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Social mishap exposures for social anxiety disorder: an important treatment ingredient

Social Mishap Exposures for Social Anxiety Disorder: An Important Treatment Ingredient Angela Fang, Alice T. Sawyer, Anu Asnaani, and Stefan G. Hofmann, Boston University Conventional cognitive-behavioral therapy for social anxiety disorder, which is closely based on the treatment for depression, has been shownto be effective in numerous randomized placebo-controlled trials. Although this intervention is more effective than waitlist control group andplacebo conditions, a considerable number of clients do not respond to this approach. Newer approaches include techniques specificallytailored to this particular population. One of these techniques, social mishap exposure practice, is associated with significant improvement intreatment gains. We will describe here the theoretical framework for social mishap exposures that addresses the client's exaggerated estimationof social cost. We will then present clinical observations and outcome data of a client who underwent treatment that included such socialmishap exposures. Findings are discussed in the context of treatment implications and directions for future research.
S OCIAL anxiety disorder (SAD) is one of the most common anxiety disorders in the U.S., with a lifetime ). The cognitive-behavioral model proposes that and 12-month prevalence of 12.1% and 7.1%, respectively SAD develops and is maintained by maladaptive cognitive and behavioral processes, which negatively reinforce defined by a persistent fear of negative evaluation by others avoidance strategies and contribute to a cycle of anxiety in social or performance situations ) and is associated with significant impair- ). The following discussion is based on the mainte- ment in occupational, academic, and interpersonal func- nance model developed by which emphasizes the importance of social cost and social mishap heterogeneous condition, as individuals with SAD may vary exposures. A more detailed explanation of this model is in the kinds of people, places, and situations that cause fear.
described elsewhere ). According to this However, common fears include formal public speaking, model, an individual with SAD experiences apprehension speaking up in a meeting or class, and meeting new people upon entering a social situation because they perceive the (Ruscio et al.). It also appears that while these situations may social standards to be excessively high and experience differentially provoke anxiety for each individual, most doubt about being able to meet those standards. Once clients with SAD share similar underlying core fears, such confronted with social threat, individuals with SAD as being rejected, looking stupid or unintelligent, expressing experience heightened self-focused attention, in which disagreement or disapproval, and being the center of attention is turned inwardly toward one's internal physical sensations and anxious thoughts . Self- Theoretical Models of SAD focused attention simultaneously triggers a variety of other There is strong empirical evidence supporting a cognitive processes, including a negative self-perception cognitive-behavioral model of SAD (e.g., "I am such an inhibited idiot"), high estimated socialcost (e.g., "It will be a catastrophe if I mess up this Video patients/clients are portrayed by actors.
"), low perceived emotional control (e.g., "I have no way of controlling my anxiety"), and perceived poor Keywords: exposure therapy; social mishap exposure; social anxiety social skills ("My social skills are inadequate to deal with this situation"). These processes, in turn, lead the client toanticipate a social mishap in which one actually does something to embarrass oneself, cause negative evaluation, 2012 Association for Behavioral and Cognitive Therapies.
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or otherwise violate social norms. This expectation contributes to the use of avoidance strategies and safety intentionally create the feared negative consequences of a behaviors to cope with the anxiety and to avoid the feared feared social situation. As a result, patients are forced to outcome, which leads to post-event rumination about one's reevaluate the perceived threat of a social situation after performance in a social situation ( experiencing that social mishaps do not lead to the feared The rumination and avoidance behaviors ultimately feed long-lasting, irreversible, and negative consequences. A back into continued apprehension in social situations.
more detailed description of this model is presented in An important reason why SAD is maintained in the presence of repeated exposure to social cues is because Early data suggest that treatment protocols that incor- individuals with SAD engage in a variety of avoidance and porate social mishap exposures show considerably greater safety behaviors to reduce the risk of rejection (e.g., efficacy than traditional CBT protocols, which are typically ). These avoidance tendencies, in turn, prevent associated with only moderate effect sizes (e.g., patients from critically evaluating their feared outcomes Other, more recent studies that include social and other catastrophic beliefs, leading to the maintenance mishap exposures (among other techniques) report and further exacerbation of the problem. Social mishap considerably larger efficacy rates. For example, exposures directly target the patients' exaggerated social reported effect sizes ranging between cost by helping patients confront and experience the actual 1.41 (pretest to posttest) and 1.43 (pretest to 12-month consequences of such mishaps without using any avoidance follow-up; Clark et al.). Similar efficacy data (pre-post effect size of 1.54) have been found in an early pilot trial).
