Social Fitness-Therapist Manual

Social Fitness Therapist Manual
June 5, 2001
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Lynne Henderson
The Shyness Institute, 2000 Williams Palo Alto CA 94306
Copyright 2001 The Shyness Institute; this information may be

copied, distributed and/or modified under certain conditions, but
it comes WITHOUT ANY WARRANTY; see the
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2001, The Shyness Institute; for details, see page 1.
June 5, 2001
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 style Restructuring
Chapter 7. Self-concept Restructuring
Chapter 8. Final session with relapse inoculation and ongoing goal setting
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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 community in 1982. Margaret Marnell directed the original group
treatment under the supervision of 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 provides the 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 skills training,
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 the self 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 or individual
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
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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 to exposures. These techniques will substitute for the 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 subtle than 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 of particular 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 of a 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 highly salient
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 self in 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 arise at 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 fitnessif 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
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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 are failing 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
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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 traitswhether
genetically or environmentally inducedas 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 Phobiafor 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.
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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 the clients 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
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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 early experiences, thereby facilitating insight into 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, youll 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
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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 selfmore 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
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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, youll 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 therapists 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
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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
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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?
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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.
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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 clients 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
achievableotherwise patients may discount progress by simply raising the bar when they do meet
a goal, or achieve a step along the way: OK I did this, 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:
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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 practice on 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. Homeworkthat
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
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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 dont 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 you as a therapist than in any other social situation they encounter. You will find
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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 and the 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
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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
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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 workresist 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 become expert at resisting being 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 Ive 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
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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.
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Difficulty Finding or Utilizing Social Situations for In 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 clients 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 clients strengths throughout the initial evaluation. This often
means pointing out the ways in which they are performing well in some situationsthey 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 persons 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
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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 goalsthat 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
June 5, 2001
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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.
June 5, 2001
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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
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
5
4. I rarely worry about what kind of impression
I am making on someone.
1
2
3
4
5
5. I am afraid that others will not approve of me. 1
2
3
4
5
6. I am afraid that people will find fault with me. 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
what they may be thinking of me.
1
2
3
4
5
9. I am usually worried about what kind of
impression I make.
1
2
3
4
5
10. If I know someone is judging me,
it has little effect on me.
1
2
3
4
5
11. Sometimes I think I am too concerned with what
other people think of me.
1
2
3
4
5
12. I often worry that I will say or do the wrong
things.
1
2
3
4
5
June 5, 2001
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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.
June 5, 2001
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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
June 5, 2001
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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June 5, 2001
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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.
June 5, 2001
Page 39 of 39
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 will be
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. Dont 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.
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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?
June 5, 2001
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If your client is using an antidepressant, discuss the importance of attributing ones 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 in situations 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) become preoccupied 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?
June 5, 2001
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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.
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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?
June 5, 2001
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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. Weve 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, youll 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 issuesometimes 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
June 5, 2001
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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 assuredin a positive and
realistic fashionthat 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
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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 caseincluding 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 Friends by 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 be ready 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 20th . 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.
June 5, 2001
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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 youd 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
June 5, 2001
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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/
Moderate anxiety/
Extreme anxiety/
discomfort
discomfort
discomfort
SUDS
Rating
Definition
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
June 5, 2001
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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.
June 5, 2001
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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:
Situation: ____________________________________________________________________
Comments:
June 5, 2001
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Situation: ____________________________________________________________________
Comments:
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.
June 5, 2001
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Session 2: Constructing a Hierarchy

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 them to 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 tried for 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 practicing new 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 if they seem too large or too small. Use the questionnaire
to guide you in exploring any negative feelings that arose 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 to a 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 explore their 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 TO ADJUST THE DOSAGE OR MAKE
OTHER SUGGESTIONS TO REDUCE THEIR DISCOMFORT.
Set Agenda
June 5, 2001
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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 to the most
feared, in which the client feels uncomfortable and wants to practice 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 wont 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 how their
thoughts often do not coincide with their behavior. If they have rated an outcome 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 how they feel.
*I NOTICE THAT ONE OF YOUR AUTOMATIC THOUGHTS WAS I WONT BE
ABLE TO THINK OF ANYTHING TO SAY. DID YOU EVENTUALLY THINK OF
SOMETHING? ISNT IT INTERESTING THAT YOUR HYPOTHESIS, THAT YOU
COULDNT SAY ANYTHING, WAS NOT CONFIRMED. ID 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 WHAT 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
June 5, 2001
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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 the course of treatment. A sample hierarchy is
provided and a blank hierarchy for the client.
June 5, 2001
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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 level of anxiety in each situation.
0----------10---------20------------30-----------40----------50-----------60------------70------------80----------90---------100
Do not avoid
Hesitate to Sometimes
Usually avoid
Invariably
situation
enter situation
avoid
situation
avoid - very
no anxiety
but rarely avoid situationmarkedly or
severe/
it - slightly/
definitely
very often
continuous
somewhat anxious
anxious
anxious
anxiety, near panic
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.
3.
4.
5.
The second worst

situation
Asking someone Im attracted to for a

date
The third worst

situation
Approaching a group of strangers
The fourth worst

situation
Approaching one opposite-sex stranger
The fifth worst

situation
Approaching a stranger of the same sex
6.
7.
8.
9.
The sixth worst

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

situation
June 5, 2001
Joining a conversation with colleagues

at work
Talking about my project in a small
work meeting
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
Page 59 of 59
June 5, 2001
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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 level of anxiety in each situation.
0----------10---------20------------30-----------40----------50-----------60------------70------------80----------90---------100
Do not avoid
Hesitate to Sometimes
Usually avoid
Invariably
situation
enter situation
avoid
situation
avoid - very
no anxiety
but rarely avoid situationmarkedly or
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.
The second worst

situation
3.
The third worst

situation
4.
The fourth worst

situation
5.
The fifth worst

situation
6.
The sixth worst

situation
7.
The seventh worst

situation
8.
The eighth worst

situation
9.
The ninth worst

situation
June 5, 2001
10. The tenth worst

situation
Page 61 of 61
June 5, 2001
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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 dont know, ask them to tell 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 you are 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 BARELY CAN TOLERATE. THIS OFTEN TURNS OUT TO BE A
PUBLIC SPEAKING TASK OR ONE-TO-ONE INTERACTION WITH A DATE OR
POTENTIAL ROMANTIC PARTNER. USUALLY THESE HAVE A SUDS LEVEL 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 SOME OF THE TIME, OR
ESTIMATES AVOIDANCE AROUND 70 OR 80, BUT HASNT 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 these examples.
*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
June 5, 2001
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or being critical of you? How much do you avoid going, or avoid participating once you are there,
on that same scale of 1 to 100.
BE SURE TO GET TEN SITUATIONS. LOOK FOR SITUATIONS THAT MAY
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 for the 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 will role-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 in these situations. Ask them to record their
SUDS levels before and afterward. *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 of the situation, how you thought it turned out overall. Was it on the
negative or positive side? Then rate your thoughts about yourself and your thoughts about the
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 they want to practice. That way you can revise the hierarchy together as needed.
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.
June 5, 2001
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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 a negative outcome (failure) of each situation. For each situation,
imagine yourself in that situation, and tell me the one major cause of that negative 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 to your stated cause. We will use the following rating scale to
make your judgment:
Rate the cause
1 2 3 4 5 6 7 8 9
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.
June 5, 2001
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Therapist says, Imagine that you are ___________(most challenging situation). Imagine that
it doesnt go as well as you had hoped or just imagine that the outcome is negative.
The cause of this outcome is
1 2 3 4 5 6 7 8 9
The degree to which the cause is due to something about you, rather
than to other people or circumstances.
1 2 3 4 5 6 7 8 9
The degree to which the cause is relevant to many different

situations, rather than being specific to a few situations.
1 2 3 4 5 6 7 8 9
The degree to which the cause can be expected to be present at the

