Social Fitness-Therapist Manual

SocialFitnessTherapistManual

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Social Fitness Therapist Manual Lynne Henderson The Shyn ess In stitu te, 2000 Wi ll iams Palo Alto CA 94306

Copyri ght © 2001 T he Shyn ess Institute; t his i nfor mation may be copie d, distributed a nd/ or modi fied under ce rtain condition s, but it comes WITHOUT ANY WARRANTY; see the Design Science License for more d etail s.

© 2001, The Shyness Institute; for details, see page 1.


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TABLE OF CONTENTS Acknowledgments Preface List of Figures Chapter 1. Therapist Introduction Chapter 2. Initial Evaluation, Session 1 Chapter 2. Group Structure and Characteristics Chapter 3. The First Session Chapter 4. The Second Session Chapter 5. Exposures in group and homework Chapter 6. Attribution styleRestructuring Chapter 7. Self-concept Restructuring Chapter 8. Final session with relapse inoculation and ongoing goal setting Design Science License



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ACKNOWLEDGMENTS XIX


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PREFACE The techniques described in this manual were developed at the Palo Alto Shyness Clinic between 1982 and 1994. The Palo Alto Shyness Clinic grew out of the Stanford Shyness Clinic, started by Philip Zimbardo, Ph.D., and his students in 1977. The Clinic was moved into the communityin 1982. Margaret Marnell directed the srcinal group treatment under the supervisionof Philip Zimbardo. Margaret Marnell trained and supervised me in 1982, and Philip Zimbardo has provided ongoing consultation since that time. The Stanford Shyness Clinic/Palo Alto Shyness Clinic providesthe most intensive group treatment for shyness and social phobia available . Groups meet weekly for six months. Weekly one and a half hour group sessions are supplemented by discussions of homework prior to each session. Therapeutic techniques include social skillstraining, simulated exposures in group and in vivo exposures, behavioral homework, relaxation training, cognitive restructuring, communication training with techniques for deepening relationships, and assertiveness training. Video tape feedback is provided during exposures for specific feedback during particular exercises, particularly during scripted role-plays designed to develop assertiveness. Some of the techniques have been described in a chapter in Focal Group Psychotherapy, edited by Matthew McKay and Kim Paleg (Henderson,1992). We are no longer using using imaginal desensitization, however, instead focusing on simulated exposures and in vivo desensitization. The treatment has evolved over time, driven by two major considerations; one is the necessity of getting group members to actively participate in order to obtain the necessary exposure, and the other is the importance of dealing with resistance to changing both behavior and the cognitions and perceptions about theself in social interaction. Richard Heimberg' s and Debra Hope's work with social phobia at the State University of New York at Albany has been helpful, in that we have adopted checking SUDS levels at one minute intervals during simulated exposures, allowing subjects more chance to practice their rational responses. The major changes in our cognitive restructuring techniques are the added direct and specific restructuring of attribution style and of biases in the selfconcept. It could easily be used adjunctively with cognitive-behavioral group orindividual treatment. The emphasis on restructuring the self concept has been motivated by concern for the recognition and maintenance of change in shyness and social phobia. Group members © 2001, The Shyness Institute; for details, see page 1.


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tend to deny the changes they are making and also to reverse the self-enhancement bias; that is, they attribute their successes to external factors, temporary factors, and specific factors, and their failures to internal, stable, and global factors. They also are shame prone, and because shame is a painful, often debilitating emotion, they are reluctant to acknowledge and discuss their feelings of inadequacy and powerlessness. Therefore, this manual focuses on attribution style change and specific techniques to change the selfconcept in addition toexposures. These techniques will substitute forthe more general cognitive restructuring techniques developed by Aaron Beck for depression and elaborated by Burns (1991) and Heimberg (1991) for social phobia, and Cheek for shyness (1990), and will draw on the early work of Zimbardo (1977). These techniques have been developed specifically for shyness and social phobia and should be used only by people trained in these particular procedures because they are more subtlethan they appear. If basic beliefs about the self in social interaction do not change, people may change behavior and appear to have changed their self-concepts, but at the first sign of frustration or disappointment with themselves in social situations, they may begin again a process of selfblame and shame that will reverse the change process and leave them more discouraged than before treatment. It may be that these techniques will be ofparticular importance for a subgroup of shy/avoidant individuals who have long-standing maladaptive attribution styles and a consequent shame-based bias in the self-concept that is difficult to change with existing methods. Eight-week shyness /social phobia groups have been conducted each quarter at Counseling and Psychological Services (CAPS) at Cowell Student Health Services at Stanford University since fall, 1990, when the author was a pre-doctoral fellow at CAPS. These groups have highlighted the effectiveness ofa brief, highly focused treatment that can provide a spring board for further self-help work in relation to shyness/social phobia. To that end this manual will describe an eight-week treatment program with meetings for two hours a week that will cover exposures, cognitive restructuring, attribution style retraining, and self-concept restructuring for undergraduate and graduate students at Stanford University. This manual should prove to be useful both for college student populations and for community treatment centers like the Palo Alto Shyness Clinic where most patients meet criteria for generalized social phobia and many for avoidant/and or schizoid personality disorders. It is also designed to provide a focused treatment approach that will be useful in terms of cost containment for managed care settings, particularly for more chronic cases.



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The manual uses both the usual cognitive-restructuring exercises and attributionalstyle and self-concept restructuring exercises. We have found that as the group progresses, the attributional and self-concept distortions need special focus in the debriefing exercises after the exposures. This is due to the fact that self-blame and shame become highlysalient after exposures as group members frequently denigrate their performance, distorting both their recent behavior and rehearsing and elaborating negative beliefs about the self. The first chapter covers the initial interview and goals and general rules for group process. Chapter 2 focuses on characteristics of therapists and groups that make for a higher likelihood of cognitive, affective, and behavioral change. Chapters 3 and 4 provide guidelines for explaining concepts and engaging group members in initial exposures. Chapter 5 covers exposures and the importance of ongoing homework. Chapter 6 covers attribution style restructuring in a detailed sequence from anticipating the feared situation, engaging in the exposure with particular attention to new attributions or more trait-like attributions and debriefing afterward, which frequently reveals new and deeper attributions about the self. Chapter 7 covers self-concept restructuring in the same format, and adds the discussion of the emotional state of shame which frequently triggers and maintains the irrational thinking patterns about the selfin social situations. This chapter includes a discussion of private and public self-awareness and of the interaction between selfawareness and a self-blaming attribution style which may exacerbate both self-blame and shame in social interaction. Chapter 8 describes termination and goal setting and shame and self-blame inoculation techniques to ensure that the gains made in the group are maintained and enhanced, with particular attention to the kinds of attributions and thinking patterns that lead to discouragement and demoralization.Problems that may ariseat this stage are also discussed.



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LIST OF FIGURES X


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THERAPIST INTRODUCTION Introduction The approach we present in this manual evolved from the methods for treating problematic shyness pioneered by Phil Zimbardo in 1975 at the Stanford Shyness Clinic (now The Shyness Clinic). Recently Lynne Henderson developed the Social Fitness Model, which uses physical fitness as a metaphor to conceptualize shyness and Social Phobia. The central idea of this approach is that social fitness, like physical fitness, is something on which any of us can choose to work at improving at any time throughout our life span. A desired level of fitness simply requires exercise, practice, and professional help when special coaching is needed or desired. As with physical exercise, there are many ways to exercise socially, and many different kinds of situations in which to practice and enjoy oneself. Shyness need not be conceptualized as a debilitating condition nor as pathology. It may be seen as a sub-optimal aspect of mental and emotional life that may be strengthened. Solutions may include exerting effort to effect changes in behavior, thinking patterns, and attitudes, working out to get in better shape," or simply a decision to choose better-fitting social niches. Most people can attain a desired state of social fitness just as most people can attain a desired state of physical fitness—if they are willing to work out, practice, and get specific kinds of education and help when needed. Overview of the Disorder Major Clinical Features Shyness and Social Phobia Extreme shyness and Social Phobia both involve an excessive concern about negative evaluation and/or an avoidance of participation in social situations that would otherwise be pleasurable or important to professional or personal growth. Discomfort or nonparticipation must be severe enough to interfere with adaptive functioning or the pursuit of life goals (Henderson 1992b). The experience is an approach/avoidance conflict that needs to be distinguished from natural introversion. Introversion is marked by a tendency to be quiet or reserved, but does not involve the overestimation of public scrutiny nor interfere with the desire to be closer to people. Introverts believe they can perform adequately socially, but tend to prefer small groups, one-on-one interaction, or their own company over that of others (Zimbardo 1982). Definitions and Diagnostic Criteria © 2001, The Shyness Institute; for details, see page 1.


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Clinicians and researchers struggle with definitional problems among the constructs of shyness, social anxiety, and Social Phobia. The terms share similarities: discomfort (and the motivation to escape situations that evoke such discomfort), interference with functioning, and maladaptive thinking patterns. Social anxiety is defined as an experience that is triggered by the perception of possible evaluation and includes unpleasant physiological arousal, fear of psychological harm, and motivation to avoid or escape the threatening situation (Leary and Kowalski 1995; Schlenker and Leary 1982). People experience social anxiety when they believe they arefailing to make the impression on others that they wish to make. Social Phobia is defined as a marked and persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing (American Psychiatric Association 1994, 416). A diagnosis of Social Phobia usually involves marked avoidance of one or more social situations and interference with functioning. We define extreme or chronic shyness as a fear of negative evaluation that is sufficient to inhibit participation in desired activities or that significantly interferes with the pursuit of personal or professional goals (Henderson 1994). Extremely shy individuals and social phobics share either a phobic avoidance of social situations or marked inhibition when in these situations. Some of these individuals report feeling little distress but nonetheless fail to participate in a way that achieves social satisfaction; for example, rarely initiating conversations, failing to discuss their own interests, or being unable to respond directly to others. While the meanings encompassed by Social Phobia and severe shyness overlap, it has been suggested that Social Phobia is defined by specific criteria while shyness is not (Turner, Beidel, and Townsley 1990). Indeed, shyness constitutes part of common language and can describe either a state or a trait. Furthermore, some people label themselves as shy but do not experience the trait as a negative or problematic quality at all. However, specific criteria for chronic shyness were delineated when treatment at the Stanford Shyness Clinic was initiated in 1977. Our criteria are somewhat similar to those for Social Phobia: fear of negative evaluation is analogous to fear of scrutiny, and there must be significant distress or interference with functioning. For convenience, we shall use shyness to designate extreme or chronic (problematic) shyness throughout this manual, unless otherwise noted. Due to our training in social psychology and personality theory, which stresses the power of situational influences on behavior as well as individual differences among people, we do not © 2001, The Shyness Institute; for details, see page 1.


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specify an absolute performance standard by which individuals are compared. Social Phobia definitions imply that significant impairment in functioning is comparable across groups. However, assessment of significant impairment is, at best, imperfect among clinical evaluators, particularly across settings and instruments, in spite of suggested guidelines for the global assessment of functioning in the 1994 Diagnostic and Statistical Manual of Mental Disorders. For instance, socioeconomic status and cultural influences constrain what shy people are able to do, and those who appear, due to their higher status, to be at a higher-functioning level may actually be underachieving in relation to their sociocultural peer group (Henderson, Martinez, and Zimbardo 1999). We rely heavily on self-reports as well as clinical evaluations because there is evidence that self-reports are as valid and reliable indicators for personality traitsÛwhether genetically or environmentally inducedÛas personality inventories with demonstrated psychometric properties, particularly among those who openly express their traits (Henderson 1997). The shy or socially phobic client who comes to your office can be distinguished by reports of considerable discomfort in one or more social situations and a strong tendency to participate minimally, if not avoid them entirely. The individual often has trouble with self-assertion and selfdisclosure. Paradoxically, some clients may present as quite open and outgoing, even remarkably so. Such behavior can be misleading to you and to others, as it may be generated by the anxiety the person is experiencing. It is, therefore, important not to discount clients’ reports of social discomfort and avoidance simply because they may appear sociable. Also note that comorbidity, including both Axis I and Axis II disorders, is very high in this population. We discuss comorbidity and its treatment implications in the assessment section below. Prevalence Prevalence of shyness in the general population is between 40 and 50 percent (Carducci and Zimbardo 1995). In a sample of adolescents who visited a shyness booth in a high school health fair, 61 percent reported that they were shy. Thirty percent of those who labeled themselves as shy tended to blame themselves in social situations with negative outcomes. This group demonstrated significantly greater fear of negative evaluation and social anxiety than the rest of the sample (Henderson and Zimbardo 1993). Prevalence of Social Phobia in community samples is currently estimated at 12 to 13 percent. Gender ratios have been generally reported as equal in normative samples of shy college students. Some samples of social phobics have suggested larger numbers of women than men, but these findings have been mixed. The gender ratio of clients presenting at the Shyness Clinic is 60 percent men to 40 percent women.



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Etiology A number of factors have been hypothesized as causal agents in the development of shyness and Social Phobia. Specific conditioning events include being teased or chastised by teachers or other children in front of others and failing to perform adequately on a given occasion. Traumatic emotional or physical abuse or neglect is also a factor, such as that found in family settings that are chaotic or involve parental substance abuse (Zimbardo 1982). Observational learning can also lead to shyness and Social PhobiaÛfor example, viewing siblings or classmates who are humiliated or harshly treated. A genetic component has also been implicated (Kagan, Snidman, and Arcus 1993). Current developmental theory suggests an interaction between temperament and environmental influence. Some studies have suggested that certain parenting characteristics promote shyness and Social Phobia. A controlling or overprotective parental style that is lacking in warmth and includes frequent correction and shaming may contribute most heavily (Bruch 1989). The important question is when and to what degree parents should encourage or even push inhibited children so that they receive adequate socialization experiences. Extended family socializing predicts less shyness in young adults (Bruch 1989). Some shy patients report that their parents were so shy, highly introverted, or withdrawn that little social interaction occurred beyond family life. Treatment Approach This treatment model distinguishes four domains of shyness and Social Phobia: 1. Behavioral. Your clients will present with inhibitory or avoidant behaviors (refusing to enter situations, becoming "invisible" in groups) or, less frequently, overactive behaviors (overcompensating for anxiety by excessive talking or “enacting” what are perceived to be favored behaviors instead of simply being themselves). Your treatment goals will include bringing inhibited or overactive behaviors into a desired balance. You will sometimes urge clients to experiment with changing behaviors in order to see which ones seem to better suit their natural style. Sometimes behavioral changes affect the other domains of shyness and Social Phobia: physiological arousal, maladaptive thinking patterns, and negative emotions. 2. Physiological Arousal. © 2001, The Shyness Institute; for details, see page 1.


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Your clients will complain of uncomfortable bodily sensations experienced in feared situations. These sensations include sweating, trembling, and racing heartbeats, etc. Treatment goals are to help clients understand that their discomfort is very likely much less apparent than they believe, that they can behave as they wish socially even though they may experience anxiety while doing so, and, eventually, to reduce the intensity of physiological arousal as the client benefits from treatment. A goal to reduce physiological arousal should be translated into a concrete and specific goal, such as a reduction of a certain number of points on the Subjective Units of Distress Scale (SUDS; this scale, on which clients rate subjective anxiety on a scale from 0 to 100 at a given time or in a given situation, is described in session 2). 3. Maladaptive thinking patterns. Shy clients tend to exercise thinking patterns which undermine their desire to feel more comfortable and to participate in difficult situations. These include simple cognitive distortions (for example, black and white thinking in which some particular performance which falls short of perfection is perceived by theclients to indicate that they are totally inadequate); maladaptive attributions (for example, shy people tend to blame themselves for perceived failures and to credit the situation for perceived successes); and distortions of the self-concept. An important component of the treatment is to challenge maladaptive thinking patterns and to replace them with thoughts which are more likely to move clients toward their goals. This process is termed "cognitive restructuring," and is a major component of this approach. 4. Negative emotions. Affect states such as embarrassment, shame, and guilt play a key role in promulgating a cycle of avoidance and anxiety. Your treatment goal is to help clients understand how their emotional states affect their thoughts and behaviors, and to help them learn strategies for coping with these states. These four domains constitute a dynamically interactive system. Changes effected in one domain sometimes bring about movement in other domains. Because the cognitive and behavioral domains lend themselves best to direct manipulation, treatment consists of exposures with cognitive restructuring, emphasizing specific attributional and self-concept restructuring for new situations and interpersonal skill-building for initiating and deepening relationships. This approach synthesizes a cognitive-behavioral approach with an educational approach that emphasizes goal formation, the development and examination of testable hypotheses, and specific skill-building. In simulated exposures, you will help clients role-play desired behaviors in feared © 2001, The Shyness Institute; for details, see page 1.


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situations. These experiences allow you to work with the client in identifying and challenging habitual negative thinking patterns. You can then jointly strategize ways to develop more adaptive kinds of self-statements and thinking relating to the specific situation. Clients often bring with them distorted ideas about the nature of interpersonal interactions based on early models and experiences with parents or peers. Therefore, we also incorporate elements of an interpersonal short-term dynamic approach into a communication-skills component. Some clients simply lack sufficient socialization experiences to have learned and practiced behavior that others learned in elementary school and during adolescence. You can help your clients by linking current behavioral patterns to earlyexperiences, thereby facilitating insightinto clients’ particular learned behaviors. These insight leads to an increased sense of choice about enacting the old, automatic behaviors or learning more adaptive ones. The realization that current difficulties and limitations stem from earlier environmental problems also allows clients to place blame for their difficulties outside of themselves, and places them in a position to reason that if maladaptive responses can be learned in an unhealthy environment, adaptive responses can be learned in the environments they experience today, or might create for themselves tomorrow. Hierarchy You will help your client construct a fear hierarchy of ten situations (see Session Two). Situations range from those in which the client reports mild but manageable anxiety that is only minimally distracting (a SUDS level of around 20 to 25; see SUDS scale and description in Sessions One and Two) to those in which they would be as terrified as they have ever been. The least and most threatening situations are used to concretize endpoints (0-100) on a continuum of fear. As clients describe situations, there may be a good deal of moving around and revision "Oh no, that one is worse yet!". When this occurs, the client may work on the hierarchy at home and complete it with your assistance during the next session. The hierarchy may be further revised as treatment develops. Simulated exposures in sessions are usually taken from the mid to high range of the hierarchy, because there may not be time for all of them. Simulated Exposures Simulated exposures are role-plays of feared situations taken from the hierarchies constructed with the client during the second session, as outlined above. The exposures are conducted with the therapist and, sometimes one or more confederates (volunteers or other staff members). Confederates may especially useful for certain situations (e.g., a stranger of the target gender and age for your client to approach for a date). However, when confederates are not available, you can



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certainly use some role-play situations to engage your creativity and become a more versatile actor! Ideally, role-plays are videotaped in order to provide immediate feedback to the client. Cognitive Restructuring The cognitive-restructuring techniques we use are based on those developed by Aaron Beck and his colleagues (1979) for depression and elaborated by Rick Heimberg and others (1991) for Social Phobia. You will help your clients identify the logical errors in the negative thinking patterns that accompany shyness and Social Phobia, using the list of cognitive distortions provided in session three. Attributional and Self-Concept Restructuring We have developed additional, especially powerful, cognitive restructuring techniques designed specifically to help clients identify and correct maladaptive attributions of credit and blame, and to help clients identify and challenge relevant core self-beliefs (Henderson, Martinez, and Zimbardo 1999). These beliefs often reflect biases in the self-concept (see Figure 1). We emphasize attributional and self-concept restructuring because these tools enable clients to recognize change and maintain more adaptive behaviors. Shy individuals reverse the selfenhancement bias; that is, they attribute their successes to external, temporary, and specific factors, and their failures to internal, stable, and global factors. Furthermore, they tend to dismiss positive feedback and positive change. A small setback is seen as evidence of basic inadequacy rather than as a natural aspect of the learning process. Many clients tend to be shame prone, and because shame is a painful, often debilitating emotion, they are reluctant to acknowledge and discuss their feelings of inadequacy and powerlessness. Therefore, in addition to the usual cognitive-restructuring exercises with exposures, you’ll want to focus on challenging maladaptive attributions and self-beliefs. By discussing and normalizing shame-related emotions early in the treatment process, you can increase the likelihood that clients will acknowledge and work with these painful feelings. Attributional and self-concept restructuring techniques have been developed specifically for shyness and Social Phobia and are particularly suited to work with the debilitating and selfdefeating thinking patterns invariably demonstrated by this population. It is important to distinguish between temporary, superficial change and lasting, substantial change in relation to basic beliefs about the self in social interaction. If behavior changes but beliefs about the self do not, clients lose ground and return to a process of self-blame and shame at the first sign of © 2001, The Shyness Institute; for details, see page 1.


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frustration or disappointment. This may reverse the change process and leave clients more discouraged than they were prior to treatment. These techniques may be of particular importance for a subgroup of shy/avoidant individuals with higher levels of general fearfulness than other shy people. This group engages in more self blaming attributions than the less fearful shy group (Henderson, Martinez, and Zimbardo 1999). Interpersonal Skill Training Interpersonal skill training areas include verbal and nonverbal communication, active listening, self-disclosure, trust-building, handling criticism, negotiation, self-assertion, and managing and expressing anger constructively. You may focus on specific skills that are lacking. Role-playing situations that require these skills can be particularly enlightening for both you and your client. Oftentimes clients are more skilled than they believe they are and the therapist can point out strengths. Deficits and maladaptive behaviors will occasion themselves in role-plays, giving you the opportunity to provide feedback that can inform strategies on the spot. Empathy Shyness is correlated with empathic concern for others. However, when shy or socially phobic clients experience negative emotion, the accuracy of social perspective taking--the ability to perceive another's point of view or assume another's frame of reference--is diminished. You can simulate situations which call for empathic responses when the client is critically self-conscious and help clients become aware of the difficulty. They can then practice articulating empathic responses both in neutral and negative emotional states in ways that promote continued dialogue and acceptance. Focus of Awareness Shy individuals are concerned about, and focused on, the impression they make on other people. This is called public self-awareness (Buss 1980). When people are simultaneously focused on making a good impression and doubt they can accomplish it, they attend to their behavior in a critical manner and lose track of another person's needs and even of the conversation itself. The frequent experience of negative emotional states such as social anxiety, embarrassment, and shame also leads to a tendency to focus inward and become hyperaware of negative emotion, which colors perception, encourages more negative thinking about the self and others, and promotes more negative emotion. This self-blaming shame cycle frequently leads to demoralization (Henderson, Martinez, and Zimbardo 1999).



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The tendency to be aware of one's own thoughts and feeling states is referred to as private selfconsciousness. Private self-consciousness moderates the tendency to blame the self and to experience shame in interpersonal situations with negative outcomes (Henderson 1992a). A client who is highly privately self-conscious, but in a neutral emotional state, is less likely to unreasonably blame the self. However, a client who is highly privately self-conscious and in a negative emotional state is more likely to unjustly blame the selfÛmore likely, that is, than both highly privately self-conscious people experiencing neutral affect and others who are less privately self-conscious altogether (less self-aware; Henderson 1994). Clients can be educated about tendencies to be publicly and privately self-aware and how such tendencies influence their ability to be sensitive to others' needs. Patients can then begin to deliberately focus their attention and to take into account the effect of self-focus on their interactions (see Figure 1). Homework In-Vivo Exposures in Relevant Situations Between sessions, clients enter feared situations and stay in them long enough to meet specific behavioral goals, such as initiating and maintaining a conversation for several minutes, making eye contact and saying hello to a specified number of people at a social gathering, making a comment to another person at a check-out stand in a supermarket, or asking someone to go out for coffee or to a movie. Telephone Calls Clients are assigned two telephone calls each week to a potential friend, coworker, or organizations such as the Sierra Club to obtain information on events and activities. This exercise provides practice on the telephone and practice in getting acquainted. The therapist should ask the client about the calls at the beginning of each session, both to reinforce the homework and to strategize or role-play interactions that have been problematic or too frightening to attempt. Research Group cognitive behavioral therapy is considered the treatment of choice for shyness and Social Phobia by most mental health researchers and clinicians (Feske and Chambless 1995; Heimberg, Liebowitz, et al 1995). A group setting, in particular, is ideal because the group itself serves as a place for clients to desensitize to interpersonal situations and interactions. Problems which have felt isolating may become normalized in the group. To date, however, few such groups exist. Given this reality, we have adapted the treatment model we have developed to maximize its benefits in a © 2001, The Shyness Institute; for details, see page 1.


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one-to-one therapeutic setting. It has been previously demonstrated that such adaptations from group work to individual therapy can be effective in treating Social Phobia (Zgourides 1989). The salient obstacle to providing optimal treatment in a one-to-one office setting is the difficulty you may encounter in arranging effective exposures. Given that the most important feature of the treatment is exposure to feared situations, you’ll want to especially impress upon the clients the understanding that entering these situations is a necessary component of the work. It can be quite difficult for many clients to carry out homework assignments in the form of in-vivo exposures, such as initiating conversations, speaking up in meetings, and asking people for dates. Therefore, role-plays need to be conducted in the therapist’s office or the therapist needs to accompany the client into feared situations. If the client cannot do so on his or her own, or with the aid of the therapist or another person, optimal progress is unlikely. Specific recommendations for encouraging in vivo exposures and for creating effective in-session exposures are provided throughout this manual. Research on the efficacy of different treatments for Social Phobia has been hampered by persistent methodological problems (Heimberg et al. 1995). The efficacy of social-skills training is as yet unproven, although the combination of social-skills treatment and exposure is being investigated with some support (Turner et al. 1994). Relaxation training alone has received little support. Exposure has produced positive results, but relapse is ubiquitous, and whether exposure alone or exposure with cognitive-restructuring produces better long-term results continues to be debated (Heimberg and Juster 1995). Pharmacological treatments appear to produce adequate results at 12 weeks, but do less well than cognitive-behavioral therapy at follow-up (Schneier, 1999) We believe the most effective treatment for shyness and Social Phobia consists of a combination of techniques, emphasizing exposures with cognitive and attributional restructuring and interpersonalskills training. The value of the skills training component has received the least empirical support. I (Henderson) have concluded from my clinical observation that skill deficits are, in fact, quite rare, and that inhibition and maladaptive coping mechanisms more often explain performance deficits. The neurobiology of Social Phobia is being investigated, but no conclusive evidence of a distinct syndrome exists, although the dopaminergic neuronal system may be implicated (Nickell and Uhde 1995). Duration of Treatment Progress is arduous for many shy people due to their longstanding avoidant patterns and the lack of social support in their lives. A course of ten weeks of treatment is described in this manual. this © 2001, The Shyness Institute; for details, see page 1.


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time constraint limits the scope of the treatment to exposures with cognitive-restructuring only. Although this is the strategic technique to emphasize to the exclusion of the others, it must be noted that relapse rates in relation to this limitation may be quite high. This fact underlines the importance of booster sessions for many clients. Informed consent as to what can realistically be accomplished in a brief time frame is essential from an ethical point of view. We are clear with clients from the outset that they will learn a set of specific skills that they will need to practice on their own, perhaps with booster work, in order to maintain their level of social fitness. We tell clients that we expect that they will continue to improve with such follow-up work. Assessment Subtypes and Comorbidity Pilkonis (1977) distinguished between privately shy and publicly shy college students. The privately shy reported distress but adequate social skill; the publicly shy reported difficulty with social behavior and increased inhibition. I (Zimbardo) have described shy extroverts as skilled but socially anxious, and shy introverts as inhibited and less skilled. Panic disorder, simple phobia, mood disorders, and substance abuse are common additional (comorbid) disorders in samples of social phobics. Rates of co-occurring diagnoses of substance abuse disorders have been found to be as high as 13 percent, but are much lower in many samples. Among clinic samples, additional disorders occur in 50 percent or more of social phobics. Personality disorders are also common in Social Phobia (56 percent to 77 percent), the most prevalent being Avoidant Personality Disorder. At the Shyness Clinic, 96 percent of our patients meet criteria for generalized Social Phobia and, depending on the diagnostic instrument used, 40 percent to 56 percent meet criteria for at least one additional Axis I disorder, most frequently dysthymia and generalized anxiety disorder. Ninety-four percent meet criteria for at least one additional Axis II disorder, according to the Millon Clinical Multiaxial Inventory, most frequently Avoidant Personality Disorder (67 percent), Schizoid (35 percent), and Dependent (23 percent; St. Lorant, Henderson, and Zimbardo 1997). Those with Avoidant Personality Disorder usually struggle with a great deal of shame-based emotion and a reluctance to risk without guarantees of acceptance. Schizoid individuals show a great deal of fear, and even dislike, of intimacy as well as novelty. Therefore, they may have © 2001, The Shyness Institute; for details, see page 1.


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trouble persisting while relationships deepen. Those with Dependent Personality Disorder tend to be submissive, but socially skilled and liked by other group members. It is important to distinguish Social Phobia with in-situation panic attacks from Panic Disorder. The hallmark of Social Phobia is the fear of scrutiny and avoidance/distress. Panic attacks in this case occur only in social situations and the fear is related to the fear of being judged, and somewhat to the fear of the symptoms themselves, but not to the fear that there is something seriously wrong physically. To distinguish Social Phobia from agoraphobia it is important to remember that in agoraphobia the person avoids public situations due to the fear of feeling ill or having a panic attack and not being able to escape, not to the fear of negative evaluation or scrutiny by others. The Initial Evaluation During the initial evaluation you will conduct in the first session, you will obtain a description of the client's current life situation and social relationships, particularly friendships, family relationships, and source of social support. Pay attention to strengths as well as weaknesses. You will also need to make note of the clients’ history to familiarize yourself with where and how social anxiety began, paying particular attention to negative interpersonal events and trauma. Shyness and social anxiety often develop in elementary school as a result of upsetting experiences with teachers or peers. The most common onset of problematic shyness and Social Phobia is early adolescence. Family and medical background should be covered, with an eye toward genetic and physiological aspects such as thyroid conditions and drug and alcohol problems. All of the following should be obtained (sample questions are detailed in session one): - Specific Nature of the Problem: How would the client like to change? What specific events, situations, or persons are problematic? - History: Time of onset of symptoms, particular trigger event(s) or situation(s), social anxiety a problem for parents or other family members? - Current Level of Functioning: To what extent are symptoms affecting the client's life? What limitations attend the problem? Energy level; Cognitive status; Presence of life stressors; Health status; Medication usage? - Differential Diagnosis: Mood disorders; thought disorders; panic disorder; phobias? © 2001, The Shyness Institute; for details, see page 1.


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- Coping Styles and Mechanisms: How are affective states managed? Substance use? Assessment instruments include the Beck Depression Inventory (BDI) (footnote: This measure may be purchased from The Psychological Corporation, 555 Academic Court, San Antonio, TX 78204-2498. 1-800-211-8378. http://www.psychcorp.com. ), and the Brief Fear of Negative Evaluation Scale (BFNE; Leary 1983; See Session One). Patient Self-Rating Scales During the initial evaluation, clients are given a Social Interaction Log and will use it throughout treatment to monitor their negative thoughts. Also as part of the initial evaluation, the client will fill out the BFNE (Leary 1983). (Both the Social Interaction Log and the BFNE are presented in session one.) Ask clients to arrive 10 minutes early for the first session so they can complete this scale prior to meeting with you. Items are rated on a five point scale, from not at all, slightly, moderately, very, to extremely true. The average score among shyness clinic clients is 4, while that of a normative college student sample is 2.98. The score provides an objective measure of the concern about negative evaluation and can be compared with the general population. The client will fill out the same questionnaire a second time at the end of treatment, which provides the opportunity for both you and your client to see how fear and concern about evaluation are reduced as avoidance is reduced. The client will also fill out the Between-Session Shyness Questionnaire prior to each session (Henderson, 1999). This questionnaire provides information about the degree of negative emotion, avoidant behavior, and social anxiety the client is experiencing between sessions. This form also provides a measure of helpfulness and therapist understanding from the previous session, which may then be discussed in the current session. Furthermore, behaviors, thoughts, and emotions that need to be changed can be targeted using the questionnaire. A copy of the questionnaire appears in session one, along with information on how to interpret and use results. These assessment measures enable you to be sensitive to particularly difficult times for clients and to be alert to potential misunderstandings. When clients feel misunderstood, it is helpful to explore those feelings. Because this treatment approach emphasizes challenging maladaptivc cognitions, clients sometimes feel that their therapist is challenging their inner reality. Questionnaire items that assess perceived empathy of the therapist can be useful in identifying these moments and acknowledging negative emotions and perceptions. © 2001, The Shyness Institute; for details, see page 1.


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Current behavior in a feared situation is assessed using a BAT (behavior assessment test, or behavioral performance test), which consists of a brief role-play or impromptu speech, usually videotaped, and includes a small audience. SUDS levels are usually assessed at intervals prior to the BAT for baseline and anticipatory levels during and immediately afterward. Thought-listing forms may also be used to record negative thoughts that occur during the BAT (Cacioppo, Glass and Merluzzi 1970; Heimberg 1991). Specific instructions for conducting a BAT and an example thought-listing form are provided in the session chapters in which they will be used. Specific Goals of Treatment and Limitations Goals During the initial evaluation you and your client will agree upon goals for treatment. Once set, your job is to help the client assess whether or not these goals have been met at the end of treatment. To do so, you should ensure that goals are distributed across the domains of shyness that are problematic. They must also be constructed according to the client’s own incentives. Individual goals in shyness treatment may include improved social skills, better interpersonal communication, reduced physiological arousal, increased emotional well-being, more adaptive thinking about the self and others in social situations, a more adaptive attribution style, and a more realistic view of the self. When constructing goals with the client, it is important to remember that they must be specific and measurable--for example, a client may want to "feel more comfortable in groups and with new people." That goal can be translated into a 20 to 30 point SUDS reduction in a feared situation that the client enters while practicing new behaviors. Reduced maladaptive thinking may be reflected in fewer negative automatic thoughts and attributions in these same situations. Examples of goals relating to improved social skills could include simply saying what one thinks more frequently or increasing contacts with others, perhaps from few or no contacts a week to three or more. Clients who have been avoidant or isolated are often unrealistic about what they can achieve. Goals must be outlined in a clear, concrete manner and must be challenging yet clearly achievableÛotherwise patients may discount progress by simply raising the bar when they do meet a goal, or achieve a step along the way: OK I didthis, but I haven’ t made any progress because I haven’ t done that. Perfect comfort is not attainable but clients imagine that others experience it, so reality orientation is one function of the goal setting process. A few good examples of goals you could construct with your clients are: © 2001, The Shyness Institute; for details, see page 1.


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1. By the completion of treatment you will be able to approach at least three people a week at work to have a brief conversation.

2. By the completion of treatment you will have asked three different people to go on a hike or out for coffee with you . 3. By the completion of treatment you will have asked for one date, or made four contacts through a personals ad, or e-mailed one person through an e-mail dating service such as match.com.

Focus on the client’ s particular incentives. That can be a challenge when a shy person with very little experience or social skill wants to establish a close love relationship right away. Hopefully, your clients will begin to see that experience with making friends in general will be requisite to experiences with dating. Initially, you might want to divide your clients’ goals into subsets, so that they can pursue both types of experiences, but do try to help them understand that the process may take time. You can also supply clients with a list of social situations in which to practice. Check local newspapers and put together a generic list, including items such as Sierra Club outings or local dance classes, to hand out in the first weeks of treatment. Also, encourage clients to practice pushing through avoidant tendencies and to experiment with social skills in those social situations that may already be regular part of their lives, such as work settings. It is important that clients understand from the outset that, although they will be learning specific techniques that will help them with adaptive social and cognitive behaviors, they will need to continue to practiceon their own. Emphasize that research has demonstrated that the completion of homework at least three times a week is essential for reduced social anxiety and other negative emotions. In order to feel better, clients must get themselves into feared situations and practice new behaviors, and they must challenge their negative thoughts. Tell your clients that just as in tennis classes, if you only play once a week in class your progress will be very slow. Homework—that is, practice--must be done in order to improve. Goals remain flexible and may be modified over the course of treatment to accommodate more realistically achievable outcomes. Sometimes clients discover that they are more naturally introverted and are in fact satisfied with a few close friends. Conversely, some clients progress a few steps, experience positive change, and may expand their goals as a result. Limitations © 2001, The Shyness Institute; for details, see page 1.


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The avoidant tendencies and self-concept distortions that attend shyness and Social Phobia have usually been practiced over a lifetime, and while significant improvement has been demonstrated, it does behoove us to inform our clients that some of these patterns may change only partially, they may change slowly, and they may change temporarily unless considerable effort is exerted to maintain positive changes. Again, we find it useful to employ the Social Fitness Model: for those who have been seriously out of shape physically, it is important to remember that regular exercise can make a tremendous change for the better in terms of overall quality of life, even if a person may never attain the physical condition of a trained athlete. Many clients will leave therapy as people who still experience significant anxiety and difficulty in social situations. The best prophylactic against demoralization and relapse is to emphasize often that improvement is important and deserving of attention and appreciation. You should assist clients to enable themselves to experience many problematic moments without discounting real progress that has been made, and remind clients that perfection is not the aim of treatment. It should be reiterated that some of the techniques learned in therapy are tools to be used to maintain social fitness over the client’ s lifetime, and that booster sessions are often useful when the client is unable to continue practicing on their own, motivation flags, or stressful life events push the client back to regressed patterns of behavior. Clients seldom leave treatment with no symptoms or no remaining behavior or cognitive problems. Stress and change cause old difficulties to flare up again. The Social Fitness Model was developed to help clients cope with this reality and to understand that social fitness, like physical fitness, takes ongoing practice and occasional coaching. Again, people don’t become profession tennis players after one set of tennis lessons. Helping clients understand that social fitness is an ongoing process with ongoing workouts is a major change in the way they view their difficulties and helps them begin to develop real self efficacy, which is related to discipline and persistence. It also helps them understand that noticing the cues that suggest they are regressing (such as withdrawal, increased tension, social alienation, lack of ongoing goal setting and challenges to negative thinking patterns) allows them to get more coaching if they need it. They may also be able to get themselves back on track by getting out their notebooks, reviewing their notes, and tracking their homework systematically again. Social fitness training is not a cure, it is a way of life. Agenda Setting The shy or socially phobic person carries into every social interaction a marked concern about being scrutinized, evaluated, judged, or rejected. This vigilance can be more acute when your client is interacting with youas a therapistthan in any other social situation they encounter. You will find © 2001, The Shyness Institute; for details, see page 1.


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yourself in a classic bind: on one hand, clients usually need time and freedom to express themselves and test your responses for interest, empathy and acceptance in order to establish trust; on the other hand, in the context of a time-constrained course of treatment, you will need to keep the client on track or the work that we know to be helpful in advancing the client’ s stated goals will not be completed. We aim for an artful compromise in which we hope to demonstrate interest, empathy and acceptance primarily by our efforts at gently and persistently keeping clients on the course they set for themselves by seeking your help with this problem. Toward that end, enlisting the client’ s assistance in setting an agenda for each session both demonstrates your interest in addressing the issues and provides a structure which you can both use to remain focused and on course. Some flexibility is inherent in the structure. However, unless an emergent issue presents (e.g., suicidality, catastrophic event), the therapist will take an active role in acknowledging any tangential or irrelevant discourse, and, in an affirming manner, redirecting to the task at hand as outlined in the agenda. In general, each session will conform to the following format: 1. Check in. The client’ s general appearance and mood state are noted. You determine whether there is any critical information which needs to be exchanged before your begin work for the session. 2. You propose to the client a plan for the current session, incorporating any significant issues raised during the check in, or left over from any previous session. You solicit the client’ s input on the construction of this plan as much as is practical. For example, if a role-play is to be performed, the client may suggest the problematic situation to be worked on. 3. Homework from the previous session is reviewed. Your attention to the client’ s homework not only informs you regarding the clients progress, but acknowledges to the client that you consider the homework valuable and important. 4. The primary in-session work is executed for that day. 5. A few minutes is taken to review the events of the session together, ask questions, and provide feedback. 6. Homework for the next session is agreed upon.



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Homework Motivation and compliance are crucial in shyness and Social Phobia work. Here’ s a simple mantra to handle this: “If we don't work out we don't increase our emotional and physical well-being.” I can't be a couch potato and stay physically fit, nor can I stay socially fit without practice in social situations. Try to help the client recognize that the decision to do or not to do homework is a choice. When a client says that he or she couldn't find the time to practice, you might respond, You chose not to do your homework this week. Perhaps you noticed negative thoughts that encouraged you to avoid doing your homework. That is a valid awareness exercise. In fact, this might be a good time to examine the choices you make andthe reasons behind them.” Such comments from clients can be part of their helpless role, and the trick for you is to maintain respect for their choices but not feed into their conceptions of themselves as helpless and out of control. Pessimism and passivity are common in the chronically shy and socially phobic, so it is useful to predict their discouragement at the outset. You will give them a notebook during the first session and ask them to bring it to the session each week. Outside of session time, clients will use the notebook to record their goals and the results of their weekly homework. This tracks their progress and, by serving as a reminder of what they have accomplished so far, bolsters them in times of discouragement. Bragging sessions during the review of homework are also helpful. Clients acquire the habit of acknowledging their work and sharing their pleasure with you. Your enjoyment of their progress will be important to them. The weekly homework is designed to encourage clients to do small things every day and to tackle one or two bigger challenges a week. Just as with interval training in sports: you must get to the top of your level of exertion range, then you can drop back to things that are easier. If clients stay in their comfort zones they do not improve, but consistent steady effort with a few bursts here and there starts to pay off and they can feel it. You will discuss homework as part of each session. At two points during the treatment regimen (sessions four and eight), you will also complete the homework inventory form to track overall effort (see Homework Inventory Form in the appropriate session chapters). Monitoring of maladaptive automatic thoughts, maladaptive attributions, and negative beliefs about the self are conducted by patients between sessions. The clients also monitor their avoidance behavior and its relationship to their negative thoughts and beliefs. Specific goals are set by the patient and the therapist at the end of each session for behavioral homework in the form of in-vivo exposures. Some assignments will involve clients asking others to assist them with challenging © 2001, The Shyness Institute; for details, see page 1.


