Explain an example of how you would use both of these therapies with social anxiety

Exposure, in which a client enters and remains in a feared situation despite distress, is a key ingredient of most CBT treatments. Exposure is partially predicated on the assumption that the client must fully experience the feared situation in order for change in affective and behavioral symptoms to occur (e.g., Foa & Kozak, 1986). The mechanism underlying the effects of exposure has been debated for decades. A recent conceptualization that we find convincing is that exposure does not lead to the client unlearning fear responses, but rather generates new, more ambiguous learning that competes with, but does not fully replace, the original fear response (Bouton, 2002, Bouton and King, 1986).

The use of exposure typically begins with creation of a fear and avoidance hierarchy. The client brainstorms a list of feared situations and ranks these situations (with therapist assistance) according to the degree of anxiety they elicit. Specific ratings of anxiety and avoidance are typically collected as well. The finished hierarchy acts as a roadmap for exposure practice.

During exposure, the client is instructed to stay in the feared situation, with the expectation that an exposure of sufficient length will produce new learning or habituation and therefore reduce anxiety in that situation. To keep situations manageable, exposures begin with lower-ranked situations (e.g., moderately anxiety-provoking) and move up gradually to more highly feared situations. Exposures are typically performed both in and out of session, with in-session exposures often taking the form of role-plays that simulate, rather than directly reproduce, the feared situation. For example, the client might carry out a casual conversation with the therapist, who takes on the role of a stranger at a party. When situations are impossible to stage, exposure can also be performed using imagery. For a more in-depth discussion of the use of exposure in treating social anxiety disorder, see treatment manuals by Heimberg and Becker (2002) and Hope, Heimberg, Juster, and Turk (2000).

Although exposure is designed to overcome overt avoidance, clinicians should be aware that subtle avoidance can defeat exposure. Clients with social anxiety disorder, for example, often focus on themselves, attending to physiological symptoms of anxiety or their own internal experience, rather than the situation (e.g., Hope et al., 1989, Stopa & Clark, 1993). Clients may also attempt to mentally distance themselves from exposure situations (e.g., by telling themselves “It's just a role-play”; Hope et al., 2000). If active engagement with the feared situation, and not merely physical placement of the client in a spatial location, is the active ingredient of exposure, then such strategies are essentially equivalent to physical avoidance of the situation. Not surprisingly, then, the addition of instructions to focus on the situation increases the efficacy of exposure, presumably because they help prevent subtle avoidance (Wells & Papageorgiou, 1998).

A similar, but conceptually distinct form of subtle avoidance is the use of safety behaviors, which are often employed by people with social anxiety disorder to reduce the perceived probability of negative evaluation by others (Clark & Wells, 1995). Safety behaviors take many forms but are typically matched to the accompanying fear. For example, fearful public speakers may hold their hands behind their back or rigid at their sides, in order to prevent themselves from shaking. Similarly, clients who are afraid of appearing unintelligent may only speak after repeatedly rehearsing the exact wording of what they will say. Clients often credit safety behaviors for their successes, even though safety behaviors may, in fact, have a number of negative consequences. In the examples above, a public speaker who holds her arms behind her back may not be perceived as shaking, but she may nevertheless be perceived as a less competent speaker because of a lack of expressiveness. Similarly, the client who mentally rehearses all verbalizations will be at a distinct disadvantage in providing appropriate responses to questions or in appearing suitably spontaneous in casual conversation. Furthermore, these behaviors should prevent habituation or the modification of negative beliefs, because the client never considers the feared consequence as likely to occur so long as he or she engages in the safety behaviors. Indeed, there is evidence that analyzing and halting safety behaviors enhances the efficacy of exposure (Wells et al., 1995).

Progressive muscle relaxation (PMR; Berstein, Borkovec, & Hazlett, 2000) is a well-known technique for the management of the physiological arousal that often accompanies anxiety. However, PMR alone has repeatedly been shown to have minimal effects (e.g., Alström, Norlund, Persson, Hårding, & Ljungqvist, 1984) and, indeed, has been used as control condition (for comparison to exposure and cognitive restructuring) in studies of the treatment for social anxiety disorder (e.g., Al-Kubaisy et al., 1992). PMR alone is generally accepted as insufficient as a treatment for social anxiety disorder, and we know of no evidence that counters this consensus.

However, PMR forms the underlying basis for applied relaxation, which has shown some efficacy in treating social anxiety disorder. In applied relaxation, clients are trained in PMR and then instructed to practice using relaxation during daily activities and, when the client is sufficiently skilled, when confronting feared situations (Öst, 1987). Essentially, then, applied relaxation is a specific treatment modality that employs a combination and adaptation of the general techniques of PMR and gradual exposure to feared situations in order to provide clients with a new coping response.

The use of social skills training is often justified with a skills deficit model of social anxiety disorder, which assumes that anxiety arises from inadequate social interaction skills. The logical treatment, given this assumption, is teaching and practicing social skills, and this is most typically accomplished with a combination of modeling, behavioral rehearsal, corrective feedback, and positive reinforcement. Evidence regarding social skills deficits in people with high versus low social anxiety is equivocal, with some studies finding differences (e.g., Stopa & Clark, 1993) and others failing to do so (e.g., Rapee & Lim, 1992). Furthermore, people with social anxiety disorder may possess adequate social skills but fail to enact them as a result of anxiety or negative beliefs about the behaviors, giving the appearance of social skills deficits when, in fact, this is not the case. In addition, social skills training inevitably involves exposure to feared situations, making its effects difficult to separate from those of exposure. Therefore, although there is good reason to believe that social skills training may be helpful, at least for some clients, it is unclear whether the specific aspects of such programs are essential for all clients.

The use of cognitive restructuring for people with social anxiety disorder is based on the rationale that it is not the situation, but the person's thoughts about the situation, that generate anxiety (e.g., Beck & Emery, 1985). The client is usually presented with this model and supporting examples. The client and therapist then work together on identifying automatic thoughts, which are defined as negative, often inaccurate thoughts that produce distress (e.g., Heimberg & Becker, 2002). The therapist models disputation of automatic thoughts for the client, and the client then practices identifying and disputing automatic thoughts inside and outside of session. When integrated into a treatment package, cognitive restructuring is most often used before, during, and after exposure in an attempt to enhance its effects. In this framework, exposure is viewed as a method of challenging automatic thoughts and beliefs rather than simply a process of habituation. For a more detailed description of the use of cognitive restructuring in the treatment of social anxiety disorder, see Heimberg and Becker (2002) and Hope et al. (2000).