same level every time the same situation occurs.
1 2 3 4 5 6 7 8 9
The degree to which the cause is a factor that you have control over.
1 2 3 4 5 6 7 8 9
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
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
feeling ridiculous, laughable
3.
feeling humiliated, "stupid," 'childish"
4.
feeling helpless, paralyzed
5.
feelings of blushing
4
4
4
4
1.
June 5, 2001
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Therapist says, Imagine that you are ___________(second challenging situation). Imagine
that it doesnt go as well as you had hoped or just imagine that the outcome is negative.
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
blame.
items).
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
3.
4.
5.
4
4
4
4
1.
June 5, 2001
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Therapist says, Imagine that you are ___________(third challenging situation). Imagine that
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
blame.
items).
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
3.
4.
4
4
4
4
5.
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
June 5, 2001
Page 68 of 68
or transmitted in any form by any means, electronic, mechanical, photocopying, recording,

or otherwise, without the prior written permission of Lynne Henderson, Ph.D.
June 5, 2001
Page 69 of 69
Use the top three situations from their hierarchies. 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 cant make conversations,
etc. Ask them to rate the cause. You said that you couldnt 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 say that something about them
caused the negative outcome. The talk did not go well because they cant 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 BE ABLE TO CONTROL A CONVERSATION
BETWEEN TWO PEOPLE. WHAT YOU ARE HOPING TO ACHIEVE IN THERAPY ARE
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 likely to 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?...
June 5, 2001
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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 to how
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 elicit questions and reactions. Communicate to the client that these are the
typical thoughts and feelings for shy and 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 is useful. Tell them they are going to 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 and the overall goals for treatment. 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 CLIENTS WILLINGNESS TO ANSWER
QUESTIONS THAT YOU KNOW BRING UP THE DISCOMFORT THEY FEEL IN THE
STRESSFUL SITUATIONS. ACKNOWLEDGE STRENGTHS, SUCH AS THE CLIENTS
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 THOUGHTS AND FEELINGS. TELL THEM TO PRACTICE ONE
June 5, 2001
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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 ABOUT THE 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 ONE OR MORE TIMES A DAY. LIKE PHYSICAL FITNESS,
IT TAKES DAILY WORKOUTS TO IMPROVE SOCIAL CONDITIONING.
June 5, 2001
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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 to 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. 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 related to 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 them feel 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 ask about 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 that you 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 in their 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 to have several from which they can choose as the
opportunities arise. If they are highly withdrawn it may be useful to just choose one that seems
manageable. Look at the social interaction log together and make note of the negative 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.
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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 that you both are likely to have good
ideas. You are not just teaching the client, you are experimenting and learning together. This
provides a model for collaborative learning and coaching, and begins to empower the client. The
form for this exercise is called Strategies for Social Situations and is provided. You can also give a
copy to the client. For instance, if the client has started to make a telephone 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.
Well 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
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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 is a
valuable exercise in itself, and we will work with your thought later. Now you can assign yourself
the call again. You can enter call John 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 your department. 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 and usefulness. I will help you identify negative automatic thoughts and
change them to more adaptive, self-supportive thinking patterns. Research shows that changing
maladaptive thinking patterns to more adaptive ones leads to increased proactive and positive
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 is to emphasize that the truth or falsity 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 to this 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 wont be able to think of anything to say, you will look foolish, everyone will be
able to tell you are nervous, and will know that you 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 will be 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 can be copied for the client. There is also a list provided in the 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: _me_______________
Outcome: -3 -2 -1 0 +1 +2 +3
How shy (%): __60_____ How pleasant (%) __ 30______
Thoughts about yourself: __ I wont 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 wasnt 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 . All-or-Nothing Thinking: You see things in black and white categories. If your performance falls short
of perfect, you see yourself as a total failure.
2 . Over generalization: You see a single negative event as a never-ending pattern.
3 . Mental Filter: 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 . Disqualifying the Positive: 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 . Jumping to Conclusions: 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 . Magnification or Minimization: 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 . Emotional Reasoning: You assume that your negative emotions necessarily reflect the way things really
are: "I feel it, therefore it must be true."
9 . "Should" Statements: You try to motivate yourself with "shoulds" and "shouldn'ts," as if you had to be
whipped and punished before you could be expected to do anything. "Musts" and "oughts" are also offenders.
The emotional consequence is guilt. When you direct "should" statements toward others, you feel anger,
frustration, and resentment.
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10. Labeling and Mislabeling: This is an extreme form of over generalization. Instead of
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
describing your
else's behavior rubs you

louse." Mislabeling involves
describing an event with language that is highly colored and emotionally loaded.
11. Personalization: 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 wont be able to
think of anything to say is an example of jumping to conclusions, 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, in that
they believe they must be perfectly smooth socially or be a total 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, but take 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 to recognize that these
are learned maladaptive thoughts that become chosen favorites that are imposed on the self. You
can also give an example of one of your favorites. After you have categorized several or all of their
negative thoughts, get out the Challenges to Cognitive Distortions. 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 do you 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 on your 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, although 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 left the conversation. This revelation allows you to point out
overgeneralization. Make them be specific. If they relate an incident or two, how many
conversations have you had in the last 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 an honest 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 couldnt think of anything to say to
account for the awkwardness. Be sure to ask them, does feeling ansious or awkward have to
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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 didnt 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 persons willingness to wait.
Even if that particular person thought you were awkward is that really so important?
Would their opinion necessarily reflect that of everyone else? Would your entire future depend 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? Thats not too long! You had the courage to come here and start making conversations
again. What would that say to you about someones elses 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 of course 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 a more 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 they do not really believe. They may
not be able to say, Ill 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 dont need to talk much, or I wont let it
upset me. First, they are framed in the negative and they will 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 it as no pain, no gain as in
sports. It is a natural part of the process of becoming a better social athlete. When an adaptive
response is chosen for one of the negative thoughts tell them to practice it during homework
exercises that trigger the thought.
Psychoeducation: Desensitization 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 in 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 inappropriately 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 is tolerate the ansiety until it 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 there are painful or catastrophic consequences for
ordinary social interaction. In this case, feared situations can 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 even gets worse. By gradually exposing ourselves to social 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 as people
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 Building: Conducting the Exposure
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 their hierarchy 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 a little. Tell them they will do the exercise with you this first time. Tell them to
report to you whatever automatic thoughts are occurring as they think about doing it. Write these
thoughts on a flip chart in black felt-tip pen. Also, the ones they would have in the actual situation,
in case there is any difference. Usually they will be similar to the ones mentioned earlier. Select
two of them, or one new one, have the client identify the 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 the negative 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
1 Minute
2 Minutes
3 Minutes
4 Minutes
5 Minutes
6 Minutes
7 Minutes
8 Minutes
9 Minutes
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 briefly the
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 ones 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, Ill be the confederate this time (or volunteer, or just your conversation
partner). Describe the situation from 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 that we
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 if they would like feedback about their 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 feel even 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 put others 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 a reasonable degree of attention to the needs 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 whom I have worked do not lack social
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 are distorted. 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 of their behavior that do need 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 all the 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 possible new behaviors and strategies in 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 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 and usefulness. We identifed negative automatic thoughts and changed them to more
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 again to 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 desensitization cannot 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 participating 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 situation from the bottom half of the hierarchy. Remind them to
use their social interaction log to record their thoughts and feelings. Tell them to practice one new
social behavior a day, such as a brief conversation with someone new, or a longer conversation
with someone they know. Ask them to write down any 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 a schedule of events and attend one event this week. 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 the client manual. Make sure you write it down
in case they forget next week.
Session Four: Attributional and Self-concept Restructuring and the