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maladaptive thoughts and beliefs when they are experiencing negative emotions such as shame and discouragement. Patients reward themselves in the form of enjoyable activities or checkmarks in their notebooks for which they pay themselves at the end of the week or month to spend on something pleasurable. Forms for tracking all of the above are provided in the session chapters that follow and in the Client Manual. Concurrent Pharmacological Treatment Medication is often used in the treatment of anxiety disorders, usually antianxiety agents or antidepressants. Antidepressants are often the treatment of choice because they do not include the risk of substance dependence. Many patients begin treatment already using antidepressant medication and wish to continue while in treatment for Social Phobia. Patients do, however, tend to attribute success to the medication, which tends to interfere with a belief in their own selfefficacy. The use of anti-anxiety medication is even more problematic because clients experience reduced anxiety immediately after taking the medication and anxiolitics buffer such clients from experiencing the anxiety necessary for effective desensitization. As a result, it is much more difficult for clients to learn that they can manage their anxiety. Due to the early relapse rates with medication in Social Phobia treatment found in several studies (e.g., Schneier, 1999.), we prefer, if possible, to have clients experience treatment without medication. If medication is being taken, however, state dependent learning effects would suggest that dosages be held steady if possible until cognitive-restructuring and behavioral skills have been thoroughly learned and consolidated. Selective serotonin-reuptake inhibitors are the most frequently used antidepressants in this population. Traditional monoamine oxidase inhibitors, specifically phenelzine (Nardil), may be most effective with Social Phobia but dietary restraints and the risk of hypotensive crisis render them unacceptable for most patients. Phenelzine carries risks for less serious side effects such as sedation, sexual dysfunction, and weight gain. The newer agents (reversible monoamine oxidase inhibitors) such as moclobemide and brofaramine, which have fewer side effects, have been unavailable in the United States and may be less effective (Schneier, 1999). We keep in touch with psychiatrists, psychopharmacologists or internists to exchange feedback that will be helpful to the client. When you are working with an internist, it is sometimes useful to tactfully share the research findings that you are aware of but that he or she might not be. Medications such as Prozac, Serzone, Zoloft, Paxil, Luvox, Celexa, and Effexor.have been useful in Social Phobia treatment and not all health care professionals may be aware of current research in this area. We © 2001, The Shyness Institute; for details, see page 1.


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use psychopharmacological consultants to keep us up to date, inviting experts to group consultations to keep us updated. Medication does help some clients enter feared situations that they would otherwise avoid. It may also improve their moods enough to help them persist toward goal attainment. In these cases medication may be useful. However, excessive reliance on medication can be a problem as can resistance to giving it up. It tends to reinforce the idea that clients will be passively "cured" rather than improving through active performance. Common Problems Learned pessimism and learned passivity are hallmarks of the chronically shy and those with Cluster C personality disorders (American Psychiatric Association 1994). Such clients may try to seduce you into doing all the workÛresist that temptation, or you may become exhausted and angry, which obviously interferes with treatment. Often we can tell when a therapist has become well-trained because they becomeexpert at resistingbeing convinced by clients’ verbal and nonverbal messages of helplessness. Thoughtfully applied, gentle humor can be an effective way to send the message that we do not share a client’ s view of their ineffectuality. In the long run such strategies often become appreciated by empowered clients. When clients begin "talking back" to me (Henderson) in sessions, challenging a comment I’ve made or rearranging an exposure to work better, I know real progress is being made. Resentment and passive aggression are also common in this group of people, often due to the fact that they have had few opportunities to practice self-assertion skills. They often believe that other people have it easier and that things just come naturally to others. They are surprised when we tell them about the research study that suggests that shy college students report fear levels and experiences similar to normal students (Maddux, Norton, and Leary 1988). The key element apparently lies in the self-labeling process. The chronically shy believe that something is wrong with them and do not see social exertion as a natural part of life. Most people are somewhat nervous in new situations; with practice they simply learn to manage their physiological arousal. Thus normalizing social anxiety and emphasizing that clients can manage it just as others must is an important message to regularly deliver to your clients. This doesn't mean that we discount truly painful earlier experiences of bullying, teasing, or abuse. In those cases the questions become, What do we want to build together from here? How do we want to make the future different from the past? How do we want to create a culture together where © 2001, The Shyness Institute; for details, see page 1.


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people don't have to feel badly about themselves if their temperaments or habits are different from others? Framing questions this way increases the likelihood that clients will come to see the responsibility for working to improve their experiences as their own. Difficulty Simulating Real-life Exposures Sometimes it is difficult to simulate the exact experience a person is dealing with at work or in meeting people socially. For instance, role-playing a dominating male boss is sometimes difficult. We will often have the client role-play the boss first, to show us how the person comes across. That has been very instructive because our expectations are often violated due to the fact that different individuals respond differently to different personality styles. For instance, a manager was described as harsh, but when role-played actually sounded direct and even reasonable. In that case our job became to help the client respond assertively with reduced anxiety to inquiries about his work on a project. In other cases, managers have been harsh and verbally abusive, and it can be difficult for clients and therapists alike to play these roles. The therapist often has to serve as the confederate, but willing confederates can sometimes be found. Here is yet another reason in which group treatment is ideal: other group members can participate in role-plays. When treating clients individually, you may find it worthwhile to explore potential sources of help. Perhaps another therapist in your professional group can assist in certain role plays. Alternatively, you may have two patients with adjoining appointment times who would be willing to serve as confederates for each other. We are developing a volunteer program in which people can be called regularly. Sometimes, due to factors such as age differences and personality, it may be challenging for therapists to present as threatening enough to role-play potential dating or sexual partners. We have found that if clients can visualize the actual situation in enough detail, their anxiety will still be aroused. Also, once they have role-played the situation, the responses are more accessible the next time the target person is encountered. In these cases the exposures function primarily as practice rather than desensitization. In many cases people who complain that they cannot raise their SUDS levels demonstrate subtle avoidant behaviors. Sometimes the instruction to make more eye contact or be more "present" helps. Alternatively, you may escalate the challenges you pose during cognitive-restructuring, exposing more of the defense mechanisms and the underlying insecurity. This is a trade-off in the therapeutic alliance because you want to help them continue to push their boundaries, but you don’ t want to overdo it and trigger too much shame. Too much shame promotes withdrawal and reduced risk-taking both during the session and in homework activities between sessions. © 2001, The Shyness Institute; for details, see page 1.


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Difficulty Finding or Utilizing Social Situations forIn Vivo Exposures Many of our clients have become isolated and alienated from themselves and other people. For very withdrawn clients, it is helpful to use supermarkets or other places where the person can simply smile and say hello. Walking a dog in one's neighborhood can be useful. Coffee areas in workplace settings can also offer an opportunity for brief contact. E-mail will get some very withdrawn clients started. As they provide opportunities to interact in a more anonymous environment, we have found e-mail or newsgroups useful with adolescents, particularly if they have formed the reputation at school of being shy or quiet. You may find it useful to provide lists of current local activities and opportunities for social interaction. These lists can be compiled from client suggestions and information in local newspapers and on the internet. Such events may include poetry readings, small concerts, walks, and local volunteer work. Secondary Gains You might enjoy several kinds of secondary gains in chronic shyness, Social Phobia, and Avoidant Personality Disorder. Others protect you, do things for you, pamper you, and don't push you. Unfortunately, the flip side of such care is that people who don't participate in their own lives become depressed and self-contemptuous. It is hard to respect ourselves if we are doing little to fulfill our potential and little to contribute to the lives of others. Interestingly, shame and guilt in small quantities stimulate our growth; it is only when people become overwhelmed by what they see as impossible tasks that they become demoralized. A certain kind of tough love must happen in treatment and therapists need to be able to model it with themselves as well as with clients. It is tempting to take the easy way out. We are a bit more self-disclosing in this treatment than in others, because socially phobic clients need the reality testing and the understanding that problems of shyness and Social Phobia are not illnesses to be cured but human problems in living. Unfortunately, diagnostic labels are often used for the purpose of avoiding appropriate interpersonal and societal challenge. Avoiding this problem suggests another benefit of using the social fitness model: instead of having Social Phobia, we suggest that clients appear to wish to increase their levels of social fitness. We then point to this wish as a roadmap toward advancing the client’s goals. Closure and Follow-Up



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Self-report tests (discussed under the Assessment section) are completed prior to the final session and should be discussed with the client along with current goal attainment and plans for future goals. Getting out of "social shape" should be discussed and plans should be formulated for the client to restart "workouts" on his or her own or with support. The BAT (behavior performance/assessment test, discussed under Subtypes and Comorbidity) should be repeated during the final interview, in session 10. At the completion of treatment, a standardized letter may be given to the client to give to two or more friends. The friends then return the letters to you with instructions to either disclose its content to the client or keep it confidential. If permission to disclose the information is given, copy the letters and send them to your client. Questions in the letter concern observable changes in behavior, changes in observed comfort level, and an open-ended question about anything the friend notices that has changed during treatment. A copy of the letter is provided in session 10. With shy clients it is particularly important to anticipate the end of treatment. The emotional connections formed during treatment may quite possibly be the first bonds they have formed and saying good-bye is threatening. Booster sessions may be arranged for clients who experience particular distress at separation. Clients may need help in planning how they will continue their work on their own; learning to anticipate pitfalls, such as demoralization at small failures; and understanding how they might communicate with you if they wish. In some cases, simply getting out their notebooks and reviewing goal setting and cognitive restructuring provides them a context within which to get back into their work.



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Session One: Getting Started Building an Initial Alliance A critical element in the establishment of any effective therapist-client relationship derives from the creation of a sense on the part of clients that their difficulties are taken seriously, that you care for them as individuals, that you can relate to them (or at least want to do so), and that you are sincerely interested in using your expertise to assist them with their problems. It is important to establish this sense early on, because the nature of your early working alliance usually produces a climate which persists throughout the duration of the treatment period. At the same time you are working to create a warm and empathetic relationship, you want to begin your assessment of your client's presenting problems and general level of functioning. Make every effort to point out your client’s strengths throughout the initial evaluation. This often means pointing out the ways in which they are performing well in some situations—they are nearly invariably focused on problems and deficits and take skills and abilities for granted. If you find this to be the case with your client, point out the usefulness of becoming aware of competencies so skills can be transferred from one situation to another. When clients are not self-conscious it is often surprising how well they can perform. Focus on connecting your clients’ efforts with their progress from the first meeting. They often think you will “fix” them; the sooner they understand that it is their motivation and positive expectancies that will make or break the treatment, the easier your job will be. You will facilitate, but they will be the drivers. From the initial meeting, you can stress to your clients that their commitment makes all the difference. Withdrawal has been the shy person’s means of coping, and you need to communicate early on that your expectation is different. You can help your clients decide early in the process whether they are willing to make this commitment to themselves and to your working relationship. You may be the first person to whom they have made a serious commitment of this nature. Encourage your client to read How to Start a Conversation and Make Friends, (Gabor, 1983). It provides ideas for engaging people in brief conversations upon meeting, and discusses the importance of nonverbal communication. Client Goals Clients' primary goals are often implicit in their complaints (e.g., "I am too nervous to speak up at a meeting"; "I can't approach a person I find attractive"; "I feel so worried I will do something © 2001, The Shyness Institute; for details, see page 1.


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wrong when talking with a stranger that I can't concentrate on the conversation and I become lost." Other goals may be elicited by questioning: "How do you think I may be able to help you?" or "What would you like to achieve in the time we will be working together?" Goals are often vague and abstract (e.g., "I want to feel more comfortable in social situations."). Help your clients operationalize their goals—that is, construct goals that are specific and measurable. It is important to do so for this population particularly because clients tend to minimize progress. Examples of specific and measurable goals include: • an average SUDS level drop of 20 to 30 points in situations that had previously caused high anxiety; • reduced negative thoughts or increased challenges to negative thoughts in problematic situations; • increased pleasant emotion in social situations; • the occurrence of new behaviors, such as speaking up at a meeting or asking someone to do something social. Assessment Have your client arrive 10 minutes early to fill out the Brief Fear of Negative Evaluation questionnaire (BFNE; Leary 1983) and the Between-Session Shyness Questionnaire. The BFNE will facilitate discussion of clients' problems and them know if they score similarly to other people who seek treatment for this type of problem. Shyness and Social Phobia were so little understood for so long that clients who have expressed their concerns in the past often suspect that their problems will be devalued or misunderstood. They also tend to be relieved that the concern with negative evaluation is common in chronic shyness. The BFNE demonstrates good reliability and validity. With only 12 items, it just takes a few minutes to complete. The score provides an objective measure of the concern about negative evaluation and can be compared with the general population and with clinical populations. Items are scored from 1 (not at all characteristic of me) to 5 (extremely characteristic of me). Norms for the scale include college students and Shyness Clinic samples. The mean rating for college students is 3.0 and the Shyness Clinic sample mean rating is 4.0. The suggested clinical cutoff is 3.5 (personal communication; Leary, 1998). Share the score and norms with the client. The client fills out the questionnaire a second time at the end of treatment to demonstrate how evaluation concern is reduced with more adaptive thinking patterns and reduced avoidance of feared situations (at least in most cases!). Instructions for the BFNE are extremely simple, so that the instrument may simply



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be provided to the client with a request to follow the instructions and to ask you any questions that might arise.



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Name__________________________________ Date _____________ BFNE

Read each of the following statements carefully and indicate how characteristic it is of you according to the following scale. Circle a number to indicate how characteristic the statement is of you: 1 = Not at all characteristic or true of me

1.

2.

3. 4. 5. 6. 7. 8. 9.

2 = Slightly characteristic or true of me 3 = Moderately characteristic or true of me 4 = Very characteristic or true of me 5 = Extremely characteristic or true of me Not at All Slightly Moderately Very Extremely I worry about what people will think of me even when I know it doesn't make any difference. 1 2 3 4 5 I am unconcerned even if I know people are forming an unfavorable impression of me. 1 2 3 4 5 I am frequently afraid of other people noticing my shortcomings. 1 2 3 4 5 I rarely worry about what kind of impression Iammakingonsomeone. 1 2 3 4 5 I am afraid that others will not approve of me. 1 2 3 4 5 Iamafraid thatpeople willfind faultwith me. 1 2 3 4 5 Other people's opinions of me do not bother me. 1 2 3 4 5 When I am talking to someone, I worry about whattheymaybethinkingofme. 1 2 3 4 5 I am usually worried about what kind of impression make. I 1 2 3 4 5

10. If I know someone is judging me, ithaslittleeffectonme. 1 2 11. Sometimes I think I am too concerned with what otherpeoplethinkofme. 1 2 12. I often worry that I will say or do the wrong t hings.

3

4 3

1

5 4

2


5 3

4

5


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The Between-Session Shyness Questionnaire is also filled out here, and before each subsequent session. The process for establishing validity, reliability and norms for this instrument is now in the data-gathering stage at the Shyness Clinic. At present, it provides a guideline that enables the therapist to judge the feeling states of the client. Extreme answers may be used as prompts for important questions that might otherwise be overlooked. You can also use the Questionnaire to track changes over the course of treatment.



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Between-Session Shyness Questionnaire

Instructions: Circle a number after each item to indicate how things have been since your last session, including today. Please answer all the questions. I have felt: Generally fearful Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Tense Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Discouraged or hopeless Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Inadequate Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Socially anxious Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Shy Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Concerned about negative evaluation Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Suicidal Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Stupid Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Embarrassed Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Self-conscious Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Humiliated Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Frustrated © 2001, The Shyness Institute; for details, see page 1.


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Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Resentful Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Irritated Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Helpless or paralyzed Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Mistrustful of others Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Boiling inside Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Secretly critical of others Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Since our last session I have: Avoided social interactions Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Always Left social situations early Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 --------Always Avoided asserting myself when I wanted to Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Always Pouted or sulked to express frustration Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Always Withdrawn from people I like



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Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Always Been satisfied with my relationships Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Expressed myself more in my relationships Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very much During our last session I felt: Understood Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very That we were making progress toward solving my problems Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very much Misunderstood Not at all -------1 -------2 -------3 -------4 -------5 -------6 -------7 -------Very Copyright @ 1994 by Lynne Henderson, Ph.D., a psychological corporation, Inc. All rights reserved. No part of this questionnaire may be reproduced, stored in a retrieval system or transmitted in any form by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of Lynne Henderson, Ph.D.



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After reviewing the BFNE and the Between-Session Shyness Questionnaire, begin your clinical interview by asking about precipitating incidents or conditions. During this process, let the client tell the story naturally. Communicate your acceptance of your client as a person and your understanding of your client's concerns. State that this initial evaluation is important because it helps you tailor the therapy to individual needs as much as possible.Tell clients that they willbe working with their own specific goals and particular situations during this treatment. When clients stray from your questions, particularly in the beginning, listen to their story because they may never have told it before. Being heard with interest and acceptance may be the most important thing the client will experience during the first session. If a client strays too far from relevant material, you can gently refocus on the particular situations that are causing them difficulty. The clinical interview provides some relief to many highly inhibited clients (and therapists!) because questions can be answered briefly without extensive detail and the therapist can guide the interview. Don’t focus on specific measurable goals until the end of the initial evaluation, when the client begins the self-monitoring process, but do try to get a general idea of what he or she hopes to get from the therapy. Often goals are idealized in the beginning and the client needs to get to know you before the two of you can get specific and realistic about what can realistically be achieved. This initial evaluation is valuable not only for obtaining a reliable diagnosis but as an opportunity for your client to become familiar with you. We provide here a list of categories which should be inquired into, as well as some sample questions: Current Functioning and Symptoms 1. What prompts you to seek treatment at this time? Usually something has triggered the decision, such as losing a job; increased isolation; trouble initiating a relationship; or negative feedback from a boss, coworkers, or family members who have become frustrated with continued dependency or isolation. 2. What specific situations or conditions are most troublesome for you? Are there social situations that you find easy?

3. Can you tell me a little bit about how you're doing in life generally these days? 4. Do you know or have any theories as to why you have this problem? A client's hypotheses about the etiology of his or her symptoms can provide a useful framework. © 2001, The Shyness Institute; for details, see page 1.


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History 1. Can you remember the first time you noticed feeling shy or socially anxious? [If yes]: When was that, and what was happening at your life at that time? 2. Have you had periods when you've felt more or less anxious or shy since that time? 3. Did you experience shyness in preschool, elementary school, junior high, high school? Next, ask about family history. This is important because you will find out whether the nuclear family was isolated, emotionally distant, or volatile, which helps you understand whether more practice in intimacy-related behaviors is important and how much the anxiety may stem from trauma: 4. Can you tell me what it was like growing up in your family? 5. Have any other members of your family been shy or socially anxious, currently or in the past?

6. What did you notice about the ways that your parents and siblings socialized with other people? 7. Has anyone in your family had any mental health problems, currently or in the past? Past Treatment and Medical History 1. Are you currently receiving care from any other mental health professional? 2. Have you received care from a mental health professional in the past? When, for what, what type of treatment did you receive, and did your symptoms or problem improve? Were there any difficulties?

3. Do you currently have any medical conditions? Have you had any major medical problems in the past?

Because anxiety may be related to the presence of conditions such as thyroid dysfunction, recommend a physical if the client has not had one within the past year. 4. Are you currently taking any medications? Which ones, what are they for, and how much are you using? Have you ever taken medication in the past for social anxiety? Which ones, and how did they effect your symptoms?



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If your client is using an antidepressant, discuss the importance of attributing one’s progress to the self rather than the pharmacological agent. If medication is used during treatment, the cognitive restructuring and new behaviors need to be practiced consistently before the client discontinues the medication. Otherwise, there tends to be a higher rate of relapse. The use of anti-anxiety medication has proved problematic in shyness and Social Phobia, particularly if clients will not enter feared situations without it. Generally it exacerbates passivity and pessimism, which evokes negative responses from others. Clients must understand at the outset that progress and maintenance of treatment gains may be limited unless they engage in exposures while gradually weaning themselves away from anti-anxiety medication. The goal is to learn to manage social anxiety as athletes learn to manage the physiological arousal that accompanies intense exertion. Idealized notions of other people who are completely relaxed are unrealistic and should be challenged. Research suggests that non-shy people may experience many of the same physiological symptoms in challenging social situations, but see them as a natural part of the social process (Maddux, Norton, and Leary, 1988). Differential Diagnosis and Comorbidity Rule out Panic Disorder With Agoraphobia and Agoraphobia Without History of Panic Disorder: 1. Is the primary reason you avoid or feel discomfort in social situations because you fear you may experience an unexpected panic attack? Do you every have panic attacks insituations other than social situations?

2. Do you avoid or experience marked anxiety in situations which do not involve scrutiny and/or possible evaluation by others? Do you experience fearfulness or panic attacks when alone outside your home or when alone inside your home; being on a bridge or in an elevator; traveling in a bus, car, train, or plane? Do feel less scrutinized and more comfortable in social situations if you have a companion with you?

A client answering yes to any of these questions should be evaluated for Panic Disorder With Agoraphobia or Agoraphobia Without History or Panic Disorder. Rule out Generalized Anxiety Disorder and Specific Phobia: 1. Do you experience worry more days than not, even when you're not in social situations, or anticipating being in a social situation? Are you anxious in only one or two very special kinds of situations, such as having blood drawn, or seeing a doctor or dentist?

A client answering yes to either of these questions should be evaluated for Generalized Anxiety Disorder or Specific Phobia.



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Assess for Avoidant Personality Disorder: 1. Do you (a) avoid work activities that require interaction with others because you fear criticism disapproval or rejection; (b) refuse to get involved with people unless you are certain beforehand that you will be liked and accepted; (c) "hold back" in close relationships because you fear you will be shamed or ridiculed; (d) becomepreoccupied with being criticized or rejected in social situations; (e) see yourself as socially inept, personally unappealing or inferior to others; (f) avoid talking personal risks or engaging in any new activities because they may prove embarrassing?

A client answering yes to four or more of a through f above should be evaluated for Avoidant Personality Disorder. Recall as we discussed in the introduction that there is considerable overlap between shyness, Social Phobia and Avoidant Personality Disorder. In fact, the DSM-IV states that there is so much overlap between Social Phobia and Avoidant Personality Disorder that "they may be alternative conceptualizations of the same or similar conditions" (American Psychiatric Association, 1994, pp. 663-664). If your client meets diagnostic criteria for both Social Phobia and any Axis II (personality) disorder, refer back to the Assessment Section in the Introduction. Assess for Schizoid Personality Disorder 1. Do you (a) neither desire not enjoy close relationships, including being part of a family; (b) almost always choose solitary activities; (c) have little or no interest in sex with another person; (d) find pleasure in very few or no activities; (e) lack any close friends or confidants aside from siblings or parents?

Does your client (f ) appear indifferent to praise or criticism by others; g() show emotional coldness, detachment, or flattened affect? If there are four or more yes answers to a through g, your client should be evaluated for Schizoid Personality Disorder. Assess for Dependent Personality Disorder 1. Do you (a) have trouble making everyday decisions without an excessive amount of advice and reassurance from others; (b) have difficulty expressing disagreement with others because you fear you might lose their support or approval; (c) have difficulty initiating projects or doing things on your own because you lack confidence in your judgment or abilities; (d) go to excessive lengths to obtain nurturance and support from others, to the point of volunteering to do things that are unpleasant; (e) feel uncomfortable or helpless when alone because you fear you will be unable to care for yourself; (f) immediately seek another relationship as a source of care and support when a close relationship ends; (g) often find yourself preoccupied with fears that you will be left to take care of yourself?



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Also assess whether the client h( ) needs others to assume responsibility for most major areas of his or her life. If there are five or more yes answers to a through h, the client should be evaluated for Dependent Personality Disorder. If a personality disorder or other problematic behavioral pattern is evident, be sure to point out to the client the behavior patterns that are likely to interfere with treatment. For example, to a client with Dependent Personality Disorder, you might say, I know it has been hard for you to assert yourself, so in order for you to make full use of this treatment it will be important to begin to say what you really think, particularly as you become more familiar with me. There will be particular exercises to help you, and if you remain aware of the need to assert yourself and you practice doing it, you will be less likely to have difficulty as you become closer to people. Your tendency to put others’ needs before your own and your inability to tolerate disapproval make relationships less pleasurable. If you work on this in the early phases of relationships it is easier in the long run. So practice with me and we will try to facilitate that.

To a client who demonstrates a passive-aggressive behavioral pattern, you might say, I know you are feeling a good deal of frustration and even resentment toward others right now, and have felt exploited many times throughout your life. I understand that it is hard to express your anger directly, but I will try to help you with assertiveness techniques that make it easier to ask for what you want directly and to express negative feelings in ways that others can accept. If you become angry with me, you may tend to withdraw and not let me know about your feelings. This will sabotage you. I need you to help me with this. How would you like to handle it? Will you call me or write to me if you are uncomfortable discussing it with me in person? That way we can begin to help you practice dealing with these uncomfortable feelings . Should a client fail to make such an

agreement with the therapist, his or her prognosis will be less optimistic. The client must have formed an adequate alliance with the therapist to tolerate and express the anxiety and suspicion they often feel with others. "Some degree of performance anxiety, stage fright, and shyness [in the ordinary sense of the word] in social situations that involve unfamiliar people are common and should not be diagnosed as Social Phobia unless the anxiety or avoidance leads to clinically significant impairment or marked distress" (DSM-IV; American Psychiatric Association, 1994, p. 416). "Screening" Questions The following questions tap into factors that may occasion a consideration of whether or not this course of treatment is appropriate for your client at this time. © 2001, The Shyness Institute; for details, see page 1.


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1. Have you been feeling down or blue lately? [If no, skip remaining questions in this paragraph]. Has this feeling persisted for two weeks or more? Have you experienced a change in your eating or sleeping habits? Have you been feeling hopeless, guilty, or worthless? Have you had any thoughts of killing yourself? [If no, skip remaining questions in this paragraph]. Have you ever attempted to commit suicide? When? By what method? What was troubling you at the time? Are you currently or recently having thoughts of killing yourself? Do you have a plan to do so?

Positive answers to questions pertaining to depression will require a more detailed evaluation of depressive symptoms and consideration about whether depression should be treated prior to beginning treatment for shyness/Social Phobia. If significant risk of suicide is present, immediate intervention is indicated and hospitalization should be considered. 2. Have you or any members of your household ever hit or hurt each other? Are you ever frightened that someone in your household might hit or hurt you? Have you ever deliberately hurt yourself?

If there are any yes answers, assess whether any intervention is necessary, or if further evaluation for post traumatic stress disorder or borderline personality disorder is warranted prior to beginning treatment for shyness or Social Phobia. 3. Have you ever been hospitalized for any nervous or psychiatric conditions? If yes, when and why?

Prior hospitalizations, especially recent hospitalizations for serious problems, may warrant further evaluation of whether or not it is appropriate for your client to practice in vivo exposures at this time. 4. Do you currently have an alcohol or drug problem? How many alcoholic drinks do you consume in a typical week? Do you ever drink to change a negative mood state? Do you drink to reduce your social anxiety? Do you have difficulties, or do you believe you would have difficulties if you were to discontinue drinking immediately? Have you found that you need to drink more and more to achieve a desired effect? Have you experienced any problems with your family, your friends or the law that is related to your use of alcohol? What about drugs? Do you ever use medications or street drugs to alter your mood? What kinds of drugs do you use for this? How often have you used drugs within the past month or so?



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How much caffeine do you typically consume during a day, including coffee, tea, colas, and caffeine tablets, and analgesics containing caffeine (e.g., Excedrin)?

We have a low incidence of substance dependence among our clients, but some use alcohol or cannabis to reduce social anxiety, often in relatively small quantities. We’ve found that many clients who use cannabis a great deal lack the motivation to tolerate the discomfort of in vivo exposures. Much higher rates of abuse or dependence are reported in some samples of social phobics. Explain to your clients that if alcohol or cannabis is used during their at-home in vivo exposures, they will not benefit from the desensitization process and will not learn that they can handle their anxiety. If you think it may be difficult for your clients to enter social situations without using alcohol, ask if they are currently able to abstain from its use while in social situations. It may not be fair to them to continue treatment for shyness and Social Phobia if they cannot benefit from the exercises between the treatment sessions which require sobriety in order to be effective. It is generally unproductive to attempt this treatment if substance abuse or dependence is present. If substance abuse or dependence is suggested, you’ll probably want to treat that condition or refer the client to a chemical-dependency counselor to address this issue before working with the shyness and Social Phobia. In addition, caffeine can be an issue—sometimes clients will not have recognized that caffeine use exacerbates social anxiety and will need to be educated about excessive use of caffeine. Sharing Your Conclusions When you have completed your clinical interview, share your conclusions with the client. Do you see shyness or Social Phobia as the primary problem? Does the client appear to be a good candidate for treatment at this time? If there is some factor which occasions you to feel that proceeding with treatment might not be indicated at this time (e.g., presence of a different primary problem or a comorbid disorder, such as a substance abuse or dependence problem) this should be discussed with the client. Construct a plan to either provide the client with services to address the more pressing problem or refer to other professonals. Then lay out a roadmap which leads the client toward being prepared to begin treatment. When your assessment has brought you to the clear conclusion that chronic shyness or Social Phobia is the primary problem and that it is appropriate for your client to begin work, let the client know this immediately. This helps clients label and frame a specific issue and prepares them to assume a positive treatment expectation. You might say,based on the tests you've completed and © 2001, The Shyness Institute; for details, see page 1.


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our discussion so far, my opinion is that you are ready to begin working on overcoming your shyness/Social Phobia. If your client has articulated maladaptive theories as to why the problem

has developed, or believes treatment gains are unlikely, you might explore these ideas to determine if you can reframe their hypotheses and expectations into a more adaptive posture. For example, clients who articulate that they believe their social anxiety is genetic can be queried in order to understand whether they feel this belief implies an inability to benefit from treatment. In such cases, you might point out that although there does appear to be some kind of autonomic reactivity which plays a role in the development of shyness in a small percentage of the population, self-conscious concern about negative evaluation is essentially a learned response to experiences, and can therefore be unlearned. Explain to these clients that it is unknown whether or not genetic factors played a role in the development of their specific difficulties, and if so to what extent, but that in any case, research has clearly demonstrated that people who are motivated to improve and who expend effort in that direction generally receive benefit. If, on the other hand, clients appear to be self-blaming in their etiological theory, for example, attributing their difficulty to weakness or stupidity, you might attempt to challenge this thinking by suggesting that any individual, no matter how bright or capable, who experiences significant negative life events or situations is vulnerable to the same challenges. Point out any strength you have noticed during the session so far that might suggest that the person is capable of effecting positive self-change. Once the client understands what the pertinent problem is, and has been assured—in a positive and realistic fashion—that there exists a real opportunity for improvement, you are ready to explain how you expect the treatment program to facilitate a positive outcome. Treatment Recommendations and Session Summary You should briefly but thoroughly outline the course of treatment on which the client will embark, explaining essentially what will happen each session and also explaining the reason that you expect each major component of the treatment to be helpful. Explicating a predictable structure that makes sense as a reasonable way to approach the client's difficulty provides the client an opportunity to experience a sense of relative security. It also provides the client with a logical roadmap toward a more comfortable and rewarding future. Both of these factors are likely to enhance motivation and therefore treatment outcome. This brief, well-organized presentation to the client should include the following: - A brief statement which conveys that you have understood essentially what your clients have communicated to you about who they are as persons and something about how they experience their history, sense of self, and their place in the world © 2001, The Shyness Institute; for details, see page 1.


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- A concise statement defining the nature of the problem on which treatment will focus. - A validating statement which demonstrates that you understand how the client fundamentally conceptualizes and experiences the particular problem. - A short discussion--which should derive from the interchange that has just occurred between you and your client--that conceptualizes one or more relatively simple ways to understand factors related to the likely etiology of the difficulty in this particular case—including at least one explanation which reduces the potential for maladaptive etiological theories, as discussed in the previous section. - A summary of what you can conclude from your assessment and interview so far, including your opinion on whether you think the client is likely to benefit from therapy at this time and an explanation of why or why not. - A short "tour" of the major components of the treatment plan: the purpose of assessment, the purpose of completing a fear hierarchy, the purpose of identifying and challenging automatic thoughts and maladaptive attribution patterns; how role-plays (exposures) are used to facilitate entering feared situations, provide desensitization experiences and provide an opportunity to practice skills and gain a sense of mastery; and a general description of what the homework will comprise. Discuss how education about overcoming shyness and Social Phobia will fit into the treatment and state in a sentence or two what your client should expect to learn during treatment. Recommend the client obtain a copy of one or two good skills-based books, such as How to Start a Conversation and Make Friendsby Don Gabor (1983) and Reaching Out by David Johnson (1997). Finally, provide an outline of the structure of each session; You should also discuss treatment goals, as jointly defined, and summarize reasonable and positive treatment expectations. Make sure your client knows on which date you expect to schedule the last session, and explain that you will be available for follow-up or booster sessions, if needed. If your assessment clearly indicates that a change should be made in psychopharmacological treatment over the course of the program, explain your recommendations and refer as appropriate. If there are critical issues which will require further assessment or analysis on your part before you make a particular recommendation, explain to your client the nature of the issue, what you need in order to reach a conclusion on the matter, and when you expect to do so.



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An example of how such a presentation might be made in a hypothetical case follows: Now I'd like to go over with you what we've covered in this session so far, let you know what my recommendations are, agree on a way to proceed and let you know what to expect. From what you've told me, my sense is that you have experienced difficulty with shyness since early childhood and you have come to a point in your life, especially as it pertains to the demands of advancing in your career right now, that you are interested in working to manage and overcome this problem. You tell me that you usually do alright in most one-on-one social situations with people you already know well, but have trouble in other situations, especially in speaking up at a work meeting or in making a presentation to a group. You stated that you felt guilty and responsible for your shyness, and we discovered that you think of it as a personal weakness. We then agreed that you might have been unreasonably hard on yourself and that some other explanations, such as the fact that your parents were not good models for socializing, that you are a sensitive person, and that you were teased by other children in elementary school taught you to be shy, and therefore it is reasonable to assume that your shyness can be un-learned. Your scores on the test you took just prior to beginning today suggests that you probably experience shyness or social fears at about the average level of other people who seek help with this issue. From all that I've learned about you, you appear to beready to begin a treatment program with an expectation that you will benefit if you work hard and are motivated to tackle this problem. We'll begin next week by constructing a list of situations and people or types of people which trigger problems or discomfort for you, and then we'll begin to look at how some of the ways you characteristically think in these situations are actually generating the anxiety that interferes with your enjoyment of others and your avoidance of certain situations in which you would really like to participate. We'll also look at how emotional states such as anger and shame play into a selfdefeating pattern that we will begin to change. After that, we'll start to take situations from the list we'll construct, and begin to role-play them while we're in session. Pretending that we're actually in one of the difficult situations will allow us to better understand what's actually happening that causes trouble for you. We'll then work on changing those patterns, replacing them with more useful patterns that should reduce your anxiety and help you learn that you can actually perform well in these situations after all.



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I'm going to give you some materials to take home with you today. The Client Manual for this program, a form for you to fill out during the week, and I'm going to recommend you read the first chapter of a book you can pick up at a local bookstore. After this week, we'll agree on completing certain kinds of homework during the week between each session. You will do some reading, write about your social experiences, and use the tools we develop in here to enter problematic situations and to practice new behaviors in them. We decided that you would consider this program a success if you are able to make at least a few comments when you attend your weekly work meetings, and able to make a presentation to your division managers. We also decided that those were reasonable goals to aim for and attain if you work hard in treatment and faithfully complete the homework that is assigned. We will plan on meeting for 10 sessions, which means our last session will be schedule for April 20 th . t I will be available after that, just in case you need to come in a time or two to brush up, or work some more on any particular challenging problems that might arise. You told me that you feel the antidepressant you have been using for some time now has improved your mood and that you and your doctor have agreed that you will continue to take the medication for the immediate foreseeable future. You'll remember what I told you about being clear that the medication may help your mood and improve your motivation, but that the work is still up to you and the progress that you make will be as a result of your work, and not simply from taking the medication. We'll establish a certain structure that we'll basically follow each week: We'll start by finding out how you're doing in general, if there's anything significant happening with you that I should know about. Then we'll take a few minutes and work out what we'd like to accomplish together for the day. After that, we'll look at the homework that you did from the previous week. And then we'll practice a particular exercise, or engage in a role play and take some time to discuss what we're learning along the way. We'll end each week by going over the hour quickly in review. I'll ask you to talk about what you experienced during the session and take any questions or suggestions that you have, and finally we'll set your homework for the following week. We'll finish up for today now by me asking you what you think about what we've discussed this hour, and whether you have any questions I can answer. then I'll give you your first homework assignment and we'll make sure you are scheduled for next week.



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Does that all sound OK?

Feedback from Client Let clients know that it might be useful to write down any questions they think of prior to the next session. Socially anxious clients often think of their questions after the session and appreciate some structure to facilitate bringing them up at the beginning of the following session. Also, tell them that you’d like them to write about any stressful or traumatic events during their lives that were not already discussed in this session. Due to the discomfort of discussing painful memories with a stranger or because the significance of an event has not been recognized previously (Lazarus 1976), clients may prefer to write about them. Homework for This Session 1. Give your client a Social Interaction Log. Ask them to write down any negative thoughts that occur in three social situations over the coming week, especially those which are anxietyprovoking. Make certain that the client is sure that three or more anxiety-producing social interactions will be encountered prior to the following week. If not, help the client problem-solve as to how such situations can be identified and purposefully entered. If the client is not sure anxiety-provoking social situations will be encountered, and is not willing to commit to seeking them out, have the client complete the log for social interactions which are not charged with anxiety, or for situations in which the client avoids social interaction. To complete the Social Interaction Log, the client will first need to understand the SUDS. Go over each form with the client: First, let's look at this Subjective Units of Discomfort Scale. This is a method we will use to put a number on how anxious you are feeling at various times, or for estimating how uncomfortable certain situations are for you. Points on the scale range from 0, where absolutely no discomfort is experienced, to 100 which would represent the most intense anxiety you have ever experienced or could imagine.

Ask the client to provide an example of a very low-anxiety producing situation, then ask what SUDS level would be experienced in that situation. Then ask about a high-anxiety producing situation and ask for a second number. If the client's numbers essentially match what is described as experienced in the situation, move on to an explanation of the Social Interaction Log. If the



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client does not seem to be using the scale to accurately describe anxiety levels, work with some more examples and descriptions until it is understood. SUBJECTIVE UNITS OF DISCOMFORT SCALE (SUDS) 0-----------------------25-----------------------50-----------------------75-----------------------100 No anxiety/ discomfort

Moderate anxiety/ discomfort

Extreme anxiety/ discomfort

SUDS Rating

Definition

0

Feeling completely relaxed, peaceful, calm, could perhaps fall asleep.

25

Experiencing mild anxiety/discomfort. Does not interfere with performance

50

Uncomfortable anxiety. Anxiety becomes distracting, but ability to continue on in activity remains. Clear awareness that the situation or activity is unpleasant. Concentration and focus begin to become affected.

75

Anxiety becomes increasingly uncomfortable. There is a preoccupation with symptoms of anxiety. Extreme difficulty in concentrating on the situation or activity. There are thoughts of wishing to escape from the situation or activity.

100

The highest level of anxiety it is possible to experience. Absolute terror and panic. It becomes impossible to continue in the situation or activity.

Then explain the Social Interaction Log:Now let's take a look at this other form, the Social Interaction Log. Most of the items on the log are clear in what they ask for, but let's review a few



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that might not be. Length simply refers to how long the interaction or social situation lasted, or how long you stayed in the situation. The "interfering thoughts?" item is a yes or no question. We'll pay a great deal of attention to specific kinds of thoughts that interfere with your ability to enjoy certain situations as we move through the treatment program. For now, I'd like you to simply notice whether or not you notice any thoughts that distract you, cause you to feel unpleasant, or cause you to leave or avoid situations. There is a space down below to make notes on what those thoughts actually are. "Mood" asks about how you're feeling emotionally during the experience. "Initiated by" and "finished by" are asking after who began and ended the interaction or experience. "Outcome" asks you to rate how positively or negatively you feel about how the situation went as a whole. You are then asked to provide a number between 1 and 100 describing how shy you felt during the interaction, and how pleasing the situation was for you.