Obviously, social mishap exposures are not the only Social Mishap Exposures aspect that distinguishes traditional CBT protocols from Consistent with the notion that clients with SAD over- more modern approaches Depending on estimate the social costs associated with social mishaps, high the specific treatment protocol, other aspects include estimated social costs have been proposed to be an strategies for attention retraining, changes in self-perception, important mediator of treatment change ( and post-event rumination. However, in-vivo social mishap . This hypothesis has been subjected to empirical exposures are the most obvious differences to traditional testing, and substantiated in a treatment outcome study that CBT approaches, which have primarily employed in-session compared cognitive-behavioral group therapy, exposure role-play situations with the goal to identify and replace therapy (without explicit cognitive intervention), and a maladaptive general automatic thoughts. The purpose of the wait-list control group . It was found that current paper is to present a case example from a group changes in estimated social costs mediated treatment cognitive-behavioral therapy protocol that emphasizes social change between pre- to posttreatment in the two active mishap exposures, and to discuss the benefits and challenges treatment conditions ). These empirical associated with its successful implementation. The case that findings therefore support the utility of social mishap follows discusses a treatment-seeking individual who pre- exposures in addressing this overestimation of costs sented to an outpatient clinic specializing in the treatment of associated with a social mishap. This is accomplished by mood and anxiety disorders.
having the client behave in a way that causes a social mishapby purposefully violating the client's perceived social norms (e.g., singing in a subway).
The Anxiety Disorders Interview Schedule (ADIS-IV; The difference between social mishap exposures and ) was administered at the exposure practices that have been typically used in intake evaluation. The ADIS-IV is a semistructured clinical cognitive-behavioral therapy protocols for SAD is that social interview that assesses mood and anxiety disorders mishap exposures cause clients to experience the feared according to DSM-IV outcomes that they try so hard to avoid by clearly appearing ) criteria. The Liebowitz Social Anxiety Scale (LSAS; incompetent, crazy, obnoxious, and so on. Standard ) is a 24-item clinician-administered mea- exposure practices of patients with SAD are typically sure that assesses fear and avoidance of social situations designed to make patients realize that social catastrophes (each rated on a 0- to 3-point scale with a range of total are unlikely to happen, and that patients are able to handle scores from 0 to 144) in the past week. The LSAS has been socially challenging situations despite their social anxiety validated in clinical samples, and has high internal (e.g., ). In contrast, the goal of consistency ). The LSAS was the social mishap exposures is to purposely violate the administered at every session throughout the course of patient's perceived social norms and standards in order to treatment, and also at six major time points: baseline, Week break the self-reinforcing cycle of fearful anticipation and 8, posttreatment, 1-month follow-up, 3-month follow-up, subsequent use of avoidance strategies. Patients are asked to and 6-month follow-up.
Social Mishap Exposures for SAD In addition, Mary described residual symptoms of was a 41-year-old married, Caucasian, insurance depression that never resolved after having lost her job company analyst, who lived with her husband and two 2 years ago. She had been working as a research analyst at children. She came to the clinic seeking outpatient a local bank, and had been fired due to the bad economy psychotherapy for her social anxiety. She presented with as well as poor reviews from clients. She reported feeling primary concerns about having suffered from anxiety like she had lost interest in many activities that she used to throughout her life. She reported "always feeling awkward enjoy, such as shopping and seeing friends, and has been and self-conscious in groups," and not knowing what it was feeling excessively guilty and doubtful of her ability to until she read more about social anxiety in online help hold her current job. Mary reported not having ever forums. Mary described her social anxiety as being at its received cognitive-behavioral therapy for either her worst when meeting new people in unstructured social depression or social anxiety concerns, but that she had gatherings, such as parties and work events, and she tried supportive therapy with a variety of health-care described the anticipatory anxiety to be so crippling that professionals, including counselors and licensed social she would often turn down invitations. She reported workers. Last year, Mary visited a psychiatrist to receive feeling nervous about what to say, asking too many psychopharmacological interventions for her depression, questions, and not feeling like herself. Mary's anxiety had which she reported being effective.