Second Simulated Exposure
Homework Review
Ask the client if new thoughts 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 the client 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 negative thoughts 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 into more manageable goals. You can suggest they start with one or two
minutes, perhaps combining it with a work-related task or comment to start. Perhaps just asking
whether the other person had a good week-end, or mentioning a good movie the client has seen.
Have the client think of at least one topic themselves, and acknowledge them for doing it. They
can practice this on a daily basis until they feel more comfortable extending the conversation. You
can briefly role-play possibilities.
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Preparation for the Second Exposure

Then tell the client what situation they 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 would like 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 go for a walk at lunchtime for exercise. It is most useful to keep the
exposures in alignment with their current homework and situational opportunities. 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 they will role-play in detail, using
the exposure form (Figure 6.). Ask them what automatic thoughts are occuring to them. Write
them on the flip chart with a black felt-tip pen. Identify the cognitive distortions 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 will be a pause and I wont know what to say. Theyll notice
Im nervous and it will be awkward. You will also notice that they use labels frequently. Not
only do they think they will they look foolish, but theyll see how shy I am and Ill look like an
idiot.
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 some way. That is, if they succeed they believe that it
is because they are smart, interesting, competent, good, substantial people. If they fail they
assume that it was something about the circumstances or the situation. 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 to learn, etc. Ask the
client what the advantage would be in having such a bias. Of course, it helps people maintain their
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 for failure and externalize success. That is, when
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we succeed we think it is because of the situation or other people. It was nt 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, doesnt 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 or hostile audience. A teacher in front of a
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 Western European males. It makes sense that in highly
competitive cultures that emphasize individualism, one way to successfully compete and maintain
ones motivation is to give oneself credit for success and assign failure to specific, temporary, and
controllable causes. It is less characteristic of Asian 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 all about learning and
practice, just like learning sports activities and games of any kind. Often the client will have 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 the handout. Have the client read them aloud or
take turns. As they read each one, see if it applies to any of the automatic thoughts on the flip
chart. Write the attributional distortions in a green felt-tip pen. Then challenge them using the
attribution challenges (Figure 8). They are questions designed to get at 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 that you have already identified cognitive distortions for (in
red felt-tip pen) and add the attributional distortions in green. For example, You said that there
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
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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 little self-conscious? Do you believe that is something about
you that is stable, that is, will always happen? Do you think that it will happen in all situations?
Do you believe that about the other person? Why do you think differently about yourself than
you do about them? Why do you think you are more ready to give them the benefit of the doubt?
Identifying Self-concept Distortions

Then point out an automatic thought that has a negative belief about the self in it. You
used a label here. That often implies what we call a self-concept distortion, that is, a negative
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 social performers 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 difficulty allowing for a natural social learning curve. They
assume others are just born that way and dont 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 interpersonal behavior. He and a friend in his MBA program started reading them together.
He was shocked to find that his friend often struggled with some of the same anxieties in 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 that it 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 a strength when they are not in situations where they fear evaluation and
are able to trust others they believe will be accepting. They often have beliefs about the necessity
to be dominating in order to be accepted. When they do show maladaptive behaviors they
generally overestimate the degree to which people are 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 disabilities or
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.
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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 you are unattractive, clumsy, etc.? What specific behavioral
evidence do you have? They will often identify a negative feeling or a few upsetting experiences as
evidence. It is important to explain that emotional reasoning works by negative emotions coloring
ones 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 that if they practice the new thoughts to
the degree they practice and rehearse the old ones they will be social geniuses. It is a question of
shifting the effort into more adaptive channels.
Help the client come up with a more adaptive response. Write the adaptive response on the
flip chart in black. We say adaptive rather than rational because 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 to the 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 talking to 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 to meet. 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 it at that or wait for
the other person to set up the arrangements. We usually suggest that they have in mind beforehand
where they would like to go and a meeting place. We have them take the initiative. Often other
people dont understand what is expected from them at the moment and the shy person says they
didnt 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 the SUDS level coming
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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 an exposure 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 using it and ask the confederate to come in. In this
example, the confederate would be the co-worker. Explain the situation to the confederate and
what you would like them to do. Ask for the clients SUDS level, have them read their rational
response, and begin timing the exposure. When the exposure is completed 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 new behaviors. 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 client taking 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 is playing. When ideas are pretty well exhausted thank the
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 to examine 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 do not 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
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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 the next time. Then we have the shame/self-blame cycle that actually feels 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 week as 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 wont have anything to say. If they blame themselves afterward there is no
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 the emotions they
may be aware of this week may be more sadness and negative feelings about the self. That is a
natural part of becoming aware of these thinking patterns and the emotional results. In the long
run, the awareness will be beneficial in helping them challenge the distortions. In the beginning
you will help them challenge them and they can 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 new thoughts 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 the client 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 to a party at which there were several different ethnic groups. He
started to approach one group and heard them speaking Greek. His automatic thought was that he
should not interrupt them because they wanted to 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 to ask the woman out and he would 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 the conversation 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 got comfortable. 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 continual negative 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 dont like
them, but fail to recognize that they have put the other person in the position of thinking they must
share the clients pessimism or 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 thinking 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 talking about a work-project informally in a small meeting. Ask them what
automatic thoughts are occuring 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,
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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 them and 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 time. I can practice in this situations until I become more
comfortable. I can change my automatic thoughts and practice new behaviors. or simply, I
can learn. or Ive met my goals before. I can learn to meet my goals in social situations too.

Conduct the exposure according to the same format used in previous sessions (see Figure
6.). Construct a specific goal, which in 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 this might be achieved. Turn on the video-tape if you are using it and
ask the confederate to come in. In this example, both you and the 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 to do. Ask for the clients SUDS level, have them
read their 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 responsibility and selfbeliefs. Remember to chart the SUDS level ratings on the flip chart and link any 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 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 thoughts during 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 their note-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 times a 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.
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Session Six: Practice in Cognitive, Attributional and Self-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 natural part of identifying the attributional 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 identifying and 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 most wearing 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 patterns which contribute heavily to 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 dont 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 an experienced 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 in goal-pursuit. Reframing discouragement about ones
inadequacy to learning to tolerate frustration as a strenuous and worthwhile goal in itself will
often help. The outcome of a given piece of homework is much less relevant to long 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 them to 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 last session, the client may report that he 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 he tried it, and he will remember 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 is useful. 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 the clients job. People who are chronically shy or socially
phobic will sometimes be exploited in the workplace. Have the client desribe the situation in detail,
the precise nature of the task and the relationship with the person who is requesting the favor.
Ask the client how high their SUDS level is 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, identifying the cognitive distortions first, then the attributional
and the self-concept distortions using the different colored markers. Examples of these thoughts
are: the person will be angry with me; I shouldnt let my boss down; maybe Ill lose my
job; it isnt nice to say no; maybe Ill hurt their feelings; maybe they wont like me.
Sometimes youll 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 of the automatic thoughts to challenge. Have the client ask the
questions from the challenge list as much as possible. You can assist them in coming up with
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 as well as the group goals.
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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 client can 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 wont be able to help you, but you might 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 the projects they could possibly both
be done by late tomorrow.

