extend the session beyond 50 minutes, you can complete the first exposure in that time frame. However, if at all possible, we highly recommend that you schedule this session for 90 minutes so that you do not have to rush orienting the client to this new procedure.

For the homework review, unless something truly remarkable happened (e.g., death of an immediate family member), even an unusually stressful week should be only briefly processed. Additionally, unlike other sessions, incomplete homework is briefly commented upon but not completed in session. Instead, move on to the exposure procedure. Otherwise, you are likely reinforcing avoidance behavior.



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b. Should be relevant to client’s therapy goals

c. Should be relatively easy to set up in the therapy setting B. Cognitive restructuring

1. Identify 5-6 ATs client is having about the situation and emotions they are causing

a) Have client rate belief in AT on a scale from 0 to 100 (optional)

2. Select 1-2 ATs for further analysis 3. Help client identify Thinking Errors in the selected AT(s) 4. Help client challenge selected AT(s) using Disputing Questions 5. Help client develop a Rational Response and record on board or paper where client will be able to see it during the in-session exposure

a) Have client rate belief in Rational Response on a scale from 0 to 100 (optional)

C. Work out the details of the exposure situation 1. Setting/circumstances 2. Roles for various people 3. Any props needed

D. Set an Achievable Behavioral Goal 1. Do-able 2. Observable and objective 3. Focused on behavior, not feelings of anxiety (or their absence)

E. Just before beginning in-session exposure 1. Inform client that therapist will be asking for SUDS ratings and review SUDS scale 2. Inform client that he/she will be asked to repeat the selected Rational Response aloud (and to focus briefly on the significance of its content) each time he/she is prompted for SUDS rating 3. Brief any role players as necessary

F. Exposure 1. Complete in-session exposure 2. Take SUDS at 1-minute intervals, trying to minimize disruption 3. As necessary, help client focus on Rational Response (and the significance of its content) 4. Criteria for stopping the exposure

a) Duration of 5-10 minutes b) SUDS have leveled off or are decreasing c) Achievable behavioral goal has been met

G. Debriefing the Exposure Experience (Debriefing can include any or all of these steps, but should always include #1)

1. Review Achievable Behavioral Goal 2. Prompt client to reward self for doing something difficult, pointing out Disqualifying the Positive if it occurs 3. Evaluate whether the things client feared actually happened.

Expert Tips

In addition to noting SUDS ratings, the therapist should also tally or make notes relevant to the goal. For example, if the client has the goal of asking two questions, the therapist should tally each time a question is asked. The therapist will provide the client with this objective feedback during the debriefing when goals are reviewed.

Therapists do not have to rigidly stick to asking for SUDS at one minute intervals. If something therapeutically relevant is happening during the exposure (e.g., the client was just asked to share his/her opinion), it is a good idea to take a SUDS rating at that point, even if it is not at the one- minute mark.



Updated: 11/2019

a) If not, emphasize that fact!

b) If so, help client think about whether they coped better than expected and what was learned.

4. Review other ATs, if any

a) Did the expected ATs occur? b) Evaluate how well the Rational Response worked to combat these ATs. Revise as needed. c) Did unexpected ATs occur?

(1) Challenge these ATs as time permits (2) Catalog unexpected ATs to challenge in future exposures

d) Re-rate belief in ATs and Rational Response (optional)

5. Review pattern of SUDS a) Identify patterns (e.g., initial rise followed by later decline) b) Link increase in SUDS to ATs c) Link decreases in SUDS to adaptive thinking or action

6. If client is being self-critical, encourage self-compassion and kindness 7. Help client identify what they can take from the experience to use in the future

IV. Assign Homework: A. Assign exposure homework

1. Negotiate a do-able exposure, typically related to the in- session exposure but less anxiety-provoking 2. Assure the client agrees to do it 3. Emphasize importance of using the BYOCT Worksheet for cognitive restructuring before and after the homework exposure 4. Record specific situation on the BYOCT form 5. Develop a back-up plan in case it is not possible for the client to carry out the planned exposure

B. Emphasize that the client should call if there is difficulty completing the exposure homework C. Read Chapter 8

Expert Tips

The therapist provides feedback to the client after the client has shared his/her perception of how the exposure went. Therapist feedback is biased toward the positive (but not to the point of not being credible). If appropriate, one problem behavior (e.g., very brief answers) during the exposure may be identified and pointed out as a function of avoidance and/or ATs. The therapist and client develop an achievable behavioral goal relevant to this problem for future exposures. NOTE: The BYOCT form is for homework, not in-session exposures. Using the BYOCT in session disrupts the flexibility of good cognitive restructuring to follow the most productive paths to help clients make cognitive change.



