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Chapter 7
Behavioral Interventions
A Cognitive Perspective
Courage is resistance to fear, mastery of fear—
not absence of fear.
—Ma r k Tw a i n (19th- century American author
and humorist, 1835–1910)Maria had struggled with severe and incapacitating generalized social phobia
since the age of 13. After 18 years of poor response to various medication regi-
mens, hospitalization, and false starts with different psychotherapists, Maria’s
anxiety disorder had worsened to the point where she was practically house-
bound, unable to work or socialize in a meaningful way. Although there was
evidence of a past comorbid bipolar I disorder, it was the social anxiety that
was the primary diagnosis at the time of assessment. She did not meet diagnos-
tic criteria for current mania or depression, so the intervention focused on her
social anxiety symptoms and associated panic attacks.
Maria had an intense fear of negative evaluation from others, especially
familiar people. She was concerned that others would stare at her and conclude
that she was “nothing” because of her poor physical appearance or because
she had achieved so little with her life. She became preoccupied with her physi-
cal appearance and attire, afraid that others would think she was wearing a
“horrible outfit” and so conclude that she was unable to take care of herself.
She developed an intense fear of meeting people from her past who she feared
would remember her inappropriate behavior during past manic episodes and
this would contribute to their harsh judgment of her. When in public settings,
Maria would frequently experience panic attacks that included chest pain,
numbness, smothering sensations, dizziness, and heart palpitations.
In an effort to reduce her heightened state of anxiety, Maria developed a
number of behavioral coping strategies. She avoided all social gatherings and
most public places, leaving her practically housebound. She spent hours getting
ready in the morning in order to look “just perfect” and would compulsively