374 TREATMENT OF SPECIFIC ANXIETY DISORDERS
client may feel highly anxious and not perform as well as he likes, but the catastrophic,
embarrassing outcome he anticipates is much less likely than expected. Instead “toler-
able discomfort” is the most likely outcome.
In addition the therapist challenges the client’s biased interpretation that her inhibi-
tory behavior will automatically be evaluated negatively by others. Instead the alterna-
tive interpretation is “people are tolerant of a fairly wide range of social behavior. I don’t
have to make an award- winning performance to be accepted.” Once this alternative
has been fully described the client is asked to rerate the probability that the initial cata-
strophic embarrassment will occur versus the alternative of “tolerable discomfort” and
others’ acceptance of “somewhat inhibited social performance.” It must be emphasized
that the rating is based not on how the client feels but on the realistic probability based
on the weight of the confirming and disconfirming evidence.
Cognitive restructuring normally concludes with the assignment of a behavioral
experiment. In most cases this involves some form of exposure to a variant of the antici-
pated anxious situation in order to collect evidence that disconfirms the exaggerated
social threat appraisal. We discuss the use of exposure in cognitive therapy for social
phobia more fully in a separate section below. In the meantime, Table 9.9 illustrates use
of cognitive restructuring for anticipatory social anxiety.
Clinician Guideline 9.18
Cognitive restructuring in social phobia involves the correction of exaggerated interpre-
tations of the probability and severity of social threat (i.e., negative evaluation by others)
through evaluation of confirming and disconfirming evidence, consideration of realistic
consequences, preparation for the worst outcome, and reevaluation in light of a more likely
alternative interpretation of the social situation and one’s inhibited social performance.Heightened Self- Focused Attention: Use of Role-Play Feedback
After completing a couple of cognitive restructuring thought records in- session and
assigning this as homework, the cognitive therapist introduces live or videotaped role-
play feedback. This is typically introduced by the third or fourth treatment session.
Role plays have long been recognized as a central ingredient in cognitive and behavioral
interventions for social anxiety (e.g., Beck et al., 1985; Beidel & Turner, 2007; D. M.
Clark, 2001; Heimberg & Juster, 1995; Wells, 1997). They serve a number of thera-
peutic objectives. Role-play feedback or behavioral rehearsal can be used to highlight
the negative effects of excessive self- focused attention, inhibitory behaviors, and safety
responses, as well as to learn a more adaptive external focus of attention (D. M. Clark,
2001). Role plays are also a less anxious form of within- session exposure that can be
used to correct exaggerated threat appraisals and negative self- evaluations of social per-
formance. Finally, role-play feedback and behavioral rehearsal can be used to help the
socially anxious person learn more effective communication and interaction behaviors
with others.
Role play was previously discussed in Chapter 7 in the section on “directed behav-
ioral change.” In the context of social anxiety, the therapist begins by role- playing with
the client moderately anxious social situations from the anxiety hierarchy. The client is