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I. Review Homework and SASCI A. Graph ratings from SASCI (on occasion)

1. Examine BYOCT Worksheet and discuss client’s experience completing the exposure 2. Reinforce the fact client faced his/her fears in a real situation 3. Reinforce completion of cognitive restructuring activities before and after the exposure 4. Troubleshoot any lack of compliance with the homework exposure

II. The ongoing routine of exposure 1. Last session was first in-session exposure. That routine will continue in the coming weeks

1. From easier (less anxiety-producing) to harder (more anxiety-producing) situations 2. From less complex to more complex situations 3. From more superficial ATs to ATs related to your core beliefs about yourself and the world 4. From working on anxiety in session with therapist to working on anxiety on your own

2. Continue to use homework for exposure to assure treatment gains transfer to real life

III. Complete second in-session exposure 1. Briefly outline situation with client and have him/her imagine it briefly 2. Cognitive restructuring

1. Identify 5-6 ATs client is having about the situation and emotions they are causing

Timeline: Typically 5-6 sessions but can vary up to 10 sessions or more depending upon the number of in- session exposure needed for a given client and the efficiency with which material in earlier segments has been covered Readings from Client Workbook: Chapter 8 Photocopies needed from Client Workbook:

Social Anxiety Session Change Index (SASCI) (Worksheet 3.3 in Client Workbook) Weekly Social Anxiety Session Change Graph (same copy as used last session)


Disputing Questions (Figure 6.1 in Client Workbook) Photocopies needed from Therapist Guide:


B. Review exposure homework

Expert Tips

Beware that SASCI scores may actually increase during this phase of treatment, especially among clients who are more highly avoidant who are being asked to confront situations they fear.

See Chapter 8 of the Therapist Guide for suggestions on possible directions to pursue when clients do not follow through with homework assignments which they have agreed to complete.

See Chapter 8 of the Therapist Guide for discussion of how to deal with various issues when conducting exposures. These include clients not getting anxious during in- session exposures, clients becoming increasingly fearful during in-session exposures, and clients who have difficulty with cognitive restructuring, among others.



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a) Have client rate belief in AT on a scale from 0 to 100 (optional)

2. Select 1-2 ATs for further analysis

3. Help client identify Thinking Errors in the selected AT(s)

4. Help client challenge selected AT(s) using Disputing Questions

5. Help client develop a Rational Response and record on board or paper where client will be able to see it during the in-session exposure

a) Have client rate belief in Rational Response on a scale from 0 to 100 (optional)

3. Work out the details of the exposure situation 1. Setting 2. Circumstances 3. Roles for various people 4. Any props needed

4. Set an Achievable Behavioral Goal 5. Just before beginning in-session exposure

1. Remind client that therapist will be asking for SUDS ratings and review SUDS scale 2. Remind client that he/she will be asked to repeat the selected Rational Response (and to focus briefly on the significance of its content) each time he/she is prompted for SUDS rating 3. Brief any role players as necessary

6. Exposure 1. Complete in-session exposure 2. Take SUDS at 1-minute intervals, trying to minimize

disruption 3. As necessary, help client focus on Rational Response (and the significance of its content)

7. Debriefing the Exposure Experience (Debriefing can include any or all of these steps, but should always include #1)

1. Review Achievable Behavioral Goal 2. Prompt client to reward self for doing something difficult, pointing out Disqualifying the Positive if it occurs 3. Evaluate whether the things client feared actually happened.

a) If not, emphasize that fact! b) If so, help client think about whether they coped better than expected and what was learned.

4. Review other ATs, if any a) Did the expected ATs occur? b) Evaluate how well the Rational Response worked to combat these ATs. Revise as needed. c) Did unexpected ATs occur?

(1) Challenge these ATs as time permits (2) Catalog unexpected ATs to challenge in future exposures

d) Re-rate belief in ATs and Rational Response

Expert Tips

This same procedure for in-session exposures continues through most sessions for the remainder of the treatment. It will become routine for both the client and therapist. Over time, the client can take more and more responsibility for each step. It is similar to the steps on BYOCT form (Worksheet 7.1 that clients will be using each week for in vivo homework exposures.