When you have arrived at both the adaptive response and the measurable goal, ask the
confederate to come in, turn on the video, and explain the situation to the confederate. You may
tell the confederate what to expect or leave it ambiguous. Ask for the clients 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 for at least 10 minutes. After the first exposure, leave out the minute-to-minute
checking of the SUDS and the adpative response. Let the client practice without interruption.
When the exposure is complete chart the SUDS level changes on the flip chart. Often you
will point out the rise in SUDS level as the person 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 to any
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 if they 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
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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 up after the last session. Find out how many times a
week they are doing the homework. See if the clients estimate and your estimate match. Remind
them that three times a week 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 CDs or rental videos. 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 to the
social domain. Come up with a list of adaptive strategies together that the 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 time every 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 client and
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 flip chart. 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 expect from 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 Spielbergers State Trait Anger Expression
Inventory (STAXI; See Table 2.). Clients are more likely to be resentful when blame is
externalized and they anticipate contempt from others. There are different patterns that you will
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 it in terms of
anticipating humiliation by others. They believe that others will be contemptuous of their anxiety,
and be very critical. Sometimes this belief is due to 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 and thoughtless. Sometimes the belief appears to be related
to a more general pattern of withdrawal from others accompanied by negative ruminative thinking
patterns which were not altered by social experiences that counteracted them. Usually these clients
did not tell family members or peers about these cognitive and emotional experiences 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 with schizotypal personality disorder are
significantly higher in expressed anger as well as shame, which probably reflects the redued
cognitive and emotional control in these clients. Individual therapy is an ideal place to begin to sort
out distorted thinking patterns in a context of empathy and compassion. If schizotypal clients
begin to establish trust it is a significant step. Exposing themselves to feared situations 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 they are feeling anxious, but more likely are 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 be friends than speakers think they will be. It is rare to find a
conversation partner who has never experienced shyness and social anxiety and who doesnt
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 in occupational functioning and disruptions in
relationships, and difficulty forming intimate relationships. When you begin to gently confront
these patterns clients may think you are blaming the victim and become highly defensive. It
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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 thoughts about themselves. Because of their distress and the 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 attributions and self-concept distortions, are challenged. We
have administered the questionnaire to college students and clients. Our initial results show that
shy college students score higher than non-shy students, and that shyness clinic clients score
significantly higher than college 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 clients early life may have been very powerful,
hurtful, and extrememely untrustworthy. However, other-blaming attributions may lead to
negative 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 them or ridicule them. You
help them challenge that thought the same way you work with the others. Do they know for
certain that will happen? What specific behavioral evidence do they have that this will happen. Be
sure that you do not accept emotional reasoning as an explanation. It just happens, I can tell when
people think I look stupid. It is just a sense you get, you cant explain it, you just know. Or
you know what I mean. They dont need to actually say it. You say, no, I mean specific
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behavioral evidence. 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 hadnt 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 about him. These thoughts bore an unmistakable resemblence to the things
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 or mistreated 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 your taste 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 by a 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 on him. 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 the friend 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 is happening 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 if the situation were reversed. They will be unlikely to fear 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 will treat 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 has the sole responsibility for ______? What
evidence do you have that you or the other person is the cause of______? What evidence do I have
that I cannot change ________? Is the other persons 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 it change 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, shes trying to
manipulate me into buying something, she knows I dont know much about how to dress, she is
pressuring me and I should buy something because I have taken her time, she wouldnt treat others
like this. Shame and anger arose when he thought about the situation, but not much anxiety.
He thought he shouldnt role-play the situation because it did not create 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 to manage. We identified the negative thoughts both about
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himself and the clerk and challenged both. The self-concept distortion appeared to be perfect 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 with a confederate he did several things. 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 and come 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 in similar 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 points in the interaction. Several weeks later he reported 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 with a 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 think about the jacket and come back. A second
goal was to ask two questions about the jacket, including the way it fit him. He actually completed
those goals in less than three minutes. Because he had done so well we could have him do 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 all the client can muster to say he will 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 that course because in the long
run they accomplish more. Brainstorm alternative behaviors that clients can 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 client to use as a guide at home.

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 to come in. Explain the situation to
the confederate and what you would like them to do. Ask for the clients 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
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responsibility and beliefs about the self and others. Chart the SUDS level ratings on the flip 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 like to try, conduct brief role-plays. Excuse the confederate and let the
client say good-bye.
If the SUDS level stays low, but the persons discomfort is obvious, discuss how a mix of
anger, shame, and anxiety will often be experienced more like general stress and discomfort. 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 aware of 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 thoughts during the week. Ask
them to practice challenging them on their own and write down 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 to practice it. Have them record that in the notebook as well.
Help them assign themselves behavioral homework. Ask them to record the automatic
thoughts about others that arise in any situation in which they feel 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 which they 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 doing their 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
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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 the client is
pushing his or her own edge, just like an athlete does. Large jumps are not necessary, but
persistence is, and they kid themselves 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 I express 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 that they will continue to build on their efforts and on our interactions
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. Ill 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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Well 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 up when 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 to go too far with this in their behavioral homework and be
rejected. The exercise will help them loosen up emotionally as well as behaviorally. If you are a
female therapist and relatively close in age, it will work well for you to do it. If you are a good
deal older, it might be useful to use a younger confederate.
Ask the client how high the SUDS level is when he thinks about the situation. Usually
they will report 80 or above. Ask for the automatic thoughts, write them on the flip chart, identify
the distortions, and challenge them. Often they relate to intruding on or exploiting a woman.
Examples are, shell think I just want her body, maybe shell 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 them in two ways. You challenge how they jump to conclusions: Do I
know for certain that shell think I want more than friendship? Do I know for certain that I 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
Im attracted to her, what is the likelihood that shell be offended by that? If she is reticent does
that mean that it is because she doesnt want to date me? 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 getting to 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 learning can occur while they practice. 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
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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 who is 15 or 16? Are there any advantages in
starting at your age? Sometimes they will become aware 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 would enhance her attraction to you? Is it possible that she might find it
appealing that you are less than perfectly smooth? What is the likelihood that she might associate
behavior that falls short of perfection with being genuine? 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 Gabors, 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 the ideas 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 the client might act like a 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 a measurable goal. In these situations the goal is often to ask her
to go to dinner (or a movie, or both) and set a 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 and place, which usually doesnt 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 shy or socially
phobic person simply takes too much effort. The goal should include a couple of possible
restaurants and movie locations.
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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 the date in the first
exposure you will move directly to the date itself for the second exposure and that is where they
will practice the compliment as well as talking about more 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 them to do. Ask for the clients
SUDS level, have them read the adaptive (or rational) response, and begin timing the exposure.
Have the client talk a few minutes and then ask for the date. It is useful to repeat the part where
they set the time and place, sometimes more than once. When the first exposure is completed,
move directly to the second one, reserving the debriefing until the end of 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 other at a table. Table settings, flowers, or
candles are great props if you have them. Tell them they will be making more personal
conversation and the client will compliment 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 a warm interpersonal style and is empathic. In these early
experiences clients need to experience interpersonal warmth and responsiveness from others.
You can omit having the client say the 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 immediately afterward. The client needs to experience both
the anxiety of delivering the compliment and then the anxiety of waiting for her response. They
often do not get to the pleasure experience when the date responds because they are caught up in
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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 dates response. Clients have many safety behaviors and subtle
avoidance behaviors they employ in these situations which interfere with desensitization. It also
gives them practice. If possible, extend the time a bit and have the 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 that relate to responsibility and beliefs about the self
and others. Chart the SUDS level ratings from the first exposure on the flip chart and link rises to
negative thoughts or to actually asking for the date or setting the time and place.
oppportunity to contrast the feedback with the 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 like 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 persons mind it is much more
effective. Ask them to pay attention to SUDS level and to see if they notice any emotional states
besides anxiety and any positive aspects to the physiological state. Usually they will begin to be
aware of positive aspects of their arousal, that is of the excitement that accompanies new challenges
with people they like. It helps them begin to differentiate more positive physiological and
emotional states.
them to practice challenging them on their own and write down 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 to practice it. Have them record that in the notebook as well.
Remind the client that the session after the next one is the final 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 new thoughts 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 in the 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 be implemented instead. For instance, if self-assertion is not a big issue at the
moment and deepening conversations with potential friends is more important, you may want to
continue to focus with increased challenges in a new exposure on the same theme. You can
discuss the pros and cons with the client.
Ask about negative thoughts that arose while doing 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 someones 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 with shy and socially phobic clients because 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 more intimate physical contact. Some very shy men will want to begin sexual
contact with a sexual surrogate. It is useful to have a referral available if that is 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 use a 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 the situation. 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 sometimes report the urge to cry and excessive
embarrassment or shame. Ask for the automatic thoughts, write them on the flip chart, identify the
distortions, and challenge them. The challenges that are useful in this exercise are usually
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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 her share 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 didnt learn the new
procedure quickly enough, I should know how to handle these situations, or people overhearing
him/her must think Im an idiot, I get tongue-tied and cant think of things to say, maybe I really
dont know how to do this job, if I were someone worth respecting he wouldnt treat me like this,
or I must be doing something wrong.
After identifying the distortions and 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 not know that she has
recourse to a human resource department to find help in dealing with a 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 dont
think it is appropriate for you to speak to me in 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 to be sarcastic about my work. It does not help me
improve. Sometimes clients can practice with a simple 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 to come in. Explain the situation to the
confederate and what you would like them to do. If you are doing it yourself tell the client what
you intend to do as the boss. Ask for the clients 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 client read 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
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contact. She can work on the eye contact later. Give her time to try asserting herself in her 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 repeat this same statement or try 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 that relate to responsibility and beliefs 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 the client made on her own behalf.
Challenge one or two of the new automatic thoughts.
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, let her be the boss and model behaviors
and verbalizations that she can use. Model and explain the power of 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 specific goal based on a different behavior or prepared 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 the 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.
give the client 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. 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 persons mind it is
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much more effective. It may be difficult in a situation where the client 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 to ask 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 or circumvent some of the consequences 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 to find out how
complaints are filed against companies. They rarely follow through on these actions, but it gives
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 fellow employee can be a useful
source of feedback and support. Many times clients deal with these kinds of problems in complete
isolation before they begin to talk about the experience in therapy.
them to practice challenging them on their own and to write down their challenges and their
adaptive or rational responses, and to practice them. Have them record them in 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 while doing 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 the last session, if the client was 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 to the avoidance? Ask what adaptive responses
she used. If she failed to think of any, help her construct one or two.
Inquire about initial contacts with human resources. Or if 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 begin to notice the behaviors of others that they want
to emulate and begin to use 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 they admire. 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 ones reasons for requests or actions, and listening to the other
persons 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 persons
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 also disrupt listening behavior simply because it is 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 the socially 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 client must give talks as part of professional 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. Lets 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 flip chart. Ask the client what negative thoughts are occurring and write them
on the flip chart. Notice that some of the thoughts will refer to the clients performance. For
example, Ill stumble over my words, Ill forget what I wanted to say, I wont make eye-contact,
Ill look foolish and make people uncomfortable. Many of the thoughts will also refer to others.
John doesnt like me anyway, and hell gloat if I make a mistake. No one will listen anyway,
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because I dont present the material well. Everyone will be uncomfortable and embarrassed for
me. They will think I dont know what I am doing. There is a great deal of mind reading.
It is important to challenge the negative thoughts about their own performance. Do they
know for certain they will stumble? If they do stumble, how bad is that? 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 about themselves afterward. As
they continue they often reveal the negative beliefs about the 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 of confusion. Careful listening and a warm reception help
any speaker do well. An accepting atmosphere encourages people to do well when presenting their
work. A critical environment makes most people 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
theyd like, can they give themselves room to learn? Would they give another person room to
learn? Would they be so critical if someone else stumbled over their words? 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 speakers performance the only explanation
for the discomfort? Could the discomfort be related to other factors, such as the listeners anxiety
regarding talking to groups? Do they know for certain that others will be critical? Does an
uncomfortable look mean that 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 can give myself room to learn. Ill
do better with practice. Others may be more supportive than I think. Practice at this task will help
me feel more comfortable in group situations. Then help the client construct a specific goal, such
as telling the audience three things about the project. Another goal is maintaining eye contact at
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).
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Write the adaptive response and the goal on the flip chart. Give the client a few moments to
prepare the talk.