affected her life in many ways. For example, in college she Based on information obtained from her baseline had majored in mathematics to avoid courses that assessment, Mary received a primary diagnosis of SAD, involved formal presentations; she had lost jobs; and, generalized subtype, and a diagnosis of major depressive ultimately, she had chosen a career that involved limited disorder (MDD), in partial remission. She had no other social interactions. When Mary was asked what she was comorbid psychiatric disorders, but reported a family concerned would happen in these situations, she could history of MDD. She had also been taking Wellbutrin not initially give an answer, but later responded that she (200 mg) for a year for her depression, which she was worried that others would judge her negatively, reject discontinued through a psychiatrist-guided taper prior her or hurt her feelings. She further explained that her to starting group treatment. Her baseline LSAS score of worst fear was that she would alienate everyone, even 90 reflected a severe level of SAD.
those who were close to her.
Mary described recent concerns about not performing Treatment Procedure well at work due to extreme distress when preparing for The treatment consisted of 12 weekly, 2.5-hour sessions group meetings and presentations and extreme anxiety of group cognitive-behavioral therapy with four to six making work-related phone calls. During her assessment, members in total. The protocol was implemented by two it was gleaned that Mary was worried that she was going to therapists, master's-level doctoral candidates, who fol- get fired from her job because she had put off making lowed the treatment manual.
some important phone calls, and clients had called her Week-to-week LSAS scores were determined by meeting supervisor to complain. She described being concerned separately with a trained independent evaluator before that she would be perceived as incompetent or un- the start of each group.
intelligent by clients and coworkers. Mary also hadconcerns about wanting to be more involved in her Sessions 1–2: Psychoeducation and Cognitive Restructuring children's lives at school because her husband worked The first session consisted of an introduction of much longer hours, but she was very apprehensive about cotherapists and group members and their reasons for attending parent-teacher conferences, parent-teacher seeking treatment. Psychoeducation about the nature of association meetings, and making small talk with other SAD as a learned habit and the adaptive aspects of anxiety mothers at her sons' sporting events and school concerts.
were presented and discussed. An overview of treatment She described being particularly afraid of unstructured was presented, with an introduction to the primary small talk with same-age parents or teachers because they treatment techniques, which included cognitive restruc- would think she was awkward. Mary explained that she turing and in-vivo exposures. The session concluded with feared other mothers perceiving her as an uninvolved and identification of automatic negative thoughts related to bad parent. She also reported severe avoidance of her attending group treatment specific to each client, and children's extracurricular events, with the exception of assignment of thought records (e.g., monitoring of such dropping them off and picking them up.
automatic thoughts) for homework.
Session 2 began with a review of the homework and an invitation from group members to share their thought records. The majority of the session focused on presenting Client name and other identifying information have been changed to protect client confidentiality.
the exposure rationale to the group by discussing the role of avoidance in perpetuating the cycle of anxiety. Examples of in-session public speaking exposures were structured safety behaviors and other avoidance behaviors were similarly to the more traditional SAD group treatment discussed by using specific recent examples. The short-term exposures, the concept of purposefully experiencing social and long-term consequences of these avoidance behaviors mishaps was introduced very early on (typically by the for the maintenance of the disorders were discussed. The second or third in-session exposure) to target these session concluded with a discussion of concerns and avoidance behaviors. In collaboration with the other questions about the start of public speaking exposures at group members and Mary, the therapist generated specific the next week's session. For homework, clients were asked exposure tasks to provide Mary with an opportunity to to generate a hierarchy of feared social situations for use examine the actual consequences of what she considered to be social mishaps. For example, during Session 5, Mary was Mary attended the group along with four other clients.