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(optional) 5. Review pattern of SUDS

a) Identify patterns (e.g., initial rise followed by later

decline) b) Link increase in SUDS to ATs c) Link decreases in SUDS to adaptive thinking or action

6. If client is being self-critical, encourage self-compassion and kindness 7. Help client identify what they can take from the experience to use in the future

IV. Assign Homework: 1. Assign exposure homework

1. Negotiate a do-able exposure, typically related to the in- session exposure but less anxiety-provoking 2. Assure the client agrees to do it 3. Emphasize importance of using the BYOCT Worksheet for cognitive restructuring before and after the homework exposure 4. Record specific situation on the BYOCT form

2. Assign a small daily homework assignment to make managing anxiety a new habit

1. Rationale a) Get in the new habit of facing fears rather than avoiding b) Larger changes build upon small ways of handling situations differently on a regular basis

2. Examples a) Say “hello” and one other thing to a person you would not normally speak with b) Send one email or text that you would usually put off for another day because you are anxious about it c) Give someone a compliment when you normally would not say anything d) Speak up one extra time in a group of people or at a meeting e) Ask someone an appropriate, non-intrusive question about himself or herself that will help you get to know the person a little better f) Make an effort to do some small task when others may be observing, such as pour someone’s coffee, put change in a vending machine, unlock a door, drive with someone in the car, write a check rather than pay cash, etc. g) In a coffee shop or a restaurant, ask a question about the menu or ask for a change in your order h) Post on social media or send an email without rechecking it

Expert Tips

Many clients complete the same small daily assignment across the rest of treatment. It becomes a habit and part of their daily routine. Whatever is picked for this session, should be re-evaluated later to see if it is still the best choice for meeting long term treatment goals. For example, an early assignment might be “say hello and one other thing to someone you would not usually talk with.” Later, for someone working on dating fears, a better daily assignment might be “say hello and 1-2 other things to someone who could be a potential dating partner.” This change would be helpful if they tend to avoid starting the types of conversations they most want to have.



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3. OK to pick a small gesture that is only mildly anxiety- provoking 4. Client may notice other people start to treat him/her

differently 3. Read Chapter 9



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I. Review Homework and SASCI A. Graph ratings from SASCI. B. Review exposure homework

1. Examine BYOCT Worksheet and discuss client’s experience completing the exposure 2. Reinforce the fact client faced his/her fears in a real situation 3. Reinforce completion of cognitive restructuring before and after the exposure 4. Troubleshoot any lack of compliance with the homework exposure

C. Briefly discuss how one or more of the procedures described in the readings (Roman Numerals II through VII below) might fit into the client’s treatment prior to conducting an in-session exposure

II. Examining the Likelihood of Negative Social Events A. Socially anxious people overestimate the likelihood of negative social events B. Pie Chart Technique is used to address the likelihood of a feared outcome, especially negative judgments based on observation of a physical symptom of anxiety (e.g., blushing, sweating, shaking)

1. After drawing a circle, the first piece of the pie typically represents the possibility that the client will not have the symptom at all (often 10% or more of the pie) 2. The second piece of the pie often represents the symptoms being present but others not noticing for a variety of reasons such as it not being severe enough to notice, the other person being distracted by something like their cell phone, and so on (often 25% or more of the pie)

Timeline: This chapter is assigned as reading homework, and the content is covered briefly as part of a homework review during an exposure session (rather than spending a full session discussing this chapter). From this point in therapy forward, this chapter may be used to help generate ideas for exposures. Readings from Client Workbook: Chapter 9 Photocopies needed from Client Workbook:

Social Anxiety Session Change Index (SASCI) (Worksheet 3.3 in Client Workbook)

Weekly Social Anxiety Session Change Graph (same copy as used last session)




Form for Recording Key Information During In-Session Exposures That Can Serve as Session Progress Note (Figure 7.B from the Therapist Guide)

Expert Tips

We typically work on the issue of likelihood in early exposures and progress to issues of consequences in later exposures.