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 the confederate 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 to 3 minutes to end on a positive note. This experience gives the
client a chance to notice how audiences can promote better public speaking. 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 a chance 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 the rational
response and to begin the talk. Check the SUDS level and have the client say aloud the rational
response at one minute intervals. When the exposure has been completed, chart the SUDS levels
on the flip chart. It is important for clients to notice 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 that it fluctuates during the talk.
Ask for automatic thoughts that occurred during the exposure. Ask the clients what
thoughts came up afterward, because these usually will relate to attributions and beliefs about the
self. Challenge the most important thoughts and help the client construct an adaptive 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 the talk 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 most important that they
actually do it in spite of the fear and find 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 the video home. It is usually helpful to leave the feedback on the tape so
the client and view it again. Excuse the confederate and let the client say good-bye.
Closure
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Ask the client to fill out the Shyness Clinic Treatment Evaluation form in Figure 11. 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 of session two. At the beginning of treatemnt, the client planned to enter
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 have entered. 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 with their responses during the initial
evaluation. Usually there is a change in attribution style, with reductions 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 Avoidant Personality 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 the community 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 with a 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 difficult and 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
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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-enhancement 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 . All-or-Nothing Thinking: You see things in black and white categories. If your performance falls short
of perfect, you see yourself as a total failure.
2 . Over generalization: You see a single negative event as a never-ending pattern.
3 . Mental Filter: 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 . Disqualifying the Positive: 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 . Jumping to Conclusions: 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 . Magnification or Minimization: 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 . Emotional Reasoning: You assume that your negative emotions necessarily reflect the way things really
are: "I feel it, therefore it must be true."
9 . "Should" Statements: You try to motivate yourself with "shoulds" and "shouldn'ts," as if you had to be
whipped and punished before you could be expected to do anything. "Musts" and "oughts" are also offenders.
The emotional consequence is guilt. When you direct "should" statements toward others, you feel anger,
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10. Labeling and Mislabeling: This is an extreme form of over generalization. Instead of
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
describing your
else's behavior rubs you

louse." Mislabeling involves
describing an event with language that is highly colored and emotionally loaded.
11. Personalization: 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
Am I 100% sure that ___________________________________?

What is the worst that could happen? How bad is that?
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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
1 Minute
2 Minutes
3 Minutes
4 Minutes
5 Minutes
6 Minutes
7 Minutes
8 Minutes
9 Minutes
Rating
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 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 all my
fault!" vs. Not me, folks!: You take sole responsibility for whatever social situation turns
out badly and none for those that turn out well.
2 . Stable for negative outcomes vs. Temporary for positive outcomes. "Always
and forever" vs. "Don't count on it": 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 is negative you assume that it will always
happen. In contrast, if an outcome is positive, you assume that it can't last, or can't be repeated.
3 . Global for negative outcomes vs. Specific for positive outcomes. "Here =
everywhere" vs. "Here = nowhere": 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. "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.
5 . Maladaptive Attribution: Any assignment of blame to your character or the character of
others that interferes with meeting your basic human needs for acceptance, social support,
contribution, and emotional connection.
6 . Compensatory Attribution: You take responsibility for everything and 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.
SELF-CONCEPT DISTORTIONS (SCD'S)
1. "It can't be me" vs. "That's just how I am": 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
June 5, 2001
Page 131 of 131
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-concept: 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, you say he/she is a "jerk".
4 . Maladaptive Self-Belief: 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.
5 . Compensatory Self-Belief: 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 is a compensation for an
underlying belief that you are inferior.
@ This material is copyrighted and may not be reproduced without permission of the author
June 5, 2001
Fig. 6. Reversal of the Self-enhancement Bias
SHYS
OTHERS
SUCCESS
FAILURE
No credit
Credit
External
Internal
Unstable
Stable
Specific
Global
Uncontrollable
Uncontrollable
Credit
No credit
Internal
External
Stable
Unstable
Global
Specific
Controllable
Uncontrollable
Page 132 of 132
June 5, 2001
Page 133 of 133
Figure 7.
CHALLENGES
To Negative Attributions and Beliefs About the Self
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 I am _________________________?
What evidence do I have that I cannot change ________________?
Is my whole personality or basic character involved in __________?
What is the likelihood that I have no control over __________________?
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?
Adapted from Sank and Shaffer (1984), Heimberg (1991), Henderson (1994).
June 5, 2001
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Figure 8.
THE SHYNESS CLINIC