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Social Interaction Log

Date: ____________ Length: ___________ SUDS Level: _______ Interfering Thoughts? ___ Situation: ____________________________________________________________________ Mood: _________________ Initiated by: _______________ Finished by: __________________ Outcome: -3 -2 -1 0 +1 +2 +3 How shy (%): _______ How pleasant (%) ______________ Thoughts about yourself: ________________________________________________________ Thoughts about other(s): ________________________________________________________ Feelings towards other(s): _______________________________________________________ Comments:




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2. Before your client leaves, be sure to give him or her the Client Manual and suggest that he or she read the Introduction to get a sense of the treatment plan and a basic understanding of the nature of shyness and Social Phobia. The client should also read at least through Session One, since it contains copies of the forms, instructions to fill them out, and a permanent record of some of the information discussed in today's session. 3. Just prior to the next session (perhaps in your waiting room before the appointment), the client should again complete the Between-Session Shyness Questionnaire.



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Session 2: Constructing a Hie rarchy Monitoring Current Status

Have the client fill out the Between Session Shyness Questionnaire in the waiting room when they first arrive. You may want to tell themto come a little early for each session to do this. You can leave the questionnaire on a clipboard in the waiting room. Begin the session by asking the client if any questions or concerns came up after the last session. Shy and socially phobic clients often need help in articulating their concerns. You can ask how they felt after the last session. If they do not respond you can say that sometimes clients feel apprehensive when they tackle things they have not triedfor awhile. If they agree you can say that “being out of shape socially” is similar to being out of shape physically, and that together you will take it a step at a time. Tell them that they will be practicingnew behaviors with you before they practice outside the session. Tell them that you want to stay aligned with their goals, and that, together you will revise the weekly goals ifthey seem too large or toosmall. Use the questionnaire to guide you in exploring any negative feelings thatarose in social situations. You can reassure him that these are common and that these feelings usually are reduced with practice in new situations. If the client has indicated that they did not feel understood or that they not sure that this treatment would be helpful to them, you can explore their thoughts and feelings about it. Sometimes they say that they feel uncomfortable even when their behavior may seem appropriate from the outside. Tell the client that sometimes discomfort is related toa need for more practice in a given situation, and sometimes it appears to be related to their negative thoughts, which you will help them begin to challenge. If they did not feel understood during the first session, it is important to exploretheir experience. *ASK WHAT you might have done to make them feel more understood. *IF THE CLIENT IS TAKING MEDICATION, ASK IF THEY ARE TAKING IT ACCORDING TO SCHEDULE AND IF THEY ARE EXPERIENCING ANY TROUBLESOME SIDE EFFECTS. IF THEY ARE HAVING TROUBLE REMEMBERING, YOU CAN SUGGEST STRATEGIES LIKE POST IT NOTES ON THE BATHROOM MIRROR OR PUTTING IT IN AN OBVIOUS PLACE, SUCH AS BY THE BED AT NIGHT OR IN THE BATHROOM IN THE MORNING. IF THEY ARE EXPERIENCING SIDE EFFECTS THAT MAKE THEM RELUCTANT TO TAKE IT, SUGGEST THEY TALK TO THEIR PSYCHIATRIST OR INTERN WHO MAY BE ABLE TOADJUST THE DOSAGE OR MAKE OTHER SUGGESTIONS TO REDUCE THEIR DISCOMFORT. Set Agenda



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Tell the client that today you will be constructing a hierarchy together *AFTER YOU REVIEW THEIR HOMEWORK. A hierarchy is a set of ten situations, from the least tothe most feared, in which the client feels uncomfortable and wants topractice new behaviors. These will be the situations that the client will simulate (role-play) with you and/or volunteers during the sessions. They will practice on their own between sessions. These may also be situations that you will practice in vivo together if the client is not able to do so on his own. Review of Homework

Ask the client to show you the social interaction log. You can acknowledge the negative thoughts that are characteristic of social phobia, like “I won’t be able to think of anything to say.” In cases where they did in fact say something, you can point out how, in spite of the negative thought, they did have something to say after all.This helps them begin to notice howtheir thoughts often do not coincide withtheir behavior. If they have rated anoutcome as negative you can ask what happened. They may have construed an ambiguous response from another person as negative. You will begin to see how their interpretations influence howthey feel. *I NOTICE THAT ONE OF YOUR AUTOMATIC THOUGHTS WAS “I WON’T BE ABLE TO THINK OF ANYTHING TO SAY. DID YOU EVENTUALLY THINK OF SOMETHING? ISN’T IT INTERESTING THAT YOUR HYPOTHESIS, THAT YOU COULDN’T SAY ANYTHING, WAS NOT CONFIRMED. I’D LIKE YOU TO PAY ATTENTION TO THOSE TIMES WHEN YOUR FEARFUL HYPOTHESIS IS NOT CONFIRMED. SOMETIMES, WHEN WE FEEL NERVOUS, WE DO NOT NOTICE THINGS THAT WE WOULD IN OTHER SITUATIONS, FOR INSTANCE, IN OUR WORK SITUATIONS. YOU RATED THIS SITUATION AS HAVING A NEGATIVE OUTCOME THAT WAS YOUR FAULT. I NOTICED THAT YOU HAD AN AUTOMATIC THOUGHT ABOUT THE OTHER PERSON. YOU THOUGHT THAT SHE WAS NOT INTERESTED IN WH AT YOU HAD TO SAY. COULD YOU DESCRIBE TO ME THE LOOK ON HER FACE OR THE BEHAVIOR THAT COMMUNICATED THAT TO YOU? IT IS ALSO INTERESTING, WHEN YOU THINK ABOUT IT. YOU DESCRIBED HER FACE AS JUST SORT OF EXPRESSIONLESS OR NEUTRAL, NOT WARM AS YOU WOULD HAVE HOPED, BUT NOT ANGRY OR COLD EITHER. THAT IS COMMON WHEN WE FEEL SHY, THAT WE READ NEUTRAL EXPRESSIONS AS THREATENING OR NEGATIVE. THERE IS QUITE A LOT OF DATA ON THIS TENDENCY. PERHAPS NOW YOU CAN NOTICE THE TIMES WHEN SOMEONE LOOKS REJECTING, EXACTLY WHAT IT IS THAT YOU ARE NOTICING THAT PROMPTS YOU TO THINK THAT THOUGHT. Concepts and Skills: Constructing the Hierarchy



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When you have discussed their reactions to the previous session and the homework, proceed with the construction of the hierarchy of ten situations that clients will practice entering and in which they will perform new behaviors during thecourse of treatment. A sample hierarchy is provided and a blank hierarchy for the client.



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Sample Hierarchy

Name:_

Date

Phobias: Fear and Avoidance Rate the degree to which you tend to avoid the situations listed below because of the fear or unpleasant feelings associated with them. Also, rate your levelof anxiety in each situation. 0----------10---------20------------30-----------40----------50-----------60------------70------------80----------90---------100 Donotavoid Hesitateto Sometimes Usually avoid Invariably situation entersituation avoid situation avoid - very noanxiety butrarelyavoid situationmarkedlyor severe/ it-slightly/ definitely very often continuous somewhat anxious anxious anxious anxiety, n earpanic Rating Description Avoidanc Fear Evaluation e (SUDS Fear ) (0-100) (0-100) (0-100) 1. The worst situation 100 95 90 Giving a talk in front of 30 or more people 2. The second worst situation Asking someone I’m attracted to for a date 3. The third worst situation Approaching a group of strangers 4. The fourth worst situation Approaching one opposite-sex stranger 5. The fifth worst situation Approaching a stranger of the same sex



6.

7.

8.

The sixth worst situation The seventh worst situation

Joining a conversation with colleagues at work Talking about my project in a small work meeting

The eighth worst situation

9.

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The ninth worst situation

10. The tenth worst situation

Asking a potential friend to go to lunch or for a hike Saying no to a request to help a friend or colleague Maintaining a conversation on the telephone


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Client Hierarchy

Name:_

Date

Phobias: Fear and Avoidance Rate the degree to which you tend to avoid the situations listed below because of the fear or unpleasant feelings associated with them. Also, rate your levelof anxiety in each situation. 0----------10---------20------------30-----------40----------50-----------60------------70------------80----------90---------100 Donotavoid Hesitateto Sometimes Usually avoid Invariably situation entersituation avoid situation avoid - very noanxiety butrarelyavoid situationmarkedlyor severe/ it-slightly/ definitely very often continuous somewhat anxious anxious anxious anxiety, near panic Rating Description Avoidanc Fear Evaluatrio e (SUDS n ) Fear (0-100) (0-100) (0-100) 1. The worst situation 2. 3. 4. 5. 6. 7.

The second worst situation The third worst situation The fourth worst situation The fifth worst situation The sixth worst situation The seventh worst situation



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8.

The eighth worst situation 9. The ninth worst situation 10. The tenth worst situation


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When constructing the hierarchy it is useful to anchor the range by first asking them to give an example of a situation that is a bit stressful, but they can tolerate without too much discomfort, with a SUDS (Subjective Units of Distress Scale) level around 20 or 25. SUDS simply refers to the degree of experienced anxiety or distress. They also rate how much (scale of 0 to 100) they avoid the situation. If they *DO NOT don’t know, ask them totell you *ABOUT the last time they were in the situation. *For example, Tell me about the last time you were in that weekly meeting. Think how anxious you felt. Was your heart pounding or your palms sweating? If you had to give those sensations a number, how anxious did you feel on a scale of zero (as relaxed as a wet noodle) to 100 (as terrified as you have ever been). How much were you concerned about being evaluated? How much did you worry about it? Estimate your concern on that same scale of 0 to 100. Now think about how much you avoid that situation. Do you ever miss one of the weekly meetings because youare socially anxious? Do you ever just decide not to go? How many times a month do you miss a meeting? Again, on that same scale of 0 to 100.

THEN ASK THEM TO NAME A SITUATION THAT IS THE MOST DIFFICULT ONE THEY CAN IMAGINE OR BARELYCAN TOLERATE. THIS OFTEN TURNS OUT TO BEA PUBLIC SPEAKING TASK OR ONE-TO-ONE INTERACTION WITH A DATE OR POTENTIAL ROMANTIC PARTNER. USUALLY THESE HAVE A SUDSLEVEL OF 90 OR ABOVE, CONSIDERABLE AVOIDANCE AND EVALUATION CONCERN. Now think of a situation that you either avoid altogether because it is so frightening, or you practically panic when you think about it or anticipate going? What is your SUDS level from 0 to 100.? How concerned are you that you will be evaluated, that people will see your nervousness and be critical of you? Can you enter the situation at all? How much do you avoid it? When was the last time you gave a talk (or went on a date)?

SOMETIMES YOU WILL NEED TO USE YOUR CLINICAL JUDGMENT ABOUT THE DEGREE OF AVOIDANCE. IF THE PERSON SAYS SOMEOF THE TIME, OR ESTIMATES AVOIDANCE AROUND 70 OR 80, BUT HASN’T GONE ON A DATE FOR A YEAR, THE AVOIDANCE IS 100. IN THE CASE OF TALKS OR PRESENTATIONS, YOU CAN ASK QUESTIONS LIKE THIS: If your boss asked you to give a talk tomorrow, would you do it? Would you try to get out of it? Do you ever volunteer to give presentations?

The next situation to ask about *IS ONE in the middle, with a SUDS level of around 50 and moderate avoidance and evaluation concern.The rest can be filled in around theseexamples. *Now think of a situation where you feel moderately anxious or upset. You really notice your anxiety, but you can tolerate it with some effort and you can function in spite the distress. On a scale of 0 to 100, how anxious do you feel? How much do you think about others watching you



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or being critical of you? How much do you avoid going, or avoidparticipating once you are there, on that same scale of 1 to 100.

BE SURE TO GET TEN SITUATIONS. LOOK FOR SITUATIONS THATMAY INVOLVE SELF-ASSERTION OR SELF-DISCLOSURE IN MORE INTIMATE SETTINGS, IF THAT APPEARS TO BE ONE OF THE PROBLEMS. NEW SITUATIONS AND CONVERSATIONS ARE IMPORTANT TO PRACTICE, BUT DEEPENING RELATIONSHIPS IS USUALLY ANOTHER DIFFICULTY WITH SHYNESS AND GENERALIZED SOCIAL PHOBIA. When the hierarchy is completed, make a copy forhe t client. Tell them that you would like them to begin to practice situations from the *BOTTOM HALF OF THE HIERARCHY ON THEIR OWN. MANY of them you willrole-play in the sessions, but some they will do on their own. Tell them to select one or two closer to the bottom of the hierarchy, such as saying hello to someone new, or having a brief conversation with someone at the office. Ask them to note any new behaviors that they notice themselves doing inthese situations. Ask them to record their SUDS levels before andafterward. *TELL THEM TO USE A SOCIAL INTERACTION LOG TO RECORD THEIR THOUGHTS AND FEELINGS DURING THE SITUATION. *This is a good place to use your social interaction log, because you will begin to notice some of the frightening thoughts you have, and what you say to yourself about this situation. Be sure to rate the outcome ofthe situation, how you thought itturned out overall. Was it on the negative or positive side? Then rate your thoughts aboutyourself and your thoughts aboutthe other person (people). Also write down what you felt toward the other person.

Tell them that they *MAY be adding new situations and behaviors that occur to them during treatment that theywant to practice. That way you can revise the hierarchy together asneeded. Tell them that you will conduct the first simulated exposure with them during the next session. Assessing Attribution Style & Reviewing Testing

After the hierarchy is completed, you fill out the Shyness Attribution Questionnaire (SAQ) with the client. A copy of the questionnaire is provided for you.



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SAQ (Shyness Attribution Questionnaire) Lynne Henderson, Ph.D.

Rating the Reasons for Success and Failure We are going to list the three most challenging situations on your hierarchy with different possible explanations for anegative outcome (failure) ofeach situation. For each situation, imagine yourself in that situation,and tell me the one major cause of thatnegative outcome. Rate the cause you have stated on each of the next five causal dimensions. Rate how much, in your experience, this item is relevant toyour stated cause. We will use the following rating scale to make your judgment: Rate the cause 123456789

little

much

Tell me the number that indicates how much you feel that cause is described by this item (causal diminsion). There is no right or wrong answer, of course, so do not spend a lot of time making your judgments; the important thing is your first impression.



1.

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Therapist says, “Imagine that you are ___________(most challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789

The degree to which the cause is due to something about you, rather than to other people or circumstances. 123456789

The degree to which the cause is relevant to many different situations, rather than being specific to a few situations. 123456789

The degree to which the cause can be expected to be present at the same level every time the same situation occurs. 123456789

The degree to which the cause is a factor that you have control over. 123456789

The degree to which the cause indicates that you are worthy of blame. Therapist says: “Now listen to each feeling carefully and decide to what extent you would be experiencing the feeling. Make your choice according to this scale: …0 =not at all, 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items). 0

0

0

1234

1.

embarrassment

2.

feeling ridiculous, laughable

3.

feeling humiliated, "stupid," 'childish"

4.

feeling helpless, paralyzed

5.

feelings of blushing

1234

1234

0

1234

0

1234



1.

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Therapist says, “Imagine that you are ___________(second challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789


The degree to which the cause is relevant to many different situations, rather than being specific to a few situations.

123456789



The degree to which the cause indicates that you are worthy of blame.

Therapist says: listen to each to what be experiencing the“Now feeling. Make yourfeeling choicecarefully accordingand to decide this scale: …0 extent =not at you all, would 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items). 0

0

0

1234

1.

embarrassment

2.


3.


4.


5.


1234

1234

0

1234

0

1234



1.

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Therapist says, “Imagine that you are ___________(third challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789





The degree to which the cause indicates that you are worthy of blame. Therapist says: “Now listen to each feeling carefully and decide to what extent you would be experiencing the feeling. Make your choice according to this scale: …0 =not at all, 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items). 0

0

0

1234

1.

embarrassment

2.


3.


4.


1234

1234

0

1234

0

1234

5. feelings of blushing Copyright @ 1996 by Lynne Henderson, Ph.D., a psychological corporation, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system



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or transmitted in any form by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of Lynne Henderson, Ph.D.



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Use the top three situations from theirhierarchies. Ask them to imagine the situation. Then ask them to imagine that the interaction (or the speech, etc.) does not go well, that the outcome is negative. Say to the client, *what would you say is the cause of that outcome? They will usually say something like they did something wrong or that they can’t make conversations, etc. Ask them to rate the cause. You said that you couldn’t think of anything to say. On a scale of one to nine, how much do you think this has to do with something about you, *RATHER THAN other people or circumstances?”

If they have difficulty, say, *what would you say to yourself right after the situation”That usually prompts the negative attributions. They will usually saythat something about them caused the negative outcome. The talk did not go well because they “can’t give talks“. (In fact, talks often go better with receptive audiences and these kinds of attributions to others do not usually occur to them.) The date did not go well because they “are awkward or shy.” Ask them to rate, on a scale of 1 to 9, each item. When asking about global attributions, they may not understand, so say,* if this happens in a talk, how much do you think the fact that you are awkward is responsible for negative outcomes in other kinds of situations, such as meeting people, conversations, etc.”

*For stable attributions, how much do you expect this same cause to be present every time this particular situation occurs, I mean giving a talk to this audience ? For control, how much control do you think you have over the cause you have given. Do you have control over your awkwardness? If so, on a scale of 1 to 9, how much control do you think you have? CONTROL CAN BE A BIT PARADOXICAL, IN THAT YOU WANT HIGH

ATTRIBUTIONS OF CONTROL OVER THEIR OWN BEHAVIOR, OR A BELIEF THAT THEY CAN LEARN TO CONTROL IT WITH EXPERIENCE AND PRACTICE. IN INTERPERSONAL SITUATIONS SUCH AS CONVERSATIONS IT CAN BE USEFUL FOR THEM TO GIVE LOWER RATINGS OF CONTROL, UNDERSTANDING THAT CONVERSATION PARTNERS SHARE THE CONTROL BETWEEN THEM. THEY DO NOT NEED TO EXPECT THEMSELVES TO BEABLE TO CONTROL A CONVERSATION BETWEEN TWO PEOPLE. WHAT YOU ARE HOPING TO ACHIEVE IN THERAPYARE MORE ADAPTIVE ATTRIBUTIONS IN PARTICULAR SITUATIONS. *For self-blame, say, how much do you blame yourself during or after you leave this situation. On a scale of 1 to 9, how much are you likelyto think that you are worthy of blame?

After the client gives their attribution ratings ask the four shame items. In * that situation, on a scale of 0 to 4, how much embarrassment do you feel? How much .do you feel rediculous or laughable? How much do you feel humiliated, stupid, or childish? How much do you feel helpless or paralyzed? How much do you feel like blushing or how much do you blush?...



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The *SAQ is helpful to use both pre and post to see if their attribution styles do change *AND HOW MUCH SHAME IS REDUCED. How much they change is often related tohow much practice they have accomplished during the course of treatment and how much they have actively practiced challenging their negative attributions.) It is important to elicitquestions and reactions. Communicate to the client thatthese are the typical thoughts and feelings for shyand avoidant people. They need to understand that you have seen this before, and that you have faith that these things change OVER TIME with simple practice and experience. This is where the Social Fitness Model si useful. Tell them they are goingto be working out every day. As they do new things and practice, their social conditioning will gradually improve. It provides an adaptive framework for them to think about, and begins to remove the stigma of shyness and social phobia. *I will show you how to challenge your negative thoughts in our next session. We have data that shows that if you consistently challenge these negative thoughts, and develop more adaptive ways of talking to yourself in social situations, you will become less self-blaming and experience less shame, which is very painful, and interferes with your enjoyment of your life. Summary of Session

Briefly summarize the session andthe overall goals fortreatment. Be sure that the client has at least one behavioral goal, such as he will have asked one person at his office to go out to lunch. It is important to have a goal related to reducing negative thoughts also. For example, when negative thoughts occur about himself in social situations, the client will challenge those thoughts and substitute a more rational response. Other examples include: entering situations where they can meet potential friends or dates; speaking up more frequently in meetings and expressing opinions, approaching a supervisor to ask for help or to ask for feedback. A goal related to physiological arousal is a reduced SUDS level of at least *20 TO 30 points in a feared situation. *FEEDBACK FROM CLIENT

IF POSSIBLE, ACKNOWLEDGE THE CLIENT’S WILLINGNESS TO ANSWER QUESTIONS THAT YOU KNOW BRING UP THE DISCOMFORT THEY FEEL IN THE STRESSFUL SITUATIONS. ACKNOWLEDGE STRENGTHS, SUCH AS THE CLIENT’S WILLINGNESS TO GIVE A TALK IF THE BOSS ASKED THEM, IN SPITE OF CONSIDERABLE DISCOMFORT. ASK THE CLIENT HOW THEY FELT DURING THE SESSION. HOMEWORK

ASK THE CLIENT TO ENTER AT LEAST ONE SITUATION FROM THE BOTTOM HALF OF THE HIERARCHY. REMIND THEM TO USE THEIR SOCIAL INTERACTION LOG TO RECORD THEIR THOUGHTSAND FEELINGS. TELL THEM TO PRACTICE ONE © 2001, The Shyness Institute; for details, see page 1.


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NEW SOCIAL BEHAVIOR A DAY, SUCH AS SAYING HELLO TO SOMEONE AT WORK, OR IN THE NEIGHBORHOOD, MAKING EYE CONTACT AND SMILING AT SOMEONE NEW, HOLDING A BRIEF CONVERSATION WITH SOMEONE IN A MOVIE LINE OR AT THE GROCERY STORE. THEY CAN USE A SIMPLE COMMENT ABOUTTHE WEATHER, OR ASK WHETHER THE PERSON IN THE MOVIE LINE HAS HEARD ANYTHING ABOUT THE MOVIE. IF THEY CAN ENTER MORE THAN ONE FEARED SITUAITON THAT WILL BE WONDERFUL, BUT ONE IS ENOUGH AS LONG AS THEY PRACTICE THE SMALLER BEHAVIORS ONEOR MORE TIMES A DAY. LIKE PHYSICAL FITNESS, IT TAKES DAILY WORKOUTS TO IMPROVE SOCIAL CONDITIONING.



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Session Three: Cognitive Restructuring and the First Simulated Exposure Monitoring Current Status

Have the client fill out the Between Session Shyness Questionnaire in the waiting room when they first arrive. You may want to remind them tocome a little early for each session to do this. You can leave the questionnaire on aclipboard in the waiting room. Begin the session by asking the client if any questions or concerns came up after the last session. Ask them if anything new came up. Have there been any significant events or concerns? Use the Between Session Shyness Questionnaire to guide you in exploring any negative feelings. You can reassure him that these are common and that these feelings usually are reduced with practice in new situations. Tell the client that sometimes discomfort is relatedto a need for more practice in a given situation, and sometimes it appears to be related to their negative thoughts, which they will begin to challenge in this session. If the client has indicated that they did not feel understood during the last session, explore their thoughts and feelings about it. Ask what you might have said to make themfeel more understood. You can also ask what it is they wanted you to understand that you may have missed. If the client is taking medication askabout any problems. If they are experiencing uncomfortable side effects suggest they talk to their psychiatrist or intern who may be able to adjust the dosage or make other suggestions to reduce their discomfort. Set Agenda

Tell the client that today you will review homework and then identify, categorize, and challenge the negative thoughts that they recorded on their Social Interaction Log as they experienced social anxiety and as they entered feared situations (this form was provided in session one). Then you will role-play one of the situations from the hierarchy thatyou constructed together during the last session. Make a copy of the Social Interaction Log for your files in order to track changes during treatment. Homework Review

Ask about the social behaviors they practiced intheir daily workouts. Possible behaviors were: saying hello to someone at work, or in the neighborhood, making eye contact and smiling at someone new, holding a brief conversation with someone in a movie line or at the grocery store, or telephoning an acquaintance. Often clients like tohave several from which they can choose as the opportunities arise. If they are highly withdrawn it may be useful to just choose onethat seems manageable. Look at the social interaction log togetherand make note of thenegative thoughts that occurred. Acknowledge any behaviors they have accomplished, however small, in spite of the negative thoughts, and encourage them to record these behaviors in a small notebook that they carry with them for that purpose. © 2001, The Shyness Institute; for details, see page 1.


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Concepts and Skills: Brainstorming to Create Behavioral Strategies

Now is also a good time to begin to brainstorm strategies that facilitate homework. Brainstorming simply refers to thinking with the client about possible behavioral strategies for homework assignments. You are communicating to the client thatyou both are likely to have good ideas. You are not just teaching the client, you are experimenting andlearning together. This provides a model for collaborative learning and coaching, and begins toempower the client. The form for this exercise is called Strategies for Social Situations and isprovided. You can also give a copy to the client. For instance, if the client has started to make atelephone call and hung up before dialing because they feared they would not think of something to say, the therapist says You can write down the things you want to say or to cover in the telephone call, and refer to it in case you want to. There is a form for you to use in your client manual for this purpose. We’ll fill this one out together and you can take it with you to use this week.



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Strategies for Social Situations

Date: _______ SUDS Level: _______ Situation: ____________________________________________________________________ My goal: _____________________________________________________________ Possible topics of conversation: ____________________________________________________________________ Specific things I want to say: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Did I meet my goal?: ____ yes ____no

What I will do differently next time: _______________________________________ ____________________________________________________________________

Other Comments: ____________________________________________________________________ Henderson, 1994 © © 2001, The Shyness Institute; for details, see page 1.


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You mentioned last week that you would like to call your friend because you have not seen him for a few months. You did not make the call because you had the thought that you would not be able to think of anything to say. You noticed the thought that prevented the call, which isa valuable exercise in itself, and we will work with your thought later. Now you can assign yourself the call again. You can enter “callJohn” on the goal line. If you telephone him you have achieved your goal, even if you still want to improve your telephone skills. Be sure to record that you met the goal if you make the call. You also said that you lost touch when he/she transferred to another part of your company in a different building. That could be your first topic of conversation. You can ask them how they like the new job. You can also tell them what has been happening in yourdepartment. You can also tell them about any new events that have occurred in the lives of people they knew in your department. You might tell them about any movies you have seen lately or books you have read. Write any ideas you can use under topics of conversation. Can you think of other things you have in common that you would like to mention? Be sure you write down any specific things you want to say, such as you have missed seeing him, or that you would like to schedule lunch with him next week or just drop by to say hello. Those can be additional goals for the conversation for which you give yourself extra credit.

Have the client think of at least one strategy themselves, and acknowledge them for doing it. Acknowledge any move toward problem solving the client makes. Be sure to wait long enough for them to speak. It is easy to become tempted to speak for them. Psychoeducation: Cognitive Restructuring

Cognitive restructuring is a term from cognitive therapy that simply means changing negative irrational or maladaptive thinking patterns that contribute to negative emotion and behavior into rational, logical or adaptive thinking patterns that allow us to use problem solving techniques based on logic, reason andusefulness. I will help you identify negative “automaticthoughts” and change them to more adaptive, self-supportive thinking patterns.Research shows that changing maladaptive thinking patterns to more adaptive ones leadsto increased proactive andpositive behavior as well as to increased well-being and a reduction in painful emotion and self-defeating behavior (Henderson & Zimbardo, in press).

I have changed the word “irrational” to “maladaptive” in my work with shy and socially phobic individuals. The reason I have done this isto emphasize that the truth orfalsity of a thought is not the major concern in overcoming shyness and social phobia. Clients tend to be highly adept at arguing the case for their negative thoughts and can often bring to bear a good deal of reasoning skill tothis process. After all, they have been ruminating and practicing these negative thinking patterns for years. The question is not whether the thought is true or false, but



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does it help the client reach his or her goal. One strategy for clarifying this for clients is to say the thoughts aloud as though to a friend, Think of someone you know that you like, but that may be concerned about performing well in a given situation. Even if this friend is not perfect, and is in the process of learning how to do something, how helpful will it be to this friend if, just before they enter the situation you say, remember: “you won’t be able to think of anything to say, you will look foolish, everyone will be able to tell you are nervous, and will know thatyou are shy and socially inept.” How will that friend feel? How likely do you think it is that these words will help your friend in the situation? Skill Building: Cognitive Restructuring

Ask about the situation from the bottom half of the hierarchy that the client entered since the last session. The thoughts from that situation willbe recorded on the Social Interaction Log in addition to those from other stressful situations. A sample Social Interaction Log is provided. Notice which thoughts are common to several situations. Get out the list of cognitive distortions. A list is provided which canbe copied for the client. There is also a list provided inthe client manual.



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Social Interaction Log

Date: ___Jan 4_ Length: _3 minutes _ SUDS Level: _60____ Interfering Thoughts?_yes _ Situation: _ conversation with coworker ______________________________________________ Mood: ____anxious ______Initiated by: _____me_____ Finished by: _m e_______________ Outcome: -3 -2 -1 0 +1 +2 +3

How shy (%): __60_____ How pleasant (%) __30 ______

Thoughts about yourself: __I won’t be able to think of anything to say, I sound stupid__________ Thoughts about other(s): ___He is smart, confident______________________________________ Feelings towards other(s): _I liked him, enjoyed conversation a little, ________________________ Comments: Not as hard as I thought to approach him, but I got nervous and cut it short and felt badly

Date: __Jan 5__ Length: _2 min ____ SUDS Level: __70_____ Interfering Thoughts? _yes __ Situation: ___ check out line at super market, commented on weather____________________________ Mood: __anxious, attracted_____ Initiated by: __me__________Finished by: ___me_______________ Outcome: -3 -2 -1 0 +1 +2 +3

How shy (%): __80___ How pleasant (%) _____60 _______

Thoughts about yourself: __I sound awkward, I look foolish__________________________________ Thoughts about other(s): __She seems friendly, she is pretty, she has to be nice to customers __ Feelings towards other(s): nervous, interested_________________________________________ Comments:



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She wasn’t as cold as I thought, and her smile made the interaction more pleasant than I thought, but I did not trust her friendliness and I was afraid I was intruding

Henderson, 1994 ©



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COGNITIVE DISTORTIONS

1.

You see things in black and white categories. If your performance falls short

All -or -No thi ng Thi nki ng:

of perfect, you see yourself as a total failure. 2.

Ov er ge ne ra li za ti on :

3.

Me nt al F il te r:

You see a single negative event as a never-ending pattern.

You pick out a single negative detail and dwell on it exclusively, so that your vision of all

reality becomes darkened, like the drop of ink that discolors the entire beaker of water. 4.

Dis qual ify ing the Pos iti ve:

You reject positive experiences by insisting they "don't count" for some

reason or other. In this way you can maintain a negative belief that is contradicted by your everyday experiences. 5.

Ju mp in g to C on cl us io ns :

You make a negative interpretation even though there are no definite facts that

convincingly support your conclusion. a. Mind Reading:

You arbitrarily conclude that someone is reacting negatively to you, and you don't

bother to check this out. b. The Fortune-Teller

Error:

You anticipate that things will turn out badly, and you feel

convinced that your prediction is an already established fact. 6. Catastrophizing:

If you think you have committed some social error, you expect extreme and horrible

consequences for yourself. A turndown for a date is evidence for a lifetime of isolation. Making a mistake at work means that you will be fired and will never get another job. 7.

Mag nif ic at ion or Min im iza ti on:

You exaggerate the importance of things (such as your goof-up or

someone else's achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called the "binocular trick". 8.

Em ot io na l Re as on in g:

You assume that your negative emotions necessarily reflect the way things really

are: "I feel it, therefore it must be true." 9.

You try to motivate yourself with "shoulds" and "shouldn'ts," as if you had to be

"S ho ul d" St at em en ts :

whipped and punished before youcould be expected todo anything. "Musts" and "oughts" are alsooffenders. The emotional consequence is guilt. When you direct "should" statements toward others, you feel anger, frustration, and resentment.



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This is an extreme form of over generalization. Instead of describing your

10. Labeling and Mislabeling:

error, you attach a negative label to yourself. "I'm a loser." When someone the wrong way, you attach a negative label onto him: "He's a stupid

else's behavior rubs you louse." Mislabeling involves

describing an event with language that is highly colored and emotionally loaded. 11. Personaliza tion:

You see yourself as the cause of some negative external event for which, in fact, were not

primarily responsible 12. Maladaptive Thought:

Any thoughts that are not useful to you in a given situation and do not help you

reach your goal. 13. Compensatory Misconception:

You believe that you need to inflate your achievements or impress others

to be socially successful. You may think only the most aggressive and the most dominant succeed. This may be a compensation for a belief in your own inadequacy and may promote suspicion and hostility toward others.



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Have the client read aloud the cognitive distortions and identify those negative thoughts that fit the distortion. Often a thought will fit several distortions. For instance, “ I won’t be able to think of anything tosay” is an example of jumping toconclusions, specifically fortune telling. It also may be an overgeneralization based on a couple of long pauses in conversations the client remembers that were highly embarrassing. It is also an example of all or nothing thinking, inthat they believe they must be perfectly smooth socially or be aotal t flop. They will not think of ANYTHING to say. (I have been doing shyness/social phobia groups for 17 years and have never seen that happen.) Another example is “I look foolish.” Foolish is a label. Most labels will begin to suggest self-concept distortions and these are the most important, buttake the longest to change. Despite the fact that an automatic negative thought will fit into several categories, you and the client quickly begin to notice the favorites. Refer to them as favorites so the client begins torecognize that these are learned maladaptive thoughts thatbecome chosen favorites that areimposed on the self. You can also give an example of one of your favorites. After you have categorized several or allof their negative thoughts, get out the Challenges to CognitiveDistortions. A list of challenges is provided.



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CHALLENGES

to Automatic Thoughts Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? What evidence do I have that _________________________? Does ___________________ have to equal or lead to _________________? Could there be other explanations? What is the likelihood that __________________? Is________________________ really so consequential or important? Does _______________'s opinion reflect that of everyone else? Is _______________________ so important that my entire future resides with its outcome? Is this the only opportunity? What is the worst that could happen? How bad is that?

Adapted from Sank and Shaffer (1984), Heimberg (1991)



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Ask the client the questions on the Challenge Sheet. Do you know for certain that you will have NOTHING to say?” On a scale of 1 to 100, how certain are you? Depending on the degree of difficulty the estimates will range from 60% to

90% in most cases. “What specific behavioral evidence doyou have?” Clients will usually cite feeling states which will allow you to point out emotional reasoning.You said there was a pause in a conversation you were having and you felt anxious and awkward . That is interesting. Anxious and awkward sound like feeling states. Do you think that is an example of emotional reasoning? That is one of our favorites when we feel socially anxious. I feel, therefore I am! Does feeling anxious and awkward necessarily mean that you have nothing to say? Could it also mean that you are simply momentarily distracted by your emotion which then increases your negative thoughts? So your cognitive resources are being spent onyour maladaptive thoughts rather than on what you find interesting about the other person or finding out what you have in common? When you cut the conversation short, does that mean you have nothing to say, or just that escaping decreases anxiety in the short run, al though it increases it in the long run? Is it possible that something would have come to your mind?

Clients often mention one or two upsetting incidents where there was a long pause or a person may have made an excuse and leftthe conversation. This revelation allows you to pointout overgeneralization. Make them be specific. If they relate an incident or two, how many conversations have you had in thelast several years? You said that you have practically no friends, but you do have conversations at work sometimes. How many conversations do you have in a week? Well I guess if you have one a day that is 5 a week or 20 a month, so 12 times 20 is about 240. I guess 2 out of 240 is how much? Still pretty small I guess.

Be realistic about the estimation in terms of amount of contact with people that the client has had. In any case if you figure the percentage, it is usually very small. The object is for them to notice the degree to which they engage in the particular distortions and to help them test reality more efficiently using hypotheses and engaging in anhonest search for real facts. When the percentage is small, they will often say that the positive conversations do not count for some reason. They are work-related, people have to be nice at work, etc. I guess that could be a good example of disqualifying the positive. What do you think? Even if the conversations are work related, you have sometimes felt anxious and engaged in them in spite of it. You could have avoided conversations altogether. I guess if you could make yourself do it there, that is specific behavioral evidence that you could motivate yourself in other situations, particularly if you could do it gradually.

Clients will often relate an incident where there was a long pause or they or the other person terminated it quickly. They use the belief that they “couldn’t” think of anything tosay to account for the awkwardness. Be sure to ask them, does feeling ansious or awkward have to © 2001, The Shyness Institute; for details, see page 1.


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equal not being able to think of something to say? Could there be other explanations?You often

must supply possibilities at the outset. Perhaps the other person was feeling a bit shy; perhaps one of you didn’t want to wait long enough. Again, these statements point out the element of choice

involved and a lack of belief in their own self-efficacy or in another person’s willingness to wait. Even if that particular person thought you were awkward is that really so important? Would their opinion necessarily reflect hat t of everyone else? Would your entire futuredepend on that outcome? What is the worst that could happen? Ok, so you would start avoiding people again. How is that any different than what you are doing now? Has that worked? Ok, so how long do you think you would avoid people? Oh, you said just until you had to do your homework again? That’s not too long! You had the courage to come here and start making conversations again. What would that say to you about someone’s else’s motivation?

After challenging the thought, ask them again the degree of the belief at this moment that they “will not be able to think of anything to say.” Usually with a successful challenge they come down to at least a 50%chance that they “will think of something.” However the percentage may drop only 5 or 10 points for entrenched beliefs about the self that accompany avoidant personality disorder, like “I am socially inferior.” That is to be expected in the early sessions. Tell them that and acknowledge that something they have practiced diligently for years and rehearsed to themselves again and again will ofcourse take longer to change and relearn. If I have grooved a tennis serve for 20 years it will take me some time to learn a new one. Help the client come up with amore adaptive response for the situation. It is best in their words and framed in the positive. The point is pragmatics. Is this response useful to you in this particular situation? I would also not have them practice one theydo not really believe. They may not be able to say, “I’ll think of something.” It may be something like, “I can learn. I have learned new things in the past.” Resist allowing them to say, “I don’t need to talk much,” or “I won’t let it upset me.” First, they are framed inthe negative and theywill not remember them as well. Second, they do in fact need to take responsibility for their end of the conversation and it obviously will upset them. They must learn to tolerate the discomfort, but see itas “no pain, no gain” as in sports. It is a natural part of the process of becoming a better socialathlete. When an adaptive response is chosen for one of the negative thoughts tell them to practice it during homework exercises that trigger the thought. Psychoeducatio n: Desensitiza tion through Exposure to the Feared Stimulus

You will be engaging in role-plays of social situations that are stressful and frightening in order to learn to manage your anxiety ni more adaptive ways and to reduce it. In fact, through a process called desensitization, which simply involves exposing yourself again and again to something that frightens you, anxiety is reduced. You have probably heard of other kinds of phobias, like spider phobias. Often a person has heard or read frightening stories about spiders or



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an older child has threatened a younger child inappropriat ely with a spider. In that case, a person simply gets closer and closer to a real spider that is harmless, finally touching the spider or letting the spider crawl on him. All the person has to do si tolerate the ansiety untilit is gradually reduced through the realization that nothing horrible happens. The idea is that in chronic shyness or social phobia, negative experiences or events, like teasing or being criticized or shamed in front of others, or starting to give a talk and being afraid and leaving a classroom, lead us to believe that thereare painful or catastrophic consequences for ordinary social interaction. In this case, feared situationscan simply be conversations, or asking for a raise, or asking for a date. If we withdraw and do not test these beliefs the fear tends to be maintained and evengets worse. By gradually exposing ourselves tosocial interaction, tolerating the anxiety until it starts to reduce, and finding out that others are not as powerful or hurtful or callous as we thought, we feel more comfortable. In fact, sometimes during childhood, adults were that powerful. Other children could also be cruel, but this tends not to be the case aspeople mature and begin to be able to take others’ perspectives better. As adults we can also choose situations in which people are friendly and supportive and learn to assert ourselves when they are not. Skill Bu ilding: Conducting the Ex posure Tell the client they are ready for their first exposure. Get out the exposure form provided. Have the videotape equipment ready. Choose a situation from theirhierarchy that is around the middle, with a SUDS level of 50 or 60, usually it is a conversation, perhaps with someone they have seen or know alittle. Tell them they will do the exercise with you thisfirst time. Tell them to report to you whatever automatic thoughts areoccurring as they think about doing it. Write these thoughts on a flip chart inblack felt-tip pen. Also, the ones they would have inthe actual situation, in case there is any difference. Usually they willbe similar to the ones mentioned earlier. Select two of them, or one new one, have the client identifythe distortions. Write the Cognitive Distortions categories in red felt-tip pen. Have the client begin to ask themselves the questions from the Challenges to Automatic Thoughts. When the belief in thenegative thought has lessened and the client is willing to consider other possibilities, develop a more adaptive response they can practice during the exposure according to the model we have just discussed.