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3. Multiple pie pieced are devoted to others noticing the

symptom but having benign reactions such as being compassionate about anxiety, attributing the symptom the effect of a medication, attributing the symptom to a physical illness, and so on 4. The last remaining piece is small and devoted to the feared outcome (e.g., 5% conclude that the symptom is a sign of incompetence or weakness) 5. A rational response is developed that reflects the idea that the feared outcome is unlikely

III. Examining the Cost of Negative Social Events A. Socially anxious people overestimate how bad it will be if negative

social events occur B. The Continuum Technique can help put a feared outcome into

proper perspective a. Draw a line b. On the left side of the line, list something unpleasant but

not very serious like stubbing your toe or getting a paper cut

c. On the right side of the line, list the absolutely worst thing that could happen to the client (usually it is best to pick something horrible happening to a client’s loved one)

d. Ask the client to consider how serious their feared social outcome is in the larger picture of his/her life and make a corresponding mark on the continuum

e. Develop a rational response that puts the feared outcome into perspective

i. RR: Even if happens, I still have the most important thing in my life – my family

ii. RR: If happens, it will be unpleasant, but I can live through it

iii. RR: Even if happens, I can cope with it and move on with my life

IV. Separating Anxiety and the Experience of Stigma A. The social anxiety that is the target of this treatment involves fear

of other people that is out of proportion to the actual danger of the given social situation

B. Sometimes, people have characteristics that lead them to be marginalized and hurt by other people a. Characteristics include but are not limited to gender identity,

sexual orientation, sex, race, religion, physical disability, obesity, nationality, etc.

b. Simply avoiding people who may stigmatize the client may not be possible or may not be desired by the client

C. Only thoughts that are unrealistic are the target of cognitive restructuring; thoughts that reflect the realities of being a member of a marginalized group are not restructured

Expert Tips

The key to making the Continuum Technique work is to get the endpoints as extreme circumstances. Sometimes clients will want a fear social outcome as the most negative event but it is essential to have them pick something that is “worst” in the overall context of their lives, even if it is extremely unlikely. The most common one we have used is “all of your family dying in a car accident.”

The example in the book is about a transgender woman but a similar approach could be used for any marginalized identity. The Introduction of the Therapist Guide has further material on using this treatment in a multicultural context, including citations to additional resources.



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D. The Me-Not Me Technique is used to develop a rational response to situations in which stigma is likely relevant

a. In the “Me” column, list how the client can act consistent with his/her values in the face of stigma (e.g., remain respectful) and list safety plan considerations as well (e.g., drive self to the event, bring a cell phone, enlist the help of a supportive person)

b. In the “Not Me” column, list things that are the product of stigma and not the client’s responsibility (e.g., rude comments, shunning, other people’s discomfort)

c. Develop a rational response that facilitates coping that is consistent with the client’s values and reminds them of the Me-Not Me exercise

E. Beyond the situation targeted with the Me-Not Me exercise a. Work with the client to develop a life that includes accepting

and supportive people as a balance against the stress of dealing with stigma, discrimination, and prejudice

b. Have the client consider whether he/she might like to become involved in social justice activities aimed at reducing bias

c. Have the client consider whether discrimination needs to be addressed via formal complaints and/or legal action

V. Including Feared Outcomes in Exposures A. Socially anxious people overestimate how bad it will be if negative

social events occur B. Including feared outcomes in exposures can help put a feared

outcome into proper perspective and help the client understand that they can cope with the feared outcome better than they might have predicted

a. Identify the feared outcome for a social situation b. Engineer an in-session exposure to make sure that the

feared outcome occurs (e.g., the client is rejected after asking for a date)

i. Often, these in-session exposures are rather short and can be repeated multiple times with slight variations

1. After one short exposure ends, immediately start again rather than doing post-processing after each short exposure (e.g., the role-player has a significant other, the role-player thinks of the client as a friend, the role-player is busy that weekend but would be interested in going out some other time)

2. The one post-processing at the end will cover all mini exposures conducted in a row

c. In addition to whatever rational response was used during the exposure, consider proposing new rational responses

Expert Tips

We usually have a few exposures to a feared situations without feared outcomes occurring first. These initial exposures provide corrective information regarding likelihood/overestimation of negative social events. We then move on to helping clients directly address their feared outcomes. Additionally, a social situation that produces a feared outcome is likely higher on the client’s hierarchy.



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based on what was learned from facing the feared outcome; this rational response may be used for the real-life homework assignment

i. RR: It is OK if (I blush, my hand shakes, I make a mistake, etc.)

ii. RR: If happens, I can handle it and move on d. Develop a homework assignment that involves the client

facing the feared outcome

VI. Learning How to Cope with the Physiological Component of Anxiety A. Socially anxious people overestimate how bad it will be if they

become very anxious or panic during a feared social situation. B. Inducing physiological symptoms intentionally during exposures is

helpful for several reasons a. It can help the client understand that they can persist

with the social task at hand irrespective of physiological arousal

b. It can help the client understand that physiological arousal typically declines over time

c. It can help the client understand that other people are not as judgmental about their physiological arousal as they expect