asked to give a 3-minute speech about cloning (of which she The other members varied in age, gender, occupation, and had little knowledge), and her specific goals were (a) to SAD symptom severity. At the first two sessions, Mary make eye contact with every member of the audience at least engaged in the discussion and appeared to relate to other once; (b) to stop speaking suddenly in the middle of her group members' experience of SAD. Similar to other speech for a long pause and to count 5 "Mississippi" before members, Mary described strong physiological reactions resuming; and (c) to pace back and forth across the room (e.g., racing heartbeat and sweaty palms) to anticipating an during the entire speech. In accordance with the research important class presentation or work meeting; she identi- on high perceived social standards and high estimated social fied jumping to conclusions as a major cognitive distortion costs associated with the speech, Mary collaboratively that emerged for her.
designed an experiment with the therapists to test howhigh the social standards and social costs were for the speech Sessions 3–7: In-Session Exposures and to see what would happen if she did run out of things to Sessions 3 to 7 consisted primarily of conducting say. Mary reported an anticipatory anxiety of 80 (on a in-session public speaking exposures, in which each group 100-point scale of subjective units of distress, or SUDS), a member gave a 3-minute speech on an impromptu topic peak anxiety of 80, and a final anxiety of 45 at the end of the that he or she had rated highly on a speech topics exposure. She described experiencing significant anxiety hierarchy. Specific behavioral goals were collaboratively when she stopped speaking at first, but that it gradually came agreed upon with the therapist at the start of the exposure down over time. She stated at the end of the exposure that to address elimination of safety behaviors during the pausing during the speech was not as bad as it sounded at exposure, as well as the individual client's core fears.
first. Upon reviewing the videotape feedback, Mary noted Incorporating social mishap during the speech exposure that the person in the video did not actually look that was introduced as a way to disconfirm negative beliefs about anxious during the long pause. This was an important feared consequences. Furthermore, automatic thoughts component of treatment for her, as she mentioned later that about the speech were identified and challenged before she was shocked by the discrepancy between how she looked and after the exposure. Speeches, conducted in front of the and how anxious she felt on the inside.
group, were videotaped to provide feedback to clients.
Speech exposures can be used to target other fears by For homework, group members were requested to repeat reevaluating the patient's estimated social costs. For their in-session speech exposures in front of the mirror each example, clients who fear looking silly during the speech day three times in a row. The mirror exposures were used to can be asked to put on a costume or prop, such as an address clients' self-focused attention by allowing them to attention-grabbing wig or witch's hat. Those who fear receive live feedback on their appearance (akin to videotape appearing unintelligent may say something factually incor- feedback during the session), and to give them a chance to rect or mispronounce a word during the speech. Those who engage in the repeated exposure model for anxiety fear that they will stutter can intentionally stutter during the speech. Speech exposures have also been used in tandem Mary described experiencing significant anticipatory with interoceptive exercises for individuals who fear the anxiety leading up to these sessions, and even admitted to physiological sensations that emerge in anticipation of or almost skipping a session to avoid giving an impromptu during the speech. Those individuals would conduct speech. Her speech exposures were particularly useful and interoceptive exercises (e.g., induced hyperventilation for relevant for the group presentations that she had to give as shortness of breath, running in place for racing heartbeat part of her job. Mary's primary fear in this domain was and sweating) for 1 minute before the start of the speech.
running out of things to say, which would cause her toengage in safety behaviors such as limiting eye contact with Sessions 8–11: In-Vivo Mishap Exposures the audience and freezing up in front of the group to Sessions 8 to 11 involved targeted in-vivo mishap minimize attention on her. As a result, while these first few exposures that were further tailored to the individual Social Mishap Exposures for SAD client's core fears. The goals for the exposures were introduction of herself to at least one individual. Mary collaboratively discussed and agreed upon with the reported that these between-session exercises were essential therapists at the outset. Social costs were incorporated to her progress, as they translated her therapeutic work to into each exposure to target specific core fears of the her real-life social situations and contexts.
