Chapter 18A Cognitive Perspective onSocial PhobiaDavid M. Clarkthe cognitive modelProcessing in Social SituationsProcessing of the self as a social objectSafety behavioursSomatic and Cognitive SymptomsProcessing of External Social CuesProcessing before and after a Social Situationempirical studies of the cognitive modelHypothesesConclusionsa theory derived cognitive treatmentTherapeutic RelationshipDeriving an Idiosyncratic Version of the ModelManipulation of Self-focused Attention and Safety BehavioursVideo and Audio FeedbackShift of Attention and Interrogation of the Social EnvironmentDealing with Anticipatory and Post-event ProcessingDealing with Assumptionseffectiveness of the cognitive treatmentacknowledgementsreferencesThe persistence of social phobia is a puzzle. Individuals with other phobias suchas claustrophobia, height phobia, and small animal phobias are able to success-fully avoid most encounters with their phobic object and it is generally thoughtInternational Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Selfand Shyness. Edited by W. Ray Crozier and Lynn E. Alden.© 2001 John Wiley & Sons Ltd.that this avoidance is the main reason for the persistence of their fears. In con-trast, the nature of modern society is such that patients with social phobia oftenhave to enter feared social situations. This distinction is recognized in recent ver-sions of the Diagnostic and Statistical Manual for Mental Disorders (APA, 1987,1994) where avoidance is necessary for the diagnosis of all phobias except forsocial 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 situa-tions? The present chapter provides an overview of a recent cognitive model ofsocial phobia (Clark & Wells, 1995; Clark, 1997; Wells, 1997, 1998; Wells & Clark,1997) that was specifically developed to explain such persistence.1Following adescription of the model, research testing key aspects of the model is summa-rized, a treatment programme which aims to reverse the maintenance processesspecified in the model is outlined, and preliminary evaluations of the treatmentand its components are reviewed.THE COGNITIVE MODELFor the purpose of exposition, the model is divided into two parts. The first partconcerns what happens when a social phobic enters a feared social situation. Thesecond concerns what happens prior to entering, and after leaving a social situation.Processing in Social SituationsFigure 18.1 illustrates the processes that Clark and Wells suggest occur when asocial phobic enters a feared social situation. On the basis of early experience,patients with social phobia develop a series of assumptions about themselves andtheir social world. The assumptions can be divided into three categories:• Excessively high standards for social performance, e.g., “I must not show anysigns of weakness”, “I must always sound intelligent and fluent”, “I shouldonly speak when other people pause”,“I should always have something inter-esting to say”.• Conditional beliefs concerning the consequences of performing in a certainway, e.g., “If I disagree with someone, they will think I am stupid/will rejectme”, “If my hands shake/I blush/or show other signs of anxiety, people willthink I am incompetent/odd/stupid”, “If I am quiet, people will think I amboring”, “If people get to know me, they won’t like me”.406 DAVID M. CLARK1The Clark and Wells model draws heavily on the writings of earlier theorists, especially those ofBeck, 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 isunique in the particular synthesis it proposes. If the reader views the synthesis as worthwhile, it isbecause its authors benefited from “standing on the shoulders of giants”.• Unconditional negative beliefs about the self, e.g., “I’m odd/different”, “I’munlikeable/unacceptable”, “I’m boring”, “I’m stupid”, “I’m different”.Such assumptions lead individuals to appraise relevant social situations as dan-gerous, 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 orambiguous social cues as signs of negative evaluation by others. Once a social situation is appraised in this way, the social phobic becomes anxious. Severalinterlinked vicious circles then maintain the individual’s distress and prevent dis-confirmation of the negative beliefs and appraisals.Processing of the Self as a Social ObjectA key factor is a shift in focus of attention and a particular type of negative self-processing.When individuals with social phobia believe they are in danger of neg-ative evaluation by others, they shift their attention to detailed monitoring andA COGNITIVE PERSPECTIVE ON SOCIAL PHOBIA 407Figure 18.1 A model of the processes that occur when a social phobic enters a fearedsocial situation (adapted from Clark & Wells, 1995)observation of themselves. They then use the internal information made accessi-ble by self-monitoring to infer how they appear to other people and what otherpeople are thinking about them. In this way they become trapped in a closedsystem in which most of their evidence for their fears is self-generated and dis-confirmatory evidence (such as other people’s responses) becomes inaccessibleor is ignored.Three types of internal information are used to generate a negative self-impression. First, feeling anxious is equated with looking anxious. This can leadto marked distortions. For example, an individual may have a strong shaky feelingand 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 occurringimages 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 butrather their fears visualized. For example, an individual who was concerned thatshe would appear stupid if she joined in a conversation with colleagues experi-enced marked tension around her lips before speaking. The
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