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 and exclusively between Lynne Henderson, Ph.D., and/or any other
therapist associated with the office and the confederate.
_____________________________
______________________________
June 5, 2001
Figure 9.
Shyness Clinic
Self-Monitoring/Attribution/Self-belief Scale
Date/Situation Thoughts/Attributions/Self-beliefs Interference (0-100)
Page 135 of 135
June 5, 2001
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Figure 10.
Sample Automatic Thoughts, Attributions, and Beliefs
Shyness Clinic
Before
I cant think of anything to say
Ill look like a fool
Ill feel ridiculous
People will see Im nervous and wont want to talk to me
Afterward
They were just being nice
This was easy because it is safe in here
I dont 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
_____________________________________________________________
Shys
Non- shys
Students
Clinic Shys
N=44
N=64
N=136
N=8
______________________________________________________
Mean 2.7
2.1*
2.3
4.4***
SD
1.4
1.0
1.3
1.4
_____________________________________________________________
note. *p < .05, **p < .01, ***p < .001.
Internal consistency (Chronbachs 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).
June 5, 2001
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Figure 11.
CHALLENGES
To Negative Attributions and Beliefs About the Other
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 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_______?
Is his/her whole personality or basic character involved in __________?
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 __________ will change it?
What is the likelihood that thinking about their negative behavior helps me change my own
behavior__________________?
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?
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?
June 5, 2001
Is this the only opportunity for ___________?
Page 140 of 140
June 5, 2001
Figure 12.
Assertiveness Skills Practice

Shyness Clinic
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:
Page 141 of 141
June 5, 2001
Praise Selves:
Page 142 of 142
June 5, 2001
Figure 13.
Anger Management Practice
Shyness Clinic
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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June 5, 2001
Practice Skills:
Praise Selves:
Page 144 of 144
June 5, 2001
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Figure 14.
Shyness Clinic Treatment Evaluation
Shyness Clinic
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 or modify? 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 not be reproduced without permission
June 5, 2001
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Appendix A.
Name__________________________________
Date _____________
BFNE
according to the following scale. Circle a number to indicate how characteristics the statement is of
you:
1.
I worry about what people will think of me

difference.
1
me.
my shortcomings.
1
me.
1
1
impression I make.
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
4
5
June 5, 2001

things.
Page 147 of 147
June 5, 2001
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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 minutes to complete. The score provides an objective measure of the concern about
negative evaluation and can be compared with the general population. 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 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. 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.
June 5, 2001
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Name__________________________________
Date _____________
BFNE
according to the following scale. Circle a number to indicate how characteristics the statement is of
you:
1.
I worry about what people will think of me

difference.
1
me.
1
my shortcomings.
1
me.
1
1
impression I make.
1
1
1
things.
1
2
2
2
3
3
3
4
4
4
5
5
5
June 5, 2001
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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 the clients hierarchy (Henderson, Martinez et al. 1996). A copy is
included in Session Two. The client is asked to imagine the anxiety producing situation and to
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 clients attributions are internal, stable, global, controllable, and self-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 at the end of treatment to measure reductions in maladaptive
attributions and accompanying shame. The therapist can show the client 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 these 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 extent to which shy and socially phobic clients endorse negative
thoughts about others. Negative thoughts about others indicate the tendency to mistrust others
which interferes with forming relationships. They are also associated with a tendency to blame
others. Clients rate items on a 7 point scale from from 1 (not at all) to 4 (moderately) to 7 (very
much). Alphas range from .89 to .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 clinic clients are
shown in Appendix xx. The mean overall score for clinic 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 and to pay particular attention to passive aggressive tendencies. Clients may think
others believe they are inadequate when in fact others react negatively to interpersonal messages
that suggest suspiciousness and the tendency 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 school students blaming others is the only
significant negative predictor of perspective taking t (2, 137) = 2.79, p. < .01) and empathic
concern t (2, 137) = 4.29, p. < .0001 (Henderson & Zimbardo, 1998).
June 5, 2001
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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.
June 5, 2001
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Estimations of Others Scale (EOS)

Lynne Henderson and Leonard Horowitz (1998)
Stanford University
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).
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 I let 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.
June 5, 2001
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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 of treatment. The Beck Depression Inventory (BDI) is a 21item questionnaire which is copyrighted, but may be purchased. The average BDI score for
Shyness Clinic clients is 13. Many clients will score 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 with the clients willingness to enter feared situations and will disrupt 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 the degree of negative emotion and
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 a scale 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 negative work 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 small audience. SUDS (subjective anxiety from 0 to 100) 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 & Merluzzi, 1970; Heimberg, 1991). See Appendix C.
for a sample of a thought-listing form.
June 5, 2001
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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 dont
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, 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 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.
*COPY OF LETTER REFERRED TO IN SESSION 10

Shyness Clinic
Letter to Friends
Zimbardo and Henderson
Dear
Thank you for taking the time to respond 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 _________________?
June 5, 2001
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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?
June 5, 2001
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Overall, how much would you say she/he has changed in the last 6 months?
1___2___3___4___5___6___7___8___9___10___
not at all
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,

Director
*INSTRUCTIONS FOR BAT AND THOUGHT-LISTING FORM

Behavioral Assessment Test (BAT)
Therapist Instructions
Shyness Clinic
June 5, 2001
Page 157 of 157
Give the behavioral assignment to the client (five minute talk, conversation with a confederate,
asking confederate for a date, etc.). Tell the client that you will give him/her three minutes to
prepare. Ask for the SUDS level (0 - 100). Write it down. Write the clients name on the insert in
the video tape with the date and whether the BAT is pre- 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 for the SUDS level and
write it down. Give the client the Thought Listing Form and read 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 any thoughts you had during the behavioral task. They may be statements like
I wont be able to think of anything to say. Ill look foolish. They will think Im an idiot. What
Im saying doesnt make sense. I look awkward Try to include thoughts you had before the
exercise, during the exercise, and afterward.
______________________________________________________________________________
__________________________________________________________________
June 5, 2001
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______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
______________________________________________________________________________
__________________________________________________________________
June 5, 2001
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Appendix D. Vicious Cycles

Figure 2.
Vicious cycle #1, Anxiety and Escape

Subjective anxiety (SUDS, Subjective Units of Distress from 0 to 100) leads
to negative automatic thoughts, which lead to increased SUDS, which leads
to behavioral avoidance, which leads to increased anxiety in next situation.
Vicious Cycle #2, Self-blame and Shame

Self-blame for social failure produces shame, shame in turn produces
more self-blame.
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 powerful and untrustworthy.
Other-blaming attributions lead to negative beliefs about others,
interfering with open-minded hypothesis-testing and forming and
sustaining relationships.
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, shame, or anger,
private self-consciousness contributes to cognitive and perceptual
distortions about one's behavior and others' reactions.
Perceptual distortions are due to increased awareness of internal
emotions and negative thoughts.
June 5, 2001
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Self-concept Distortions and Distortions about Others