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EXPOSURE SIMULATION RECORDING FORM

Client Date

Session #

Exposure #

Description of Feared Situation:

______

Others involved:

Patient's Goal in Exposure Simulation:

Adaptive Response Used in Exposure Simulation:

SUDS Record: Time

Rating

Initial 1Minute 2Minutes 3Minutes 4Minutes 5Minutes 6Minutes 7Minutes 8Minutes 9Minutes 10 Minutes

_______

Adapted from Heimberg, 1991



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Develop a specific goal for the situation. For example, you will converse for 10 minutes. In that time you could ask the person two questions about themselves and tell them two things about yourself. Count the number of questions and statements about the self. Usually the client

will ask a few more. You can also say, this is additional, because it is not part of your goal, but you could look for at least one common interest in this process. At that point, cover brieflythe way conversations develop. Conversations usually progress from observations about the situation, to facts about the self like where you live and what you do, to current events, movies, hobbies, interests, opinions, and at deeper levels your goals, aspirations, and dreams and feelings about one’s world and oneself and each other. All you need to deal with in getting acquainted conversations is the first two or three levels. Take a minute to think about one or two interests, movies or books you like, TV programs, sports events, etc.

Then say, I’ll be the confederate this time (or volunteer, or just “your conversation partner”). Describe the situationfrom the hierarchy. You know me a little from your sailing class, where we are in the same group. The two of us will be waiting for a class to start and will just be making conversation about things like what we think of the class, what made us decide to take it, etc. and then perhaps find out a little about each other.Usually it is best to stand up, but you could

do it sitting down if more appropriate. Turn on the videotape recorder. Ask the client what their SUDS level is. Write it down. Ask the client to read the adaptive response aloud (you can point to the flip chart to remind them), and then ask them to begin the conversation. Start the stopwatch. Check the SUDS level at one-minute intervals and have the client read the adaptive responses from the flip chart out loud. Skill Building:

Debriefing and Feedback after the Exposure

When the exposure has been completed, write the SUDS elevations on the flip chart minute by minute so the client can see that the anxiety often goes up in relation to a negative automatic thought, and in relation to a new challenge, such as beginning to speak after a pause. It usually comes down over the course of the exposure so you can also point that out. This is the desensitization that we have been describing, where simply engaging in a conversation often becomes easier with time spent. Sometimes, however, their anxiety does not come down, or

comes down only a few points. If that is the case, acknowledge that they were able to perform in spite of a high level of perceived discomfort.Look how well you were able to do in spite of your anxiety! Were you aware of any new automatic thoughts during the exposure? If they were, write the thoughts on the flip chart and suggest that the client write them down and challenge them after the session.



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Are there negative thoughts that have occurred to you since the interaction ended? Sometimes these are negative thoughts related to attributing to yourself any perceived failures in the interaction and any successes to your conversation partner.We will go over this tendency thatwe call attribution style and any negative beliefs about yourself in the next session and it will provide us a place to begin. These thoughts often occur after social interaction and may be accompanied by sad feelings, discouragement, or feelings of embarrassment or shame, rather than the fear and physiological arousal that you generally experience before a role-play or exposure. I will show you how to work with these thoughts and beliefs in our next session.

Ask the client ifthey would like feedback abouttheir behavior during the interaction. Tell the client what you like about their behavior, what made you feel comfortable, and what the client could do to make you feeleven more comfortable. This procedure emphasizes the fact that social interaction is a negotiated event between two people who have equal responsibility to make themselves and the other person feel comfortable.Clients will generally putothers on a pedestal and wait to be told whether and how their performance meets some standard. In fact, there are many different styles of interaction and many different ways of presenting oneself that are acceptable if there is areasonable degree of attention to theneeds of each person. It is the passivity of the social phobic or the extremely shy person that makes others feel as if they must put “too much effort” into the interaction. Most social phobics with whomI have worked do not lacksocial skills. They frequently just do not use them. There may be some things to point out like increased eye contact or an equivalent amount of self-disclosure to match the your self-disclosure, which will be helpful. Try not to overload the client. Tell them a couple of things to improve, but not more. Fine-tuning can happen later. Show the client the videotape. Ask them what they think. They often have performed better than they thought they would. Sometimes their perceptions of themselves aredistorted. There may be a big discrepancy between what you think, and what they think, even when you are watching the same video. If there are aspects oftheir behavior that doneed improvement, you can brainstorm different ways of doing things using the Strategies for Social Situations form (Henderson, 1994). Brainstorming demonstrates how many different ways there are to do things that are equally acceptable, so the client understands that you do not have allthe answers. They have many of their own. You are exploring together. Session Summary

Briefly summarize the session, reviewing brainstorming, cognitive restructuring, and desensitization. While we were discussing your homework we used a technique called brainstorming to think about possiblenew behaviors and strategiesin social situations. Brainstorming simply refers to thinking as freely as we can together about possible behavioral strategies for homework



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assignments. Hopefully we can say whatever comes to mind, without worrying about the quality of the ideas, just to generate new ones. Then we can decide which ones you like the best. Just to review the other things we covered today, you probably remember that cognitive restructuring is a term fromcognitive therapy that simply means changing negative irrational or maladaptive thinking patterns that contribute tonegative emotion and behavior into rational, logical or adaptive thinking patterns that allow us to use problem solving techniques based on logic, reason and usefulness. We identifed negative “automatic thoughts” and changed them tomore adaptive, self-supportive thinking patterns. We also discussed desensitization, that is, engaging in role-plays of social situations that are stressful and frightening in order to learn to manage your anxiety in more adaptive ways and to reduce it. Desensitization simply means exposing yourself again and againto something that frightens you until your anxiety is reduced. Are these things clear and do they make sense to you? Any questions? Feedback from Client

Ask the client how they felt during the session. If they remark on their anxiety during the exposure, acknowledge how painful the discomfort can be, and reassure them that, although painful, the anxiety is a good sign. It means that desensitization can take place. If the anxiety is avoided or suppressed, effective desensitizationcannot occur. If they express pleasure that the experience was less negative than they feared, you can reinforce their experience with your own gratification or enjoyment in participat ing in tackling the feared situation with them.Let clients know that it might be useful to write down any other reactions that occur to them prior to the next session. Socially anxious clients often think of questions or reactions after the session and appreciate some structure to facilitate bringing them up at the beginning of the following session. Homework for This Session

1. Give your client a Social Interaction Log or have them copy them from the client manual. Ask the client to enter at least one situationfrom the bottom half of the hierarchy. Remind them to use their social interaction log torecord their thoughts and feelings. Tell them to practice onenew social behavior a day, such as a brief conversation with someone new, or a longer conversation with someone they know. Ask them to write downany negative thoughts that occur in three social situations over the coming week, especially those which are anxiety-provoking. Make certain that the client is sure that three or more anxiety-producing social interactions will be encountered prior to the following week. If not, help the client problem-solve as to how such situations can be identified and purposefully entered. If the client is not sure anxiety-provoking social situations will be encountered, and is not willing to commit to seeking them out, have the client complete the log for social interactions that the client is avoiding.



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Help the client design specific measurable homework goals. For example, “I will contact the Sierra Club Office for aschedule of events and attend one event thisweek.” “I will ask my coworker to go to lunch.” “I will say three things in this meeting.” . Other examples include: entering situations where they can meet potential friends or dates, expressing opinions, approaching a supervisor to ask for help or for feedback. Make sure they write the homework in their small notebooks or on the forms provided in theclient manual. Make sure you write itdown in case they forget next week.

Session Four: Attributional and Self-concept Restructuring and the Second Simulated Exposure Homework Review

Ask the client if newthoughts or questions came up after the last session.Make a copy of any negative thoughts they recorded while doing homework. Ask about the behavioral homework and brainstorm possible strategies with theclient if there are problems. If they have assigned themselves homework that they did not do, ask them if they can identify any negative thoughts they had while thinking about doing it. Usually they will report at least one or two. An example is a woman who planned to have at least one brief conversation with two co-workers during the week. She wanted to talk for five minutes. She reported in the following session that, “they were too busy; there was too much work to do; they would not want to be interrupted.” You can then help the client challenge the negativethoughts and find a more adaptive response. You can also ask if they would like to “chunk” the homework into smaller pieces. Usually when clients do not do homework, negative thoughts are interfering and/or they need to break it down intomore manageable goals.task Youorcan suggesttothey with one two minutes, perhaps combining it with a work-related comment start.start Perhaps just or asking whether the other person had a good week-end, or mentioning a good movie the client has seen. Have the client thinkof at least one topic themselves, and acknowledge them for doing it.They can practice this on adaily basis until they feelmore comfortable extending the conversation. You can briefly role-play possibilities.



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Preparation for the Second Exposure Then tell the client what situationthey will role-play this week. You can take the next situation above the last to graduate the exposures, but you can also ask the client if anything has come up since the last session that they wouldlike to role-play. Sometimes they have made a telephone call or held a brief conversation with a co-worker and they now want to role-play asking the person to lunch or to gofor a walk at lunchtime for exercise. It is most useful to keep the exposures in alignment withtheir current homework and situationalopportunities. Sometimes they

have spoken more in a meeting and now want to practice giving a brief review of their work on a project. Then say, “this week we will identify your negative automatic thoughts, but we will also focus more on how you assign responsibility for social situations and on any negative beliefs about yourself that shy people often have.” Describe the situation that theywill role-play in detail,using the exposure form (Figure 6.). Ask them what automatic thoughts are occuring tothem. Write them on the flip chart with a black felt-tip pen. Identify the cognitivedistortions involved. Write the cognitive distortions, such as “jumping to conclusions” in red felt-tip pen. Usually you will notice at least one automatic thought that contains the idea that the client is responsible for the entire interaction. For example, “there willbe a pause and I won’t know what to say.“ “They’ll notice I’m nervous and it will be awkward.” You will also notice that they use labels frequently. Not only idiot.”do they think they will they look foolish, but “they’ll see how shy I am and I’ll look like an Explaining the Self-enhancement Bias Get out the handout with the chart describing the shy vs. the non-shy attributional style and give them a copy (Figure 7.) Explain the self-enhancement bias. Tell them that most people take credit for success and externalize failure in someway. That is, if they succeed they believe thatit is because they are smart, interesting, competent, good, substantial people. If they fail they assume that it was something about the circumstances or thesituation. If they fail an exam they think the exam did not adequately test their knowledge. Not only do they attribute success to themselves, but to stable, global characteristics of themselves. They also attribute failure to specific, temporary factors. They were tired, they did not prepare enough for an exam or a meeting. They attribute success and failure to controllable factors. That is if they fail, they find out what they did not do that they need to do next time. Or what they need tolearn, etc. Ask the client what the advantage wouldbe in having such a bias. Of course, it helps people maintaintheir motivation when they are working toward goals and when people believe they are efficacious, they are much more likely to succeed (Bandura, 1997). Then tell they that when we become chronically shy or socially avoidant, we reverse the self-enhancement bias and give ourselves credit forfailure and externalize success. That is, when © 2001, The Shyness Institute; for details, see page 1.


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we succeed we think it is because of the situation or other people. “It was n’t that hard. People were being nice to me. She was just a nice person. They felt sorry for me.” When we are shy we give ourselves credit for failure. If a conversation, a date, even a presentation, doesn’t go well we assume it is because we fell short in some way. And when you think about it, even a talk will often depend on whether the speaker has a friendly orhostile audience. A teacher in front ofa deadpan class has much more difficulty showing his teaching skill to a non-receptive audience. They have often never thought of this and when they think about situations they recognize it. It is important to say “we” here, because everyone can do this occasionally. In fact, women tend to do it more than men and those who dominate in any culture tend to externalize and those who are subservient internalize responsibility for failure.It is also highly dependent on class and culture. It is particularly characteristic of WesternEuropean males. It makes sense that in highly competitive cultures that emphasize individualism, one way to successfully compete and maintain one’s motivation is to give oneself credit for success and assign failure to specific, temporary, and controllable causes. It is less characteristic ofAsian cultures and highly collaborative cultures (Markus & Kitayama, 1991). Ask them how they think it affects their motivation when they reverse the self-enhancement bias. They usually will react strongly to this understanding. Then say, “often we only do this in the situations in which we feel shy or socially anxious.” “We may not do it in our work or in areas where we are practiced.” This reinforces the idea that their shyness work is allabout learning and practice, just like learning sports activities and games of any kind.Often the client willhave an area of expertise where they feel confident and can compare their attributions in that situation to those in social situations. Then say that research with self-labeled shy people has shown that they blame themselves for social failure and see it as uncontrollable (Anderson & Arnoult, 1985; Henderson, 1992). They also see others as more powerful and in control, irrespective of actual competence. Identifying and Challenging Attributional Distortions Identify the attributional distortions using thehandout. Have the client read them aloud or take turns. As they read each one, see ifit applies to any of the automatic thoughts on theflip chart. Write the attributional distortions ni a green felt-tip pen. Then challenge themusing the attribution challenges (Figure 8). They are questions designed to getat the attributions more specifically. Of course, some of the questions will apply and some will not. Use the ones that do apply. Go over the automatic thoughts thatyou have already identified cognitive distortions for (in red felt-tip pen) and add ht e attributional distortions in green. For example, “You said thatthere would be a long pause and you would look like an idiot.Does that mean you are taking all the responsibility for the pause? Could the other person think of something to say? Do you think you are both equally responsible for helping each other feel comfortable and accepted in any social © 2001, The Shyness Institute; for details, see page 1.


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interaction? Is there something about the other person that you are reacting to? Could they also be feeling a bit shy or awkward, or a littleself-conscious?” “Do you believe that issomething about you that is stable, that is, will always happen?Do you think that it willhappen in all situations?” “Do you believe thatabout the other person?” Why do you think differently about yourself than you do about them? Why do you think you are more ready togive them the benefit of the doubt?” Identifying Self-concept Distortions Then point out an automatic thought that has a negative belief abouthet self in it. “You

used a label here. That often implies what wecall a self-concept distortion, that is, anegative belief about the self that organizes alot of incoming information and you usually are not aware that it is happening.” “For example, you said you would look like an idiot. Do you believe that you are a social idiot?” Then have them read aloud the self-concept distortions. Write the identified self-concept distortions in blue felt-tip pen. Often they are using “perfect self vs. real self”. If they are not perfect socialperformers they are failures. They expect themselves to perform perfectly in situations that would be difficult for anyone, like meeting people in bars, or in situations in which they have little practice. They have difficultyallowing for a natural social learning curve. They assume others are just born that way and don’t need social learning. In fact, in one of the groups that Henderson conducted at the Stanford Health Center, it was sufficient for one student to recognize that it was ok to use social skills books, that people often did that to help them learn about behavior. and often a friend in his MBA program started them He wasinterpersonal shocked to find that hisHe friend struggled with some of the samereading anxieties in together. class and during presentations and was interested in reading about how others coped. This experience served to normalize his fears. He also began to believe thatit was useful to ask for feedback and it need not mean he was inadequate. He made good progress in the group and within eight weeks his discomfort and avoidance were considerably reduced. What you will notice is that there is little correlation between behavior and feelings in many social phobics and chronically shy people. They are often warm, charming, and sensitive to others. This sensitivity is astrength when they are notin situations where theyfear evaluation and are able to trust others they believewill be accepting. They often have beliefs about the necessity to be dominating inorder to be accepted. When they do show maladaptive behaviors they generally overestimate the degree to which peopleare going to be critical. In some cases, particularly those with longstanding avoidant personality disorder and more extreme hypersensitivity they have Shame-based Self-concepts and overvalued beliefs about themselves and others which approach paranoid delusions. Some believe they have learning disabilitiesor speech problems that others do not see. It is wise to have these individuals tested, in case there are difficulties that are real, but in many cases they hyperfocus on some aspect of behavior they believe to be negative and greatly exaggerate it. © 2001, The Shyness Institute; for details, see page 1.


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Challenging Self-concept Distortions Identify and challenge the self-concept distortions using the same challenges that are used with attributional distortions, that is, the questions that fit the particular distortion. For example, “do you know for certain that youare unattractive, clumsy, etc.?” What specific behavioral evidence do you have? They will often identify anegative feeling or a few upsetting experiences as evidence. It is important to explain that emotionalreasoning works by negative emotions coloring one’s thinking. At the clinic we have a saying that group members begin to joke about. Instead of

the quote of Descartes, “I think therefore I am,” for them it is “I feel, therefore I am ____.” Be sure you get them to identify specific behavioral evidence. When they remember upsetting experiences have them estimate how many of those there were in relation to all the times that they engaged in conversation, approached someone, etc. The percentage usually turns out to be small. A client at the clinic had been severely teased as a child.Even though that stopped at a certain point and had not happened in years, he approached everyone with the same expectation. The adaptive response he developed for himself in new situations was “That was then, this is now.” Another man said “I am now a grownup and I am among grownups.” They rehearse these experiences in solitude for many years. I suggest to clients thatif they practice the new thoughts to the degree they practice and rehearse the old ones theywill be social geniuses. It is a question of shifting the effort into more adaptive channels. Help the client up withrather a morethan adaptive response. the adaptive response on ht e flip chart in black. Wecome say adaptive rational becauseWrite neither response may be “rational”. The question is a pragmatic one. Does it help the client do what they want to do. Does it help them reach their goal? Conducting the Exposure Have the video-tape equipment ready. Conduct the exposure according tothe same format used in the third session (see Figure 6.). Develop a specific goal for the situation and write it on the flip chart. An example of a second exposure could be talkingto a co-worker and then asking the co-worker to go out for lunch. The specific goal is actually asking the person. Subgoals are to specify a particular day and time and where tomeet. When people are chronically shy or socially phobic they often leave things vague and up in the air. For instance, “would you like to go to lunch sometime?” If the other person says yes the shy individual might leave itat that or wait for the other person to set up the arrangements. We usually suggest thatthey have in mind beforehand where they would like to go and a meeting place. We have them take the initiative. Often other people don’t understand what is expected from them at the moment and the shy person says “they didn’t really want to go with me.” We will signal the person toward the end of the 10 minutes that they need to ask the question and specify time and place. Usually we end exposures with theSUDS level coming © 2001, The Shyness Institute; for details, see page 1.


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down and suggest that you do not want it to rise at the end because the client lacks a sense of mastery. However, it is better to extend anexposure until the person actually sets the time and place even if the SUDS level is high, and then give them an extra minute or two to chat while it comes down a little. Turn on the video-tape if you are usingit and ask the confederate to come in. In this example, the confederate would be theco-worker. Explain the situation tothe confederate and what you would like themto do. Ask for the client’s SUDS level, have themread their rational response, and begin timing theexposure. When the exposure iscompleted remember to chart the SUDS level ratings on the flip chart. Ask for new automatic thoughts afterward and identify particularly the ones that relate to responsibility and self-beliefs. If you have used a confederate ask the confederate to give the client feedback. Use this opportunity to contrast the feedback with the negative thoughts. Give your feedback. If there are particular behaviors the client would like to change or improve, conduct brief role-plays with the confederate to have the client experiment with newbehaviors. It is important to refer to these role-plays as experimenting because it takes the focus away for the illusion of “perfect social behavior” with you having all the answers and allows the three of you to brain storm with the clienttaking as much control as possible. Both you and the confederate can mention times in your own lives when particular behaviors worked and other times that other behaviors worked in similar situations. Keep the discussion away from right and wrong and into the “social sandbox” where everyone isplaying. When ideas are pretty well exhausted thankthe confederate and let the client thank the person and say good-bye. If the client is ready for more challenge, the confederate can role-play saying no to the lunch invitation. That give the client an opportunity toexamine new automatic attributions and self-concept distortions and to point out that asking the question is meeting the goal and is considered success for the client. They begin to understand that they donot need to expect themselves to control outcomes of social situations.They only need to control their own behavior. With time and practice positive outcomes are likely to increase, but nobody gets continual positive social outcomes. In fact, frequent college daters get turned down fairly frequently. They just ask for dates much more often than non-daters. Describing the Second Vicious Cycle: The Shame-self-blame Cycle In the privacy of the session with just the two of you, point out to the client that when they are rehearsing attributional and self-concept distortions after an exposure they may not be feeling anxiety, but usually depressive emotion such as sadness, shame, or embarrassment. These are often more painful than the anxiety and leave them feeling more vulnerable the next time they enter a social situation. Describe to them the second vicious cycle (Figure 1.). First we have © 2001, The Shyness Institute; for details, see page 1.


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fight/flight, negative thoughts, rising anxiety and an exit from the situation, which reduces the fear, but tends to increase it thenext time. Then we have the shame/self-blame cycle that actuallyfeels a bit relaxing. We can sink into the sadness and hopelessness, but that actually increases the feeling of vulnerability the next time. That is why it is particularly important to challenge the negative attributions and self-concept distortions. It is very seductive to sink into this part of the process, because it is a way we let ourselves off the hook and avoid others, but we have not opportunity to check things out and find out the difference between our assumptions and reality.” Homework Give them the homework that they identify negative attributions and self-concept distortions during the weekas well as the cognitive distortions. These are especially important because if a client jumps to conclusions, they can often immediately test the hypothesis, for instance, that they won’t haveanything to say. If they blame themselves afterward there isno hypothesis testing process. If they have developed a shame-based self-concept, which Henderson believes many have, it will operate outside awareness and exacerbate the passivity and pessimism that is so pervasive among the people who have become very withdrawn. Help them assign themselves behavioral homework. Acknowledge that theemotions they may be aware of this weekmay be more sadness and negative feelings about the self.That is a natural part of becoming aware of thesethinking patterns and the emotional results. In the long

run, the awareness be beneficial in helping challenge thedistortions. In the beginning you will help them will challenge them and they canthem ask others to help them until they become more practiced.

Session Five: Practice in Cognitive, Attributional and Self-concept Restructuring and the Third Simulated Exposure Homework Review Ask the client if newthoughts or questions came up after the last session.Make a copy of any negative thoughts they recorded while doing homework. Ask about the behavioral homework and brainstorm possible strategies with theclient if there are problems. If they have assigned themselves homework that they did not do, ask them if they can identify any negative thoughts they had while thinking about doing it and how those thoughts related to the choices they made.

For example, a client had gone toa party at which there wereseveral different ethnic groups. He started to approach one group andheard them speaking Greek. His automatic thought wasthat he should not interrupt them because they wantedto speak their native language. When I asked him if he would have the same reaction if he had been speaking his language, he said no, that it would be fine to speak English. He could then see that his automatic thought had stopped his approach. He



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could also begin to develop more hopeful alternative thoughts, such as “it is interesting to meet people from other countries.” When he started to approach a man and a woman talking he decided against it because the man might be trying toask the woman out and hewould be angry. When I asked if my client would have the same reaction, he said, well maybe, but not at the person, at the situation. He also could see that if theconversation seemed intimate he could politely move on.He did not approach two women talking because he thought it would be harder than approaching a woman alone. When we discussed it he could see also that it might be easier because they could carry some of the conversation as he gotcomfortable. Also, they might think that he was friendly rather than “trying to pick someone up” if he approached both of them at the same time. The client lost another opportunity by thinking that he needed an opening line to approach a woman standing alone. By the time he thought of one she had moved to another room. There is no problem with helping clients strategize about things they can say to start conversations, but it is particularly important to help them notice how their negative thoughts influence their behavior and their feeling states. Otherwise they think their continualnegative thinking patterns are simply a reflection of reality. When clients are thinking negatively they may also dwell on the negative in conversations. Others sometimes respond by withdrawing slightly.Clients think that other people don’t like them, but fail to recognize that they have put the other person in the position of thinking they must share the clients’ pessimismor distance themselves. Unfortunately the negative thinking patterns tend to be a reflection of a pessimistic “inner reality” that does not change if they fail to see the control that they can take over the negative hinking t patterns. Help them challenge the negative thinking patterns, particularly question the automatic attributions and negative beliefs about the self. Preparation for the Third Exposure Decide with the client what situation they will role-play this week. You can take the next situation above the last to graduate the exposures, but as before, you can ask the client if anything has come up since the last session that they would like to role-play. Keep the exposures in alignment with their current homework and situational opportunities. Then say, “this week we will identify and challenge your negative automatic thoughts, your negative autromatic attributions,and your negative self-concept distortions.” Describe the situation that they will role-play in detail, using the exposure simulation form (Figure 6).An example of a third exposure could be talkingabout a work-project informally in asmall meeting. Ask them what automatic thoughts areoccuring to them. Write them on the flip chart. Identify the cognitive, attributional, and self-concept distortions involved.Have them first identify the cognitive distortions, then the attributional distortions, and finally the self-concept distortions. As before, © 2001, The Shyness Institute; for details, see page 1.


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write the cognitive distortions in red, the attributional distortions in green, and the self-concept distortions in blue. Help the client challenge each kind of distortion, one at a time so they begin to notice the differences among themand the different emotional states attached to each one. Help the client develop an adaptive response, this time waiting for them to think of at least one or two of their own during your dialogue. Make sure they are framed positively. “I can be anxious and achieve my goal at the same itme.” “I can practice in this situations until I become more comfortable.” “I can change my automatic thoughts andpractice new behaviors.” or simply, “I can learn.” or “I’ve met my goals before. I can learn to meet my goals in social situations too.” Conducting the Exposure Conduct the exposure according to the same format used in previous sessions (see Figure 6.). Construct a specific goal, whichin this case might be to tell the group three things about the project. For instance, the target date for completion, progress up to this date with any relevant statistics, and one problem and how it has been solved. Another possibility would be mentioning a need for extra help and how thismight be achieved. Turn on the video-tape if you are usingit and ask the confederate to come in. In this example, both you andthe confederate could be coworkers, or one of you might be the supervisor and the other a co-worker. Explain the situation to the confederate and what you would like them todo. Ask for the client’s SUDS level, have them read their rational response, and begin timing the exposure. When the exposure is completed ask for new automatic identifylevel particularly thethe ones that relate to responsibility and selfbeliefs. Rememberthoughts to chart and the SUDS ratings on flipchart and link any rises to negative thoughts or to tackling a new challenge. If you have used a confederate ask the confederate to give theclient feedback. Use this opportunity to contrast the feedback with the negative thoughts. Give your feedback. Watch the video-tape together. Point out strengths. If there are new behaviors the client would like to try, conduct brief role-plays with the confederate to have the client experiment with them. Homework Have the client continue to identify negative automatic thoughtsduring the week. Ask them to categorize each thought as to the kind of cognitive distortion it is, whether jumping to conclusions, overgeneralization, etc. Then ask them to categorize the same thought into attributional and self-concept distortions. Ask them to write them in theirnote-books for you to review together during the next session. Help them assign themselves behavioral homework. Clients should be doing something every day and be assigning themselves one bigger challenge two or three timesa week. Using the example of the exposure conducted in this session, the client could offer to give a report on work activities prior to a group meeting at work, or could simply assign themselves an informal update that they would deliver at some point during a group meeting. © 2001, The Shyness Institute; for details, see page 1.


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Session Six: Practice in Cognitive, Attributional andSelf-concept Restructuring and the Fourth Simulated Exposure Homework Review Ask the client about if any questions came up after the last session and about negative thoughts while doing their behavioral homework. If the clients report depressive emotions, such as sadness, shame, embarrassment, or discouragement, you can acknowledge to them that these

feelings are a naturalpart of identifying theattributional and self-concept distortions. They recognize how much they are undermining themselves, but may feel often overwhelmed at the amount of effort it takes to keep identifyingand challenging the thoughts. This is particularly true for the clients with avoidant patterns and dysthymia in addition to shyness or social phobia. Doing the behavioral homework in spite of these feelings is the most strenuous part of the treatment for the client and sometimes the mostwearing for the therapist. A great deal of repetitive challenging of the negative thoughts is necessary in order to begin to break into well-practiced negative thinking patternswhich contribute heavilyto behavioral avoidance. You can comfort yourself as I do by remembering that shy and socially phobic college students significantly reduced self-blaming attributions and shame in their toughest situations in eight-week treatment groups, and began to challenge self-concept distortions [Henderson, 1998 #2590]. Using analogies to sports is also useful here. If you have practiced a serve in tennis for many years, it takes a good deal of practice to change it. The 23rd mile of a marathon is often the hardest. Runners often don’t know when they will “hit the wall,” but pushing through it becomes one of the greatest sources of confidence building. Confidence-building in shyness and social phobia work actually means learning to trust oneself to follow through on tasks one has set oneself. Treating oneself as a friend that deserves a commitment to help them achieve a goal begins to substitute for the idealized notion that they will quickly feel socially self-confident and perform like anexperienced social athlete. It is an interesting paradox that they many tend to be pessimistic, but have high expectations for a “quick cure” and are easily frustrated ingoal-pursuit. Reframing “discouragement about one’s inadequacy” to “learning to tolerate frustration” as a strenuous and worthwhile goal in itself will often help. The outcome of a givenpiece of homework is much less relevant tolong term gains than is the simple practice of the behavioral homework they assigned themselves, but you need to point that out many times. Clients obtain your support and admiration from just doing the homework consistently. You do not require themto be socially successful immediately in order to trust that they will eventually reach their goals. Acknowledging the feelings is important, but maintaining your expectation that they may be late bloomers, but bloomers nonetheless, is very reassuring to them.



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Again, brainstorm strategies that may be used if problems come up in homework situations. Continuing the example from the lastsession, the client may report thathe stumbled over the words in reporting to the group and he only said half of what he planned. Suggest that he gets full points for doing it. This was the first time hetried it, and he willremember more with practice in the situation. He can use notes, rehearse in front of a mirror, and rehearse with you at this moment. It can be useful to ask the client to talk to you as he did to them. He may recognize he did more than he thought, but you can help him articulate what he left out that was important, and how he could lead with that point next time, etc. Preparation for the Fourth Exposure Varying the exposures isuseful. If the client has practiced starting conversations and meeting people, it can be a good idea to switch to a situation in which self-assertion is required. For instance, saying no to a colleague or co-worker, or an employer who is giving the client extra responsibilities that are not part of theclient’s job. People who are chronically shy or socially phobic will sometimes be exploited inthe workplace. Have the client desribe the situation indetail, the precise nature of the task and the relationship with the person who is requesting the favor. Ask the client how high their SUDS levelis as they think about the situation. Often they will not report anxiety, but a general feeling of distress or discomfort, so do not be surprised if the SUDS level is 50 or less. Ask what the client is thinking as they think about saying no. Write the automatic thoughts on the flip chart, cognitive distortions first, of then thethoughts attributional and the self-concept distortions usingidentifying the differentthecolored markers. Examples these are: “the person will be angry with me;” “I shouldn’t let my boss down;” “maybe I’ll lose my job;” “it isn’t nice to say no;” “maybe I’ll hurt their feelings;” “maybe they won’t like me.” Sometimes you’ll notice more guilt than shame in these situations and beliefs that people should always be helpful or that they are not entitled to have needs that are different from others. Sometimes a strength of the person is their tendency to look out for the interests of a whole group, rather than just themselves. It can be useful to acknowledge this tendency as a strength, but to remind the person that if they become overworked and resentful it may show up in passive aggressive ways that are self-defeating, like missing meetings or being late. Choose one or two ofthe automatic thoughts to challenge. Have the client ask the questions from the challenge list as much as possible.You can assist them in coming upwith challenges or asking questions they may have left out, such as “could there be other possibilities?” You can help the client see that others may react positively to a clear statement that the client does not have time to do this extra task. They can then find someone else. Help the client come up with an adaptive response that is a positive statement, such as “It is understandable that I need to complete my own work before I help others.” “I can learn to assert myself effectively with practice.” “I have the right to pursue my individual goals aswell as the group goals.” © 2001, The Shyness Institute; for details, see page 1.


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You can also brainstorm alternative behaviors that can be useful in work situations (see Figure 14.). For example, you can suggest that the clientcan negotiate more effectively by listing projects or tasks with the manager and asking him to help them prioritize the tasks the manager thinks should be done first. Help the client find a goal that is manageable and measurable. A common goal in these situations is simply to deliver a prepared statement to the co-worker or boss. “I need to complete this project today and won’t beable to help you, but youmight try _____.” To the boss, “we had agreed (or, ‘I had understood’) that this project was the most urgent today. Do you want me to put this on hold and do the other task, or would you prefer I complete this today and start on that tomorrow? If I split the time today between theprojects they could possibly both be done by late tomorrow.” Conducting the Exposure When you have arrived at both the adaptive response and the measurable goal, ask the confederate to come in, turn onthe video, and explain thesituation to the confederate. You may tell the confederate what to expect orleave it ambiguous. Ask for the client’s SUDS level and have them read their adaptive response. If you are doing the exposure you can repeat it more than once with different responses from you as co-worker or boss. If they assert themselves before the 10 minutes is up, just have them do it again, or come up with a spontaneous variant. Make sure the client is engaged forat least 10 minutes. After the first exposure, leave outthe minute-to-minute checking of thetheSUDS andthe adpativechart response. Let the client practice interruption. When exposure is complete the SUDS level changes on without the flip chart. Often you will point out the rise in SUDS level as theperson delivers the statement. It usually comes down with successive tries, but it depends on the difficulty of the situation for the client. Ask for new automatic thoughts, focus on attributional or self-concept distortions, challenging them at the moment or having the client write them down for challenging on their own. Watch the video together, give feedback, brainstorm any new strategies that come to mind with the client. If the client would like to try a new response, it can just be said out loud. Thank the confederate. Homework Ask the client to continue to identify negative thoughts, categorize and challenge them. If there is one that is particularly troubling to the client, get them started with one or two questions from the challenge list so they have started the procedure with you. Help them assign themselves behavioral homework.Ask the client to pay attention toany situations in which self-assertion would be useful and think to themselves what they might say to the person. Tell them to carry out the homework ifthey can. Otherwise tell them to choose at least one situation in which they could practice, and identify the negative thoughts that came up as they were imagining themselves doing it. Tell them that any self-assertion, saying no, asking for © 2001, The Shyness Institute; for details, see page 1.


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something, will count as homework this week. It will help them decide how to set manageable goals in this area.

Session Seven: Identifying Automatic Thoughts About Others, the Third Vicious Cycle, and the Fifth Simulated Exposure Homework

Ask the client if any questions came upafter the last session. Find out how many times a week they are doing the homework. See if the client’s estimateand your estimate match. Remind them that three times aweek is a minimum for a useful result from therapy. If they are doing less, brainstorm ways that they can remind themselves and reward themselves for doing homework. They can use gifts of CD’s or rental video’s. They can use things they enjoy doing as rewards, like warm baths, listening to music, going for walks, reading books they like, etc. Ask the client to think about ways in which they have procrastinated in the past in other areas and overcome it. Often they will not transfer skills they have learned in other domains tothe social domain. Come up with a list of adaptive strategies together thatthe client can use. Some of our clients use post-it notes on the bathroom mirror or on the telephone. Some telephone us when they have done something important. Others do the homework at the same timeevery day to help them remember. Some make a large to-do list of homework exercises with us and choose two each day. Having a homework buddy is ideal if you are working with more than one clientand they would be willing to do homework together or discuss it on the phone with each other. Then ask about negative thoughts that occurred while doing the behavioral homework. Write them on the flipchart. Many clients begin to report negative thoughts about others as well as negative thoughts about themselves. This is not surprising, given their tendency to see other people as more powerful. Furthermore, the criticism they expectfrom others naturally engenders resentment, which is revealed in elevations on MMPI scales measuring a sense of vulnerability, mistrust and anger (Henderson, 1997). Our recent research has shown that shyness clinic clients score significantly higher in shame than people in normative samples and that resentment is associated with their shame [Henderson, 1998 #2590]. Beyond social avoidance, shame predicts self-abasement, selfdefeating behavior, and passive aggression. Moreover, shyness Clinic clients score at the 80th percentile on the suppressed anger subscale of Charles Spielberger’s State Trait Anger Expression Inventory (STAXI; See Table 2.). Clients are more likelyto be resentful when blame is externalized and they anticipate contemptfrom others. There are different patterns that youwill observe and they may correspond to different styles of attachment related to early experience(Bartholomew & Horowitz, 1991).



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Identifying and Challenging Automatic Thoughts About Others Some clients feel ashamed, but they are aware that it is because they are not living up to their own standards, and often they do not recognize that they do not apply these same standards to others, particularly friends. Other clients experience shame and think about itin terms of anticipating humiliation by others. They believe that others will be contemptuous of their anxiety, and be very critical. Sometimes this belief is dueto early experiences with critical or abusive parenting, at other times anticipating humiliation seems more related to early experiences with peers

when other children were indeed cruel andthoughtless. Sometimes the belief appears tobe related to a more general pattern of withdrawal from others accompanied by negative ruminative thinking patterns which were notaltered by social experiences thatcounteracted them. Usually these clients did not tell family members or peers about these cognitive and emotionalexperiences so they were also not met with verbal challenges to these negative beliefs about the self and others. Our current data suggests that clients with avoidant personality disorder tend to be both more shame-prone and more likely to externalize blame (Henderson & Zimbardo, 1998, August), so you may want to be alert to that dynamic. A compelling reason to administer the MCMI is to help you identify these patterns. Moreover, clients withschizotypal personality disorder are significantly higher in expressed anger as well as shame, which probably reflects the redued cognitive and emotional control inthese clients. Individual therapy is an ideal placeto begin to sort out distorted thinking in a context of empathy compassion. If schizotypal begin to establish trustpatterns itis a significant step. Exposingand themselves to feared situationsclients will be done in very small steps. It may be a real revelation to some clients to find that most other people do not feel contempt for them when theyare feeling anxious, but more likelyare concerned and empathic. In fact, a study that Leonard Horowitz and I are conducting is demonstrating that people who are listening to speakers telling about vulnerable experiences are generally well-disposed to the speakers. Even when listeners are rushed and hurried, they are much more likely to want to interact again and even to befriends than speakers think they will be. It is rare to find a conversation partner who has never experienced shyness and social anxiety and who doesn’t identify, at least to some degree, with some kind of vulnerable emotional state. Not unexpectedly, however, there is a strong association (ranging from .41 to .58) between shyness and self-reported interpersonal problems (Henderson & Horowitz, 1999). When clients are shame-prone and externalize blame you can expect self-defeating behavior and passive aggression, according to our analyses of data gathered at the clinic (Henderson & Zimbardo, 1998, August). Furthermore, you can expect interference inoccupational functioning anddisruptions in relationships, and difficulty forming intimaterelationships. When you begin to gently confront these patterns clients may thinkyou are “blaming the victim”and become highly defensive. It © 2001, The Shyness Institute; for details, see page 1.


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takes time and trust to begin to touch on these issues. One of the benefits of group therapy is that other groups members may begin react negatively to these patterns and you can help clients to rework these patterns “in the moment” or “in the heat of difficulty, if not outright battle.” Clients themselves are often as distressed by their negative thoughts about others as they are about negative thoughtsabout themselves. Because of their distress andthe negative consequences that followed in their relationships, Len Horowitz and I developed a questionnaire based on the automatic thoughts that clients reported in the shyness groups about others (Henderson & Horowitz, 1998). The questionnaire can be found in Appendix H. These are examples of the thoughts you are likely to hear and that can be challenged in the same way that other negative cognitions, including attributionsand self-concept distortions, arechallenged. We have administered the questionnaire to collegestudents and clients. Our initial resultsshow that shy college students score higher than non-shy students, and that shyness clinic clients score significantly higher thancollege students. We are therefore focusing particularly on developing interpersonal skills that allow the person to develop alternative models of relationships. The Third Vicious Cycle These findings bring us to the third vicious cycle. As you recall, shame is a painful emotional state which may be reduced by blaming others who are seen as more powerful and untrustworthy. In fact, important people in the client’s early life may have been very powerful,

hurtful, extrememely untrustworthy. However, other-blaming attributions may lead to negativeand beliefs about others which interfere with hypothesis-testing in the process of forming and sustaining relationships (see Figure 1.). Blaming others leads to anger which leads to more otherblame which leads to more anger and so on, “ad nauseum.” In fact, a queasy stomach may be one of the physiological symtpoms shy people develop. People who suppress anger, do not assert themselves, and ruminate about the transgressions of others tend to develop somatic symptoms like high blood pressure, headaches, and hypertension. Furthermore blaming others is a highly significant negative predictor of empathic concern for others, and of perspective-taking in high school students (Henderson & Zimbardo, 1998, August). Shyness by itself has been positively associated with empathic concern for others and perspective-taking is one of the components of empathy that is most associated with emotional well-being and satisfying social relationships (Davis & Franzoi, 1986). For example, your client may say that people will make fun of themor ridicule them. You help them challenge that thought the same way you work withthe others. Do they know for certain that will happen? What specific behavioral evidencedo they have that thiswill happen. Be sure that you do not accept emotional reasoning as anexplanation. “It just happens, I can tell when people think I look stupid. It is just a sense you get, you can’t explain it, you just know.” Or “you know what I mean. They don’t need to actually say it.” You say, “no, I mean specific © 2001, The Shyness Institute; for details, see page 1.


