376 TREATMENT OF SPECIFIC ANXIETY DISORDERS
first asked to role-play “how she typically would respond in the situation.” Ratings of
anxiety are obtained and the cognitive therapist, acting as the observer, elicits the indi-
vidual’s anxious thoughts and interpretations associated with the role- played situation.
The therapist then discusses an alternative approach in which the client shifts attention
from an internal focus to processing external feedback from others (see D. M. Clark,
2001). Safety or concealment responses are eliminated and attention to positive cues in
the external environment is encouraged. Adaptive coping statements that counter auto-
matic social threat interpretations can be constructed. The therapist then models this
more adaptive approach in the role play, after which the client repeatedly practices the
constructive approach with the therapist providing corrective feedback.
D. M. Clark (2001) considers role play and video feedback critical for modifying
the heightened self- focused attention in social phobia. First, clients rate their anxiety
after role- playing a social situation in which they self-focus on interoceptive cues and
rely on safety behaviors. In a second condition they rate their anxiety after adopting
an external focus of attention and drop maladaptive safety responses. D. M. Clark
notes that this exercise teaches individuals that intense self-focus and safety behaviors
actually increases their anxiety and their assumptions of how well they think they per-
formed are greatly influenced by how they felt during the role play. D. M. Clark found
videotape feedback particularly useful in helping socially anxious individuals obtain
realistic information on their social performance and how they actually appear to oth-
ers. Furthermore, videotape role plays provide feedback on clients’ inhibitory behaviors
and corrects their negative assumptions that their inhibitory behavior has a detrimental
effect on how they are received by others.
table 9.9. (c o n t .)
- Error identification—going over her thought processes when anticipating the meeting, Carol
was able to see that she was catastrophizing (assuming her coworkers will think she is mentally
ill), and engaging in tunnel vision (only focused on the negative aspects of the situation) as well
as emotional reasoning (assuming that things must be going really bad because of her anxiety
level).
Construct alternative interpretation
Carol and her therapist developed the following alternative interpretation: “I will feel
uncomfortable in the meeting and others may notice my discomfort. However, it is a tolerable
discomfort that does not prevent me from offering an opinion. I may not be as eloquent as some
and I may show signs of discomfort but my work colleagues know me well and are most likely to
conclude that I’m a shy person who feels uncomfortable expressing myself in a group.”
Rerated likelihood and severity
Based on the evidence, Carol rerated the more extreme social threat scenario as 40% likely and the
alternative interpretation as 90% likely. Likewise the alternative was rated much less severe than the
original threat interpretation.
Assigned behavioral experiment
Carol indicated that a follow-up meeting had been scheduled at work. She agreed to go to that
meeting and attend as closely as possible to other people’s reactions to her rather than to her own
internal feelings of anxiety. She was able to use the Alternative Interpretation Form (Appendix 6.4)
to record her observations.