368 TREATMENT OF SPECIFIC ANXIETY DISORDERS
individual might become excessively self-aware of blushing, trembling, verbal hesita-
tions, stuttering, mind gone blank, or other involuntary inhibitory behaviors in social
situations. The self- monitoring is motivated by a desire to conceal the symptoms and
involuntary inhibitions from others in an effort to avoid a negative evaluation such as
“What’s wrong with her, she’s blushing” or “He must be terribly anxious because he is
stuttering so bad I can’t understand what he’s saying.” The Self- Consciousness Rating
Form (Appendix 9.3) can be used to obtain critical information on the role of heightened
self- focused attention in anxiety- provoking social situations. Furthermore, the Physical
Sensation Self- Monitoring Form (Appendix 5.3) and the Expanded Physical Sensations
Checklist (Appendix 5.5) can be used to determine if certain physical symptoms of
anxiety are excessively self- monitored when the person is socially anxious. Assessment
of excessive self- awareness should provide the cognitive therapist with an indication of
how the person thinks he appears to others when in social settings.
Gerald was very concerned that other people would notice that he was socially
awkward or inhibited around other people. When exposed to social interactions he
became intensely aware of blushing, his verbal hesitations and difficulty in maintain-
ing a conversation, the tension in his muscles, and a general sense of feeling extremely
uncomfortable. Gerald was convinced that he appeared anxious and inept to others, to
put it in his words “a real arse,” who must have a serious mental illness.
Safety Behaviors
The socially phobic person’s reliance on safety- seeking strategies in order to conceal
anxiety, counter unwanted inhibitory behavior, and appear more socially competent is
another key element in the case formulation. Butler (2007) listed a number of common
safety behaviors that are seen in social anxiety such as looking at the floor to avoid eye
contact, wearing heavy makeup to hide blushing, rehearsing or mentally checking one’s
verbal comments, hiding the face or hands, speaking slowly or mumbling, avoiding
challenging or controversial comments, being accompanied by a safe person, or the like.
It is important to identify the various cognitive and behavioral safety strategies the indi-
vidual uses to reduce social threat. In particular, does the client think these strategies
are effective in reducing anxiety or the social threat and does he perceive any negative
consequences associated with the safety strategy? In our case illustration, avoidance
of eye contact, slow and hesitant verbal responses (i.e., involuntary inhibitory behav-
iors), as well as reluctance to initiate conversation, were common coping strategies that
Gerald used to minimize social interaction. In fact these response strategies were very
prominent even in the therapy sessions. The Behavioral Responses to Anxiety Checklist
(Appendix 5.7) and the Cognitive Responses to Anxiety Checklist (Appendix 5.9) can
be useful for exploring the client’s use of safety- seeking responses.
Autobiographical Recall of Social Threat
Another important element in the cognitive case formulation is to determine whether
recall of past social experiences plays any role in the individual’s social anxiety. Are
there particular past incidents that come to memory when the client anticipates or is
exposed to a similar social situation? During postevent processing, does the individual
focus on the most recent social event, or does she recall other past experiences? Does the