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behavioralevidence. Has anyone said anything recently? Or made fun of you openly in front of

others?” “Think of the most recent time you felt this way.” The client who used the adaptive response, “That was then and this is now,” had been severely teased as a child. When questioned he could not recall an instance of overt contempt since he was 10 years old. He hadn’t realized how much his thoughts and beliefs about the elementary school experience were affecting him currently until he responded to challenges to his negative attributions. Not only was he jumping to conclusions about what could happen with others, he was assigning whatever discomfort he was feeling in a social situation to others. If he felt uncomfortable, embarrassed or ashamed, it was because others were feeling contemptuous of him. He began to recognize the degree to which he engaged in mind reading during social interactions. Subsequent to these interactions he would go home and ruminate about what he presumed people were thinking abouthim. These thoughts bore anunmistakable resemblence to the hings t he heard as a child, but also to the things he said to himself as he nursed his hurt and rage. In fact they were thoughts he had been rehearsing for 40 years. He noticed he was making these assumptions during interactions in a group. He began to check his perceptions with other group members whenever he felt the discomfort. As he began to trust their responses he began to ask others at work for feedback if he thought they were denigrating his work. He was suprised to find that many people respected his work, but feared his sarcasm and his intimations that others, particularly authority figures, misunderstood him ormistreated him. His attitude problems at work began to clear up and he was no longer suspicious of women who appeared to like him. He also noticed that he chose unavailable or somewhat withdrawn women who provided him little feedback to counteract his negative thoughts. He began to explore friendships with women who were warmer and more supportive. We call this “developing yourtaste in people.” Automatic Thoughts About Others that May be True: Pragmatism Reigns, Challenge Usefulness Automatic thoughts related to fears that people will talk behind their back or sabotage them in some way can be challenged both as to their reality, but also as to their actual impact when people do gossip. A client felt bullied bya coworker who was arrogant and did treat him somewhat condescendingly. He suspected that the coworker gossiped about him. We challenged what effect that actually needed to have onhim. “If people gossip about you, does that mean something about you or about them? If people gossip do you think others know they gossip? How do you think others react? How would you react if the office gossip told you something about a coworker? Would you believe it? How would you react to the gossip? Do you think others might react as you do? What would you say to a good friend who thought someone was gossiping about him? Would it change your feeling about thefriend or the gossip?”



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Clients become more observant of the behavior of a difficult person toward others. This enables them to take things less personally, and to separate their negative attributions and beliefs about themselves from what ishappening in the situation. Sometimes they gossip themselves and are passive aggressive with others. This will often come out when you ask questions about what they would think or do ifthe situation were reversed. They will be unlikely tofear others less if they are also sabotaging others. If they begin to change their passive aggressive patterns they are more likely to trust that others willtreat them well. In fact, others often do begin to treat them differently, more as a result of the increased trust between them than what they believe is the basic worth of the client. If a manager or boss is in fact sabotaging them, they will feel more comfortable about changing to a different situation with the hope that others may be more trustable. Use the challenges in Figure 13.particularly for these kinds of situations. Give the client a copy to take home. “Do you know for certain that he/she hasthe sole responsibility for ______? What evidence do you have that youor the other person is the cause of______? What evidence do I have that I cannot change ________? Is the other person’s whole personality responsible? Could there be a less harsh way of viewing my own behavior or that of others? Does labeling myself or others improve our performance? Is this the only opportunity for _______?” Also, “if I really believe that this person is destructive and other people seem to think so too, can I change my own behavior or thoughts in this situation? Do I need to ruminate about the behavior of the other person? Does thinking about itchange it? Do my fantasies of getting even help my mood? Do they help me change my own behavior? What will happen if I do not get my way?” Preparation for the Fifth Exposure After you have helped the client challenge automatic thoughts, attributions, and beliefs about others, you can choose a situation from the hierarchy. If you can, choose one that is related to a situation in which frustration and anger arise as well as anxiety. For example, one of our clients became not only anxious, but angry and humiliated in department stores, both if he felt that a clerk pressured him into buyingsomething or that the clerk was aloof or condescending when he had a question. He discovered that his automatic thoughts were: “I sound stupid, she’s trying to manipulate me into buying something, she knows I don’t know much about how to dress, she is pressuring me and I should buy something because I have taken her time, she wouldn’t treat others like this.” Shame and anger arose when he thought about the situation, but not much anxiety. He thought he shouldn’t role-play thesituation because it did notcreate much anxiety. I suggested that often there are emotions besides anxiety that arise in situations to which we are desensitizing. Managing anger, embarrassment, and shame is equally important. Shame will trigger withdrawal and the inner turmoil that results from anger can feel as debilitating as anxiety. Often the mix of feelings seems harder tomanage. We identified the negative thoughts both about © 2001, The Shyness Institute; for details, see page 1.


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himself and the clerk and challenged both. The self-concept distortion appeared to beperfect self vs. real self. He had an image of a “perfectly smooth” shopper who never got rattled even if clerks were condescending or rude. Also he seemed to be doing alot of mind-reading with clerks, so we suggested he role play it with the clerk being polite and the clerk in fact being condescending and pressuring him. When the client role-played the situation witha confederate he did several ht ings. He took time to look in spite of feeling pressured, he asked questions of the salesperson, he said he would think about buying the jacket he was trying on andcome back later. The anger and shame he felt was palpable in the room. Other clients felt uncomfortable. After the exposure we discussed how many different feelings came up for people insimilar situations. The confederate gave him realistic feedback about how she had experienced him. He was surprised to hear that she perceived him as assertive, even aggressive at some pointsin the interaction. Several weeks later hereported that he had done the exercise in a department store and felt more competent to handle the situation. When you have chosen the situation, collect the automatic thoughts, and write them on the flip chart with the colored pens, adding a new color for cognitive, attributional, and self-concept distortions about others. Identify the distortions. Choose two or three to challenge, being sure to include at least one about others. Challenge the negative thoughts and come up witha rational response. In the example above, the client used, “It is ok to take care of myself.” Construct a specific behavioral goal. For instance, in the example we just outlined, one of his goals was to tell the salesperson that he would thinkabout the jacket and come back. A second goal was to ask two questions about the jacket, including theway it fit him. He actually completed those goals in less than three minutes. Because he had done so well we could have himdo it again with more pressure from the salesperson. He could also tell her how he wanted her to behave in order to increase his discomfort. Sometimes it is allthe client can muster to say hewill not take the jacket or to ask a question. In that case it is useful to just repeat the same behavior several times with a similar response from the confederate or from you if you are conducting the exposure by yourself. If a client is willing to “up the ante” I will often pursue thatcourse because in the long run they accomplish more. Brainstorm alternative behaviors that clientscan try in the situation you have chosen if the client has trouble coming up with ideas.You can use the handout in Figure 16. for strategies. Give a copy to the clientto use as a guide at home. Conducting the Exposure Conduct the exposure using the same format as in previous sessions (see Figure 6). Turn on the video-tape and, if you are using aconfederate, ask them to come in. Explain the situation to the confederate and what you would like them todo. Ask for the client’s SUDS level, have them read the adaptive (or rational) response, and begin timing the exposure. When the exposure is completed, ask for new automatic thoughts and identify particularly the ones that relate to © 2001, The Shyness Institute; for details, see page 1.


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responsibility and beliefs about the self and others.Chart the SUDS level ratings on theflip chart and link rises to negative thoughts or to tackling a new challenge. If you have used a confederate, ask the confederate to give the client feedback. Use the oppportunity to contrast the feedback with negative thoughts.If you did the exercise alone, give the client your feedback. Watch the video-tape together. Point out strengths. If there are new behaviors the client would liketo try, conduct brief role-plays. Excuse the confederate and let the client say good-bye. If the SUDS level stays low, but the person’s discomfort is obvious, discuss how a mix of anger, shame, and anxiety willoften be experienced more like general stress anddiscomfort. Tell the client that the feeling of discomfort should also be reduced with practice in these situations. Tell them not to be surprised if they are awareof more irritation or frustration this week. The feelings would be natural given that you are beginning to work on these kinds of situations. Homework Ask the client to continue to identify negative automatic houghts t during the week. Ask them to practice challenging themon their own and writedown their challenges. Tell them to write the thoughts, the kinds of distortions, and the challenges in their notebooks and bring them to the next session. Ask them to come up with at least one adaptive or rational response of their own during the week and topractice it. Have them record that in thenotebook as well.

them assign to record the automatic thoughtsHelp about others thatthemselves arise in anybehavioral situation inhomework. which theyAsk feelthem stressed or resentful. If they do not report these feelings, ask them to record any thoughts that they think others might have, even if they do not. Ask them to record any situations in whichthey feel frustrated or unfairly treated, even if they do not notice automatic thoughts in these situations.

Session Eight: The Sixth and Seventh Simulated Exposures and Anticipating Closure Homework Review Ask the client if any questions or new thoughts came up after the last session and about negative thoughts while doingtheir behavioral homework. Make a copy of the negative thoughts they recorded while doing homework. By this time you will probably see the full array of negative thoughts about the self and others. Ask about the behavioral homework and brainstorm possible strategies with the client if there are problems. Ask the client what their thoughts were when thinking about closure. Discuss how far they think they have come. It can be useful to normalize the disappoint clients often feel when they recognize they are just scratching the surface of very longstanding patterns that will require © 2001, The Shyness Institute; for details, see page 1.


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consistent work. The sports model is again useful. They have practiced some new behaviors like tennis strokes or serves. They also have a set of exercises like calisthenics to do on their own when they identify and challenge negative thoughts and do small pieces of homework that will lead to larger coordinated movements and behaviors. Earlier we discussed varying the exposures. I am giving you a sampling in this protocol, but your client may do much less in ten sessions with you. Some clients work on eye contact, brief conversations, and perhaps asking a coworker to go to lunch or for a walk during lunchtime. They may do this for weeks and not proceed further. The trick for you is to help them push themselves each week, each day, just a little. The feeling you both want to have is that theclient is pushing his or her own edge, just like an athlete does. Large jumps are not necessary, but persistence is, and they kidthemselves and you that they“cannot do it.” I have pushed them harder over the years because I have learned intuitively when to back off, or to just “plant a seed” without a time line. Sometimes I go further and tell them I think they could do more, that somewhere they may have picked up the belief that they are fragile.I point out times when they have role-played with me or with a confederate, and how much better they did than they expected. If our relationship is good Iexpress a little dissatisfaction (not much) about their effort.I almost never focus on the results of their efforts, but only on the things they actually DO each week. I have learned to trust ht at they will continue tobuild on their efforts and on ourinteractions around their efforts. We are conducting a follow-up study on clients who completed groups as many as 10 to 15 years ago. I have been surprised and gratified at how many have been doing well since. Some have had setbacks and some have gotten more help in the form of Toastmasters, singles groups, and other therapists, but they persist and they grow, which I find the most exciting thing I have known as a therapist. I am devoted to these people and they are worth every bit of frustration that you sometimes feel in the beginning. And they do know how to frustrate you and themselves initially. If things have gone very well your client may be seeing more of people and beginning to develop intimate relationships. The progression from interaction with colleagues to dating is often the usual for shy men, who frequently have more difficulty with intimacy than shy women do. Women often struggle with self-assertion at work, with authority figures, with public speaking, and sometimes dating. We will discuss an exposure designed for a male in this session. However, the exposure may be adapted for a woman by having the woman invite a man to dinner, a movie or a party. I’ll cover an exposure with a shy woman and an abusive manager in the next session, and in the final session we will work with public speaking which is common to both men and women. Preparation for the Sixth and Seventh Exposures



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We’ll assume that your client has been chatting with a woman at work and has gone to lunch with her a few times. Now he wants to take her to dinner and a movie. It can be useful to try to work in two exposures if you can in this session. Do one in which he asks for the date and one in which they are on the date and he starts to talk about more personal things about himself and asks her more personal questions. If at all possible, have him give the woman a compliment that is genuine, but unmistakably communicates sexual interest.It can be something like commenting on her warmth or that her face lights upwhen she smiles. Tell him that he need not do this on a first date, but that you want him to have the experience in the safety of your office, in order to practice for the situation when it presents itself. Shy men often believe that they are intruding on women if they communicate interest or sexual attraction. They are unlikely togo too far with this in their behavioral homework and be rejected. The exercise will help them loosen up emotionallyas well as behaviorally. If you are a female therapist and relatively close in age, it willwork well for you to doit. If you are a good deal older, it might be useful to use a younger confederate. Ask the client how high theSUDS level is when he thinks about thesituation. Usually they will report 80 or above. Ask for the automatic thoughts, write them on theflip chart, identify the distortions, and challenge them. Often they relate to intruding onor exploiting a woman. Examples are, “she’ll think I just want her body, maybe she’ll be offended that I thought we could be more than friends, what if she only wants to be friends,” etc. These are particularly important because you challenge ht em in two ways. You challenge how they jump to conclusions: “Do I know for certain that she’ll think Iwant more than friendship? Do I know for certain thatI do want more than friendship? How well do I really know her?” Then you challenge the assumptions that often go along with these thoughts, which reveal attributional and self-concept distortions, as well as distortions about women. “If she does think I’m attracted to her, what is the likelihood that she’ll beoffended by that? If she is reticent does that mean that itis because she doesn’t want to dateme? Could there be other explanations? Maybe she is shy. If she only wants to be friends, does that mean that I am deficient in some way? Could my belief in my own deficiency have another explanation other than women will not be attracted to me? Could this be a way to practice gettingto know more about women? What specific behavioral evidence do I have that women are offended by my interest?” The other thoughts you challenge often have to do with whether or not rejection can be tolerated and whether social el arning can occur while theypractice. Idealized beliefs surface that were formed in adolescence and remain unexamined. These kinds of beliefs are usually challenged and changed during the course of dating and in the context of female friendships in highschool and college. Many shy and socially phobic men have not dated or had women friends, so they have not had the opportunity to go through these natural stages. They will produce thoughts that are © 2001, The Shyness Institute; for details, see page 1.


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also unfortunately true, that they have less experience than their peers, that they are behind in social learning, and so forth. Challenge these by saying, “if you are lagging behind some of your peers in experiences with women, does that mean that you are unable to learn?How do you think your learning curve might compare to a person whois 15 or 16? Are there any advantages in starting at your age?” Sometimes they will becomeaware that they have more experience in learning other things, that they can transfer strategies from one domain to another, that they can use other kinds of learning and accumulated wisdom and apply them socially. If they are really stuck, they do not recognize these possiblities. Humor can help. “Is this a contest with your peers or a learning experience for you? How experienced do you want a woman to be? Will a history of a large number of men in her life influence your attraction to her? Do you think that wouldenhance her attraction to you? Is it possible that she mightfind it appealing that you are lessthan perfectly smooth? What is the likelihood that she mightassociate behavior that fallsshort of perfection with beinggenuine?” In fact, studies of dating behavior suggest that men who are too smooth are unappealing to women and that one of the major dating skills is taking a genuine interest in the woman and self-disclosing at a rate equivalent to hers. A helpful book for clients to use is Don Gabor’s, How to Start a Conversation and Make Friends (Gabor, 1983). The book includes a nice description of levels of disclosure as intimacy develops. Suggest that the client buy the book and read it during the week, reviewing levels of self-disclosure just before the date. Tell the client that having theideas fresh in his mind will facilitate his using them during the evening. At this point it can be useful to discuss “host” behaviors, which seem to be one of the skill areas that women appreciate in men, and brainstorm how theclient might act likea good host. For example, finding out what kind of food the woman likes and what kind of movies she likes to see, offering alternatives for her to choose from, suggesting that he will pick her up or meet her at the restaurant, whichever feels more comfortable to her. Help the client construct an adaptive response and write it on the flip chart. Examples are “I have learned how to do other things, I can learn dating skills,” “I can just be myself,” “I can be open to whatever happens,” or “I have time to learn, I may as well get started.” Help the client construct ameasurable goal. In these situations the goalis often to ask her to go to dinner (or a movie, or both) and seta time to meet and a place to go that is specific. Often shy people will say, “do you want to go out sometime?” and leave the other person hanging, left to come up with alternatives and decide the time andplace, which usually doesn’t happen. They then believe that the other person did not like them, rather than the person who does the initiating needs to take responsiblity for the plans. Other people frequently think than an extremely shyor socially phobic person simply takes too much effort. The goal should include a couple of possible restaurants and movie locations. © 2001, The Shyness Institute; for details, see page 1.


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In addition to this goal, have the client think of one compliment that is personal and communicates sexual attraction and interest.(After they practice asking for thedate in the first exposure you will move directly to the date itself for the second exposure and that is where they will practice the complimentas well as talking aboutmore personal topics.) Help the client choose at least two personal things to tell about himself.It can be talking about something that is a strong interest. It is best if it is something the person cares about, or values. It can be an aspiration or a dream. Perhaps a goal that is really important to the person. The client can think of subjects about which he has strong values. It should not be “troubles telling” and negative in content. Sometimes socially avoidant men and women will focus on the negative, and complain about things as a way to connect with others. It tends to be off-putting, particularly early in relationships. Conducting the Exposures When you have arrived at goals and adaptive responses for both situations you are ready for the exposures. Conduct the exposurex using the same format as in previous sessions (see Figure 6). Turn on the video-tape and, if you are using a confederate, ask them to come in. Explain the situation to the confederate and what you would like themto do. Ask for the client’s SUDS level, have them read the adaptive (or rational) response, and begin timing the exposure. Have the client talk a few minutes and thenask for the date. It is useful to repeat the part where they the time andsecond place, sometimes more once. When theend firstofexposure is completed, moveset directly to the one, reserving thethan debriefing until the the second exposure. Describe the setting of the date, usually dinner at a local restaurant, and, if possible, have the client and the confederate sit across from each otherat a table. Table settings, flowers, or candles are great props if youhave them. Tell them they will be making more personal conversation and the client willcompliment the date. Say to the confederate, “respond just as you would if someone you knew a little and liked were talking more personally with you, communicating interest in you and giving you a compliment.”It is important in the more intimate exposures that the confederate has awarm interpersonal style andis empathic. In these early experiences clients need to experience interpersonal warmth and responsiveness from others. You can omit having the client say he t adaptive response out loud. If the client has not disclosed anything personal by the third minute, prompt them by reminding them of the goal. Prompt them for the second personal disclosure by the fifth minute and then prompt for the compliment by minute seven. It is important that the compliment is not followed by a “bail out” which clients are likely to do. They attempt to end the exposure immediatelyafterward. The client needs to experience both the anxiety of delivering thecompliment and then theanxiety of waiting forher response. They often do not get to the pleasure experience when the “date” responds because they are caught up in © 2001, The Shyness Institute; for details, see page 1.


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their own worry and anxiety. You may need to say to the client. “Try to be present. Just focus on the interaction and on your date’s response.” Clients have many safety behaviors and subtle avoidance behaviors they employ inthese situations which interfere with desensitization. It also gives them practice. If possible, extend the time a bit and have he t client practice the compliment more than once. When the second exposure is completed, ask for new automatic thoughts that occurred in both exposures. Identify particularly the ones thatrelate to responsibility andbeliefs about the self and others. Chart the SUDS levelratings from the first exposure on the flipchart and link rises to negative thoughts or to actually asking for the date or setting the time and place. If you have used a confederate, ask the confederate to give the client feedback. Use the oppportunity to contrast the feedback with thenegative thoughts. If you did the exercise alone, give the client your feedback. Watch the video-tape together. Point out strengths. If there are new behaviors the client wouldlike to try, conduct brief role-plays. Excuse the confederate if you used one, and let the client say good-bye. Homework If at all possible, have the client do the first exposure in vivo before the next session. If this can be achieved while the simulated exposure is still fresh in the person’s mind it is much more effective. Ask them to pay attention to SUDS level and tosee if they notice any emotional states

besides any positive theisphysiological state.Usually they will begin tobe aware ofanxiety positiveand aspects of their aspects arousal,tothat of the excitement that accompanies new challenges with people they like. It helps them begin to differentiate more positive physiological and emotional states. Ask the client to continue to identify negative automatic houghts t during the week. Ask them to practice challenging themon their own and writedown their challenges. Tell them to write the thoughts, the kinds of distortions, and the challenges in their notebooks and bring them to the next session. Ask them to come up with at least one adaptive or rational response of their own during the week and topractice it. Have them record that in thenotebook as well. Remind the client that the session after the next one is thefinal session. Ask them to write down how far they think they have come toward their initial goals and what they think is the most important are to focus on between now and termination.

Session Nine: The Eighth and Ninth Simulated Exposures and Anticipating Closure Homework Review



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Ask the client if any questions or newthoughts came up after the last session. Ask them what they think is most important to focus on in this session and the next. Usually their thoughts will relate to situations or behaviors that are presenting new challenges or where they feel a bit stuck. It can be useful to brainstorm strategies for implementing new behaviors for the new challenges or for taking things in smaller chunks inthe areas they feel stuck. Often you will want to stay with the exposures they have not tackled, but if other situations or behaviors seem more important, they may beimplemented instead. For instance, if self-assertion is not abig issue at the moment and deepening conversations with potential friends is more important, you may want to continue to focus with increased challenges in anew exposure on the same theme. You can discuss the pros and cons with the client. Ask about negative thoughts that arose whiledoing their behavioral homework. Make a copy of the negative thoughts they recorded while doing homework. Choose one or two to challenge. Ask about the behavioral homework. If the client did not ask someone for a date, find out if they delivered any compliments to anyone, if they talked more personally with anyone, and if they took any steps to come closer to asking someone out. When you help them think about it, they tend to notice subtle changes in their behavior they otherwise overlook. Brainstorm strategies with the client to help them find opportunities to ask for dates, such as dropping by someone’s office, or getting coffee at the same time they do. Explore different ways of asking someone to join them in activities they enjoy like hiking, tennis, cycling, dancing, etc. Dance clubs have become popular withshy and socially phobic clientsbecause they can observe, take lessons, join in group activities, or ask people to dance, etc. If the client has been successful you can proceed to role-plays of more intimate disclosures, or to strategizing ways to begin to initiate moreintimate physical contact. Some very shy men willwant to begin sexual contact with a sexualsurrogate. It is useful to have a referral available if that si the case. Preparation for the Eighth and Ninth Exposures A common occurrence for shy or socially phobic women is a domineering boss who may be exploitive or even abusive. In this case it can be helpful to usea confederate, preferably of the gender of the boss, but you may play the role yourself. You can ask the client to role-play the boss while you play the client prior to the exposure, so that you can more closely simulate the behavior of the boss during the exposure. Ask the client how high the SUDS level is when she thinks about thesituation. SUDS levels range from 50 to 100 in these cases. The discomfort may take the form of suppressed anger, resentment, physical symptoms like knots in the stomach, or general feelings of distress rather than simple subjective anxiety. Clients will sometimesreport the urge to cry and excessive embarrassment or shame. Ask for the automatic thoughts, write them onthe flip chart, identifythe distortions, and challenge them. The challenges that areuseful in this exercise are usually © 2001, The Shyness Institute; for details, see page 1.


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attributional and self-concept distortions (see Figure 7.).Often the client is blamed unrealistically for common mishaps so it is best in this case to focus on the thoughts about the self, rather than challenging negative thoughts about the other.The client is usually taking more than hershare of the responsibility for the interactions so focusing on thoughts about the other is not as fruitful. Common thoughts are: “if I were better at this job it would help, I didn’t learn the new procedure quickly enough, I should know how to handle these situations, or people overhearing him/her must think I’m an idiot, I get tongue-tied and can’t think of things to say, maybe I really don’t know how to do this job, if I were someone worth respecting he wouldn’t treat me like this, or I must be doing something wrong.” After identifying the distortionsand challenging the thoughts, help the client develop an adaptive response. It may be something like, “I deserve to be treated with respect as a person, even if my job performance falls short of perfect.” The client also may notknow that she has recourse to a human resource department to find help in dealing witha manager who is abusive. It may be useful at this point to ask the client what available resources are and say that you will discuss strategies for getting help during the homework section at the end of the session. Help her develop a specific goal for this particular interaction, such as saying, “I don’t think it is appropriate for you to speak to mein this tone.” Or “I am uncomfortable with the tone you are using in speaking to me.” Or “I am happy to do my work for you to the best of my ability, but it is not necessary to call me names or tobe sarcastic about my work. It does not help me improve.” Sometimes clients can practice with asimple “I beg your pardon?” when being spoken to in an inappropriate fashion. Sometimes a goal is repeating a request such as, “I understand that you did not like the way I wrote the report, however I still believe that I deserve a raise” or “I understand that you may be shorthanded, but I do need to take Friday afternoon off to see the dentist.” Write the goal(s) on the flip chart. Conducting the Exposures When you have arrived at a goal and and adaptive response you are ready for the exposure. Conduct the exposure using the same format as in previous sessions (see Figure 6). Turn on the video-tape and, if you are using a confederate, ask them tocome in. Explain the situation to the confederate and what you would like themto do. If you are doing it yourself tell the client what you intend to do as the boss. Ask for the client’s SUDS level, have them read the adaptive (or rational) response, and begin timing the exposure. In this exposure get the SUDS level at one minute inervals and have the clientread the adaptive response each time. Adaptive responses are particularly important in these exercises because they need to be reminded of their rights. If the client is timid in the interaction, suggest that she raise her voice or make eye contact more forcefully. If necessary suggest that she stare at the bridge of the nose if she cannot hold eye © 2001, The Shyness Institute; for details, see page 1.


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contact. She can work on the eye contact later. Give her time to try asserting herself inher own way, but if she is faltering, tell her to deliver her statement or to read her prepared statement if she cannot remember it. She can continue to repeatthis same statement or rt y several, but prompt her to continue responding, at least once per minute. When the exposure is completed, ask for new automatic thoughts that occurred during the exposure. Identify particularly the ones thatrelate to responsibility andbeliefs about the self. Chart the SUDS level ratings on the flip chart and link rises to negative thoughts or to delivering the prepared statements. Acknowledge any assertive statements theclient made on her own behalf. Challenge one or two of the new automatic thoughts. If you have used a confederate, ask the confederate to give the client feedback. Use the oppportunity to contrast the feedback with thenegative thoughts. If you did the exercise alone, give the client your feedback. Watch the video-tape together. Point out strengths. The next exposure can be related to the first. If new ideas occurred to the client or to you, if new information was revealed in the exposure, or if the confederate had suggestions for improvement, use those to design the next exposure. The more practice the better on these. Both you and the confederate can model assertive behaviors for the client.You can be the boss and then the confederate. If you are doing it alone with the client, el t her be the boss and model behaviors and verbalizations that she can use. Model and explain the powerof nonverbal behaviors that suggest assertion, such as facing the person squarely, looking them in the eye, keeping the head up, and using a forceful tone of voice. Help the client develop a new adaptive response (or if they prefer they can use the same one). Develop another specificgoal based on a different behavior orprepared statement. Conduct the second exposure in the same format as the first. Turn on the video-tape, ask for the SUDS level and have the client read ht e adaptive response from the flip chart. Check SUDS levels each minute and ask for the adaptive response. Prompt the client for the assertive behaviors including the nonverbal ones. When the exposure is completed ask for new automatic thoughts, write them on the flip chart. Challenge one of them. Chart the SUDS level ratings on the flip chart and link rises to negative thoughts or to delivering the prepared statements. If you have used a confederate, ask the confederate to give the client feedback. Use the oppportunity to contrast the feedback with thenegative thoughts. If you did the exercise alone, give the client your feedback. Watch the video-tape together. Point out strengths. If there are new behaviors the client wouldlike to try, conduct brief role-plays. Excuse the confederate if you used one, and let the client say good-bye. Homework If at all possible, have the client do some part of the exposure in vivo before the next session. If this can be achieved while the simulated exposure is still fresh in the person’s mind it is © 2001, The Shyness Institute; for details, see page 1.


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much more effective. It may be difficult in a situation where theclient is still very intimidated. It can be useful to suggest that they visit someone in human resources in their company to find out what their rights are and toask for help in handling the situation. This allows them to register with someone that the manager is a problem. This is often not news and employees in human resources are skilled in helping people handle orcircumvent some of theconsequences they fear. The client needs to find out what her rights are and what the possible consequences of confronting the problem directly may be. It sometimes helps clients to consult attorneys tofind out how complaints are filed against companies. They rarely follow through onthese actions, but itgives them a sense of their rights, and increased confidence in confronting managers or asking for help. They may also become less ashamed and begin to speak with other employees who may have experienced similar things. They can strategize together and the fellowemployee can be a useful source of feedback and support. Many times clients deal with these kinds of problems incomplete isolation before they begin to talk about the experience in therapy. Ask the client to continue to identify negative automatic houghts t during the week. Ask them to practice challenging them on their own and to write down their challenges and their adaptive or rational responses, and topractice them. Have them record themin their notebook. Suggest that the client read the chapter, “Resolving Interpersonal Conflicts” in the book, Reaching Out by David Johnson (1997). The chapter will help them with ideas that you can discuss during the next session. Remind the client that the following session is the final one, at least for this round of treatment.

Session Ten: The Tenth Simulated Exposure and Closure Homework Review Ask the client if any questions or new thoughts came up after the last session. Ask about negative thoughts that arose whiledoing their behavioral homework. Make a copy of the negative thoughts they recorded while doing homework. Choose one or two to challenge. Ask about the behavioral homework. Using the example from thelast session, if the clientwas unable to be more assertive with the boss, what specific automatic thoughts, attributions, beliefs, came up as she thought about it? How did these contribute tothe avoidance? Ask what adaptive responses

she used. If sheabout failedinitial to think of any,with help her construct oneOroriftwo. Inquire contacts human resources. there were any questions she was able to ask fellow employees about procedures. Ask if she noticed assertive behaviors on the part of co-workers. Clients will sometimes beginto notice the behaviors of others that they want to emulate and begin touse others as models. You want to acknowledge and reinforce this as an adaptive strategy. If they have not done so, you may suggest that they observe others whose



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behavior in this area theyadmire. Tell them to record these behaviors in their notebooks so they can use them to brainstorm possible new behaviors on their own. Ask if they have noticed any changes in their behavior toward the boss or other employees. They can usually think of something, however small, that they have begun to do differently. Brainstorm strategies they can use to assert themselves or ask for help from others. Use the chapter from Reaching out to help you brainstorm (Johnson, 1997). For instance, expressing cooperative intentions, presenting one’s reasons for requests or actions, and listening to the other person’s reasons. Other helpful techniques include focusing on needs and goals, rather than positions and clarifying the differences in interests before negotiating an agreement (p. 263-267). Suggest they practice with coworkers or family members with whom they feel less threatened. If time permits, it can be useful to role-play briefly at least one disagreement taken from an example at work or home. In this role-play focus on perspective-taking. After each of you presents one side of the argument, paraphrase back your understanding of the other person’s position. Change roles so you do both sides. As we mentioned previously, shy people often blame others as well as themselves for negative social outcomes. Blaming others significantly interferes with perspective taking and with empathic concern in adolescents (Henderson & Zimbardo, 1998, August). An increase in the skill of perspective-taking often reduces suppressed anger and maladaptive behavior, and increases the ability to reach goals and get more of what they want from others. Social anxiety can alsodisrupt listening behavior simply because itis hard to concentrate. When clients focus on their own negative thoughts and feelings they are also more likely to misinterpret incoming information in the direction of their fears and negative beliefs about themselves. Preparation for the Final Exposure Public speaking is frequently the nemesis of the shy or thesocially phobic. At least one exposure probably should be devoted to this situation. Some clients will want to do more than one. Whether or not the clientmust give talks as part ofprofessional or volunteer activities, these exposures help the client speak in front of any group, including small informal groups. This situation is frequently at the top of the fear hierarchy so it is usually the final one conducted. Take the situation from the hierarchy you constructed during the initial evaluation or inquire about possible situations that may arise. Let’s assume it is a talk given to a group of colleagues describing a project. Most often people will need to give brief updates on ongoing projects. Write the situation on the flipchart. Ask the client whatnegative thoughts are occurring and write them on the flip chart. Notice that some of the thoughts will refer to the client’s performance. For example, “I’ll stumble over my words, I’ll forget what I wanted to say, I won’t make eye-contact, I’ll look foolish andmake people uncomfortable.” Many of the thoughts will also refer toothers. “John doesn’t like me anyway, and he’ll gloat if I make a mistake. No one will listen anyway, © 2001, The Shyness Institute; for details, see page 1.


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because I don’t presentthe material well. Everyone will be uncomfortable and embarrassed for me. They will think I don’t know what I am doing.” There is a great deal of mind reading. It is important to challenge the negative thoughts about their ownperformance. Do they know for certain they willstumble? If they do stumble, how bad isthat? What is the worst that can happen? If that happens what will they do? Then what? I try to take this one as far as possible, because what they usually get to is the fact that if the talk does not go as well as they want it to, they will engage in a good deal of negative thinking aboutthemselves afterward. As they continue they oftenreveal the negative beliefs aboutthe self. Not only was an imperfect performance worthy of self-blame and taking the entire responsibility for any awkwardness that ensued, but they have exposed themselves to others as the social idiots they always knew they were. It may be a revelation to discover that even public speaking tasks may be considered shared responsibilities. It is easier to give talks to receptive audiences. There are questions that can be asked to help a speaker clarify points ofconfusion. Careful listening and awarm reception help any speaker do well. An accepting atmosphere encourages people to dowell when presenting their work. A critical environment makes mostpeople more inhibited. So you can also help them challenge their attributions. Do they have sole responsibility? Even if they do not do as well as they’d like, can they givethemselves room to learn? Would they give another person room to learn? Would they be so critical if someone else stumbled over theirwords? If they did not make eye contact, could that be considered a learned skill that they could practice next time, and gradually increase? If someone else becomes uncomfortable is the speaker’s performance the only explanation for the discomfort? Could the discomfort berelated to other factors, suchas the listener’s anxiety regarding talking togroups? Do they know for certain that others will be critical? Does an uncomfortable look meanthat the listener is critical? Could the attitude be something else? For example, wanting to help and being uncertain as to how to help? Finally, challenge the self-concept distortions, usually perfect self vs. real self, in come cases the shame-based self concept, the belief that the person is inadequate or has not the ability to learn this task and perform satisfactorily. If the speaker does not know how to do something they have seldom practiced, does that mean they cannot learn? Help the client develop an adaptive response, such as “I cangive myself room to learn. I’ll do better with practice. Others may be more supportive than Ithink. Practice at this task will help me feel more comfortable ingroup situations.” Then help the clientconstruct a specific goal, such as telling the audience three thingsabout the project. Another goal is maintaining eye contactat least 40% of the time with someone specific (with the understanding that probably between 60 and 70% is as good as it needs to be for a longer term goal). © 2001, The Shyness Institute; for details, see page 1.


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Write the adaptive response and the goal on theflip chart. Give the client a fewmoments to prepare the talk. Conducting the Exposure Conduct the exposure using the same format as in previous sessions (see Figure 6.). If you are using a confederate, ask them to come in.Explain the situation to theconfederate and tell them what you would like them to do. It may be useful to have the confederate (or you, or both) be a receptive audience for five minutes, then a tougher audience for five more, and finally a receptive audience for another 2 to3 minutes to end on a positive note. This experience gives the client a chance to notice how audiences can promote better publicspeaking. It also gives the client a chance to desensitize to a more negative audience.In the second five minutes you can also try having the confederate be non-receptive or critical and you be receptive and supportive and then switch roles. This just gives the client achance to notice that they can probably manage both responses and that an audience is composed of people with different attitudes, not just one. Turn on the video-tape and ask for the SUDS level.Ask the client to read aloud therational response and to begin the talk. Check the SUDS level and have the client say aloudthe rational response at one minute intervals. When the exposure has been completed, chartthe SUDS levels on the flip chart. It is important for clients tonotice when their adaptive responses reduce anxiety. The SUDS level is usually lower by the end of the talk than it was at the beginning, in spite of the fact thatAsk it fluctuates duringthoughts the talk.ht at occurred during the exposure. Ask the clients what for automatic thoughts came up afterward, because these usually will relate to attributions and beliefs about the self. Challenge the most important thoughts and help ht e client construct anadaptive response. Have the client write down the rest of the thoughts to challenge later as part of the ongoing homework. Rewind the video and watch thetalk with the client. Ask if the client noticed strengths in the talk. Point out strengths that you see. Ask the confederate, if you used one, for feedback and give your feedback. For a first attempt, keep the feedback simple. Give them feedback about eye contact, posture, suggest things to do with the hands. If they want more practice with public speaking, Toastmasters is very helpful and coaches provide more specific feedback. If you like, you can suggest they make only three points, tell the audience in the beginning what they will talk about, and summarize their points at the end. For the first exposure it is mostimportant that they actually do it in spite of the fear andfind that they can. SUDS levels are usually around 90 and above for these exposures, but often come down to around 50 or lower. Turn off the video and tell the client they can take thevideo home. It is usually helpful to leave the feedback on the tape so the client and view it again. Excuse the confederate and let theclient say good-bye. Closure © 2001, The Shyness Institute; for details, see page 1.


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Ask the client to fill out the Shyness Clinic TreatmentEvaluation form in Figure11. When the client has completed the form you can review their progress and construct new goals for the next six months (see Appendix H. for a therapist guideline). We will use the example we presented at the end ofsession two. At the beginning oftreatemnt, the client planned toenter feared situations where they could meet people, speak more often in meetings at work, ask for help or feedback from a supervisor, identify and challenge negative thoughts in at least three problem situations, and to obtain a SUDS level drop of at least 20 points in a situation in which they practiced. Count the number of new situations they haveentered. To help them determine how much progress they have made, ask how many times they spoke in the last meeting at work. Did they get help, ask for feedback, or provide an update to a supervisor? Ask how many times since the last session they challenged an automatic thought, and ask how much the SUDS level has dropped in at least one situation where they have practiced entering and interacting with others. Administer the Attribution Questionnaire (Appendix E.) covering the most challenging three situations on the fear hierarchy. Compare the answers withtheir responses during the initial evaluation. Usually there is a change in attribution style, withreductions in internality, stability, globality, and self-blame. There is usually a reduction in shame as well. Greater changes seem to occur in situations in which they have practiced. Sometimes you see changes in situations where, in spite of practicing less, they have worked actively to challenge the negative thoughts and to come up with more adaptive responses. You can also administer the Social Phobia section of the ADIS-IV to see whether they still meet criteria for social phobia. Our adaptation of the AvoidantPersonality Disorder Exam by Loranger can be found in Appendix B for a post-test measure of avoidant personality disorder. Acknowledge their progress and discuss ways to continue working with the situations that are problematic. Discuss psychoeducational opportunities in thecommunity and have the client write down one or two. Help the client construct three more goals for the next six months. Usually they are working to continue making progress in meeting people, dating, partipating more actively at work, asserting themselves, and getting to know people better. Examples of goals are: continuing to ask co-workers to lunch, at least two times a week; continuing to respond to personals’ ads, at least once a week, continuing to hike with the Sierra Club at least two times a month, and initiating contact with an organization they may want to join, like Meeting for Good, a local singles organization. It may be having some social contact witha manager, beyond talking about work, such as asking about their week-end, sharing something interesting they have read or movie they have seen. Contacts with authorities are sometimes difficultand they need to practice maintaining contact with supervisors or managers. Cover what they should do if they get off track, such as reviewing cognitive distortions and challenging automatic thoughts, getting out their hierarchies to remind themselves of progress they © 2001, The Shyness Institute; for details, see page 1.


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have made, keeping a journal about homework accomplished and changes in negative thought patterns, giving themselves a check mark in a notebook to indicate each time they do behavioral homework. They can make the check marks worth so much money and pay themselves at the end of the week for homework done, or take themselves to a movie or buy a CD to openly acknowledge their progress. It is also useful to give them a “Letter to Friends” (See Appendix I.). Ask them to give one or two of these to someone who knows them to see if others also notice behavioral changes. The person can send the letter to you and if you have permission to share the information you can send it to the client. Ask the client if there are any thoughts and feelings remaining. Say good-bye. Be sure the client understands that if they are becoming more symptomatic or regressing, that they can call you to schedule a booster session or to discuss another intervention.



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Figure 1. Shyness Clinic Components of Shyness

•Behavior - inhibited, avoidant, overactive •Physiology - symptoms of fight or flight reaction triggered in sympathetic nervous system- heart racing, trembling, sweating; adaptive in evolution, now an overestimate of danger •Cognitions - maladaptive thoughts (AT's), attributions (ATT's) self-beliefs (SB's) •Negative emotions - embarrassment, shame Vicious cycle #1, Anxiety and Escape •Subjective anxiety (SUDS, Subjective Units of Distress from 0 to 100) leads to AT's which lead to increased SUDS which leads to behavioral avoidance which leads to increased anxiety in next situation Attribution Style •How people assign responsibility for interpersonal interactions positive outcomes negative outcomes •Self-enhanceme nt bias

Ordinary person takes credit for success, externalizes failure or specific, temporary, and controllable factors •Self-enhancement bias is reversed in social situations in shyness When shy, take credit for failure and attribute success to specific, uncontrollable factors •See failure as "characterological" See failure as internal, global, stable, uncontrollable, blame the self


attributes it to

temporary and


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Role of Private Self-consciousness

•Private self-consciousness leads to seeing the self as others do, in general. •However, during negative emotional states like fear or shame, private self-consciousness may contribute to perceptual distortions about one's behavior and about others' reactions. Perceptual •

distortions are due to increased awareness of internal emotions and negative thoughts. Vicious Cycle #2, Self-blame and Shame •Self-blame for social failure produces shame, shame in turn produces more self-blame. •Vicious cycle may lead to increased feelings of vulnerability when enter the next social situation Self-concept Distortions

•Self-blaming attributions may lead to negative beliefs about the self which organize information around the increased articulation of biases in the self-concept. •

May take place outside awareness, so successful goal completion is discounted, as is progress

toward long-term goals. Vicious Cycle #3, Other-blame and Anger •Shame is a painful affective state which may be reduced by blaming others who are seen as more powerful and untrustworthy (some may have been) •Other-blaming attributions may lead to negative beliefs about others which interfere with hypothesis-testing and with forming and sustaining relationships



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Figure 2. COGNITIVE DISTORTIONS

1.