individual client. In addition, automatic thoughts about As stated previously, these exposure exercises should the exposures were identified and challenged before and specifically challenge the patient's social cost estimates after the exposure. When group members returned from (e.g., walking around with toilet paper hanging out of the the exposures, the therapists led a discussion of whether shirt, buying and minutes later returning the same book, each exposure was successful by reviewing the clients' walking on a busy street with the zipper of the pants wide open, spilling water in a restaurant, asking a random woman Mary's in-vivo mishap exposures were designed to target on a street out on a date) to be most effective. When her fears of inconveniencing others, being the center of conducting these social mishap exposures, it is important to attention, and being thought of as unintelligent. To address clearly define the goal of the exposure situation and not to her fear of inconveniencing others, the therapists worked link the success or goal of the exposure to the patient's with Mary to design an exposure in which she negotiated a anxiety (i.e., "I want to do it nonanxiously" is not an romantic vacation package at a nearby five-star hotel. Her acceptable goal). Instead, the goal should be linked to goals were to ask for tickets to a ballgame, for rose petals to specific behaviors that allow the patients to test the be strewn on the bed, and for a horse-drawn carriage tour of anticipated consequences of the social mishaps. It is essential the city. At the end of stating those three requests, her goal that patients refrain from avoidance or safety behaviors, was to obtain an itemized list with the final price, negotiate such as apologizing, or any other behavior that might lessen the price, and then reject the offer because she "changed the patients' anxiety in the situation. For this reason, it is her mind" without apologizing or giving any excuses. She advisable to provide detailed instructions to the patients to described having automatic thoughts that she would get give them no room to engage in any such avoidance kicked out of the hotel, and that the concierge staff would behaviors. provides further examples of social roll their eyes at her. Mary's anticipatory anxiety was a 90, mishap exposures that clinicians may utilize in treatment.
her peak anxiety was a 90, and her final anxiety rating was a Our research group has filmed a series of treatment 40. Upon completing her exposure, she stated that she was sessions to exemplify various aspects of the intervention.
surprised by the concierge's accommodating nature, These can be found online at the Boston University despite her outrageous requests, and that she did not Psychotherapy and Emotion Research Laboratory receive the kind of negative response she had anticipated by the concierge staff. She met all of her goals and left the particular, the following video clips depict three treatment exposure with a sense of accomplishment for minimizing phases germane to the current paper: Video 1 demon- any use of safety behaviors (e.g., apologizing excessively for strates how to set up for an in-vivo exposure turning down the offer).
Other exposures that Mary conducted in subsequent Video 2 demonstrates how to conduct a social mishap sessions addressed similar fears: interrupting a group of people in a restaurant to practice a toast for a maid-of- ; and Video 3 demonstrates the honor speech (targeting inconveniencing others and being postprocessing of a social mishap exposure the center of attention); asking strangers in a bookstore to read the back cover of a book because she did not know howto read (targeting being thought of as unintelligent); and, Session 12: Relapse Prevention while wearing bandages on her face, asking people on the The treatment concluded with a discussion of relapse street if they were "Carl Smith" because his car was being prevention strategies. Clients reviewed their progress, towed (targeting inconveniencing others, being the center discussed areas of improvement, assisted each other in of attention, and being thought of as weird).
detecting warning signs, and generated ways to maintain Mary was assigned between-session in-vivo exposures to their progress. Similar to the recommendations for contin- practice the effects of repeated exposure. She was encour- ued use of other treatment components (e.g., cognitive aged to be creative, be concrete in specifying the behavioral restructuring techniques, approach to feared situations), goals of the exposures, and to try out other group members' ongoing use of social mishap techniques posttreatment were exposures. During the course of treatment, opportunities suggested in those cases where overestimated social cost and arose for Mary to make important phone calls at work and fear of social norm violation remained a primary issue. For attend parent meetings at her children's school. She had instance, Mary was encouraged to continue targeting her assigned goals for herself that minimized the use of safety fear of being the center of attention by engaging in behaviors behaviors, such as not procrastinating and initiating for which she thought she would be negatively judged. She

Table 1Examples of Social Mishap Exposures 1. Ask three people in the subway if they can spare $20.
2. Walk backwards slowly in a crowded street for three minutes.
3. Wear your shirt backward and inside out and buttoned incorrectly in a crowded store. Goal: Look three people in the eye.
4. Pay for an embarrassing item with change, and then state that you don't have enough and leave the store.
5. Approach people on the street asking if they can help you tie your shoelaces when you're wearing shoes without laces.
6. Recite "Twas the Night Before Christmas" in the subway 7. Go to a fast food restaurant and only order water, then spill the water, clean it up, and stay in the restaurant.