C. Prior to the in-session exposure, have the client run in place or do some other exercise (e.g. rapidly walking stairs) in order to produce noticeable physiological arousal

a. Ideally, one or more therapists in the clinic would serve as role-players in the exposure; they would not be told that they client is exercising prior to the exposure

b. The client is explicitly told not to tell the audience that they were just exercising i. This would be considered a safety behavior that could

undermine the exposure ii. The client is typically afraid that the audience will

attribute their physiological arousal to anxiety, which they equate with something like weakness; therefore explaining to the audience that they were just exercising would prevent them from fully facing what they fear

c. In post –processing, we ask the role-players for their honest reactions to the whole exposure, which typically results in the audience members talking about a variety things and perhaps mentioning the physiological arousal in passing i. We would query whether noticing the arousal was

equated by the audience with the feared outcome (e.g., physiological arousal = incompetence)

ii. We would point out that performance is rarely judged solely on anxiety level

Expert Tips

This procedure is a variation of facing feared outcomes (the feared outcome is becoming extremely physiologically aroused in a social situation). As with that procedure, we typically first have several exposures where the client confronts feared social situations and confronts the naturally resulting physiological sensations. Intentional induction of physiological symptoms typically occurs in later exposures.



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d. In addition to whatever rational response was used during the exposure, consider proposing new rational responses based on what was learned from facing the feared

outcome of experiencing a great deal of physiological arousal during a social situation; this rational response may be used in real-life homework assignments

i. RR: I can be anxious AND (give a speech, carry on a conversation, etc.)

ii. RR: Most people will still accept me if I (sweat, shake, etc.)

iii. RR: It is OK to (make a mistake, tremble, stumble over my words, etc.)

e. Discuss what a cruel response to the client’s social anxiety means i. The client is merely having a human reaction that

communicates that he or she cares what others think ii. The person making the cruel response is the one who

has done something that reflects poorly upon him- /herself

iii. In this way, there is some overlap with stigma and the Me-Not Me intervention as well

VII. Be a Scientist A. Socially anxious people overestimate how visible their anxiety is

and underestimate the quality of their social performance B. During an in-session exposure, the client, therapist, and any

additional role-players silently make ratings of the client’s SUDS, specific aspects of the client’s performance that the client is concerned about (e.g., hands shaking, stumbling over words, fidgeting), and the overall quality of the performance

a. Performance scale ranges from 0 = disastrous performance to 100 = performance of a typical person in that situation

b. Physiological symptom scale ranges from 0 = symptom (e.g., hand tremor) at a level similar to most people engaging in that activity to 100 = symptom at a level where someone should call for medical assistance

C. During post-processing, all ratings are revealed and graphed D. The discrepancies between client and observer ratings and the

lack of a strong correlation between anxiety and performance can lead to a variety of rational responses that can be used during future social situations

a. RR: (my tremor, blushing, stuttering, etc.) is not as obvious to others as it is to me

b. RR: (shaking, stumbling over words, etc.) does not equal poor performance

VIII. Conduct an In-Session Exposure

Expert Tips

Also see Chapter 9 in the Therapist Guide for Video Feedback, which is a similar procedure but involves making ratings before and after viewing a recording of a previous in-session exposure.

We only use this “silent SUDS” procedure with clients that we have engaged in 2-3 in-session exposures. We are looking for clients who have performed within the normal range in terms of social skills. We are also looking for client who continue to report significant concerns about appearing anxious that seem well out of proportion to the observable anxiety. We do not use this procedure with clients with very poor social performance and/or very visible anxiety symptoms.



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IX. Assign homework: A. In vivo exposure with cognitive restructuring

a. Ideally incorporate one of the techniques presented in

this chapter in homework or in the planning of next week’s in-session exposure B. Instruct the client to continue small daily assignments C. Read Chapter 10 of the Client Workbook



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II. Rationale behind covering Chapters 10 and 11 in session A. Even if client is not anxious in conversations (Chapter 10) or public

speaking (Chapter 11), there are ATs and strategies for cognitive restructuring that will be useful for most clients.

B. Vary time spent in session on the content depending on how relevant it is to the client’s own social anxiety and overall treatment goals.