You see things in black and white categories. If your performance falls short

All -or -No thi ng Thi nki ng:

of perfect, you see yourself as a total failure. 2.

Ov er ge ne ra li za ti on :

3.

Me nt al F il te r:

You see a single negative event as a never-ending pattern.

You pick out a single negative detail and dwell on it exclusively, so that your vision of all

reality becomes darkened, like the drop of ink that discolors the entire beaker of water. 4.

Dis qual ify ing the Pos iti ve:

You reject positive experiences by insisting they "don't count" for some

reason or other. In this way you can maintain a negative belief that is contradicted by your everyday experiences. 5.

Ju mp in g to C on cl us io ns :

You make a negative interpretation even though there are no definite facts that

convincingly support your conclusion. a. Mind Reading:

You arbitrarily conclude that someone is reacting negatively to you, and you don't

bother to check this out. b. The Fortune-Teller

Error:

You anticipate that things will turn out badly, and you feel

convinced that your prediction is an already established fact. 6. Catastrophizing:

If you think you have committed some social error, you expect extreme and horrible

consequences for yourself. A turndown for a date is evidence for a lifetime of isolation. Making a mistake at work means that you will be fired and will never get another job. 7.

Mag nif ic at ion or Min im iza ti on:

You exaggerate the importance of things (such as your goof-up or

someone else's achievement), or you inappropriately shrink things until they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called the "binocular trick". 8.

Em ot io na l Re as on in g:

You assume that your negative emotions necessarily reflect the way things really

are: "I feel it, therefore it must be true." 9.

You try to motivate yourself with "shoulds" and "shouldn'ts," as if you had to be

"S ho ul d" St at em en ts :

whipped and punished before youcould be expected todo anything. "Musts" and "oughts" are alsooffenders. The emotional consequence is guilt. When you direct "should" statements toward others, you feel anger, frustration, and resentment.



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This is an extreme form of over generalization. Instead of describing your

10. Labeling and Mislabeling:

error, you attach a negative label to yourself. "I'm a loser." When someone the wrong way, you attach a negative label onto him: "He's a stupid

else's behavior rubs you louse." Mislabeling involves

describing an event with language that is highly colored and emotionally loaded. 11. Personaliza tion:

You see yourself as the cause of some negative external event for which, in fact, were not

primarily responsible 12. Maladaptive Thought:

Any thoughts that are not useful to you in a given situation and do not help you

reach your goal. 13. Compensatory Misconception:

You believe that you need to inflate your achievements or impress others

to be socially successful. You may think only the most aggressive and the most dominant succeed. This may be a compensation for a belief in your own inadequacy and may promote suspicion and hostility toward others.



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Figure 3. CHALLENGES

to Automatic Thoughts Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? What evidence do I have that _________________________? Does ___________________ have to equal or lead to _________________? Could there be other explanations? What is the likelihood that __________________? Is________________________ really so consequential or important? Does _______________'s opinion reflect that of everyone else? Is _______________________ so important that my entire future resides with its outcome? Is this the only opportunity? What is the worst that could happen? How bad is that?

Adapted from Sank and Shaffer (1984), Heimberg (1991)



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Figure 4. EXPOSURE SIMULATION RECORDING FORM

Client Date

Session #

Exposure #

Description of Feared Situation:

______

Others involved:

Patient's Goal in Exposure Simulation:

Adaptive Response Used in Exposure Simulation:

SUDS Record: Time Initial 1Minute 2Minutes 3Minutes

Rating

4Minutes 5Minutes 6Minutes 7Minutes 8Minutes 9Minutes © 2001, The Shyness Institute; for details, see page 1.


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10 Minutes Adapted from Heimberg, 1991

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______



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Figure #5. ATTRIBUTIONAL DISTORTIONS Reversing the Self-Enhancement Bias.

Success = no credit vs. Failure = credit:

If you succeed socially, get a date or a job, or just have a pleasant conversation at a party, you give external or temporary factors the credit. If you fail you take allthe credit, frequently relating it to something about your character, your ability, or your personality. 1. In ter na l for negative outcome s vs. Ext ern al for positive outcomes. "It's all my You take sole responsibility forwhatever social situation turns fault!" vs. “Not me, folks!”:

out badly and none for those that turn out well. 2. Stable for nega tiv e out com es vs. T empo rary for posi tive outcome s. "Alw ays

If you make a mistake socially or don't meet your own expectations in a given instance, you see it as a never-ending pattern rather than due to a temporary factor such as fatigue. If a social outcome isnegative you assume that itwill always happen. In contrast, if an outcome is positive, you assume that it can't last, or can't be repeated. and forever" vs. "Don't count on it":

3. Glob al for negative outcomes vs. Specif ic for positive outcomes.

"Here =

If you have an off night, you assume that this reflects the reality about you in most situations. However, If you have a good conversation or a good time, you assume that it won't happen again in different social situations. 4. Uncontrollable for both. "I blew it" vs. "Cluel ess": If someone doesn't respond to you in the way you hope, you assume you blew it, or worse, you're a loser. If people do respond well to you , you "haven't a clue" what it is about you that makes it happen. 5 . Maladaptiv e Attribut ion: Any assignment of blameto your character orthe character of others that interferes with meeting your basic human needs for acceptance, social support, contribution, and emotional connection. 6 . Compensa tory Attribution: You take responsibility for everythingand everyone because you must avoid the disapproval or discomfort of others. You may think you are the only one who is willing to do what is necessary to solve problems. You do not trust others to be trustworthy or competent, particularly when it comes to your welfare. everywhere" vs. "Here = nowhere":

SELF-CONCEPT DISTORTIONS (SCD'S)

You reject positive feedback and successful behavior by insisting they "don't count" for some reason or other. In contrast, when you get negative feedback, you say, of course, that's how I am and/or have always been. 2. The Perfect Self vs. the Real Self: There is some idealized standard you must meet in order to be an acceptable person. You may be more tolerant of others than of yourself. When you 1. "It can't be me" vs. "That's just how I a m":



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do apply this idealized standard to others you may feel resentful or superior, and your behavior may be hostile or passive aggressive. 3. Shame-based Self- conce pt: Instead of focusing on anyparticular behavior or attitude you want to change, you attach alabel that implies basic inadequacy toyourself: "I'm a loser." When someone else's behavior disappoints or irritates you, you say he/she is a "jerk". 4. Malad apti ve Sel f-B eli ef: Any belief about your personality, your ability, or your character, that interferes with giving or reaching out for friendship and intimacy, or with pursuing your goals.

In spite of a modest exterior you see yourself as superior and entitled to special treatment. If the belief is unrecognized you don't think people accord you the respect and admiration you deserve. You may be aware that this belief isa compensation for an underlying belief that you are inferior. @ This material is copyrighted and may not be reproduced without permission of the author Lynne Henderson, Ph.D. 5. Compensatory Sel f-B eli ef:



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Fig. 6. Reversal of the Self-enhancement Bias SUCCESS

SHYS

OTHERS

No credit

FAILURE

Credit

External

Internal

Unstable

Stable

Specific

Global

Uncontrollable

Uncontrollable

Credit

No credit

Internal

External

Stable

Unstable

Global

Specific

Controllable

Uncontrollable



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Figure 7. CHALLENGES To Negative Attributions and Beliefs About the Self

Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? Am I 100% sure that I have the sole responsibility for ___________? What evidence do I have that I am the cause of _______? What evidence do I have that _________________________? What evidence do I have that I am _________________________? What evidence do I have that I cannot change ________________? Does ___________________ have to equal or lead to _________________? Is my whole personality or basic character involved in __________? Could there be other explanations? What is the likelihood that __________________? What is the likelihood that I have no control over __________________? Is________________________ really so consequential or important? Does my opinion or _______________'s opinion reflect that of everyone else? Could there be a less harsh way of viewing my own behavior or that of others? Would I view a friend this way? If I see a social behavior that I want to change, does that mean I am inadequate, deficient, incapable of change? Does labeling myself improve my performance? Is _______________________ so important that my entire future resides with its outcome? Is this the only opportunity? Adapted from Sank and Shaffer (1984), Heimberg (1991), Henderson (1994).



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Figure 8. THE SHYNESS CLINIC Lynne Henderson, Ph.D. Director

Confidentiality Agreement for Confederates

Date ________________________

Any and all information discussed, reviewed in written or pictorial form, role-playing, and including but not limited to patients, confederates, and therapists shall remain within the confidences of this office andoffice exclusively Lynne Henderson, Ph.D., and/or any other therapist associated with the and thebetween confederate.

_____________________________

______________________________ Lynne Henderson, Ph.D.



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Figure 9. Shyness Clinic Self-Monitoring/At

tribution/Self-bel

ief Scale

Date/Situation Thoughts/Attributions/Self-beliefs Interference (0-100)



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Figure 10. Sample Automatic Thoughts, Attributions, and Beliefs Shyness Clinic

Before I can’t think of anything to say I’ll look like a fool I’ll feel ridiculous People will see I’m nervous and won’t want to talk to me Afterward They were just being nice This was easy because it is safe in here I don’t really have social skills - the other person just knew what questions to ask If they met me in real life they would not like me You (to the therapist) have to say good things and so does the confederate



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Table 1. SHY VS. NON-SHY COLLEGE STUDENTS; COLLEGE STUDENTS VS. CLINIC PATIENTS: ESTIMATIONS OF OTHERS SCALE (EOS)

COLLEGE STUDENT SAMPLE AND CLINIC SAMPLE N=144 _____________________________________________________________ S hy s

No n- s h ys

Stu den ts

N=44

N=64

N=136

_____________

Mean 2.7

_______________

2.1*

______________

2.3

Cl in ic S hy s

N=8 ____________

4.4***

SD1 .4 1.0 1.3 1.4 _____________________________________________________________ note. * p < .05, ** p < .01, *** p < .001. Internal consistency (Chronbach’s Alpha) .91 (N=138).



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Table 2. Average scores of Shyness Clinic Patients STATE TRAIT ANGER EXPRESSION INVENTORY (STAXI) SHYNESS CLINIC SAMPLE N=22

Experience

Suppression

Expression

Control

Mean 58 80 58 46 SD 29 22 27 28 ____________________________________________________________ note. Percentile Scores (Spielberger, 1996). Anger suppression is associated with higher systolic blood pressure (SBP) and diastolic blood pressure(DBP).



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Figure 11. CHALLENGES To Negative Attributions and Beliefs About the Other Lynne Henderson, Ph.D.

Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? Am I 100% sure that he/she has the sole responsibility for ___________? What evidence do I have that he/she is the cause of _______? What evidence do I have that _________________________? What evidence do I have that people are _________________________? What evidence do I have that others cannot change ________________? What evidence do I have that I cannot change even if others do not_______? Does ___________________ have to equal or lead to _________________? Is his/her whole personality or basic character involved in __________? Could there be other explanations? What is the likelihood that __________________? What is the likelihood that I have no control over __________________? Is________________________ really so consequential or important? Does my opinion or _______________'s opinion reflect that of everyone else? Could there be a less harsh way of viewing the behavior of others? Do I need to ruminate about the behavior of the other person? What is the likelihood that dwelling on his/her __________ willchange it? What is the likelihood that thinking about their negative behavior helps me change my own behavior__________________? Would I view a friend this way? If he/shedoes __________ , does that mean that he/she is callous, hostile, incapable of change? What is the likelihood that labeling others will improve my performance? Is my need to feel superior compensating for something? What? What is the likelihood that I mostly just want my own way_________? Do my fantasies of getting even help my mood? Is _______________________ so important that my entire future resides with its outcome? How important is it that I believe that I am right? How important is it to convince others that I am right? What is the likelihood that I will convince others through my self-righteousness? What will happen if I do not get my way? © 2001, The Shyness Institute; for details, see page 1.


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Is this the only opportunity for ___________?


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Figure 12.

Assertiveness Skills Practice Shyness Clinic Lynne Henderson, Ph.D.

Identify Skill: egs., asking someone for help, asking for directions, asking your room-mate to clean up a mess, asking someone to turn down loud music, saying no to a request for a favor or to borrow something, asking your boss for a raise, saying no to a coworker or boss

Visualize practicing:

Visualize problems that may arise and ways to cope:

Practice Skills:


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Praise Selves:


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Figure 13. Anger Management Practice Shyness Clinic Lynne Henderson, Ph.D.

Identify Skills: Planning: recognize the emotion of anger, resist jumping to conclusions, think about needs and wants, assess the risk of expressing the anger, assess the consequences of suppressing the anger, Confronting the other: describe the specific behavior of the other person, say what the feelings are in response to the behavior, if interpreting, say what the interpretation is, focus on the task, assess impact on the other person, think about ways that all participants can benefit from the encounter, acknowledge strengths of the other and of the relationship, if decide not to express, think of ways to transcend the situation, if withdrawal seems the only alternative, plan how that will be done.

Visualize practicing:

Visualize problems that may arise and ways to cope:


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Practice Skills:

Praise Selves:


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Figure 14. Shyness Clinic Treatment Evaluation Shyness Clinic Lynne Henderson, Ph.D.

On a scale of 1 to 10, how much did you meet your goal in treatment? ________ What behavior did you change? _____________________________________________________________ _____________________________________________________________ What thoughts did you change or modify? _____________________________________________________________ _____________________________________________________________ What belief about yourself did you change ormodify? What belief about others? _____________________________________________________________ _____________________________________________________________ How much? Self 1 to 10 __________ Others 1 to 10 __________________ What feelings are changed? _____________________________________________________________ _____________________________________________________________ How much has your SUDS level (0-100) come down in a situation that you were afraid of? ___________________________ What did you like about the treatment? _______________________________________________________________ _______________________________________________________________ What would you like to see improved or changed? _______________________________________________________________ @ This material is copyrighted and may notbe reproduced without permission



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Appendix A. Name__________________________________ Date _____________

BFNE

Read each of the following statements carefully and indicate how characteristic it is of you according to the following scale. Circle a number to indicate howcharacteristics the statement is of you: 1 = Not at all characteristic or true of me 2 = Slightly characteristic or true of me 3 = Moderately characteristic or true of me 4 = Very characteristic or true of me 5 = Extremely characteristic or true of me Not at All Slightly Moderately Very Extremely

1. I worry about what people will think of me even when I know it doesn't make any difference. 2. I am unconcerned even if I know people

3. 4. 5. 6. 7. 8. 9. 10. 11.

1

2

3

4

5

are me.forming an unfavorable impression of 1 2 I am frequently afraid of other people noticing my shortcomings. 1 2 3 4 I rarely worry about what kind of impression I am making on someone. 12345 I am afraid that others will not approve of me. 12345 Iamafraidthatpeoplewillfindfaultwithme. 1 2 3 4 5 Other people's opinions of me do not bother me. 1 2 3 4 5 When I am talking to someone, I worry about whattheymaybethinkingofme. 1 2 3 4 5 I am usually worried about what kind of impression make. I 1 2 3 4 5 If I know someone is judging me, ithaslittleeffectonme. 1 2 3 4 5 Sometimes I think I am too concerned with what otherpeoplethinkofme. 1 2 3 4 5 © 2001, The Shyness Institute; for details, see page 1.

3 5

4


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12. I often worry that I will say or do the wrong t hings.

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1

2


3

4

5


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Therapist and Client Measures of Evaluation Anxiety, Maladaptive Attributions, and Negative Emotion

The Brief Fear of Negative Evaluation Scale is completed by the client a few minutes prior to the first session (Leary 1983). Reliability and validity are good and with only 12 items,it just takes a few minutesto complete. The score provides an objective measure of theconcern about negative evaluation and can becompared with the general population. Items are scored from 1(not at all characteristic of me) to 5 (extremely characteristic ofme). Norms for the scale include college students and clinic samples. The mean rating for college students is 3.0 and the Shyness Clinic sample mean rating is4.0. The suggested clinical cutoff is3.5. The client fills out the questionnaire a second time at the end of treatment to demonstrate how evaluation concern is reduced with more adaptive thinking patterns and reduced avoidance of feared situations.



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Name__________________________________ Date _____________

BFNE Read each of the following statements carefully and indicate how characteristic it is of you according to the following scale. Circle a number to indicate howcharacteristics the statement is of you: 1 = Not at all characteristic or true of me

2 = Slightly characteristic or true of me 3 = Moderately characteristic or true of me 4 = Very characteristic or true of me 5 = Extremely characteristic or true of me Not at All Slightly Moderately Very Extremely

1. I worry about what people will think of me even when I know it doesn't make any difference. 1 2 3 4 5 2. I am unconcerned even if I know people are forming an unfavorable impression of me. 1 2 3 4 5 3. I am frequently afraid of other people noticing my shortcomings. 1 2 3 4 4. I rarely worry about what kind of impression I am making on someone. 12345 5. I am afraid that others will not approve of me. 12345 6. Iamafraidthatpeoplewillfindfaultwithme. 1 2 3 4 5 7. Other people's opinions of me do not bother me. 1 2 3 4 5 8. When I am talking to someone, I worry about whattheymaybethinkingofme. 1 2 3 4 5 9. I am usually worried about what kind of impression make. I 1 2 3 4 5 10. If I know someone is judging me, ithaslittleeffectonme. 1 2 11. Sometimes I think I am too concerned with what otherpeoplethinkofme. 1 2 12. I often worry that I will say or do the wrong t hings.

3

4 3

1

5

5 4

2


5 3

4

5


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Measures of Maladaptive Attributions and Depression The Shyness Attribution Questionnaire is administered by the therapist using the most difficult three situations from theclient’s hierarchy (Henderson, Martinez et al.1996). A copy is included in Session Two. The client is asked to imagine the anxiety producing situation andto assume that it does not go well,that the outcome is negative. The client is asked to indicate the cause of the negative outcome and to rate it on nine-point scales which measure the degree to which

the client’s attributions are internal,stable, global, controllable, andself-blaming. Four items indicating the degree of shame that would accompany the negative outcome are rated on a scale of 0-4. This scale is also administered atthe end of treatment to measure reductions in maladaptive attributions and accompanying shame. The therapist can show theclient how negative attributions about the self are aspects of the negative thinking patterns in shyness and how these patterns sabotage progress and undermine motivation. The client is told that challenging ht ese patterns will be part of the work of therapy. The client also completes the Estimations of Others Scale (EOS) (Henderson and Horowitz 1998). This scale measures the extentto which shy and socially phobic clients endorse negative thoughts about others. Negative thoughts about othersindicate the tendency tomistrust others which interferes with formingrelationships. They are also associated with a tendency to blame others. items a 7topoint scale from from 1 (not atall) to 4 (moderately) to 7 (very much). Clients Alphas rate range fromon.89 .91 (Henderson and Zimbardo 1998). Shy college students score significantly higher than non-shy college students and clinic clients score significantly higher than college students.Mean item scores of clinicclients are shown in Appendix xx. The mean overall score forclinic clients is 4.6 and the standard deviation is 1.2. The mean overall score for a college student sample (N=144) is 2.4 and the standard deviation is 1.4. Scores on this questionnaire are correlated significantly with resentment, shame, and shyness. High scores on this scale means that the therapist will need to address the tendency to blame others andto pay particular attention ot passive aggressive tendencies. Clients may think others believe they are inadequate when in fact others react negatively to interpersonal messages that suggest suspiciousness and thetendency to blame others. The tendency to externalize blame and shame both predict work interference on the MMPI (Henderson & Zimbardo, 1998), which logically follows because work life usually requires cooperative behavior and a trusting orientation to collaborate effectively. Additionally, among high schoolstudents blaming others isthe only significant negative predictor of perspective takingt (2, 137) = 2.79, p. < .01) and empathic concern t (2, 137) = 4.29, p. < .0001 (Henderson & Zimbardo, 1998).



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It is important to explore with the client early relationships in which emotional or physical abuse took place. Because these reactions are understandable when early abuse took place, the therapist can help the client explore ways to hypothesis test in relation to these beliefs.



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Estimations of Others Scale (EOS) Lynne Henderson and Leonard Horowitz (1998) Stanford University

To what extent do yourelate to each of these statements? Please make a rating on a7 point scale from 1 (not at all) to 4 (moderately) to 7 (very much). 1. ___If I let people know too much about me they will say hurtful things to me, or talk about me behind my back to others. 2. ___People will make fun of me and ridicule me. 3. ___People are indifferent to my feelings and don't want to know about me. 4. ___If people see my discomfort they will feel contempt for me. 5. ___People are more powerful than I am and will take advantage of me. 6. ___I must not let people know too much about me because they will misuse the information. 7. ___If I'm not watchful and careful, people will take advantage of me. 8. ___People do not relate to my problems. 9. ___People will be rejecting and hurtful if Ilet them close to me. 10. ___People do not identify with me when I am uncomfortable. 11.___When people see my discomfort they feel superior. 12.___People do not care about me. Henderson, L., & Horowitz, L. M. (1998). The Estimations of Others Scale (EOS) : Stanford University.



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It is useful to have the client fill out a self-report questionnaire regarding depressive symptoms at the beginning and end oftreatment. The Beck Depression Inventory (BDI) is a21item questionnaire which is copyrighted, but may be purchased. The average BDI score for Shyness Clinic clientsis 13. Many clients willscore much higher. It is important to recognize the cases in which dysthymia is present because it indicates a tendency toward greater passivity and pessimism. It also suggests more entrenched negative beliefs about the self. Extreme depression will interfere withthe client’s willingness toenter feared situations and willdisrupt treatment. In this case the depression should be addressed before shyness treatment is undertaken. Weekly Measure of Client Symptoms and Perceptions of Therapist Helpfulness and Understanding The client will also fill out the Between-Session Shyness Questionnaire prior to each session. This questionnaire provides information about thedegree of negative emotionand avoidant behavior that occurs between sessions. This form also provides a measure of progress and therapist understanding from the previous session, which may be discussed in the current session. Items are rated on ascale of 1 (not at all) to 7 (very). Items related to resentment and passive aggressive behavior are also included, which allows the therapist to track the degree to which with cognitive and attributional retraining during the session is adequately addressing

thoughts about others. For example, if a client says they avoided asserting themselves and also rated resentfulness highly, the therapist can inquire about negative thoughts and beliefs about others that may be countered by behavioral experimentation as well as challenging negative thought patterns. As mentioned previously, clients frequently demonstrate negativework attitudes that interfere with on-the-job performance (Henderson and Zimbardo 1998)

Measure of Behavioral Performance Current behavior in a feared situation is assessed using a BAT (behavior performance/assessment test), which consists of a brief role-play or impromptu speech, usually

video-taped, and includes a smallaudience. SUDS (subjective anxiety from 0to 100) levels are usually assessed at intervals prior to theBAT for baseline and anticipatory levels, during, and immediately afterward. Thought-listing forms may alsobe used to record negative thoughts that occur during the BAT (Cacioppo, Glass & Merluzzi, 1970; Heimberg, 1991). See Appendix C. for a sample of a thought-listing form.



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Hierarchy of Feared Situations A hierarchy of ten feared situations is constructed with the client to role-play in simulated exposures in the group sessions and to practice in-vivo during self-assigned behavioral homework between sessions. Clients can be given copies of these hierarchies to guide their practice, and to revise as goals are met or changed. Limitations of Treatment

Clients seldom leave treatment with no symptoms or no remaining behavior or cognitive problems. Stress and change cause the old difficulties to flare up again. The reason the Social Fitness Model was developed was to help clients cope with this reality and to understand that social fitness, like physical fitness, takes ongoing practice and occasional coaching. People don’t become profession tennis players after one set of tennis lessons. Helping clients understand that social fitness is an ongoing process with ongoing workouts is a major change in the way they view their difficulties and helps them begin to develop real self efficacy, which is related to discipline and persistence. It also helps them understand that noticing thecues that suggest theyare regressing (such as withdrawal, increased tension, social alienation, and lack of ongoing goal setting and challenges to negative thinking patterns) allows them to get more coaching if they need it. They may also be ableto get themselves back on track bygetting out their notebooks, reviewing their notes, and rtacking their homework systematically again. Social fitness training is not a cure, it is a way of life.

*COPY OF LETTER REFERRED TO IN SESSION 10 Shyness Clinic Letter to Friends Zimbardo and Henderson

Dear

Thank you for taking the what time helps torespond to this Weand are what interested in assessing do at the Shyness Clinic, people wholetter. feel shy, doesn't. Your helpthe in work this we evaluation process is deeply appreciated and will help further our work with shyness. How often do you interact with _________________?



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How would you describe your relationship with her/him?

Have you noticed any change in her/his behavior in the last _____ months? Yes No (circle one) If no, how would you describe this person socially, intellectually, emotionally or in any way you think relevant?

If yes, could you be as specific as possible in listing changes?

What does she/he do now that she/he didn't do before?

What doesn't she/he do that she/he used to?

What does she/he do differently?



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Overall, how much would you say she/he has changed in the last 6 months?

all not at

1___2___3___4___5___6___7___8___9___10___ very much

__________________________________________________ -4 -3 -2 -1 0 +1 +2 +3 +4 worse no change better

Do we have your permission to share this information with ______? Yes No (circle one) If no, your confidentiality will be respected.

Many thanks for your cooperation,

Lynne Henderson, Ph.D. Director

*INSTRUCTIONS FOR BAT AND THOUGHT-LISTING FORM Behavioral Assessment Test (BAT) Therapist Instructions Shyness Clinic



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Give the behavioral assignment to the client (five minute talk, conversation with a confederate, asking confederate for a date, etc.). Tell the client thatyou will give him/her three minutes to prepare. Ask for the SUDS level (0 - 100). Write it down. Write the client’s name on the insert in the video tape with thedate and whether the BAT ispre- or post- treatment. Turn on the camera (video-tape recorder). At the end of three minutes tell the client to begin and ask again for the SUDS level. Write it down. At the end of the exercise ask the client again forthe SUDS level and write it down. Give the client the Thought Listing Form andread the instructions to him/her. Then say, “just include anything that came into your head before, during, and after the exercise.” Turn off the camera. SUDS at anticipation phase ___________ SUDS at start of exercise _____________ SUDS at end of exercise ______________

THOUGHT LISTING FORM THAT ACCOMPANIES THE BAT: Thought Listing Form Shyness Clinic Please write down anythoughts you had during thebehavioral task. They may be statements like “I won’t be able to think of anything to say. I’ll look foolish. They will think I’m an idiot. What

I’m saying doesn’t make sense. I look awkward” Try to include thoughts you had before the exercise, during the exercise, and afterward. ______________________________________________________________________________ __________________________________________________________________



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______________________________________________________________________________ __________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________ ______________________________________________________________________________ __________________________________________________________________



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Appendix D. Vicious Cycles

Figure 2.

Vicious cycle #1, Anxiety and Escape •Subj ective anxiety (SUDS, Subj ective Uni ts of Di stress fr om 0 to 100) leads to negative automatic thoughts, which lead to increased SUDS, which leads to behavioral avoidance, whi ch leads to incr eased anxiety in next situation .

Vicious Cycle #2, Self-blame and Shame •Self-blame for social failure produces shame, shame in turn produces mor e self -bl ame. •Vicious cycle leads to increased vulnerability when enter the next social situation.

Vicious Cycle #3, Other-blame and Anger •Shame is a painful affective state which is reduced by blaming others who are seen as more powe rf ul and u ntr ustworthy. •Other-blaming attributions lead to negative beliefs about others, in terf eri ng with op en-min ded hyp othesis-testin g and for ming and sustaining relationships. Role of Private Self-consciousness

•Pr ivate self -consciousness leads to seein g the self as others do, i n general. •H owever, du ri ng n egative emotional states li ke fear, shame, or anger, pr ivate self -consciousness contri butes to cogni tive and p erceptual distorti ons about on e's behavior and o thers' reactions. •

Perceptual distortions are due to increased awareness of internal emotions and negative thoughts.



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Self-concept Distortions and Distortions about Others

•Self -blamin g and other-blamin g attri buti ons may lea d to negative beliefs about the self and others. These beliefs organize in for mation. In creased articul ation of b iases in the self -concept and biases abou t others occurs. •

Negative beliefs operate outside awareness, so successful goal completion

is di scoun ted, as is pr ogress toward lon g-term goals.

Fight/Flight

Shame/self-blame Anger/other-blame

fear

shame

anger

automatic

self-blame

other-blame

thoughts Approach

Avoidance

Aggression

Private self-consciousness increases awareness of negative emotions and thou ghts, leadin g to perceptual distorti ons in social situations. The result is alienation from self and others. From Social Fitness Training Manual Copyr ight @ 1994 by Lynne Henderson, Ph.D., a psychological corpor ation, In c. Al l ri ghts reserved. No part of t his publi cation may be reprod uced, stored i n a retrieva l system or transmitte d in any for m by any means, electron ic, mechanical, photocopyi ng, record in g, or oth erwise, withou t th e pr ior written p ermission of Lyn ne Henderson, P h.D.



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Appendix E. SAQ (Shyness Attribution Questionnaire) Lynne Henderson, Ph.D.

Rating the Reasons for Success and Failure We are going to list the three most challenging situations on your hierarchy with different possible explanations for anegative outcome (failure) ofeach situation. For each situation, imagine yourself in that situation,and tell me the one major cause of thatnegative outcome. Rate the cause you have stated on each of the next five causal dimensions. Rate how much, in your experience, this item is relevant toyour stated cause. We will use the following rating scale to make your judgment: Rate the cause 123456789

little

much

Tell me the number that indicates how much you feel that cause is described by this item (causal diminsion). There is no right or wrong answer, of course, so do not spend a lot of time making your judgments; the important thing is your first impression.



1.

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Therapist says, “Imagine that you are ___________(most challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789





The degree to which the cause indicates that you are worthy of blame. Therapist says: “Now listen to eac h feeling carefully and decide to what extent you would be experienci ng the feeling. Make your choice according to this scale: …0 = not at all, 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items).

0

0

0

0

0

1234

1.

embarrassment

2.


3.


4.


5.


1234

1234

1234

1234



1.

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Therapist says, “Imagine that you are ___________(second challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789


The degree to which the cause is relevant to many different situations, rather than being specific to a few situations.

123456789



The degree to which the cause indicates that you are worthy of blame.

Therapist says: “Now listen to eac h feeling carefully and decide to what extent you would be experienci ng the feeling. Make your choice according to this scale: …0 = not at all, 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items).

0

0

0

0

0

1234

1.

embarrassment

2.


3.


4.


5.


1234

1234

1234

1234



1.

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Therapist says, “Imagine that you are ___________(third challenging situation). Imagine that it doesn’t go as well as you had hoped or just imagine that the outcome is negative.” The cause of this outcome is

.

123456789





The degree to which the cause indicates that you are worthy of blame. Therapist says: “Now listen to eac h feeling carefully and decide to what extent you would be experienci ng the feeling. Make your choice according to this scale: …0 = not at all, 1 = somewhat, 2 = moderately, 3 = very much, 4 = intensely. How much ______ would you feel? (for all 5 items).

0

0

0

0

0

1234

1.

embarrassment

2.


3.


4.


5.


1234

1234

1234

1234



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Appendix F.

Name____________________________ Pt. ID#___________________________ Date______________________ SHYNESS CLINIC THOUGHT LISTING FORM

In the boxes below, please write down as many thoughts as you can recall having while involved in the interaction orspeaking situation just completed. Examples of thoughts a person may have include: "I'm not making a good impression" "They probably won't like me" "I know I'm going to panic" "I'm all alone" "There is no reason for me to be upset like this" "I think they like me" "I feel like..." Remember, these are only examples. Please write whatever you were thinking. Please be completely honest and rememberthat your responses willremain confidential. Don't spend too much time on any one thought in each box. Please try to remember as many thoughts as possible. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ © 2001, The Shyness Institute; for details, see page 1.


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________________________________________________________________________ ______________________________________________________________________________ ____________________________________________________



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Appendix A. Estimations of Others Scale (EOS) 1998 Clinic Sample Mean scores

To what extent do you relate to each of these statements?Please make a rating on a 7 point scale from 1 (not at all) to 4 (moderately) to 7 (very much). N=8

1. 4 . 1 3 People do not care about me. 2. 4 . 0 0 When people see my discomfort they feel superior. 3. 4 . 0 0 People do not identify with me when I am uncomfortable. 4. 4 . 3 8 People will be rejecting and hurtful if I let them close to me. 5. 4 . 1 3 People do not relate to my problems. 6. 4 . 1 3 If I'm not watchful and careful, people will take advantage of me. 7. 4 . 6 3 I must not let people know too much about me because they will misuse the information. 8. 4 . 7 5 People are more powerful than I am and will take advantage of me. 9. 5 . 3 8 If people see my discomfort they will feel contempt for me. 10. 5 . 1 3 People are indifferent to my feelings and don't want to know about me. 11. 5. 0 0 People will make fun of me and ridicule me. 12. 5 . 0 0 If I let people know too much about me they will say hurtful things to talk about me behind my back to others. _____________________________________________________________________ © 2001, The Shyness Institute; for details, see page 1.

me, or


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note. (Chronbach’s Alpha, .91; N=138). Henderson, L., & Horowitz, L. M. (1998). The

Estimations of Others Scale (EOS) : Stanford University.



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Estimations of Others Scale

To what extent do yourelate to each of these statements? Please make a rating on a7 point scale from 1 (not at all) to 4 (moderately) to 7 (very much). Shy

Non-shy

N=15

27

3.6

2.5

3.0

2.2

College Students

1. ___People do not care about me. 2. x __When people see my discomfort they feel superior.

2.2 3. x __People do not identify with me when I am uncomfortable. 3.5 2.3 4. x __People will be rejecting and hurtful if I let them close to me. 5. X __People do not relate to my problems. 3.3 1.6 3.9 2.4 6. X __If I'm not watchful and careful, people will take advantage of me. 7. X __I must not let people know too much about me 4.6 2.1 because they will misuse the information. 8. X __People are more powerful than I am and will take 3.5 1.5 advantage of me. 3.2 1.8 9. X _If people see my discomfort they will feel contempt for me. 3.0 2.1 10. x __People are indifferent to my feelings and don't want to know about me. 11. X __People will make fun of me and ridicule me. 2.9 1.7 2.8 1.9 12. ___If I let people know too much about me they will say hurtful things to me, or talk about me behind my back to others. ___________________________________________________ note. x , p. < .05; X , p. < .01. Alpha .89. Henderson, L., & Horowitz, L. M. (1998). The Estimations of Others Scale (EOS) : Stanford University. 3.2



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Appendix H. THE SHYNESS CLINIC

Lynne Henderson, Ph. D., Director Final Interview Outline

Instructions for Therapists: 1. Talk about specific goals forthe future and plans tomeet them. Record 3 specific goals for the next six months:____________________________________________ 2. What should they do if they get off track? (egs., review cognitive/attributional distortions and challenge negative thinking; write down challenges and rational responses; call someonewith whom they can strategize about behavioral goals or get help with negative thoughts and feelings; review their hierarchies, specify specific goals and write down situations in which to practice; schedule a booster session). 3. Discuss possible psychoeducational opportunities, such as community college classes for communication skill building or public speaking, and Toastmasters. For unmarried clients, discuss local singles groups such as Meeting for Good and the Sierra Singles club as places to continue to practice meeting people. Include gay and lesbian groups. Make a list they can take home. 4. Administer the Shyness Attribution Questionnaire (SAQ) and comparet iwith the one they filled out during the first session. Discuss how they changed their attributions when they did change them. If they did not change their negative attributions in agiven situation, discuss how they can continue to challenge them and what adaptive responses they can use. 5. Social Phobia (Doespatient still meet criteria? Rate the degree of anxiety and avoidance experienced in each situation: conversations, small groups, dating, speaking to authority figures, parties) 7. Administer the BAT and have the client fill out the Thought Listing Formafterward. Point out to them the changes they have made, such as fewer negative thoughts, and more positive or neutral thoughts.



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Shyness Clinic Letter to Friends Zimbardo and Henderson

Dear Thank you for taking the time torespond to this letter. We are interested in assessing the work we do at the Shyness Clinic, what helps people who feel shy, and what doesn't. Your help in this evaluation process is deeply appreciated and will help further our work with shyness. How often do you interact with _________________? How would you describe your relationship with her/him?

Have you noticed any change in her/his behavior in the last _____ months? Yes No (circle one) If no, how would you describe this person socially, intellectually, emotionally or in any way you think relevant?

If yes, could you be as specific as possible in listing changes?

What does she/he do now that she/he didn't do before?



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What doesn't she/he do that she/he used to?

What does she/he do differently?

Overall, how much would you say she/he has changed in the last 6 months?

all not at

1___2___3___4___5___6___7___8___9___10___ very much

__________________________________________________ -4 -3 -2 -1 0 +1 +2 +3 +4 worse no change better

Do we have your permission to share this information with ______? Yes No (circle one) If no, your confidentiality will be respected. Many thanks for your cooperation, Lynne Henderson, Ph.D. Director References



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Anderson, C. A., & Arnoult, L. H. (1985). Attributional style and everyday problems in living: Depression, loneliness, and shyness. Social Cognition, 3, 16-35. Bandura, A. (1997). Self-efficacy, the exercise of control. New York: W.H. Freeman. Bartholomew, K., & Horowitz, L. M. (1991). Attachment styles among young adults: A test of a model. J of Pers & Soc Psy, 61 , 226-244. Davis, M. H., & Franzoi, S. L. (1986). Adolescent Loneliness, Self-Disclosure, and Private Self-Consciousness: A Longitudinal Investigation. Journal of Personality and Social Psychology, 51 (3), 595-608. Gabor, D. (1983). How to Start a Conversation and Make Friends. New York: Fireside Books. Henderson, L. (1992). Self-blame and Shame in Shyness. Dissertation Abstracts International, 53(60B), 3198. Henderson, L. (1997). MMPI Profiles of Shyness in Clinic Patients. Psychological Reports, 80 , 695-702. Henderson, L., & Horowitz, L. (1999). Vulnerability and empathic failure: Painful sides of a priceless coin. Manuscript in preparation. Henderson, L., & Horowitz, L. M. (1998). The Estimations of Others Scale (EOS) : Stanford University. Henderson, L., & Zimbardo, P. (1998, August, ). Trouble in river city: shame and anger in chronic shyness. Paper presented at the American Psychological Association, 106th National Conference, San Francisco, CA. Horowitz, L. M., Krasnoperova, E. N., Tatar, D. G., Person, E. A., Hansen, M. B., Galvin, K. L., & Nelson, K. L. (1998). The way to console depends on the goal. . Johnson, D. (1997). Reaching Out: Interpersonal Effectivenessand Self-Actualization. (sixth ed.). Englewood Cliffs, New Jersey: Prentice Hall. Leary, M., & Kowalski, R. (1995). Social Anxiety. New York: The Guilford Press. Markus, H. R., & Kitayama, S. (1991). Culture and the self: Implications for cognition, emotion, and motivation. Psychological Review, 98(2), 224-253. Spielberger, C. D. (1979). State-trait Anger Expression Inventory (STAXI), . Odessa, Florida: Psychological Assessment Resources, Inc. Feske, U. and D. L. Chambless (1995). “Cognitive behavioral versus exposure only treatment for social phobia: A meta analysis.” Behavior Therapy 2 6 : 695-720. Heimberg, R. G., M. Liebowitz, et al., Eds. (1995). Social phobia: Diagnosis, assessment and treatment. New York, Guilford Press.



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Heimberg, R. G., D. G. Salzman, et al. (1993). “Cognitive-Behavioral Group Treatment for Social Phobia: Effectiveness at Five-Year Followup.” Cognitive Therapy and Research 1 7 (4): 325-339. Henderson, L. and L. M. Horowitz (1998). The Estimations of Others Scale (EOS), Stanford University. Henderson, L., A. Martinez, et al. (1996). Shyness Attribution Questionnaire. Stanford, CA, Shyness Institute. Henderson, L. and P. Zimbardo (1998). Trouble in river city: shame and anger in chronic shyness . American Psychological Association, 106th National Conference, San Francisco, CA. Leary, M. (1983). “A brief version of the fear of negative evaluation scale.” Personality and Social Psychology Bulletin 9 (3): 371-375.