Self-blaming and other-blaming attributions may lead to negative beliefs
about the self and others. These beliefs organize information. Increased
articulation of biases in the self-concept and biases about others occurs.
Negative beliefs operate outside awareness, so successful goal completion
is discounted, as is progress toward long-term goals.
Fight/Flight
Shame/self-blame Anger/other-blame
fear
shame
anger
automatic
thoughts
self-blame
other-blame
Approach
Avoidance
Aggression
Private self-consciousness increases awareness of negative emotions and

thoughts, leading to perceptual distortions in social situations. The result is
alienation from self and others.
From Social Fitness Training Manual
Copyright @ 1994 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 or transmitted in any form by any means,
electronic, mechanical, photocopying, recording, or otherwise, without the
prior written permission of Lynne Henderson, Ph.D.
June 5, 2001
Page 161 of 161
Appendix E.
SAQ (Shyness Attribution Questionnaire)
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 a negative outcome (failure) of each situation. For each situation,
imagine yourself in that situation, and tell me the one major cause of that negative 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 to your stated cause. We will use the following rating scale to
make your judgment:
Rate the cause
1 2 3 4 5 6 7 8 9
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.
June 5, 2001
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Therapist says, Imagine that you are ___________(most challenging situation). Imagine that
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
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
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
3.
4.
5.
4
4
4
4
1.
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Therapist says, Imagine that you are ___________(second challenging situation). Imagine
that it doesnt go as well as you had hoped or just imagine that the outcome is negative.
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
blame.
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
3.
4.
5.
4
4
4
4
1.
June 5, 2001
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Therapist says, Imagine that you are ___________(third challenging situation). Imagine that
1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9

1 2 3 4 5 6 7 8 9
1 2 3 4 5 6 7 8 9
blame.
0
0
0
0
0
1
1
1
1
1
2
2
2
2
2
3
3
3
3
3
1.
embarrassment
2.
3.
4.
5.
4
4
4
4
June 5, 2001
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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 or speaking 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 remember that your responses will remain confidential. Don't spend too
much time on any one thought in each box. Please try to remember as many thoughts as possible.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
June 5, 2001
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________________________________________________________________________
______________________________________________________________________________
____________________________________________________
June 5, 2001
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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.
_____________________________________________________________________
me, or
June 5, 2001
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note. (Chronbachs Alpha, .91; N=138). Henderson, L., & Horowitz, L. M. (1998). The
Estimations of Others Scale (EOS) : Stanford University.
June 5, 2001
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Estimations of Others Scale

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).
Shy
Non-shy College Students
N = 15
27
3.6
2.5
1. ___People do not care about me.
3.0
2.2
2. x __When people see my discomfort they feel superior.
3.2
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.
3.3
1.6
5. X __People do not relate to my problems.
3.9
2.4
6. X __If I'm not watchful and careful, people will take
advantage of me.
4.6
2.1
7. X __I must not let people know too much about me
because they will misuse the information.
3.5
1.5
8. X __People are more powerful than I am and will take
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.
2.9
1.7
11. X __People will make fun of me and ridicule me.
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.
June 5, 2001
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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 for the future and plans to meet 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 compare it with 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 a given situation, discuss how they can
continue to challenge them and what adaptive responses they can use.
5. Social Phobia (Does patient 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 Form afterward. 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 to respond 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?
1___2___3___4___5___6___7___8___9___10___
not at all
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,
Director
References
June 5, 2001
Page 173 of 173
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 Effectiveness and 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 26: 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 17(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.
June 5, 2001
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Chapter : Session 1- Group Therapy

SESSION ONE FOR GROUP THERAPY
Patients experience considerable apprehension before the first group 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 Treatment Outcome [Heimberg, 1991 #1712]
7. Training in the model
We have adopted Heimbergs 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 Recorder & 90 minute tape (for supervision and feedback)
6. Camcorder for recording a five minute interaction among the group 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 to remember
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 further describes how communication progresses from comments and
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 it appeared. 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 and beliefs
about the self into awareness and makes them more accessible during the discussion.
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Developing the model: 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.
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 habits that
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 find most difficult and what do 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 are falling
into categories? Behavioral, physiological, cognitive (or thinking) patterns, and emotional
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 a dominant leader in
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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 intentions of 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 patterns or cognitions; that is, the way we think
about ourselves in social interactions. You may notice that there are a number of what 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 in the 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 in a 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
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your energy; it actually involves the parasympathetic nervous system rather than the
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 these situations; then you experience the urge to leave and/or you
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 more shame 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 in your daily lives. Deliberately exposing yourself to the feared
situations whether in simulated situations in the group where you are practicing 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 out that social situations are not so
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 to get 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 to shyness 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
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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 a bit formal and there wasn't much time to let 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 I had participated so much in moving 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 that it 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 that we REVERSE this self-enhancement bias! 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, which is referred to as
characterological self-blame. This self-blame, according to my research, is also correlated
with shame, which means that you 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, which is 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 while you 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.
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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 at 100. So associally, expecting yourselves to engage in the
kind of dialogue we see at the theatre or in movies. On the other hand, it may be that it 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 thats 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 rational thinking, and that focusing on emotions can amplify 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 blame yourself in a global and/or a
stable way. You may operate from the assumption that there is something wrong with you
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 in neutral 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
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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 activation in the left hemisphere, as do non-socially phobic people. These
findings suggest that the socially phobic individuals are processing visual images rather
than thinking rationally and planning for the talk. Now, visual images are correlated 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 also seems 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 you begin to process incoming information in relation to
this bias in the self-concept. For example, you will notice and remember better the
particular information which is consistent with your self-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
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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 look startled 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 take just a moment of their time." Reflexively coming down on
yourself will always provide the same old information. Careful analysis of the particular
situation gives new and useful information. Examining our behavior at the level of
specifics enables us to take appropriate responsibility for our actions.
Let me summarize. The way we will be working together is to stage 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 you will also be recording your
thoughts, attributions and beliefs in relation to 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 youre 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
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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 real life. 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 that my 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 work with 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, that people
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 a general way, rather than being specific or behavioral; that is, I was
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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 utterly unhelped. I then recognized that this irrational 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 attribution pattern going and a negative belief
about myself that would interfere with my collaborating with others and with making my
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 social interactions. Examples might be "I will never 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 that works 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 very pleased with himself and the 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 that prompt anxiety and feelings of inadequacy. This
exercise will make you more aware of your attribution style and any negative beliefs about
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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 in social situations? Can you also think of any negative beliefs
about the self that you are aware of? or any that are implied by the things that you are
saying to yourself about yourself and others in social situations?" As the therapist collects
attributions and beliefs the other therapist can be writing them on the flip chart. The second
therapist may also share examples from his or her life to help 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).
1 . All-or-Nothing Thinking: 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
perfectly are cues to black and white thinking (Persons, 1989). Words like sometimes,
frequently, partially, somewhat, and occasionally indicate more adaptive attributions and
self-statements.
2. Over generalization: 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.
3. Mental Filter: 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.
4. Disqualifying the Positive: You reject positive feedback and successful 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.
5. Jumping to Conclusions: You assume that others will 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 that someone is reacting negatively to
you, and you don't bother to check this out.
5b. The Fortune-Teller Error: You anticipate that things will turn out badly for
you, no matter how they actually are going in the situation. You are convinced that your
prediction is an already established fact.
6. Magnification/Minimization: You exaggerate the importance of things (such as
your goof-up or someone else's achievement), or you inappropriately shrink things until
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they appear tiny (your own desirable qualities or the other fellow's imperfections). This is
also called the binocolar trick.
7. 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.
8. Emotional Reasoning: You assume that your negative emotions necessarily reflect
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.
9. "Should" statements: 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,
10. Labeling and Mislabeling: 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 with language that is highly colored and emotionally loaded. 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.
11. Personalization: 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.
12. Maladaptive Thought: Any negative thought about yourself or the world 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 value are useful only as sticks with which to beat yourself; whereas
other, equally true, thoughts will help you to move toward your goals.
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13. Compensatory Misconception: You believe that you need to inflate your
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 and professional goals. This may be a compensation for a
belief in your own inadequacy and promotes suspicion and hostility toward others.
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Fig. Challenges to Automatic Thoughts