III. Importance of small talk A. Definition

1. Small talk is any short casual conversation about superficial or impersonal topics 2. Most people with social anxiety tell us that they hate small talk 3. Examples:

a) Complimenting your neighbor on the beautiful flowers on her patio as you leave for work b) Asking a co-worker whether he did anything fun this weekend




List of thinking errors (Table 5.1 in Client Workbook)

Disputing Questions (Worksheet 6.1 in Client Workbook)



Expert Tips

The Client Workbook for this chapter has many of the most common ATs that we have seen for conversational fears. Certainly, there are many ways to challenge a given AT and different clients may have somewhat different means for the same AT, requiring different approaches. However, the examples in this chapter are a good place to start.

Many therapists, especially novice ones, can find ATs about experiencing marginalization especially challenging to address. In addition to the Me-Not me example in Chapter 9, this chapter contains an example of how a client might use valued goals to help them figure out how and whether to enter a potentially marginalizing situation.



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c) Commenting to someone else in line at the takeout counter that the restaurant seems fairly quiet today. d) Commenting to someone while waiting for the instructor to arrive that the class is interesting but more work that you had expected it to be e) Striking up a conversation with a sales clerk by asking whether he or she has heard if the weather will be warm this weekend

B. Purpose of small talk 1. Used to initiate and/or maintain social relationships

a) All friendships and dating relationships start with small talk b) Helps develop a relationship as repeated casual conversations become more serious

2. Social psychologist Donn Byrne’s research suggests friendships and relationships develop with those who are nearby as a result of casual conversations

IV. Complete in-session exposure (per session outline in Chapter 7 of this Therapist Guide)

V. Assign homework C. In vivo exposure D. Instruct the client to continue small daily assignments E. Read Chapter 11



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II. Public speaking anxiety is common A. #1 fear experienced by the general public B. Extremely common (90%+) among individuals with social anxiety

1. Often seek treatment for other fears such as dating because these fears interfere more in their life

C. May more forms of public speaking than just giving formal presentations

1. See list in Client Workbook Chapter 11 a few examples: a) telling a joke to a group of people who are sitting

around talking b) serving as the chairperson for a committee meeting at

work c) offering a prayer aloud during a religious service d) making a toast at a wedding reception or other

celebration e) telling a story of an interesting experience to a group

of people

Timeline: Typically one session; may be more or less depending on client’s presenting concerns Readings from Client Workbook: Chapter 11 Photocopies needed from Client Workbook:

Social Anxiety Session Change Index (SASCI) (Worksheet 3.3 in Client Workbook)




Be Your Own Cognitive Therapist (BYOCT) Worksheet (Worksheet 7.1 in Client Workbook)

Peeling Your Onion – Discovering and Challenging Your Core Beliefs (Worksheet 12.1 in Client Workbook)

Photocopies needed from Therapist Guide:

Figure 7.B Form for Recording Key Information During In-Session Exposures That Can Serve as Session Progress Note (Therapist Guide, p. 92)



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f) giving a report during a meeting

g) explaining how to do something to a group of people h) being called on to answer a question in a class i) making a presentation in a class

2. These other situations allow work on public speaking gradually without giving a major speech right away

III. In-session exposure sequence A. Consistent with the general approach of graduate exposure

used in this treatment, clients specifically working on public speaking anxiety can progress from easier to harder situations, consistent with their treatment goals.

B. See Chapter 11 of Therapist Guide for a typical sequence of several exposures for a client with anxiety about speaking at meetings and who occasionally needs to make formal presentations.

C. Many of the strategies in this chapter will also be helpful for clients for whom public speaking anxiety is only one aspect of their social anxiety.

IV. Assign homework:

A. In vivo exposure 1. Client may need to devote some effort to finding settings in which they may have the opportunity to engage in personally relevant public speaking activities on a regular basis.

B. Instruct the client to continue small daily assignments C. Read Chapter 12 of the Client Workbook, if the client is ready for advanced cognitive restructuring

1. Complete Worksheet 12.1 in the Client Workbook (Peeling Your Onion – Discovering and Challenging Your Core Beliefs)

Expert Tips Assembling an audience for public speaking exposures can be challenging at times. Here are some things to keep in mind: If your client fears being the center of attention, the audience need not be large, sometimes just yourself or yourself plus only 1-2 others will be enough.

Using a lectern and arranging the chairs to simulate an audience may be helpful even if the audience fails to fill the chairs.

It is often a viable alternative to set up a video camera (or even use a smartphone camera for the purpose) as that may elicit sufficient anxiety. it may also be useful for the provision of video feedback as well.

Sometimes moving the exposure to a more formal setting can be helpful.

Sometimes the client fears a circumstance that is not possible to simulate well, as might be the case for a client who is only fearful about speaking before large audiences. In that case, imaginal exposure with cognitive restructuring might be a viable alternative. See Chapter 11 of the Therapist Guide for further discussion of the use of imaginal exposure for public speaking fears, as well as other tips for in-session and homework exposures.