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Chapter : Session 1- Group Therapy SESSION ONE FOR GROUP THERAPY Patients experience considerable apprehension before the firstgroup meeting. It is important to be aware of their fears and to invite them to share them early on, perhaps describing one's own apprehension, setting an example of open participation early in the life of the group. Therapists may be ready to carry more of the discussion the first time, but also be ready to allow and encourage group participation, the key to the success of this type of group. Areas to cover during the first meeting: 1. Introductions 2. Basic rules of the group 3. Discussion of individual goals and problem areas, including what prompted each person to join a group at this time 4. Discussion of the Social Fitness treatment model 5. Developing the attribution retraining, self-concept restructuring model,including a discussion of the moderating effect of self-focus. 6. Assessment of Expectancies for TreatmentOutcome [Heimberg, 1991 #1712] 7. Training in the model We have adopted Heimberg’s practice of administering the Beck Depression Inventory (BDI) at the beginning of each session in order to know which patients may be needing extra attention and support that week[Beck, 1961 #1715 ][ Heimberg, 1991 #1716]. The BDI's are left on a table for group members to fill out as they come into the group room. Materials for the first session are as follows: 1. BDIs and pencils 2. Group Confidentiality Contract 3. Copies of the Reaction to Treatment Questionnaire 4. Self-monitoring logs for attributions and beliefs related to the self. 5. Audiocassette (for supervision andgroup feedback) 6. Camcorder for Recorder recording&a 90 fiveminute minutetape interaction among the members for baseline behavioral data Therapists start by introducing themselves, with name, internship status, degree, and a couple of things about themselves, like a hobby or interest, and ask the group



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members to do the same, including their major, or field of interest if they are graduate students. It may be difficult for some to able to say anything, and if that is the case a therapist may introduce the patient to the group, prompting with something like, "I thought I heard you say you liked to play soccer on week-ends". Therapists use the names of the members frequently so the group members learn them and begin to use them with each other. It may also provide a model for simply acknowledging being unable toremember someone's name on first meeting. One of the therapists then goes to the flip chart and writes the acronym, SOFTEN, which signifies the nonverbal aspects of a receptivity to social interaction which is useful when meeting new people. The therapist explains that 70%of communication is considered to be nonverbal. Smile, open posture, forward lean, touch, eye-contact and nod are explained with examples and group members are asked to think of examples as well. The therapist furtherdescribes how communication progresses from commentsand questions about the immediate environment (in this case the campus community), the wider culture (the San Francisco Bay Area), current events, facts about the self, hobbies and interests, values, goals and aspirations, opinions, attitudes, and finally to feelings. During initial meetings people often progress to facts about the self, and interests, often looking for common interests, but there is a wide range of possibilities. Comments and thoughts about how much they usually disclose are solicited from the group. After the discussion students are asked to find one person in the group and to talk to them for five minutes using these non-verbal behaviors. Group members are told that the goal of this exercise is simply to practice the nonverbal behaviors involved in expressing interest in social interaction, and perhaps to find out a couple of things about each other. When students have completed the exercise (if it appears lively we may let it go for ten minutes), therapists ask them what the experience was like, and group members are usually able to comment on how uncomfortable they felt at first, but how reassuring it was to find that it was less difficult than itappeared. This is done particularly for the student groups because we have found that they are more motivated if they have early contact with at least one other person in the group. If group members are willing, we have them practice making contact by calling two people per week in the group to talk for just a few minutes about homework. This exercise also brings automatic attributions andbeliefs about the self into awareness and makes them more accessible during the discussion.



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discuss attribution style, the self-enhancement bias, development of a negative bias in the self-concept due to self-blame and shame, and the moderating role of self-consciousness. Developing the model:

Therapists begin by covering the basic components of shyness/social phobia, describing social anxiety as a learned response involving behavioral, physiological, cognitive, and affective elements. T1 "The first aspect of shyness/social anxiety we will discuss is the fact that it is a learned response, a learned habit in response to social events that may have led to painful experiences in the process of growing up, or in response to the behavior or attitudes of important people in one's life. Habits can be changed and replaced with other habitsthat are more self-supportive and self-enhancing. Who can think of a time when you first noticed you felt shy or anxious in a social situation? What was your response to that situation? Now think of the current situation you findmost difficult and whatdo you notice about your reactions, what is your experience like?" At this point the other therapist can start writing on the flip chart, putting the various responses into the four separate categories. T1 "Do you notice as we write these responses on the board that they arefalling into categories? Behavioral, physiological, cognitive (orthinking) patterns, andemotional responses. The first we'll discuss is behavioral. (Therapist 2 underlines behavioral responses) The behavior you may notice is under-activity, that is, inhibition and/or avoidance, either the avoidance of particular situations or a more subtle kind of avoidance where you sort of "drop out" during group situations. Another form of behavior is overactivity, often seen in "shy extroverts", first described by Philip Zimbardo, where you find yourself "performing", enacting what you think are appropriate social responses rather than just being yourself. Anyone experience that?" "The second category involves physiological arousal. Your heart races, your hands feel clammy, you may begin to sweat, you may feel shaky from the adrenaline rush. Physiological arousal is an adaptive evolutionary response to danger, part of the response of the sympathetic nervous system which prepares the body for flight or flight. Only now, social anxiety may be an overestimation of danger. It has been adaptive, and still is,to fear predators and more dominant creatures; animals signal submission to adominant leader in © 2001, The Shyness Institute; for details, see page 1.


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order to remain in the group. It is just that learned shyness may lead you to signal submission in situations where you don't need to, where you are overestimating the power and/or distorting the intentionsof others and underestimating yourself. If you are uncomfortably aroused physiologically, and feeling fearful, your brain registers danger which may trigger flight,either behaviorally or mentally. This flight reduces your anxiety, which reinforces the avoidance of social situations. This leads to a vicious circle in which you do not "desensitize" or habituate to the social situation and to your own arousal, which will naturally come down. This physiological arousal we call your SUDS level, your subjective units of distress scale. It is measured on a scale from zero to 100, from relaxed as a wet noodle to freaked out of your mind! I'm making this sound funny, but of course it isn't when I'm actually experiencing it, and I imagine it isn't for you either. It's unpleasant and painful. However, the whole experience gets to be a little more humorous as we go along and play with it a bit." "The third category is thinking patternsor cognitions; that is, the way we think about ourselves in social interactions. You may notice thatthere are a number ofwhat we call maladaptive thoughts up there, such as 'she's going to notice how nervous I am, they will see I'm blushing, I must look like an idiot, he seems so much more sure of himself', etc., etc. There are many cognitions that are irrational and maladaptive inthe sense that they are not useful in the situation. The question is not whether they are true or false, but whether or not they are useful. Imagine now that your best friend were feeling nervous in a social situation. Would you say those things to that person? Probably not, you would probably focus more on statements that would be more rational as well as more helpful, such as, 'you got yourself here in the first place, in spite of the fact that you were nervous; anyone would be nervous in this situation, you just met these people!' Shyness and social anxiety or social phobia may be largely related to the way we treat ourselves in social situations. In fact, the research shows that when we label ourselves as shy we probably are not actually experiencing anything that others don't experience, but it may be the way we interpret our reactions and perceive ourselves that is the real issue. “The fourth category is emotion, and it ties into the others to make a vicious cycle that can keep repeating itself. Let me explain. If you are already feeling fear ina situation, which is not uncommon in new situations, and you say these things we've just mentioned to yourself , such as "This is ridiculous, others don't seem so nervous, what is the matter with me?" the emotion you are likely to trigger is the emotion of embarrassment, or in more painful cases, shame. Shame is a painful emotion that tends to wash over you and saps © 2001, The Shyness Institute; for details, see page 1.


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your energy; it actually involves the parasympathetic nervous system rather thanthe sympathetic nervous system, which controls the so-called fight or flight response. Following the mobilization involved in the fear response, shame triggers a sense of fatigue, or physical weakness, a letting down involved in the conservation of resources by the parasympathetic system. Shame can be experienced as a wish to hide, a sense of pulling into yourself, wanting to sink through the floor, feeling powerless among powerful others. This feeling reinforces the tendency to avoid or leave the situation, and reinforces the sense that you will not be able to master your own responses and be competent in the situation. “Let's summarize. You go into a situation. You feel fear. Your physiological arousal level becomes uncomfortable, this triggers negative automatic self-talk that you have learned in thesesituations; then you experience theurge to leave and/oryou experience a sense of helplessness, hopelessness, or feeling of inadequacy. You may find yourself leaving in a negative emotional state, but without awareness of the thoughts that triggered it, and you may never have recognized the emotional state as shame, or a bad feeling about the self. The behavioral withdrawal may trigger moreshame which may trigger more negative automatic self-talk which may trigger more behavioral avoidance and more fear and more physiological discomfort which may trigger more negative self-talk and more shame and more avoidance, etc., etc. Cognition- "That person didn't respond when I said hello, what's

wrong?"

Physiological discomfort - ^SUDS - hands become clammy, heart pounds, shaky feeling. Negative self-talk - "I must look ridiculous, why can't I control this? I don't belong, I'm a loser. Avoidance - Leaves. Shame - "Why can't I get a handle on this. I'll never make friends. There's something wrong with me. This is harder for me than other people. I must be inadequate." Therapists may use situations from their own lives or ask for examples from the group. Group members often start to laugh when they recognize their own words coming from others. There is relief in discussing embarrassment and/or shame openly.



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"All four elements are important and need to be dealt with to change your behavior as they all interact, forming the vicious circle that leads to avoidance and demoralization. Therefore each one is treated. We'll use role-plays in the group and you will do behavioral homework to deal with the physiological and behavioral elements. These role plays are called EXPOSURES when actual situations are simulated in the group, and IN VIVO outside the group inyour daily lives. Deliberately exposing yourself to thefeared situations whether in simulated situations inthe group where you arepracticing with real people and real feelings, or in actual situations outside the group, will bring your SUDS level down and decrease the avoidance which maintains the fear and prevents new learning from occurring. The new learning involves finding outthat social situations are notso dangerous or life threatening, nor are they as black and white as we fear. They may not be ideal, but they are not disastrous either. For an exposure to be effective, you must stay in a situation, without escaping, until you meet your specific goal, such as having a four minute conversation, or approaching a group and participating in the conversation for five minutes. For this group to be effective, you must stick with it, which means participating and doing your behavioral homework, including using no drugs or alcohol to dull your awareness. We will do this in a gradual way rather than throwing you into your most feared situation so you have a chance toget a handle on the process. Remember you are going for long term gain here. Social fitness is like physical fitness. You must work out to get in shape and to find exercise pleasurable, and you must continue to work out to stay in shape. Few of us may be world class social athletes but most of us can be socially fit, enjoy our social exercise and feel a good sense of emotional health and well-being. For the cognitive aspect, which takes the form of automatic thoughts, attributions, and beliefs, and for the emotional component which is the fear, embarrassment and/or shame, we will work with cognitive restructuring, and what we call attribution style. People who are socially anxious make particular kinds of logical errors in their thinking about social situations, other people, and themselves. Social situations are seen as dangerous and other people are seen as powerful critics. Furthermore, how we attribute responsibility for social situations that do not have the outcome we want is critically important toshyness and social phobia. The average person demonstrates what is called a self-enhancement bias: when failure occurs, he or she is likely to attribute the failure to external circumstances or other people, to temporary factors such as fatigue or lack of effort, specific factors such as the difficulty of a task, or to a specific internal state like overwork, that is, to factors over which he or she had no control. For example, in a situation where a person didn't get the phone number of a © 2001, The Shyness Institute; for details, see page 1.


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person approached at a party, or didn't get a raise at work, the attributions would go like this: "Oh well, the party was abit formal and there wasn't much time tolet the person get to know me. I was also a bit tired and it is difficult to ask for a phone number when you've just met someone. I will make more effort next time. I'm glad I started and maintained the conversation with her, though. She may be at the next get-together and I can continue where we left off." or "I'm disappointed I didn't get the raise I asked for, but I'm glad I made the effort. My boss didn't seem to know how much work I had done on our current project or that Ihad participated so much inmoving the job forward. That tells me I must let him know more about what I am actually doing for the company to help us all reach our goals. He did seem to listen and did say thatit had more to do with recent cutbacks than with my performance. I've laid the groundwork for my next review, so I'm still closer to my goal." “Now listen to this. Guess what we do when we call ourselves shy? Research has pretty consistently shown thatwe REVERSE this self-enhancement bias! We take credit for failure and and give other people orexternal circumstances credit for our success. And more than that, when we fail socially we sometimes blame ourselves in a way that makes it hard to motivate ourselves to keepmaking efforts toward our goals. At those times we attribute social failure to our traits or general characteristics, which is referred to as characterological self-blame. This self-blame, according ot my research, is also correlated with shame, which means thatyou are ias! We take credit for failure and and give other people or external circumstances credit for our success.And more than that, when we fail socially we sometimes blame ourselves in a way that makes it hard to motivate ourselves to keep making efforts toward our goals. At those times we attribute social failure to our traits or general characteristics, whichis referred to as characterological self-blame. This selfblame, according to my research, is also correlated with shame, which means that you are likely to experience shame whileyou are engaged in self-blame. If you continue this process you are more likely to score higher in shame-proneness in general. Another fascinating aspect of this is that we do not necessarily do this in other areas of our lives. So, and this may really apply to you students in a demanding academic environment, we might engage in the self-enhancement bias in our academic work and even in our professional work, but reverse this bias only in social situations. Can you give me some examples in your lives of times you have noticed that you attribute responsibility in this way? Therapist collects statements while the other therapist writes on flip chart. © 2001, The Shyness Institute; for details, see page 1.


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"How about experiences of shame and/or embarrassment when you are doing this? On a scale of 0 to 100 how much shame did you experience? From no shame, 0, to extreme or debilitating shame at100. So associally, expecting yourselves to engage inthe kind of dialogue we see at the theatre or in movies.On the other hand, it may be thatit is specifically this tendency to take ALL the responsibility in social situations when they fail, and to blame yourselves in characterological ways, that is a good deal of the difficulty. You may see social interactions which disappoint you as saying something about you as a person, rather than simply recognizing that’s just the way interactions go sometimes, no matter how social or gregarious you might be. "There is a very important distinction here to pay attention to, and that is that if you take responsibility for situations that don't work out, but you see the responsibility specifically in terms of your behavior, and you see your behavior as controllable, then you will work to improve your social behavior, including your attitudes, until you habituate to challenging social situations as you would like to.Situations that tend to be challenging for most people are formal situations, situations involving authority figures, public speaking, interactions involving sexual attraction and/or sexual performance, dating situations, group situations, etc. Now, let me add a last wrinkle here. It is clear that intense emotion is likely to interrupt and bias rationalthinking, and that focusing on emotions canamplify them. There is research that shows that people who are self-aware (that is, aware of their feelings and thoughts) tend to to assume too much responsibility in social situations. So here is a double whammy. Not only are you likely to reverse the self-enhancement bias when shy/or sexual performance, dating situations, group situations, etc. Now, let me add a last wrinkle here. It is clear that intense emotion is likely to interrupt. This may be OK if you take responsibility only for your own specific behaviors, but if you are both shy and self-aware you may tend to be more characterologically selfblaming. That is, in negative emotional states you may blameyourself in a global and/ora stable way. You may operate from theassumption that there is something wrong withyou as a person rather than that you sometimes behave in specific ways that you would like to change. Self-aware people generally are more objective inneutral emotional states, so if you are relaxed, or just yourself, you may have pretty accurate self-perception. BUT, if you become fearful or ashamed, both of which are very intense emotional states, that may © 2001, The Shyness Institute; for details, see page 1.


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knock out this adaptive feature of self-awareness, and at that point you may find yourself more characterologically self-blaming than you might have been, had you not been selfaware. Again, this is true simply because self-awareness amplifies your feeling states, and intense emotion interrupts and biases rational thinking. "A recent piece of research has shown that socially phobic individuals, when anticipating giving a brief talk, show continuous activation in the right hemisphere of the brain rather than activationin the left hemisphere, as donon-socially phobic people. These findings suggest that the socially phobic individuals are processing visual images rather than thinking rationally and planningfor the talk. Now, visual images arecorrelated with intense emotion, suggesting that in these instances emotionality displaces adaptive coping. As you deliberately shift to more rational self-talk and plan your behavior, your SUDS level will come down, as will your embarrassment and/or shame, and the action will shift to the left-side of the brain. Furthermore, If you think of the brain as an associative network with emotion nodes as well as concept nodes, you can envision how it is that new, more adaptive (problem solving) cognitions will generate new associative networks, and that as these cognitions become more habitual, new associative pathways may override the older ones. We are talking here about truly changing your mind." “Pay attention to this tendency to let your emotional state overwhelm your rational consciousness this week as you do your behavioral homework, while you are gettin into situations that trigger your feelings of shyness. We'll come back to all of this later, so we'll have lots of time for review and practice. If you learn to blame yourself in this characterological manner, something else alsoseems to happen. That is, you can actually develop a negative bias in the self-concept, or as researchers refer to it, a bias in the selfschema. This simply means that youbegin to process incoming information in relation to this bias in the self-concept. For example, you willnotice and remember better the particular information which isconsistent with yourself-image. In fact, recent research is showing that people who label themselves as shy remember more negative than positive feedback after an interaction with another person in which the amount of positive and negative feedback they were actually given was equal. “Let's say this another way, if you are self-blaming you may begin to see yourself as inadequate. When you get feedback, which everyone does, that suggests you need to improve in some given area, you may use that feedback to reinforce your belief that you are inadequate. "See I knew this would happen, how could I imagine that I would be able to © 2001, The Shyness Institute; for details, see page 1.


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do this.", rather than, "That is useful information, I think I'll try this behavior next time." Let's make this more concrete and specific. Say you approach someone you don't know at the coffee house and they lookstartled and appear curt. If you are characterologically selfblaming, and see yourself as inadequate, you may say to yourself, "I shouldn't have intruded, how awkward and clumsy. I'm just no good at this." If you are open to examining the specifics of your behavior in an objective manner, you might say to yourself, "She/he was studying, and maybe wanted privacy. Next time I'll approach someone who may be more available, or perhaps I'll acknowledge that they may want privacy, but ask if I can takejust a moment of their time." Reflexively coming down on yourself will always provide thesame old information. Careful analysis of theparticular situation gives new anduseful information. Examining our behavior atthe level of specifics enables us to take appropriate responsibility for our actions . Let me summarize. The way we will be working together is tostage controlled exposures to feared social situations, so that you can practice beginning to do what you want to. Your SUDS level will come down simply through these repeated exposures, which is what we call desensitization. During that time youwill also be recording your thoughts, attributions and beliefs in relationto social interactions. Once these are out in the open, we can work directly to change your negative thoughts, attributions and beliefs about yourself in social interaction. So our aim is twofold: both to gain awareness about what actually goes on internally for you in social situations, and to acquire tools with which to change thinking and beliefs that are inaccurate and/or interfering. This combination of techniques should not only make you feel better in social situations currently, but should also help ensure that you do not "relapse", that is, that you do not become demoralized later on when you are working with these techniques on your own, so that you do not undermine your own motivation with self-blaming attributions and resist change because you’re certain that social success and enjoyment are not meant to be your lot in life. "Okay, now to the homework. I can't emphasize enough how important your homework is going to be to your success in this group. I know all of you are incredibly busy with academic homework and numerous obligations, but this is going to be your key to lasting change and to ongoing social fitness. This first week we want you to record on the sheet we've just given you your thoughts and your feelings in social interactions, particularly situations that are difficult or challenging for you. Please record your SUDS © 2001, The Shyness Institute; for details, see page 1.


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level, your behavior, whether you said or did what you wanted to (or whether you avoided the situation or inhibited yourself), your attributions and your thoughts about your self." TREATMENT OUTCOME EXPECTANCY ASSESSMENT When therapists have finished going over the homework sheet we administer the Reaction to Treatment questionnaire developed by Rick Heimberg, using his own work and that of Borkovec & Nau and Amies, Gelder, & Shaw. Therapists look them over immediately, and if responses to this questionnaire are negativistic or highly cautious, the therapists briefly discuss them as Heimberg suggested. This allows the group members to verbalize their concerns and gives the therapists and other group members the opportunity to explore them, to correct misconceptions, and to recognize the connections between attitude, degree of effort, and long term gain. INITIAL TRAINING IN ATTRIBUTION RETRAINING AND SELF-CONCEPT RESTRUCTURING "Let's take an example from reallife. A few weeks ago I started preparing a clinical workshop for a conference. This conference includes a number of people who are working with shyness and social phobia, some of whom are very well known among academics as well as practitioners. My first thoughts were thatmy session would not seem important to other therapists because none of this material would be that new or useful. When I asked myself what evidence I had for that belief, I recognized that my own combination of material had come out of my workwith patients and was pretty specific. Up popped the next thought or underlying thought that somehow I was not going to measure up, that somehow I was an outsider or not as good as other researcher/clinicians. When I felt stumped as to how to help a particular patient or someone struggling with shyness I assumed it was because I wasn't smart enough or wasn't adequate to the task of helping change these thoughts, feelings, and behaviors. I recognized that I was blaming myself, rather than sharing responsibility with patients and other clinicians and researchers who were also struggling to come up with new techniques and ideas that would help with these problems. I was also not acknowledging the difficulty of the problem itself, thatpeople have been studying shyness and performance anxiety for years, making progress in small steps usually, rather than huge insights that happen much less frequently, or are the product of years of study and effort to understand a particular problem. I further noticed that I was blaming myself in ageneral way, rather than being specific orbehavioral; that is, I was © 2001, The Shyness Institute; for details, see page 1.


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assuming that if I didn't understand something at this moment or didn't provide a useful intervention immediately, the implication was that I couldn't in the future through learning, consulting, experience, or practice. This is the black & white aspect of the thinking that perfectionists are prone to, e.g., that an intervention is either useful or not useful/patients are cured or left utterlyunhelped. I then recognized that thisirrational assumption of responsibility in a general way led to a belief about myself that was not going to be helpful in sharing with my colleagues my experience and knowledge from my research and from patients. In other words I had a maladaptive attributionpattern going and a negative belief about myself that would interfere with my collaborating with others and with makingmy own specific contribution to other clinicians and researchers. See how it goes? Identifying the particular attribution patterns and beliefs about the self enables us to let go of cognitions that are demoralizing, lead to feelings of inadequacy, and interfere with our motivation to contribute to others and to share with others in the pursuit of common goals. “Now, my problem had to do with public speaking anxiety. Yours may have to do with other kinds of socialinteractions. Examples might be "I willnever be able to be outgoing like Ann or Paul. They were probably just born that way," rather than “Paul and Ann seem particularly skilled socially, maybe I will talk to them about social skills, how they learned them, what they do thatworks etc.” As a matter of fact one of the students in these groups at Stanford did that spontaneously as part of his homework, as he began to learn about how shyness works, how it inhibits us from reaching social and professional goals. He restructured viewing himself as stupid, to viewing himself as in a learning mode, to interview another student whom he saw as particularly competent socially, about social skills. They spent three hours over coffee having a interesting conversation about the ideas the group has been discussing, and that the other student had been studying informally. Our group member returned verypleased with himself andthe rest of the group applauded his courage and extra effort to get past his feelings of shyness to talk openly about human problems and feelings we all struggle with. He focused on effort, behavior, skill building, and risk taking, all behaviors within his control, to prevent shyness from interfering with his interpersonal and professional goals. Because he was a graduate student in the business school we were confident that his efforts would serve him well in the long run, as well as changing a belief about the self that would have hampered him professionally. So, this is how we work with these attributions and beliefs about the self. We'll give you your homework sheets now to fill out this week as you encounter social and academic situations thatprompt anxiety and feelings ofinadequacy. This exercise will make you more aware of your attribution style and any negative beliefs about © 2001, The Shyness Institute; for details, see page 1.


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yourselves, and then we'll work with these next week in our first exposures from the hierarchies you filled out in your initial interviews." "As you look at your homework sheets, can any of you think of negative attributions you have made insocial situations? Can you also think of any negative beliefs about the self that you are aware of? or any that are implied bythe things that you are saying to yourself about yourself andothers in social situations?" As the therapist collects attributions and beliefs the othertherapist can be writing ht em on the flip chart. The second therapist may also share examples from his or her life tohelp the group get started. If there are few responses that is fine, because this is a difficult exercise early in the life of the group and they may be able to come up with more the following week after they have a chance to think about the exercise.



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Figure 3.1 Self-Monitoring/Attribution/Self-belief Scale Date

Situation Thoughts/Attributions Self-beliefs Interference (0-100)



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Figure 4.1, List of Cognitive Distortions (adapted from Burns 1980; and Persons, 1989). You see social situations, other people, yourself, in black and white categories. If your performance falls short of perfect, you see yourself as a total failure. Your mistake or someone else's shortcoming is seen as bad; there are no shades of grey. You may think someone else is perfect or has no problems, while you are inadequate and continually struggling. Words like always, never, completely, totally, or 1 . All-or-Noth ing Thinking:

perfectly are cues to black and white thinking (Persons, 1989). Words like sometimes, frequently, partially, somewhat, and occasionallyindicate more adaptive attributions and

self-statements. If you make a mistake or don't meet your own expectations in a given instance, you tell yourself that you can never “do it right”, likewise, any flaw in your appearance becomes an overall lack of attractiveness. 2. Over generalization:

You pick out a single negative detail about yourself, your appearance, your behavior, your attitudes, and dwell on it exclusively, so that your vision of yourself becomes darkened, like the drop of ink that discolors the entire beaker of water. 3. Mental Filter:

the Positive: You reject positive feedback andsuccessful behavior by insisting they "don't count" for some reason or other. You were just lucky, people were nice. In this way, you can maintain a negative belief about yourself that is contradicted by your everyday experience. 4. Disqualifying

You assume that otherswill be judgmental and critical of you. If a situation is ambiguous you assume the worst, without checking it out. You make a negative interpretation, even though there are no definite facts that convincingly support your conclusion. 5a. Mind reading: You arbitrarily conclude ht at someone is reacting negatively to you, and you don't bother to check this out. 5. Jumping to Conclusions:

5b. The Fortune-Teller Error: You anticipate that thingswill turn out badlyfor you, no matter how theyactually are going in thesituation. You are convinced that your prediction is an already established fact.

You exaggerate the importance of things(such as your goof-up or someone else's achievement), or you inappropriately shrink things until 6. Magnification/Minimization:



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they appear tiny (your own desirable qualities or the other fellow's imperfections). This is also called the binocolar trick. If you think you have committed some social error, you expect extreme and horrible consequences for yourself. A turndown for a date is evidence for a lifetime of isolation. Making a mistake at workmeans that you will befired and will never get another job. 7. Catastrophizing:

You assume that your negative emotions necessarilyreflect the way things really are: "I feel insecure or vulnerable, therefore social situations must be dangerous. I feel embarrassed or ashamed, therefore I must be inadequate.” 8. Emotional Reasoning:

You try to motivate yourself with"shoulds" and "shouldn'ts", as if you need to be whipped and punished before you could be expected to do anything. This is true of "musts” and “oughts" as well. This stance towards the self promotes shame and guilt. When you apply these standards to others you feel anger, frustration, and resentment. 9. "Should" statements:

This is an extreme form of overgeneralization. Instead of describing your error or shortcoming, you attach a negative label to yourself: "I'm a loser." When someone else's behavior rubs you the wrong way, you attach a negative label to him/her: "He's a louse." Labeling and mislabeling involve defining an event or person withlanguage that is highly colored and emotionallyloaded. When used about the self it promotes shame and a feeling of helplessness, when used about others, anger. It also interferes with seeing another's point of view. 10. Labeling and Mislabeling:

You see negative events as indicative of some basic inadequacy or defect in your self. You take responsibility for things you cannot control or were not your doing. You see yourself as responsible for others' well being. You see disappointing social occasions as your fault. 11. Personalization:

12. Maladaptive Thought : Any negative thoughtabout yourself or theworld that interferes with pursuing your goals, or meeting your basic human needs for acceptance, social support, and emotional connection (adapted from Persons, 1989). Many thoughts which have some truth valueare useful only as stickswith which to beat yourself; whereas other, equally true, thoughts will help you to move toward your goals. © 2001, The Shyness Institute; for details, see page 1.


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You believe that you need to inflateyour achievements or impress others to be socially successful. Life is a jungle out there, with the most aggressive and the most dominant succeeding. You think people must be tough and even callous to meet social andprofessional goals. This may be a compensation for a belief in your own inadequacy and promotes suspicion and hostility toward others. 13. Compensatory Misconception:



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Fig. Challenges to Automatic Thoughts CHALLENGES

to Automatic Thoughts Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? What evidence do I have that _________________________? Does ___________________ have to equal or lead to _________________? Could there be other explanations? What is the likelihood that __________________? Is________________________ really so consequential or important? Does _______________'s opinion reflect that of everyone else? Is _______________________ so important that my entire future resides with its outcome? Is this the only opportunity? Adapted from Sank and Shaffer (1984), Heimberg (1991)



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Fig. xx Reversal of the Self-enhancement Bias SUCCESS SHYS

OTHERS

No credit

F AILURE

Credit

External

Internal

Unstable

Stable

Specific

Global

Uncontrollable

Uncontrollable

Credit

Nocredit

Internal

External

Stable

Unstable

Global

Specific

Controllable

Uncontrollable



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Chapter 4: Session 2

Figure 4.2, List of Attributional and Self-concept Distortions (based on the work of Anderson, 1985; Arkin, 1980; Girodo, 1981; Henderson, 1992, 1993; Leary, 1986; Teglasi, 1984; and Zimbardo, 1977). ATTRIBUTIONAL DISTORTIONS Reversing the self-enhancement bias.

"Success = no credit" vs. "Failure =

credit" :

If you succeed socially, get a date or ajob, or just have a pleasant conversation at a party, you give external or temporary factors the credit. For example, the person didn't want to hurt your feelings, or there couldn't have been that many good applicants for the job. You appeared better than you really are. If you fail you take all the credit, frequently relating it to something about your character, your ability, or your personality. 1. Internal for negative outcomes vs.

external for positive outcomes. "It's

You take sole responsibility forwhatever social situation turns out badly. If you are in a group and the group falls silent, you assume it is something about your mere presence thatcaused the conversation to stop. On the other hand, if the group has a lively discussion and you play a role in it, you assume that somehow other people made it happen, and you just went along for the ride. all my fault!" vs. Not me, folks!:

2. Stable for negative outcomes vs.

Temporary for positive outcomes.

If you make a mistake socially or don't meet your own expectations in a given instance, you see it as a never-ending pattern rather than due to a temporary factor such as fatigue. In contrast, if an outcome is positive, you assume that it can't last, or can't be repeated. It must have been a fluke. In this way you sabotage your motivation and make yourself painfully self-conscious and fearful while, objectively, you may be doing well. It makes it difficult to perceive your strengths "Always and forever" vs. "Don't count on it":

and enjoy your successes. You may push people away in the process without recognizing you are doing so, by discounting or rejecting positive feedback or assuming that specific negative feedback means that people don't like you or think you are inadequate.



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3. Global for success vs. specific for failure.

Page195of195 "Here = everywhere" vs.

If you have an off night, you assume that this reflects the reality about you in most situations. For example, if you disappoint yourself at a party, you assume it will generalize to dinners, clubs, and classes. However, If you have a good conversation with a new person at a particular event, you assume that it won't happen again in different social situations. "Here = nowhere":

both. "I blew it" vs. "Clueless": If someone doesn't respond to you in the way you hope, you assume you blew it, or worse, you're a loser. If people do respond well to you, you "haven't a clue" what it is about you that makes it happen. You discount your own assets, what is interesting, attractive, and unique about you. You also discount the effort you make with others, the times you are considerate or thoughtful, the times you reach out to others. In both cases you do not think you have any control over the impression you make on others. 4. Uncontrollable for

Any assignment of blameto your character or the character of others that interferes with meeting your basic human needs for acceptance, social support, contribution, and emotional connection. 5. Maladaptive Attribution:

You take responsibility for everything andeveryone because you must avoid the wrath of others. You may think you are the only one who is willing to do what is necessary to solve problems. You do not trust others to be trustworthy or competent, particularly when it comes to your welfare. This may compensate for an underlying belief that you are helpless and/or powerless with others who are insensitive and powerful. 6. Compensatory Attribution:

SELF-CONCEPT DISTORTIONS (SCD'S)

You reject positive feedback and successful behavior by insisting they "don't count" for some reason or other. In this way, 1. "It can't b e me" vs. "That's just how I am" :

you can maintain a negative belief about yourself that is contradicted by everyday experience. In contrast, when you get negative feedback, you say, of course, that's how I am and/or have always been. That is also when you are likely to withdraw, not check things out, and lose opportunities for positive feedback.



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There is some idealized standardyou must meet in order to be an acceptable person. You may not apply thesame standard to others, viewing them as acceptable in spite of shortcomings, but you do not show the same tolerance towards yourself. You don't trust yourself to perform socially or behave well without comparing yourself to this ideal, and you may believe that your demanding conscience is your mostdistinctive and redeeming feature. The emotional consequences are shame and guilt. When you do apply thisidealized standard to others you may feel 2. The Ideal Self vs. the Real Self:

resentful and superior; you may be also be hostile or passive aggressive. Instead of focusing on any particular behavior or attitude you want to change, you attach a label that implies basic inadequacy to yourself: "I'm a loser." When someone else's behavior disappoints or irritates you say he/she is a "jerk". When inadequacy descriptors are used about the self they promote shame and a feeling of powerlessness. When descriptors are used about others, they may appear dominating, intimidating, or callous. Self and other descriptors of this nature interfere with finding alternative ways tocope with ordinary problematicinterpersonal situations. It further interferes with seeing another's point of view, understanding situational influences and constraints, and with seeing your own behavior in a more objective and compassionate manner. 3. Shame-base d Self-concep t:

Any belief about your personality, your ability, or your character, that interferes with giving or reaching out for emotional support, affection, and warmth. It also applies to beliefs that interfere with pursuing your own goals in your professional and personal life. 4. Maladaptive Self-Belief:

In spite of a modest or unassuming exterior you see yourself as superior. If this belief is unrecognized, you may just be aware that people don't seem to accord you the respect or recognition you deserve. You may wonder why you don't feel understood, or why you need to defend yourself so often. You may also experience continual social striving or internal pressure. 5. Compensato ry Self-belief:



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Fig. Challenges to NegativeAttributions and Beliefs Aboutthe Self CHALLENGES

to Negative Attributions and Beliefs About the Self Do I know for certain that __________________________________? Am I 100% sure that ___________________________________? Am I 100% sure that I have the sole responsibility for ___________? What evidence do I have that I am the cause of _______? What evidence do I have that _________________________? What evidence do I have that I am _________________________? What evidence do I have that I cannot change ________________? Does ___________________ have to equal or lead to _________________? Is my whole personality or basic character involved in __________? Could there be other explanations? What is the likelihood that __________________? What is the likelihood that I have no control over __________________? Is________________________ really so consequential or important? Does my opinion or _______________'s opinion reflect that of everyone else? Could there be a less harsh way of viewing my own behavior or that of others? © 2001, The Shyness Institute; for details, see page 1.


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Would I view a friend this way? If I see a social behavior that I want to change, does that mean I am inadequate, deficient, incapable of change? Does labeling myself improve my performance? Is _______________________ so important that my entire future resides with its outcome? Is this the only opportunity? Adapted from Sank and Shaffer (1984), Heimberg (1991), Zimbardo (1977)

Chapter 4: Session 2 SES SIO N 2, GR OUP TH ERA PY

Materials:

* * * * * * *

Between sessions shyness questionnaire List of Cognitive Distortions List of Challenges to Cognitive Distortions List of Attributional/Self-Concept Distortions List of Challenges to Attributional/Self-Concept Distortions Self-Monitoring/Cognitive RestructuringForm Self-Monitoring/AttributionalRestructuring Form

Topics:*Assessment of Emotional State * Review of Homework Assignments * Identification of Cognitive and Attributional Distortions * Identification of Self-concept Distortions inBeliefs about the Self * * * * *

Challenging AutomaticThoughts, Attributions andSelf-beliefs Developing Rational Responses Developing Self-enhancing Attributions andBeliefs about the self Homework Assignments Preparation for Exposure Situations



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Assessment of Emotional State Review Between-sessions shyness questionnaire for higher scores to see who may be needing extra attention, support. Deal with concerns, questions or difficulties with homework. Review of Homework Assignments Group members have recorded automatic thoughts, attributions and beliefs about the self during the week to increase theirawareness of them in social situations. Therapists ask members to volunteer examples that came up in social situations and collect them on the flip chart, writing them down as group members report them. Group members who don't volunteer can be gently questioned about where they experienced some social anxiety during the week and even given examples of the kinds of thoughts, attributions and beliefs about the self that sometimes comeup. If they report that none came up, an automatic thought, attribution or belief about the self that commonly occurs with shyness (or the therapist has experienced) can be written on the flip chart as an example.If it is difficult to obtain responses therapists can ask group members what reactions they are having about reporting their responses or hearing other group members report them. Ask them to describe the situation and ask what effect the thought, attribution or belief had on their mood and on the desire to leave the situation. Therapists can look for commonalties among the group members, asking if others have experienced those that are being reported. Therapists should note that characterological attributions and negative beliefs about the self frequently lead toactually leaving a social situation. Fear may be prominently involved, as in the fight or flight response, but shame may be the salient affect which is prompting the person to want to withdraw or hide. Because the parasympathetic nervous system is involved in the shame response, there is a reduction in arousal state which reinforces the impulse to withdraw. The person no longer feels fearful and high in adrenalin. This may promote copingbehavior, but the person mayinstead experience a flooding hurt feeling, a shrinking from contact, and a feeling of helplessness which promotes behavioral inhibition and a turning inward. Identification of CognitiveDistortions in Automatic Thoughtsand Beliefs Therapists distribute the firstlist of Cognitive Distortions, beginning by each reading one and giving a prepared example and one from personal experience. and © 2001, The Shyness Institute; for details, see page 1.


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following by asking each group member to read one. The first list is based on the important work of Beck, Rush, Shaw, and Emery (1979), Burns (1980), Heimberg (1991), and Persons (1989) with depression; of Cheek (1989) with shyness. Included are thoughts about social situations and others that may or may not be specifically related to the attribution of responsibility in social situations orto beliefs about the self. Examples are: "This person won't like me", "they will be critical of me", "this situation is too hard", "I shouldn't interrupt their conversation", etc. Therapists discuss the meaning of each, explaining in detail, giving examples from clinical experience, their own lives, and linking them to examples collected from thegroup. If the group member can thinkof one from his or her own life, that is optimal, but not necessary. This section needs to be handled carefully. Examples involving jumpingto conclusions about whatnegative event will occur and what others are thinkingare most frequent. Overgeneralizing about previous negative events and dichotomizing into perfect and inadequate, success and failure, are also common. These kinds of automatic thoughts aremore easily challenged in thebeginning because they do not necessarily indicate the presence of more painful, longstanding beliefs about the self. Going directly to beliefs about the selfas well as attributional distortions is too large a risk for most people initially, so staying with examples that are less emotionally revealing is useful. Have a collection of commonexamples at hand, point out ht at human beings in general may use many or have a few "favorites", neither of which indicates severity of difficulty. Some people produce vague and painfully global self-distortions almost instantly, withfewer articulated automatic thoughts. They need help in articulating ther specific fears and automatic thoughts. All-or-Nothing Thinking, Things are seen in black and white categories. Examples include good-bad, cause and effect, and success-failure. "I totally screwed up. She would have gone out with me if I were attractive, interesting, or smart." "The conversation stopped after just a few minutes because I couldn't think of anything to say." Words like “always”,” never”, “completely”, “totally”, or “perfectly” are cues to black and white thinking in general (Persons, 1989) and seem to apply to attributions and self-statements particularly.Words like “frequently”, ”partially”, “somewhat”, and “occasionally” indicate more adaptive thinking. Overgeneralization Overgeneralization occurs in relation to negative experiences with others, perceived mistakes or flaws, and blaming oneself. A patient successfully completed a homework assignment by holding a short conversation with someone he didn't know after a class he © 2001, The Shyness Institute; for details, see page 1.


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was taking. When the conversation paused and he couldn't at the moment think of something to say he assumed that the entireconversation was a failure. The group challenged his thought thatthe conversation was afailure because there was apause. They also challenged his generalization to new situations, in that he assumed that he would not be able to initiate another conversation, and that further conversation with someone he was getting to know would beas difficult as the first. He had already identified areas of mutual interest. Mental Filter In mental filter the person obsesses on any less than perfect behavior in a social situation and, like the drop of ink that colors the beaker of water, that imperfection colors the entire experience. The overall objectivelook at a situation is lost. Like the patient who saw one pause in the conversation as indicative of a failed social interaction, another patient thought she had "bad skin" because she had a few blemishes from time to time. She was actually quite attractive, with many other aspects of her appearance and her personality to which the group responded positively. She was shocked to discover that some people hadn't noticed at all, and others had noticed occasionally, but it had seemed minor in relation to the rest of her general attractive appearance, so they actually hadn't thought about it. Disqualifying the Positive In this distortion positive feedback and positive experience is rejected or overlooked. After a man in his forties succeeded in asking a woman for adate he described her as “just friendly”, and concluded that she probably would have gone out with anyone. The regularity with which this distortion is encountered with shy patients is one of the factors that led to the idea of the shame-based self-concept to explain why information is processed in this manner. A young woman in one of the groups was rather strikingly attractive. When she received feedback about her appearance she immediatelydiscounted it by saying. "You people feel sorry for me because you know I am insecure, and this is how you try to reassure me." Furthermore, if a man approached her she decided he probably wasn't too discriminating, or was just friendly, that it had nothing to do with her attractiveness or her behavior. The fact that she was taking new risks, such as reaching out, making herself more available, making eye contact with men she found attractive, and initiating conversations was completely ignored. Continual disqualification ofgood experiences and personal assets can lead to a lowering of overall motivation and a decrease in homework. © 2001, The Shyness Institute; for details, see page 1.