CHALLENGES
to
Automatic Thoughts
Am I 100% sure that ___________________________________?
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Fig. xx Reversal of the Self-enhancement Bias
SHYS
OTHERS
SUCCESS
FAILURE
No credit
Credit
External
Internal
Unstable
Stable
Specific
Global
Uncontrollable
Uncontrollable
Credit
No credit
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 a job, 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
all my fault!" vs. Not me, folks!: You take sole responsibility for whatever 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 that caused 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.
2. Stable for negative outcomes vs. Temporary for positive outcomes.
"Always and forever" vs. "Don't count on it": 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
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. "Here = everywhere" vs.
"Here = nowhere": 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.
4. Uncontrollable for 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.
5. Maladaptive Attribution: Any assignment of blame to your character or the
character of others that interferes with meeting your basic human needs for acceptance,
social support, contribution, and emotional connection.
6. Compensatory Attribution: You take responsibility for everything and everyone
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.
SELF-CONCEPT DISTORTIONS (SCD'S)
1. "It can't be me" vs. "That's just how I am": You reject positive feedback and
successful behavior by insisting they "don't count" for some reason or other. In this way,
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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2. The Ideal Self vs. the Real Self: There is some idealized standard you must
meet in order to be an acceptable person. You may not apply the same 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 most distinctive and redeeming feature. The emotional consequences
are shame and guilt. When you do apply this idealized standard to others you may feel
resentful and superior; you may be also be hostile or passive aggressive.
3. Shame-based Self-concept: 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 to cope with ordinary problematic interpersonal 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.
4. Maladaptive Self-Belief: 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.
5. Compensatory 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.
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Fig. Challenges to Negative Attributions and Beliefs About the Self

CHALLENGES
to
Negative Attributions and Beliefs About the Self
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 I am _________________________?
What evidence do I have that I cannot change ________________?
Is my whole personality or basic character involved in __________?
Could there be a less harsh way of viewing my own behavior or that of others?
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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?
Adapted from Sank and Shaffer (1984), Heimberg (1991), Zimbardo (1977)
Chapter 4: Session 2
SESSION 2, GROUP THERAPY
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 Restructuring Form
Self-Monitoring/Attributional Restructuring Form
Topics:*Assessment of Emotional State

* Review of Homework Assignments
* Identification of Cognitive and Attributional Distortions
* Identification of Self-concept Distortions in Beliefs about the Self
* Challenging Automatic Thoughts, Attributions and Self-beliefs
* Developing Rational Responses
* Developing Self-enhancing Attributions and Beliefs 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 their awareness 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 come up. 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 to actually 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 coping behavior, but the person may instead experience a
flooding hurt feeling, a shrinking from contact, and a feeling of helplessness which
promotes behavioral inhibition and a turning inward.
Identification of Cognitive Distortions in Automatic Thoughts and Beliefs
Therapists distribute the first list of Cognitive Distortions, beginning by each
reading one and giving a prepared example and one from personal experience. and
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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 or to 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 the group. If the group member can think of one from his
or her own life, that is optimal, but not necessary. This section needs to be handled
carefully. Examples involving jumping to conclusions about what negative event will
occur and what others are thinking are most frequent. Overgeneralizing about previous
negative events and dichotomizing into perfect and inadequate, success and failure, are also
common. These kinds of automatic thoughts are more easily challenged in the beginning
because they do not necessarily indicate the presence of more painful, longstanding beliefs
about the self. Going directly to beliefs about the self as 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 common examples at hand, point out that 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, with fewer 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
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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 entire conversation was a failure. The group
challenged his thought that the conversation was a failure because there was a pause. 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 be as 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 objective look 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 a date 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 immediately discounted 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 of good experiences and
personal assets can lead to a lowering of overall motivation and a decrease in homework.
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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 in his work with social phobia. Both involve
a negative interpretation in the absence of evidence,
a) in mind reading the person assumes he/she is being 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 knows ahead of time that a given social situation is
going to be too painful, difficult, or that a goal is unattainable. 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 do their 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 the tendency 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,
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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 easily forgiven 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 not intended. 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 had been given a new
set of professional responsibilities that involved considerable responsibility, initiative, and
decision making discretion. She received negative feedback from a colleague, 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
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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 lead to 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 that would 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 and guilt which, via
emotional reasoning, feeds back into the pattern of negative thinking which creates more
shame and guilt and the downward spiral continues. A group member called it
"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 shoulds and shouldn'ts that he had a difficult
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 label to 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 of helplessness 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 to practice relating to others seems more and 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 that several others seemed a little nervous. 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
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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 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 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 by referring to the example from the week before. For example,
"Remember when we examined my automatic thoughts, attributions and negative beliefs
about myself last week when I 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 that I 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 to speak in class with practice? Even if I am
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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 the group generate alternatives. Other AT's are taken from the 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 clinical samples. The list of Attributional and Selfconcept Distortions is then distributed using the same format. Group members again read
each Distortion. Therapists give examples from their lives and elicit 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 in shyness. 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 the self. 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
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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 than they 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 beliefs through 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 in one 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 to make 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 the self. These should be rehearsed ahead of
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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 particularly useful with Avoidant Personality
Disorder and Generalized Social Phobia. These patients frequently have more 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
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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 willing to 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 that the 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 some situation at some point in 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
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were not all completely at ease 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 failure and unreachable goals. In this manner, motivation to attempt
new behaviors in new settings is systematically decimated.
In social situations with positive outcomes the bias is reversed. 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 me feel 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 men begin 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 will begin to challenge the member, encouraging him to continue
to explore for learning purposes if that is the goal, but to reserve judgment until they have
gained experience relating more closely with 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 match his idealized image. When women are reluctant to
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 human community. 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 that she 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
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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 each time 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 debilitation if it goes unchallenged. This experience is frequent with the
chronically shy. If a minor mistake at work carries this implication, it becomes obvious
that the maintainance of behavioral gains is a 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 that she would never be a valued 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 a situation is
lost, like the patient who saw one pause in the conversation as indicative of a failed social
interaction and was sure he had made a 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 the team would be
responsible, that their support would have enabled 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
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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 positive outcomes. 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 generalize to
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 of the self. For example, a patient had the
homework assignment of greeting a female security guard as he entered his place of work.
She responded with a smile on one occasion and then did not respond the next time. 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 no proof 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 indicated that he could not initiate 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
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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 in the form of the overcontrolling group member. This person may talk excessively when socially anxious 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 to the belief that the therapists 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 to be
able to let go of "helping" and to have the freedom 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 invited and helped to participate. Sometimes, however, it is a
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 the rigidity 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 met in 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 and accepted. 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 with social and professional functioning. Examples include men in
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 little shy 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 into subjects 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
June 5, 2001
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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 in working 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 state shame. 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
June 5, 2001
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acquaintance relationships to deeper intimacy. In the subsequent group she started

challenging her attribution style and her 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 that is 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 getting the belief to a more specific level. "Not as
beautiful as whom? What feature is it that 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 the question, "does
that belief bring you closer to your goal?" "What mood does it put you 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 until the 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 in interpersonal 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
June 5, 2001
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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 in interactions with them. Often a sense of
humor will emerge as people 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 to admit to beliefs like this themselves, it greatly
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 out to be so elaborate that people were reluctant
to devote the time to doing the same thing, or to invite 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 that he 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.
June 5, 2001
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Figure x Exercise in Disputing Automatic Attributions and Beliefs about the Self
Situation: Your professor in a large class says that he wants 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
June 5, 2001
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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 call out all
automatic thoughts, including attributions and 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 the help 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/Attributional and Self-concept distortions in
each situation. They challenge each AT, ATT and negative Self-belief and develop a
rational response to each. Group members are asked to do this at least once a day, and
preferably twice, in the situations that trigger 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 the importance of contact with each
other as a support group through their phone calls and emphasize how important it is that
everyone is committed to this process together. It is a learning process in a safe
environment where we all learn to take risks and practice new behaviors. Tell them that
June 5, 2001
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their anticipatory anxiety is important because it will inform them about their automatic
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.
June 5, 2001
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