The difficulty of the public speaking exposure can be manipulated by using the dimensions that underlie a client’s fear. Typically these include amount of preparation, questions or other challenges from the audience, reading versus speaking spontaneously, or the

extensiveness of the client’s notes. Some of these dimensions also incorporate feared outcomes into the exposure.



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1. Examine BYOCT Worksheet and discuss client’s experience completing the exposure 2. Reinforce the fact client faced their fears in a real situation 3. Reinforce completion of cognitive restructuring before and after the exposure 4. Troubleshoot any lack of compliance with the homework exposure

II. Rationale behind Advanced Cognitive Restructuring A. Until now work has focused on ATs that are more superficial

1. Initially superficial ATs that are easy to identify 2. As treatment progressed, may have discovered some “deeper” ATs

a) Don’t come to mind as easily

b) More difficult to talk about c) Evoke stronger emotions

B. Onion Analogy 1. ATs come in layers like an onion 2. Can’t see underlying layers until discuss and challenge top layers 3. At center of the onion is a Core Belief

a) Underlying theme across many ATs b) Probably not aware of it when started treatment

Timeline: 1-2 sessions initially, then additional sessions as needed to address core belief Reading: Chapter 12 in Client Workbook Materials Needed: All completed BYOCT worksheets from previous sessions and homework exposures Photocopies needed from Client Workbook:






Peeling Your Onion – Discovering and Challenging your Core Beliefs (Worksheet 12.1 in Client

Workbook)

Expert Tips

The four case examples in Chapter 12 are to illustrate the process of identifying core beliefs and need not be covered specifically in session. These examples represent typically core beliefs we have seen in our own clinical work with socially anxious clients and in cases we have supervised. Even if a client indicates one of the core beliefs in a vignette fits them perfectly, it is still useful to go through the “peeling the onion” process to explore the nuances for their individual psychological experience.

Although identifying a core belief may lead to an “ah-ha” reaction, this insight does not necessarily lead to behavior change. Additional exposure that serve as behavioral experiments to test a core belief or at least practice enacting a healthier belief is essential to positive long term outcomes.



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III. Conduct Peeling Your Onion Exercise A. Work through the “Peeling Your Onion” Worksheet (Worksheet 12.1 in the Client Workbook) with client, using strategies described below as appropriate. B. Strategies for identifying a core belief - refer to vignettes in Client Workbook as needed

1. Follow from one AT to the next 2. Define key words in an AT like “right,” “competent,” or “fall apart.” 3. Focus on experiencing the emotions evoked by ATs to see what other ATs come to mind

a) Experiencing the emotion may be uncomfortable b) Other emotions increase then decrease just as

anxiety does 4. Consider what would happened if an AT came true 5. Identify the source of ATs as it appears client may be close to the core belief

a) Often the core belief was learned early in life b) Client may have a specific memory of when or how it was learned

IV. Assign homework A. In vivo exposure should be a test of core belief derived in Peeling Your Onion Exercise B. Instruct the client to continue small daily assignments

C. Do not assign chapter 13 in the Client Workbook until treatment is

nearing completion.

Expert Tips

Use Worksheet 12.1 as a guide for this process in session but a specific client may need additional prompts within one of the sections or skip some prompts all together. It is usually helpful to shift between the cognitive approach in the Worksheet with occasional Rogerian skills to further explore affective responses to uncover additional ATs.



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I. Review SASCI and homework A. Graph ratings from SASCI. B. Review homework from previous session.

II. Review progress thus far A. Checklist of Progress (Beginning of Chapter 13 in Client Workbook) B. Re-rate Fear and Avoidance Hierarchy without looking at original ratings

1. Compare to original ratings 2. Usually Avoidance ratings change first 3. As stop avoiding, SUDS ratings decrease as well

C. Review graph of weekly SASCI ratings D. Identify progress and what still needs work

1. Help client congratulate self for progress 2. Watch out for Disqualifying the Positive

a) Sample AT: “I’ve done all of those things but social anxiety is still a big problem.” b) Challenge using cognitive restructuring skills

E. Normal to still have some social anxiety after several weeks of treatment

III. How to continue to progress A. Avoid avoidance

1. Avoidance rewards the anxiety and makes it worse 2. Some avoidance is like taking two steps forward and one

step back 3. Avoidance should be near zero

B. Keep using the cognitive skills

Timeline: 1 session, may be extended to 2 sessions if discussion of progress reveals need for further intervention Reading: Chapter 13 in Client Workbook Photocopies needed from Client Workbook:



Client’s completed BYOCT Worksheets




Completed Fear and Avoidance Hierarchy from Chapter 3 – copy with ratings and copy with

situations and no ratings

Expert Tips

We move to Chapter 13 only when we are confident that treatment for social anxiety is complete or nearly complete. It is the last session in our research protocols. In non-research settings, this may mean therapy will end or that ongoing treatment will shift primarily to other concerns. It is a powerful experience if the client re-rates the Fear and Avoidance Hierarchy without seeing the previous ratings. When the therapist provides the previous ratings for side-by-side comparison, it is dramatic evidence of how much change has occurred. Clients often underestimate how severe their fears were at the beginning and become emotional with this concrete evidence of progress.



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1. Don’t take short cuts by skipping steps in cognitive restructuring 2. Continue to use BYOCT Worksheets

C. View an increase in anxiety as an opportunity to work on overcoming fears

1. Change mindset from trying to protect self from anxiety 2. Anxiety should be a signal to charge ahead, not stop, escape, or avoid

D. Reward yourself for your success 1. Facing fears takes courage and motivation 2. Give self credit for success 3. Tell therapist about accomplishments 4. Celebrate successes with friends or family who know client is working on social anxiety 5. Celebrate ways life is improving as making progress on anxiety

E. Use additional strategies to control anxiety. 1. If progress insufficient, consider adding strategies 2. Medication 3. Relaxation and breathing retraining that therapist can teach

IV. When to Stop Seeing Your Therapist Regularly A. Treatment usually 15-20 sessions

1. May be longer if spend time on other topics during sessions 2. May then shift to other issues with therapist, but stop emphasizing social anxiety in sessions 3. If anxiety is more severe, it may take longer

B. Signs that client may be ready to stop seeing therapist regularly 1. Completed in-session exposures for the most difficult situations on your Fear and Avoidance Hierarchy and completed homework exposures for nearly all of the situations on hierarchy 2. Met most important treatment goal such as going back to school, getting/changing a job, going on a few dates, facing a specific difficult situation such as an important speech or social occasion 3. Social anxiety does not interfere in day-to-day functioning in any important way. May still get some anxiety but you feel able to handle it and, rarely, if ever, avoid anything due to anxiety.

V. Identify any needed in-session or in vivo exposures to be completed before finishing treatment

VI. Celebrate client’s accomplishments and set goal for continued progress

A. Complete My Accomplishments During Treatment for Social Anxiety form (Worksheet 13.1 in Client Workbook)

Expert Tips

Occasionally an additional in-session or in vivo exposure will be needed before ending treatment. The most important factor for when to end treatment is to make sure the client is ready to work on their own, not that all anxiety is gone. Sometimes clients will work on their own for a month and then come back for a final check-in session to ensure gains are maintained and the client continues to avoid avoidance.



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B. Set a goal for one month after treatment ends (Worksheet 13.2 in Client Workbook)

1. Immediately after treatment, it is easy to stop working so hard to face fears 2. Setting a goal for one month after active phase of treatment will help get back on track after taking this expected rest 3. Tapering sessions will help provide support

VII. Describe common experience with long term treatment outcome A. Most people still have some anxiety at end of treatment B. Social anxiety is normal; it will always show up in some situations C. Most people who have made good progress, continue to improve over the 6-12 months after stopping treatment as they continue to apply what they learned

VIII. New Situations Mean New Challenges A. After treatment, the client may be in situations never before entered

1. Relationship breakup for someone who had never dated

2. Getting a new job B. Anxiety may occur because these are new challenges

1. Does not mean client is losing treatment gains 2. It is a sign of treatment success

C. Handling anxiety in these new situations 1. Use cognitive restructuring and exposure skills learned in treatment as outlined on BYOCT Worksheet 2. Call therapist for a “booster session” if needed

IX. Terminating treatment A. Some sadness over not seeing therapist regularly any more is normal B. Ending treatment is a positive event

1. Signals client has improved 2. Ends commitment of time, money, and emotional energy 3. Call therapist if

a) Facing new situation and have not been able to handle anxiety using the skills learned in treatment b) Anxiety appears to be returning

(1) Most likely to occur if have some very stressful life event (2) Don’t wait too long or it will be more difficult to get back on track



Introduction to Session Outlines for Managing Social ...

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