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Jumping to Conclusions This distortion turns out to be one of the favorites of shy/socially phobic people. Burns (1980) described two types, mind reading and fortune telling, and Heimberg (1991) gave cogent descriptions of specific examples inhis work with social phobia. Both involve a negative interpretation in the absence of evidence, a) in mind reading the person assumes he/she isbeing evaluated critically, that is, that the other person is thinking they are unintelligent, unskilled, awkward, boring etc. It is very important in this one to ask for behavioral evidence, particularly because shy/socially phobic individuals operate on little data, interpreting ambiguous situations as negative. They tell elaborate stories using many negative adjectives, and the absence of evidence may only become obvious with persistent questioning. For example, a patient did not approach a woman for several years because his invitation to an eight week dance class had been turned down by someone he was dating. They were dancing together in another group on a less frequent basis, which she wanted to continue. He became hurt, angry, and frustrated, decided he was inadequate and dating was hopeless as he elaborated the event and his own ineffectuality in his mind. Furthermore he could not bring himself to check out her response to him. He found subtle ways to avoid any real engagement with women, even when he continued his dance classes. b) In fortune telling the patient knowsahead of time that agiven social situation is going to be too painful, difficult, or that a goal isunattainable. The person anticipates a negative outcome. She or he may assume that someone will be critical of behavior, appearance, etc. When shy people anticipate that things will turn out badly and, further, that they will be at fault, their tendency to avoid situations increases, and their reluctance makes it difficult to dotheir homework. If the fortune telling involves anticipating that people will label them, they may elaborate their concepts of themselves in highly negative ways. For example, they say things like, "I'll look stupid; they will think I'm a jerk, a nerd, hopeless, inadequate, weak, a creep, etc.", rehearsing negative beliefs about the self. Magnification/Minimization Persons (1989) separated this distortion from Burns (1980) category of Catastrophizing and Heimberg (1991) followed suit.Magnification is thetendency to give one's own mistakes, shortcomings, or negative outcomes exaggerated significance. Minimization is the tendency to give much less importance to one's strengths, successes, © 2001, The Shyness Institute; for details, see page 1.


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positive behaviors. In contrast, another's strengths, admired behaviors, or successes are magnified and his/her flaws, mistakes, or shortcomings are minimized. Others are both idealized and more easilyforgiven for human failings. Burns calls it the binocular trick. Heimberg refers to it as the tendency to endorse higher standards for oneself than for others. An example he used was the public speaking phobic who was highly self-critical of any stumbling he did while speaking, but jumped in to reassure others that a mistake didn't affect their overall presentation. Others' abilities, characteristics, power, etc., may be given such exaggerated importance that, while they are not critically evaluated in the same way as oneself, others may be seen as intentionally neglectful or denigrating, when this is notintended. For example, one male group member was engaged in an exposure where he was approaching other group members and talking for three minutes to each, in order to practice initiating conversations. Another male in the group was hard of hearing and wore a hearing aid. When he had difficulty hearing another person he would become embarrassed and uncomfortable, which would result in nervous laughter. The person starting conversations interpreted the laughter as ridicule, minimizing the other's discomfort and magnifying his own awkwardness, which triggered anger as well as embarrassment. He had difficulty during the debriefing seeing the other's discomfort as an alternative explanation for the laughter. This occurs repeatedly with group members who are shame-prone. When they feel ashamed others are seen as powerful and devaluing, rather than human and humane. Catastrophizing When someone catastrophizes he or she assumes extreme and terrible consequences to relatively ordinary mistakes and shortcomings, as well as to negative events and outcomes. A turndown for a date, a job that was not obtained, criticism personally or professionally, means that a partner will never be found, a job will never be gotten, a mistake will never be forgiven, one will always be thought incompetent, etc. These "disaster fantasies" may culminate in abandonment, shame, humiliation, defeat, and a sense of exclusion from the human community. A female group member hadbeen given a new set of professional responsibilities that involved considerable responsibility, initiative, and decision making discretion. She received negative feedback from acolleague, and she took his word for the fact that she had blundered. Her goal in her shyness group had been to assume the new responsibilities in spite of her fear, and much of her homework was related to her job. She had been distraught, assuming that she had failed, that her boss and mentor for a number of years would remove her, and that our group would be angry and disappointed in her. She imagined "flunking her shyness group!" As the group challenged © 2001, The Shyness Institute; for details, see page 1.


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her catastrophic thoughts she remembered why she had made the decision she had. She began to articulate her own position and why she believed it was the best course of action, so at worst hers had been a sensible judgment call, given the information she had. It turned out that her colleague simply held a different perspective about how the project would proceed, and either plan was viable. In fact, her project team chose hers in an open discussion the following week. By that time she had successfully challenged automatic thoughts and could articulate her position clearly.

Emotional Reasoning When shy/socially phobic patients experience a negative emotion, particularly fear, embarrassment, or shame, they assume that the emotion reflects an external reality or a negative truth about themselves (Persons 1989). The emotions frequently leadto painful rumination, self-blame, and a sense of powerlessness because they believe they are incompetent or defective, and therefore unable to change. In the previous example, the woman's feelings of insecurity led to the conviction that she must have made a terrible mistake thatwould lead to losing her job. She expected to be fired if she had made a mistake, although she herself had a healthy tolerance for other's human foibles, and was supportive and compassionate when others were learning. Should Statements Shy patients sometimes blame and punish themselves more and more harshly for anticipated or past misdeeds in an attempt to motivate themselves with "shoulds" and "shouldn'ts". Standards become more perfectionistic because, as goals are achieved, the habit of driving themselves leads them to select another harder goal and proceed in the same manner. As patients drive themselves they experience shame andguilt which, via emotional reasoning, feeds back into the pattern of negative thinking which creates more shame and guilt and the downward spiralcontinues. A group member calledit "musterbating". Whenever other group members would praise him he would respond with "Actually, I should have done it differently; I could have ........; it would have been better if I had......". He was so focused on his shoul ds and shouldn'ts t hat he had a difficul t time attending to what was being said in the way of feedback. Furthermore, the shame that follows the shoulds may promote a sense of powerlessness and even rage that interferes with accurate empathy for others[Tangney, 1991 #1252].



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Labeling and Mislabeling Labeling has been referred to as an extreme form of overgeneralization (Heimberg, 1991) which may signify resignation. Instead of describing a behavior a person wants to change he or she attaches a negative labelto it (Zimbardo, 1977). In fact, Zimbardo noticed that when people experienced feelings of shyness, it was the self-labeling process that caused the most difficulty in continuing to take the social risks that would lead to meeting desired goals. As patients label themselves, feelings ofhelplessness promote shame, guilt, depression, and an increasing reluctance to take social risks. They fail to check out perceptions of others' judgments, begin to withdraw from others, and frequently become socially isolated to the point that the possibility of seeking out a benign environment in which topractice relating to others seems moreand more remote. A shy man who was turned down for a date labeled himself as hopelessly shy and inadequate. He waited three years before asking another woman out! Personalization Personalization is the tendency to see oneself as responsible for negative social outcomes and others' well being, regardless of the degree of actual control, and even the degree of participation. An example is a woman in group who was standing with a group of people she had met at a Sierra Club hike. Most of the people were new to each other, and she recalled thatseveral others seemed a littlenervous. In spite of her awareness of others' shy behavior, when the conversation was slow to get started, she assumed it was because she was present, that she somehow made others feel awkward because they sensed that she was shy. As the group members challenged her automatic thoughts she remembered that she had been one of the first people to make a comment about the hike. She had completely forgotten that she had indeed participated and that others also were reticent. Maladaptive Thought Persons (1989) added a category she called "maladaptive thought." These are thoughts that may not be distorted or irrational, but are just not useful in terms of reaching one's goals. Dwelling on these thoughts may create a problem, particularly when they are somewhat ruminative in nature. An adolescent was working with feelings of shyness prompted by transferring to a new academically demanding private school where many friendships had been formed in earlier years. She focused on the difficulty of breaking into established groups to the point where she had trouble recognizing the openings that were available to her for conversation, group activities, and growing friendships. Nearly every © 2001, The Shyness Institute; for details, see page 1.


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description of previous or upcoming homework began to be prefaced by the statement : "This is so hard, this is really hard, this is going to be so hard." We began working with those statements as automatic thoughts which would begin to erode her earlier concept of herself as friendly and confident. She began to challenge her belief thatinitiating contacts was "too hard for her", which translated into "I am not up to this challenge". As a result, her attitude toward her homework assignments became more positive, as did her emotional stance toward others. Compensatory Misconception This maladaptive conception of social interaction is one added from Zimbardo's writings and the observation of patients at the Shyness Clinic. Sometimes group members try to impress each other, and others with whom they are initiating contact outside the group, in an effort to do what they think is necessary in social interaction. They may be aggressive with people seen as more shy or socially awkward. Sometimes they are effusive in their admiration of others' accomplishments, but communicate envy or hostility. These patients think that socializing is primarily a dominance struggle, or at the very least, a competition where someone must lose. Many had parents who were highly concerned about the public image of the family or very invested in the public accomplishments of the child. They often fail in their own eyes, or push others away inadvertently, either by appearing ingratiating or arrogant, or by setting up competitive interactions. Challenging Automatic Thoughts The therapist can begin byreferring to the example fromthe week before. For example, "Remember when we examined my automatic thoughts, attributions and negative beliefs about myself last week whenI was preparing my talk?" "I had some irrational thoughts about how critical people might be, and I had some irrational assumptions about the degree of responsibility I had in trying to understand and work with shyness. I also had some irrational beliefs about who I am as a person. Let's imagine another scenario, and say I'm the one who's been called on in class. I could ask myself if I know for certain that I can't do this. Does feeling nervous mean that I can't do it? Could there be other explanations? Do I know for certain thatI am stupid? What evidence do I have? Does my opinion reflect reality?or others' opinions? Do I know for certain that I shouldn't be nervous? Or if I am nervous that there is something wrong with me? Would I judge someone else in this manner? Could there be other explanations? What is the likelihood that I cannot learn tospeak in class with practice? Even if I am © 2001, The Shyness Institute; for details, see page 1.


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nervous and it shows, is that so important that my whole future depends on it? What is the worst that can happen? How bad is that? The other therapist suggests that the group try to answer the questions, asking each one and letting thegroup generate alternatives. Other AT's are taken fromthe easel and and the process continues. Therapists emphasize that each question needs to be answered because these form the basis of more thoughts which are more rational. Each person in the group identifies the cognitive distortion.. The negative physiological, behavioral, and emotional responses should be identified that occurred in relation to the AT's, and the group should be asked if these would be less likely to occur or would occur to a lesser degree. Attributional Distortions and Distorted Beliefs about the Self After the list of cognitive distortions is discussed, therapists distribute the handout with the description of the self-enhancement bias and how it is reversed in shyness. This handout is carefully explained with examples from personality and social psychology research with student samples and clinicalsamples. The list of Attributional and Selfconcept Distortions is then distributed usingthe same format. Group members again read each Distortion. Therapists give examples from their lives andelicit examples from the group. The list of Attributional Distortions is based on the seminal work of Zimbardo (1977) with shyness and attribution style, and the subsequent work of Henderson (1992) with self-blame and shame. The rest of the discussion is taken from Shyness Clinic groups and workshops, the Stanford Counseling Center student groups, and research with attribution style, self-blame and shame inshyness. It will become apparent that several distortions may be simultaneously involved in one automatic thought/attribution or belief about the self and different categories may be useful for different aspects of the attribution or belief. The Attributional and Self-concept Distortions differ from the traditional list of cognitive distortions chiefly in the specific focus on the assignment of responsibility in interpersonal situations and on underlying beliefs about theself. When Self-concept Distortions are discussed, therapists again refer to attributional style and the information processing model. If the self is blamed in social situations, shame is induced, which through emotional reasoning may elicit more self-blame and more distorted thinking about the self in social situations. If this process is repeated frequently in the context of high negative affect and high self-awareness, it will likely lead to well articulated distorted © 2001, The Shyness Institute; for details, see page 1.


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beliefs about the self and/or others. When there is a highly elaborated self-concept that is shame-based, that is, where the self is seen as basically socially inadequate, it serves as an enormously powerful organizer of incoming information. Information may then be organized both around the concept of self as inadequate, but also around others as more powerful and more critical thanthey are. Research suggests that social phobics see situations as controlled by powerful others ( [Cloitre, 1991 #1412]). Furthermore, these negative self-beliefs are frequently not accessible in a given moment, that is, they operate outside immediate awareness, so what patients will actually do is is say vague things like "I don't think I can...", "In the past...", "What if the other person...", "What if they don't want to hear from me...?" "I think I have a harder...". They sometimes need help articulating these beliefsthrough gentle questioning,or examples from others. Individual sessions may be useful here to help them articulate the beliefs before they say them in the group. Therapists can cite studies that have shown that people who label themselves as shy remember more negative than positive feedback when they are given equal amounts, as contrasted with non-shys who either remember more positive feedback or a balance of positive and negative feedback[Smith, 1975 #395 ]. Therefore, they may attend to and remember negative feedback more than positive feedback.It is important to impress upon group members that this can have a devastating effect on continuing motivation to take the risks to develop the social skills necessary for social interaction and to gain enough social experience to recognize that human beings aren't perfect, that there is always room to learn and to grow, and to develop satisfying social interactions. Here therapists can use the social fitness model developed at the Shyness Clinic. There are few world class social athletes, just like there are few world class physical athletes, and even world class athletes excel usually inone activity or situation. But most of us can exercise socially on a regular basis and enjoy the benefits of it, just like people do with physical exercise. We can get in shape and stay in shape, but we need tomake a continual effort to stay in social shape, just as we need to continue to exercise to stay in physical shape. We can't work out for a week or a month and expect to maintain good social stamina and flexibility anymore than we could maintain physical conditioning. Besides, we have many social activity choices, just as we do choices of physical exercise. We can play tennis, jog, play volleyball, or join a frisbee club; we can go to the movies, have dinner, join clubs, learn to make small talk, have deep conversations about philosophical or personal issues, or all of the above at different times in different situations. Therapists need to be prepared to take emotional risks themselves in disclosing their own negative attributions and beliefs about theself. These should be rehearsed ahead of © 2001, The Shyness Institute; for details, see page 1.


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time so that therapists have experienced any embarrassment or shame that may come up. This will help with the ability to have empathy for group members' experience, which is essential in working with this kind of affect, but therapists will not be focused on their own experience to the point of losing empathy for group members. Ask each group member to find the distortions in each attribution and belief about the self. Members can help each other with this process, but therapists should acknowledge that the person's own sense of the importance or relevance of a given distortion is the essential issue. Each person is learning about his or her own thoughts, attribution style and belief system. Our clinical observations have suggested that a more specific focus on attributional and self-concept distortions is necessary in order to bring these beliefs into patients' awareness, and/or to allow them to articulate them with each other. Perhaps, in part, because they are so irrational that they hesitate to discuss them with other people, who may be shocked or skeptical, particularly when a patient appears to be functioning well on the surface. These beliefs cause a good deal of suffering and with short term work there has been insufficient time and specific focus on underlying beliefs to allow them to come to the surface more naturally as group members bond with each other. We expect that these techniques may be more applicable to shy individuals and social phobics with early onset and long-standing difficulties than to those with more reactive and specific problems. They may be particularlyuseful with Avoidant Personality Disorder and Generalized SocialPhobia. These patients frequently havemore difficulty maintaining treatment gains, and my hope is that working with these entrenched negative attitudes and beliefs will serve to inoculate patients against their reemergence after treatment when negative outcomes or simply ambiguous situations trigger them. Originally we thought that this specific focus on attribution style and self-concept distortions would be more applicable to our clinic population than to our Stanford students and college students in general. However, in working with these techniques with the students we are finding that the self-blaming style and self-concept distortions are more common than we thought, and have actually been astounded at how much the students have been willing to reveal when helped to work specifically with the negative beliefs about the self. Reversal of the Self-enhancement Bias, or Success = no credit; Failure = credit. Responsibility is seen as dichotomous. Someone, usually oneself, is seen as completely responsible for an interpersonal interaction while the other person is either assigned no responsibility, or assigned a different kind of responsibility. The self often gets the blame, and shame or embarrassment follows. If blame is assigned to the other © 2001, The Shyness Institute; for details, see page 1.


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person, the other person is usually not seen as a failure, but as successful and uncaring. If this is the case, anger or resentment may follow. When blame is assigned to the self, it is frequently characterological in nature, that is, blame involves the whole personality, which may imply that one has no control over the impression one makes. "I totally screwed up. She would have gone out with me if I were attractive, interesting, or smart." "That awkward pause in that group discussion was my fault. Everyone knows I'm shy and I make everyone else uncomfortable." This may occur even in situations where the person recognizes control over behavior, and is able to see that he or she is performing new behaviors. Furthermore, if the situation is ambiguous or some awkwardness occurs, failure is assumed and self-blame usually follows. "The conversation stopped after just a few minutes because I couldn't think of anything to say", rather than assuming that if there are two people participating, two people share the responsibility. Subtle blaming of others is seen in statements like, "I am overlooked at parties because only the beautiful/handsome/brilliant/jocks/ heroes etc. are appreciated." "I don't speak up in groups because only loud aggressive people get the floor," or "people only want to talk to people who are willingto make superficial small talk." "No one will listen to me anyway, who wants to hear what I have to say." "I look like a jerk, everyone else finds socializing easy. I'm the only one who has a hard time with this." Others may be blamed for not being more considerate, if they cared they would reach out in spite of the fact they are not getting cues thatthe shy/socially phobic person wants to participate.Other people may be construed as powerful and uncaring and sometimes as cruel. Many shy/socially phobic individuals have been teased and treated cruelly by other children or trusted adults, but subsequent social withdrawal has prevented new learning, whether it be more proficient social skills or the increased tolerance and empathy that begin to occur in adolescence (Davis & Franzoi, 1991). One group member showed considerable surprise when he learned that 40% of the population acknowledges being chronically shy, in that it presents a problem either professionally or personally, including a large Stanford student sample. In fact, 93% of the population acknowledges being shy in somesituation at some pointin the life span. He said it didn't occur to him that others might be feeling uncomfortable. He was so wrapped up in his own self-critical evaluation that he hadn't stopped to notice whether anyone else felt uncomfortable. Zimbardo (1977) suggested the exercise of simply observing other people in a social situation and reporting back to the group the expressions on others' faces. We asked this group member to do this. The following week he evidenced surprise and relief to find that others appeared uncomfortable or occasionally nervous in group interaction, that they © 2001, The Shyness Institute; for details, see page 1.


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were not all completely atease and functioning like movie actors. When someone is chronically shy, any mistake may mean total failure, and any outcome that is less than ideal indicates inevitable failureand unreachable goals. In this manner, motivation to attempt new behaviors in new settings is systematically decimated. In social situations withpositive outcomes the bias isreversed. If an interaction goes well, and the individual gets the date, or the job, success is attributed to external, unstable, specific, and uncontrollable factors. Others are praised for how supportive they were, the good mood they were in, how the environment was particularly and unusually facilitative in some way. "She was just trying to make mefeel good because she knew I was uncomfortable and that I'm inadequate socially. She was feeling sorry for me. That's why she talked to me." Frequently they go on, however, as in the old joke, the fraternity/sorority must not have been that good to begin with if they let the shy person in. We have seen this repeatedly as shy menbegin to date. When they have success they may devalue the person they are dating, and see her as less attractive than just a few weeks earlier. Often the group willbegin to challenge the member, encouraging him tocontinue to explore for learning purposes if that is the goal, but to reserve judgment until they have gained experience relating more closelywith other people. Fantasies about romantic relationships may have persisted since junior high school and need to be tested slowly. If this is not taken into consideration shy men may get their feelings unduly hurt, and sometimes unknowingly hurt others' feelings by communicating that they are practicing, and the particular woman doesn't matchhis idealized image. When women are reluctant ot continue dating them , they have been surprised and rejected, rather than acknowledging that the relationship just isn't the right "fit" at this time. Stability vs. instability, or "Always and forever vs. never never" A turndown for a date, a job that was not obtained, criticism personally or professionally, means that a partner will never be found, a job will never be gotten, one will never be forgiven for a mistake, will always be thought incompetent, etc. These scenarios usually culminate in abandonment, shame, humiliation, defeat, and a sense of exclusion from the humancommunity. The woman mentioned earlier,who received negative feedback from someone about her new job responsibilities thought that if she couldn't "make it here", she would "never make it", the outcome would always be the same. When questioned about her attributions she reported thatshe not only assumed that the feedback was correct, but that it was a prediction about the future. Whatever it was, she would be doomed to repeat. When asked for evidence, she became aware of a number of successes in her job in the past as a result of considerable effort to learn whatever skills © 2001, The Shyness Institute; for details, see page 1.


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she needed. She had also played a large role in a successful team project previous to this one, but she maintained that she had little impact, that the group was very capable and would have managed at least as well without her, besides she probably couldn't repeat it. When questioned further about specific behavior she was able to begin to see how much was not using evidence of her consistency in the past to predict continuing contribution and success. Group members also mentioned how frequently and consistently she contributed to the group, whether with homework ideas, feedback, support of others, etc., which she also attributed to temporary factors, as though eachtime was an exception. The belief that negative outcomes will be repeated and that success is a fluke, is confused with reality and leads to emotional debilitationif it goes unchallenged. This experience is frequent with the chronically shy. If a minor mistake at work carries thisimplication, it becomes obvious that the maintainance of behavioral gains isa problem. A string of successes can be overwhelmed by one failure. Another example is a female programmer who was criticized by a coworker for an error in her code in a particular program. She berated herself for the error and her selfblame reactivated an ongoing belief thatshe would never be avalued contributor. She focused on her mistakes rather than her successes, knowing that she would repeat them, not allowing for the fact that she would be likely to repeat her successes as well. In fact, she was very bright and was considered an excellent programmer. She began to withdraw at work and started to look in the paper for other jobs. She further procrastinated in her job search because, since she was convinced she would repeat mistakes and could not change, she saw her job performance as negative and stable, there was really no point in applying for another. Internality vs. Externality, or "It's all my fault!" vs. "I had no role in it". The person obsesses on any less than perfect behavior in a social situation and blames any disappointment on that behavior. The overall objective look at asituation is lost, like the patient who saw one pause in the conversation as indicative of a failed social interaction and was sure he had madea bad impression. The woman mentioned earlier who was working on a team project, felt completely responsible for its success or failure, in spite of the fact that there were other people working on it.If it failed it would be her fault. When asked what she would think if it succeeded she said that theteam would be responsible, that their support would haveenabled her contribution. This patient had been actively contributing,but had a difficult time seeing her role in team successes. When the team struggled or failed, she was sure that it was her inadequacy that was causing whatever difficulty the team was having, including carrying out their individual responsibilities! She © 2001, The Shyness Institute; for details, see page 1.


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had survived four consecutive layoffs during the preceding three years, but she was convinced that she was the one who would be fired. She further had trouble believing her manager's reassurance, but did not acknowledge her insecurity to her manager because it seemed "weak". She finally could laugh at herself when the group members continued to challenge her distortions, citing examples in the group when she acknowledged others, but was selfdenigrating. However, the suffering she endured during the week before she came to group was intensely painful. She acknowledged that she was practicing internal selfblaming attributions for any negative outcome, and ignoring her role on the team when there were positiveoutcomes. She resolved to challenge her self-blaming attributions earlier and more systematically during her homework exercises, which she was increasingly able to do with the group's help and on her own. She also paid more attention to her own role in team successes. Globalization or "Here = Everywhere", and "Behavior = Self" Globalization occurs particularly in relation to blaming oneself for disappointing social interactions. The person may be self-blaming inappropriately and then generalizeot all other social situations. Or, an individual does not perform in a hoped for way in a given interaction and generalizes across across all parts ofthe self. For example, a patienthad the homework assignment of greeting a female security guard as he entered his place of work. She responded with a smileon one occasion and thendid not respond the nexttime. The patient assumed he had done something wrong that caused her to ignore him. He then generalized to any social interaction involving a woman, in fact he announced to the group that if he couldn't be successful in such a routine encounter there was no point in attempting to say hello to women anywhere else where it would be harder! Another patient successfully completed a homework assignment by holding a short conversation with someone he didn't know after a class he was taking. When the conversation paused and he couldn't at the moment think of something to say he assumed that he had failed, the pause was "all his fault", and it meant that he may as well not try the other situations he had planned for his homework that week. He was convinced he would do equally poorly in all situations. The group pointed out that there was noproof that the conversation would not have continued, that the other person would not have said something next, or that he would not have thought of something to say himself in a moment. There was also nothing that ni dicated that he could notinitiate more conversation in the other places he had planned, like his volleyball group or an eating club he had joined. When group members mentioned previous successes in saying hello to women and making eye-contact, he had not generalized from these successes. He began to see that trying © 2001, The Shyness Institute; for details, see page 1.


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different situations would be likely to bring continued practice and an increased frequency of good outcomes. He also generalized across aspects of the self, in that he did not view looking for something to say as a specific social skill he was practicing, but saw it as something about himself that was "built in", tied to his whole personality, his silence was equated to his "awkwardness", which was identified as a large component of himself. The woman mentioned previously, who was mortified abut her complexion, had never engaged in a reality check. When she asked the group for feedback about how much they were aware of her "bad skin" she began to slowly become less global about minor imperfections in her appearance. This woman met criteria for Body Dysmorphic Disorder in her ruminative preoccupation with minor imperfections in her appearance. Controllability or "I blew it" vs. "Clueless" The adolescent who was working with social anxiety and avoidance prompted by transferring to a new private school did not recognize that she had control over her own behavior, and therefore of the impression she was making, as she met new people. This belief that "self-confident others" were in control of her social interactions added significantly to her sense of inadequacy and growing resentment toward others whom she viewed as snobbish and cold. She assumed she "blew it" or worse, that there was something wrong with her when others were not more welcoming. She became more and more passive and withholding in casual conversations with classmates. When we explored the possibility that others were already involved with established activities, which might just mean that she would need to make a bit more effort, she began to challenge both her self-blame and her belief that initiating contacts was "too hard for her", which translated into "I am not up to this challenge". As a result, her attitude toward her homework assignments became more positive as did her emotional stance toward potential friends. When asked whether former friends had sought her out in her previous school setting she responded positively, but was "clueless" as to why . As she thought about her previous social life she remembered that others had commented on her friendliness, helpfulness with others, and general consideration of classmates and friends. She began to observe her own behavior and that of others more objectively as she assigned herself specific tasks, like asking someone about a homework assignment or for help with a math problem. She could then begin to look for friends in the new school who were more like she had been, instead of focusing on whatever was “wrong” with her when previously formed groups were not as receptive to newcomers as she had hoped. Compensatory Attribution



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The compensatory attributional pattern frequently appears inthe form of the overcontrolling group member. This person may talk excessively when sociallyanxious and unknowingly dominate group process. Other group members may become angry and rejecting when this occurs, so it is useful to comment early on that overactivity can be a reaction to social anxiety, just like underactivity can be.One of the therapists can think of an example where he/she talked excessively when nervous, and didn't recognize that another person couldn't get a word in edgewise! It helps to use humor and to laugh at oneself here. This pattern often is connected tothe belief that thetherapists either can't help because the problem is overwhelming, or need help themselves. Some shy people had parents they viewed as inadequate socially or otherwise, and shy children frequently get attention from teachers by always being helpful. It may be a relief to the shy person tobe able to let go of "helping" and to have thefreedom to take care of him/herself. It is also frequently a relief to know that overactivity or pressured participation isn't necessary because everyone will be invitedand helped to participate. Sometimes, however, it isa difficult role to relinquish because of previous reinforcement and the escape it offered from the anxiety of participation "for oneself". SELF CONCEPT DISTORTIONS

"It can't be me" vs. "That's just how I am." The programmer mentioned above who made stable attributions in relation to perceived mistakes at work procrastinated in updating and distributing her resume to potential employers, giving many explanations about how her skills were too outdated, her years of experience of no value, how she would not interview well, etc. When the group began to challenge her attribution style she resisted vehemently, becoming angry particularly when maladaptive thinking patterns became apparent. What emerged was an entrenched negative belief in her own inadequacy and unacceptability, which made it difficult for her to accept group support. Her belief, and the accompanying shame, was expressed in a kind of angry obstinence that pushed even the most intrepid members away. They became frustrated both with therigidity of her belief and with her expressed anger. She did not recognize either her own self-defeating pattern or the rejection others were feeling when she responded angrily to their efforts to help. When she could express her embarrassment and shame the group better understood her obstinacy and became more patient, and she began to see the negative impact of her behavior.



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The other side of this coin is the resistance to the successful self concept. If homework goes well without too much effort, and people are responding well, or if the person gives the talk and it's well received, shy group members communicate a sense that it can't last. Sometimes when successes are pointed out they actually say, "this isn't me," or "somehow it doesn't feel right." Other times they will say, "I don't want to let others know I am doing well, because then they will expect it of me all the time and I don't think I can do that." The fear of others' expectations will appear to other group members as clinging to the old self-concept, but it can be useful to describe what looks like clinging as just the slow process of reconceptualizing the self, of adding and reworking associative links, just as in other kinds of learning. The Perfect Self vs. The Real Self Perfectionism in shy individuals and social phobics takes the form of idealized external social standards that must be metin order to be an acceptable person. This appears to be exacerbated in shy people who become isolated (some eventually diagnosed with avoidant personality disorder), perhaps because they have none of the intimate relations that allow people to share and see each others' imperfections. They idealize others' capacities. They also don't receive the interpersonal feedback that would allow them to see themselves more clearly. Shy extroverts, however, work to perform like entertainers or actors and may still cut themselves off from real relationships where social masks are removed and imperfections become more apparent andaccepted. They experience internal stress and discomfort in trying to maintain their "roles", and attentional and cognitive capacity is used to evaluate the self, rather than to focus on interpersonal or work-related tasks at hand. This strategy interferes withsocial and professional functioning. Examples include menin the group who think they must approach women with a practiced "line", being completely smooth and impeccably skilled. They are surprised when female group members report that they respond well to men who don't have a practiced approach, that in fact, too smooth an approach suggests that the woman is a conquest, not a person. Confederates have said they appreciate it when a man who feels a littleshy at a social gathering says so. They then don't misunderstand reticence as snobbery or emotional unavailability, and they feel more comfortable themselves. The conversation often moves intosubjects of mutual interest rather than critical evaluation of the self or the other person. It is important for group therapists to pay particular attention to this tendency to perfectionistic thinking about social interaction as theatre with all others being expert actors. This is usually correlated with the tendency to think that others do not experience shyness and that others expect perfection of the shy person. Shy group members may be highly © 2001, The Shyness Institute; for details, see page 1.


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critical of themselves and, less frequently, highly critical of other members. If these tendencies are not brought to the surface and challenged, the group cannot be a safe container for experimentation and practice with new behaviors. Shame-based Self-concept: The tendency to see the self as basically inadequate, particularly in relation to behaviors and attitudes that the shy/socially phobic person wants to change, is one of the most important areas to target inworking with this population. When working with automatic thoughts in general, particularly for those with entrenched shyness patterns, the shame-related labels applied to the self interfere with challenging distorted thinking about social situations in general and challenging assumptions about others' reactions. Furthermore, shame-related labels are frequently accompanied by idealizing or powerrelated labels for others. The shame-based self-concept, which is the belief that that the self is truly defective, probably arises from continuing cognitive, particularly attributional distortions, especially continuing self-blame with accompanying stateshame. When the shy person sees himself or herself as a loser, expectations of both oneself and others are distorted. Furthermore, positive feedback can be seen as untrustworthy. When working with cognitive distortions in general, these labels may emerge in the disputation process, but often do not in the time allotted, particularly in a short-term group. Painful beliefs about the self are hard to acknowledge, particularly by those who are shame-prone. Therapists need to distinguish between more accessible and less threatening cognitive distortions, and distortions that point to a shame-based self-concept, that is, the view of the self as basically and irrevocably flawed or defective. For example, a college freshman successfully completed an eight-week shyness group, entering feared situations and completing assigned homework. She returned as a senior when she began to recognize that although she was comfortable with acquaintances and expressing her thoughts and opinions in classes, she had not been deepening friendships to the point where she could share real concerns and feelings with others. As she was close to graduation she realized that finding friends was not going to be easier in graduate school. In her second group experience she began to look at attribution style and self-concept distortions more specifically, and recognized that she had a longstanding belief that she was inadequate socially. She recognized that when a group of friends had dissolved in highschool she had blamed herself for the event and had assumed that she was the problem. Had she been adequate socially, she would have been able to hold the group together. Although she had made substantial progress in her first group experience she still had been reluctant to self-disclose in relationships, which interfered with going from © 2001, The Shyness Institute; for details, see page 1.


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acquaintance relationships to deeper intimacy.In the subsequent group she started challenging her attribution style andher self-beliefs more specifically. She began to change her attribution style and beliefs about herself, and was able to begin to let others know her better. Maladaptive Self-belief It is useful when working with shy or socially phobic individuals to recognize a category of self-belief besides negative or shame-based labels, that is maladaptive in that it is used to prevent them from reaching interpersonal and professional goals.It may be a belief about the self thatis not necessarily inaccurate or even necessarily that negative.The belief may be as simple as "I am not beautiful", but it may imply, "one has to be beautiful to find a partner". Shy women often focus on appearance when they are avoiding dating. They may be correct, in that they may not be beautiful like the 110 pound 5'10" model, or the classic beauty in cosmetic ads, but they are frequently attractive enough to find partners they would enjoy. Often it simply takes gettingthe belief to a more specific level. "Not as beautiful as whom? What feature is itthat you don't like?" The truth or falsehood may not be as important as the function, and time can be wasted if the person holds more tenaciously to the belief as the group challenges it.What is important is thequestion, "does that belief bring you closer to your goal?" "What mood does it putyou into when you focus on that belief? Does that mood help you make contact with others?" "If a friend held that belief what would you think?" With men it is frequently the belief that in order to date they must act like aggressive salespeople selling a commodity, or like sitcom actors with a quip for every occasion. They may believe accurately that they are not as aggressive as some men, but they often overvalue aggression and undervalue the traits they possess. They may also confuse aggression with self-assertion. Again it helps to challenge their thoughts untilthe belief becomes more specific, and if they are amenable to it, specific behavioral feedback from other group members and confederates is very helpful. Compensatory Self-belief The belief that many shy/socially phobic people hold, that they must compensate for feelings of inadequacy or unacceptability by maintaining a perfect social image, interferes with taking risks ininterpersonal situations. Those that are able to maintain a nearly perfect image in spite of intense discomfort, may do well in social interaction, but experience ongoing tension and have difficulty with spontaneity because they seldom have the opportunity to find that others may actually feel more comfortable with them if they aren't perfect. They may be experienced as formal by others, who often do not recognize their anxiety. Sometimes they are seen as passive or even rigid. They may be left out of social © 2001, The Shyness Institute; for details, see page 1.


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gatherings not because people do not like them, but because they seem unapproachable. They are frequently surprised when they begin to take risks in the group setting, that people respond favorably and become more engaged ininteractions with them. Often a sense of humor will emerge aspeople loosen up. Working with this belief by educating patients about how it may push people away may begin to make it more comfortable to bring the beliefs to the surface. If therapists are able toadmit to beliefs like this themselves, itgreatly facilitates this process.. Zimbardo (1977) used the example of the shy person who thought he had to give the perfect dinner party. His party turned outto be so elaborate that people were reluctant to devote the time to doing the same thing, or toinvite him over on a more casual basis. A graduate student who thought that small talk or ordinary conversation would make him appear stupid, remained quiet or chastised himself for saying "vapid" things, and was reluctant to approach others. People assumed thathe was arrogant. When he became more spontaneous during the group he turned out to have a lively sense of humor, including an appreciation of the absurdity of ordinary human struggles, resulting in his instigation of considerable hilarity in all of us.



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Figure x Exercise in Disputing AutomaticAttributions and Beliefs aboutthe Self Situation: Your professor in a large class says that hewants you to summarize the content and define the central issues involved in the papers you read for today. He'll give you about 10 minutes. Initial reactions: Your SUDS goes up to around 70 - 80 Your mind goes blank Your heart pounds You feel slightly faint Possible Automatic Attributions and Self-beliefs He must know I can't do this Whatever made me think I could do this I'll sound stupid People will find out that I'm not as smart as everyone else I shouldn't be nervous, there is something wrong with me Results of Challenging ATT's and SB's SUDS begins to come down Mind begins to work, start thinking about the material Heart rate slows Sense of staying on one's own side returns



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Challenging Automatic Attributions and Self-Concept Distortions The therapist can again refer to the example from the week before and the distortions that are already on the flip chart. Using the second list of challenges, therapists begin to challenge the attributions and self-beliefs already listed or that are implied in the automatic thoughts previously collected. Group members also challenge the attributions and beliefs. At this point the example (fig. x) is handed out and patients callout all automatic thoughts, including attributionsand self-beliefs. As these are collected, attributional distortions, and self-concept distortions are highlighted as needing special effort, because they are apt to be powerful., Both lists of distortions are used to find the best fit for each thought. Group members then challenge (with thehelp of the therapists) any thought, belief, or attribution using the second list of challenges. Homework Assignment Group members are asked again to monitor their AT's, ATT's and Self-beliefs (SB's) as they did the previous week, but use the list of Thought/Attributional and Selfconcept Distortions and Challenges to help them begin the actual Thought/Attributional and Self-concept retraining. They need to record the date, the situation, their AT's, ATT's and Self-beliefs. They need to identify Cognitive/Attributionaland Self-concept distortions in each situation. They challenge each AT, ATTand negative Self-belief and developa rational response to each. Group members are asked to do this at least once a day, and preferably twice, in the situations thattrigger social anxiety. They are encouraged to start performing the feared behaviors, or entering situations that will bring up their SUDS levels, such as approaching a stranger or speaking up in class. They are given them several copies of the self-monitoring form, and told that the homework will help them identify the AT's, ATT's and SB's. They need also to have the List of Attributional and Self-concept distortions and the Challenges. Preparation for Exposures Group members are nervous at this point, and it is a time when drop-outs may occur. Acknowledge their discomfort and reiterate theimportance of contact witheach other as a support group through their phone calls and emphasize how important it is that everyone is committed to thisprocess together. It is a learning process in asafe environment where we alllearn to take risks and practice new behaviors. Tell them that © 2001, The Shyness Institute; for details, see page 1.


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their anticipatory anxiety is important becauseit will inform them about theirautomatic thoughts, including attributions and self-beliefs, and it is important that their SUDS levels come up in the group exposures in order to get the desensitization that will allow their anxiety to come down in the long run. We will be challenging their AT's, ATT's and SB's as we do the exposures, and we will start manageable situations and work up from there.



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DESIGN SCIENCE LICENSE TERMS AND CONDITIONS FOR COPYING, DISTRIBUTION AND MODIFICATION Copyright © 1999-2001 Michael Stutz Verbatim copying of this document is permitted, in any medium. 0. PREAMBLE. Copyright law gives certain exclusive rights to the author of a work, including the rights to copy, modify, and distribute the work (the "reproductive," "adaptative," and "distribution" rights). The idea of "copyleft" is to willfully revoke the exclusivity of those rights under certain terms and conditions, so that anyone can copy and distribute the work or properly attributed derivative works, while all copies remain under the same terms and conditions as the srcinal. The intent of this license is to be a general "copyleft" that can be applied to any kind of work that has protection under copyright. This license states those certain conditions under which a work published under its terms may be copied, distributed, and modified. Whereas "design science" is a strategy for the development of artifacts as a way to reform the environment (not people) and subsequently improve the universal standard of living, this Design Science License was written and deployed as a strategy for promoting the progress of science and art through reform of the environment. 1. DEFINITIONS. "License" shall mean this Design Science License. The License applies to any work which contains a notice placed by the work's copyright holder stating that it is published under the terms of this Design Science License. "Work" shall mean such an aforementioned work. The License also applies to the output of the Work, only if said output constitutes a "derivative work" of the licensed Work as defined by copyright law.



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7. NO WARRANTY. THE WORK IS PROVIDED "AS IS," AND COMES WITH ABSOLUTELY NO WARRANTY, EXPRESS OR IMPLIED, TO THE EXTENT PERMITTED BY APPLICABLE LAW, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. 8. DISCLAIMER OF LIABILITY. IN NO EVENT SHALL THE AUTHOR OR CONTRIBUTORS BE LIABLE FOR ANY DIRECT, INDIRECT, INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES (INCLUDING, BUT NOT LIMITED TO, PROCUREMENT OF SUBSTITUTE GOODS OR SERVICES; LOSS OF USE, DATA, OR PROFITS; OR BUSINESS INTERRUPTION) HOWEVER CAUSED AND ON ANY THEORY OF LIABILITY, WHETHER IN CONTRACT, STRICT LIABILITY, OR TORT (INCLUDING NEGLIGENCE OR OTHERWISE) ARISING IN ANY WAY OUT OF THE USE OF THIS WORK, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGE. END OF TERMS AND CONDITIONS


Social Fitness-Therapist Manual

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