378 TREATMENT OF SPECIFIC ANXIETY DISORDERS
anxiety will be used in the present context, except now the focus is on experiences
of actual exposure to the anxious situation. Along with role-play feedback, cognitive
restructuring of actual social situations is introduced in the fifth and sixth sessions in
order to correct biased threat interpretations, redirect attention to external stimuli, and
deliberately refocus processing capacity on the positive cues in the social environment.
This therapeutic focus will begin to address some of the underlying core beliefs about
social threat, personal vulnerability, and inadequacy that are important in social pho-
bia.
Clinician Guideline 9.20
Throughout treatment cognitive restructuring is routinely applied to the biased thoughts,
images, and interpretations associated with various situations in the social anxiety hierarchy
in an effort to achieve crucial change in the maladaptive social self- schemas that underlie
social phobia.Exposure to Social Threat
By the seventh or eighth session in vivo exposure to moderately anxiety- provoking situ-
ations in the social anxiety hierarchy should be introduced into treatment. Heimberg
and colleagues offer a comprehensive outline for exposure sessions and recommend
the integration of within- session and between- session exposure exercises (Heimberg &
Becker, 2002; Turk et al., 2008). As with cognitive therapy for other anxiety disorders,
exposure to anxious social situations is essential for effective treatment of social phobia.
Moreover, the most effective way to correct the maladaptive interpretations and beliefs
of social anxiety is through exposure-based behavioral experiments. Exposure exercises
also allow clients (1) to practice shifting attention away from internal states toward
external social stimuli, (2) to learn better tolerance of moderate anxiety levels, (3) to
interpret their social performance and inhibitions more positively, and (4) to gather criti-
cal disconfirming evidence of their biased social threat interpretations.
A detailed description of the use of exposure within cognitive therapy can be found
in Chapter 7; the guidelines outlined there apply to treatment of social phobia. The
therapist should begin exposure with the low to moderately anxious social situations
in the social anxiety hierarchy. It is preferable to first role-play the situation in session
before assigning it as an in vivo between- session homework assignment. Heimberg and
Becker (2002) list numerous social situations that might be used for exposure such as
initiating a conversation with an acquaintance, talking to a classmate before or after
class, introducing yourself to a stranger, making a telephone call to someone you like,
making a speech, asking a question in class, eating in front of other people, engag-
ing in a job interview, asking someone out on a date, and the like. The within- session
role play identifies any faulty thinking that will undermine the in vivo exposure and
allows the client opportunity to practice corrective modes of cognition and more adap-
tive responses to social anxiety. Of course, in cognitive therapy exposure is presented as
a behavioral experiment to test whether the client’s experience confirms or disconfirms
his exaggerated social threat interpretation or its alternative. The Empirical Hypothesis-