8. Ask multiple people in a specific and obvious location (e.g., right Video 1. Demonstrating how to set up an in-vivo social mishap outside XXX Park, or a T stop) where to find that location exposure with patient.
("Excuse me, I am looking for XXX Park").
9. Ask a staff member in Barnes and Noble for their opinion about whether to buy the Kama Sutra or the Joy of Sex, have along conversation about this, buy the books and then returnthem immediately.
10. Initiate conversations with/tell jokes to strangers in Barnes and Noble while wearing hair in a side ponytail with bandages onface.
11. Dance or sing in the street or subway wearing attention-grabbing 12. Call Barnes and Noble, ask to place on hold The Gas We Pass and Everybody Poops as well as a chocolate chip cookie fromthe in-house café.
13. Go to a hotel. Have the patient conduct a long conversation with the concierge about romantic vacation packages (askingabout in-room massages, arranging horse-drawn carriageride, etc.), book a package, and then cancel for no reason Video 2. Patient conducting in-vivo social mishap exposure in the except changing their mind.
presence of the clinician.
14. Go to every table in a crowded restaurant asking for Joe Smith.
15. Tell someone at B & N that you don't know how to read and ask them if they can read the back cover to you.
16. Approach group of people at bar or restaurant and ask if you can practice a best man's toast.
17. Enter a food establishment and interrupt people asking if they own a silver Camry because their car is being towed.
was encouraged to try out social mishap exposures that othergroup members had engaged in during the course oftreatment to target this fear (e.g., wearing bright coloredarticles of clothing, talking loudly into her cell phone in acrowded area, and opening her umbrella indoors).
Video 3. Demonstrating how to conduct postprocessing of in-vivoexposure.
Summary of Treatment At the end of treatment, Mary's LSAS score decreased to 38, which represented a 57.8% reduction of SADsymptoms from baseline. Mary continued to improve and symptom severity and maintenance of such progress even maintain her progress following acute treatment, as her 6 months later. Please see for a visual represen- LSAS scores indicated further improvements in SAD tation of Mary's outcome data at each time point.

Social Mishap Exposures for SAD group format may provide additional motivation for singlepatients. At the same time, a group format provides lessflexibility to treat comorbid conditions in the context of thisprotocol. Consistent with research indicating that SADrarely occurs in isolation (amajority of the clients in the group had other comorbidclinical disorders. Although Mary's depression remained inpartial remission during the course of treatment, and inlight of research showing the negative impact thatcomorbidities such as depression have on SAD treatmentoutcomes (), the group treatment for SAD may not Figure 1. Outcome data for case of Mary.
have been appropriate had she experienced anotherdepressive episode. It is also worth noting that the cases presented in the current study represented a highly Although Mary improved in a clinically meaningful way motivated subset of individuals who participated in our by the end of the treatment, she presented certain group treatments, which may not be generalizable to the challenges to the therapists who led her group. One primary larger population of clients with SAD. This worked to our difference in Mary's case compared to the other group advantage because they were not only engaged in the members was that Mary had a longer duration of illness (she treatment, but they also served as cotherapists in the group was the oldest member of the group) and she had a higher by encouraging other group members to engage in baseline severity of symptoms than the other members. She treatment. We recommend that future treatment studies had therefore developed highly evolved and idiosyncratic incorporate social mishap exposures and further investi- avoidance strategies. For example, it was not until the gate their relative efficacy by directly comparing them to therapists conducted a functional analysis during treatment more traditional exposures. Additionally, although in our that they discovered that Mary's overdelegation of work experience all patients benefit to some extent from (related to making phone calls) to the administrative engaging in social mishap exposures, it is important to assistants in the office was an avoidance strategy couched systematically examine whether particular subsets of in her mind as a justification for enhancing her efficiency at patients benefit more than others (e.g., patients of certain work. In other cases, clients have entered treatment with age groups, clinical presentations, motivation levels).
significant stigma about seeking treatment, and have felt Appendix A. Supplementary data initially resistant to in-vivo exposures because of a fear of"being discovered" as having social anxiety by people in the Supplementary data to this article can be found online area where they were engaging in exposure exercises. These thoughts had to be addressed directly through cognitive restructuring to motivate members to attempt the exerciseassigned, and were even tested as predictions in the American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
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