Chapter 18 A Cognitive Perspective on Social Phobia David M Clark the cognitive model Processing in Social Situations Processing of the self as a social object Safety behaviours Somatic and Cognitive Symptoms Processing of External Social Cues Processing before and after a Social Situation empirical studies of the cognitive model Hypotheses Conclusions a theory derived cognitive treatment Therapeutic Relationship Deriving an Idiosyncratic Version of the Model Manipulation of Self focused Attention and Safety Behaviours Video and Audio Feedback Shift of Attention and Interrogation of the Social Environment Dealing with Anticipatory and Post event Processing Dealing with Assumptions effectiveness of the cognitive treatment acknowledgements references The persistence of social phobia is a puzzle Individuals with other phobias such as claustrophobia height phobia and small animal phobias are able to successfully avoid most encounters with their phobic object and it is generally thought International Handbook of Social Anxiety Concepts Research and Interventions Relating to the Self and Shyness Edited by W Ray Crozier and Lynn E Alden 2001 John Wiley Sons Ltd 406 DAVID M CLARK that this avoidance is the main reason for the persistence of their fears In contrast the nature of modern society is such that patients with social phobia often have to enter feared social situations This distinction is recognized in recent versions of the Diagnostic and Statistical Manual for Mental Disorders APA 1987 1994 where avoidance is necessary for the diagnosis of all phobias except for social phobia where it is specified that the phobia situation must be either avoided or endured with intense distress APA 1994 p 417 emphasis added Why does social phobia persist despite regular exposure to feared social situations The present chapter provides an overview of a recent cognitive model of social phobia Clark Wells 1995 Clark 1997 Wells 1997 1998 Wells Clark 1997 that was specifically developed to explain such persistence 1 Following a description of the model research testing key aspects of the model is summarized a treatment programme which aims to reverse the maintenance processes specified in the model is outlined and preliminary evaluations of the treatment and its components are reviewed THE COGNITIVE MODEL For the purpose of exposition the model is divided into two parts The first part concerns what happens when a social phobic enters a feared social situation The second concerns what happens prior to entering and after leaving a social situation Processing in Social Situations Figure 18 1 illustrates the processes that Clark and Wells suggest occur when a social phobic enters a feared social situation On the basis of early experience patients with social phobia develop a series of assumptions about themselves and their social world The assumptions can be divided into three categories Excessively high standards for social performance e g I must not show any signs of weakness I must always sound intelligent and fluent I should only speak when other people pause I should always have something interesting to say Conditional beliefs concerning the consequences of performing in a certain way e g If I disagree with someone they will think I am stupid will reject me If my hands shake I blush or show other signs of anxiety people will think I am incompetent odd stupid If I am quiet people will think I am boring If people get to know me they won t like me 1 The Clark and Wells model draws heavily on the writings of earlier theorists especially those of Beck Emery and Greenberg 1985 Butler 1985 Hartman 1983 Heimberg and Barlow 1988 Leary 1983 Salkovskis 1991 Teasdale and Barnard 1993 and Trower and Gilbert 1989 but is unique in the particular synthesis it proposes If the reader views the synthesis as worthwhile it is because its authors benefited from standing on the shoulders of giants A COGNITIVE PERSPECTIVE ON SOCIAL PHOBIA 407 Figure 18 1 A model of the processes that occur when a social phobic enters a feared social situation adapted from Clark Wells 1995 Unconditional negative beliefs about the self e g I m odd different I m unlikeable unacceptable I m boring I m stupid I m different Such assumptions lead individuals to appraise relevant social situations as dangerous to predict that they will fail to achieve their desired level of performance e g I ll shake I ll make a fool of myself and to interpret often benign or ambiguous social cues as signs of negative evaluation by others Once a social situation is appraised in this way the social phobic becomes anxious Several interlinked vicious circles then maintain the individual s distress and prevent disconfirmation of the negative beliefs and appraisals Processing of the Self as a Social Object A key factor is a shift in focus of attention and a particular type of negative selfprocessing When individuals with social phobia believe they are in danger of negative evaluation by others they shift their attention to detailed monitoring and 408 DAVID M CLARK observation of themselves They then use the internal information made accessible by self monitoring to infer how they appear to other people and what other people are thinking about them In this way they become trapped in a closed system in which most of their evidence for their fears is self generated and disconfirmatory evidence such as other people s responses becomes inaccessible or is ignored Three types of internal information are used to generate a negative selfimpression First feeling anxious is equated with looking anxious This can lead to marked distortions For example an individual may have a strong shaky feeling and assume that others must be able to see his or her hand shaking violently when all that can be observed by others is a mild tremor or nothing at all Second many patients with social phobia appear to experience spontaneously occurring images in which they see themselves as if viewed from an observer s perspective Unfortunately what they see in the image is not what the observer would see but rather their fears visualized For example an individual who was concerned that she would appear stupid if she joined in a conversation with colleagues experienced marked tension around her lips before speaking The tension triggered an image in which she saw herself with a contorted facial expression looking like the village idiot Third more diffuse types of felt sense can also contribute to the
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