I have written three posts recently on Self-practice/Self-reflection (SP/SR) and cutting edge CBT for social anxiety disorder - the most recent went onto the website yesterday.  There is also a further associated post - "Assessment & monitoring questionnaires for CBT treatment of social anxiety disorder" - which gives ten or so relevant downloadable questionnaires & handouts.  I mentioned that David Clark suggested (at the workshop I attended with him) that there are "five treatment innovations" in his approach to social phobia treatment - 1.) self-focused attention & safety behaviours experiments; 2.) video (and still) feedback; 3.) attention training; 4.) behavioural experiments; and  5.) then v's now discrimination training & rescripting for early socially traumatic memories. I already wrote a good deal about safety behaviours and avoidance yesterday.  In today's post I continue to explore this territory.

David Clark's team use the 28 item "Behaviours questionnaire" (PDF file and Word doc) to help them assess individuals' use of safety behaviours.  Also freely available on the web - from the Australian "Centre for emotional health" - is Ronald Rapee & colleagues' slightly longer 32 item "Subtle avoidance frequency examination (SAFE)" (PDF file and Word doc).  I slightly prefer this latter scale because there is some research (reproduced on the version of the "SAFE" questionnaire downloadable from this website) giving likely frequency scores for people suffering from social anxiety and for a "normal" population.  While talking about other academic centres with a focus on social anxiety, I would also like to mention David Moscovitch & colleagues' work.  They have been publishing interesting contributions to our understanding of social anxiety for about ten years now.  David Moscovitch's webpage at the University of Waterloo in Canada gives more details of his approach and ... wonderfully ... gives free full text access to his numerous research studies.

Of particular relevance is his 2009 paper "What is the core fear in social phobia? A new model to facilitate individualized case conceptualization and treatment" with its abstract reading "What, exactly, do individuals with social phobia fear? Whereas fear of anxiety-related bodily sensations characterizes and defines panic disorder, is there a fundamental focus of anxiety that unifies individuals under the diagnostic category of social phobia? Current conceptualizations of social phobia suggest several possible candidates, including the fear of negative evaluation, embarrassment, and loss of social status. However, it is argued here that these conceptualizations are fundamentally flawed and confusing, and the lack of clarity with respect to this question has hampered our ability to conceptualize and treat patients with social phobia in a manner that is tailored to individual differences in symptom presentation. In the present article, I will propose a novel conceptualization of core fear in social phobia, demonstrate how this conceptualization can be used to classify individuals with social phobia in a manner that eliminates confusion and accounts for symptom heterogeneity, and illustrate its potential utility for both clinical practice and research."  I like this elegant paper with its teasing out of the distinction between feared stimulus, feared consequences, fear triggers/contexts, and fear-related avoidance, escape & safety behaviours.  So he writes " ... understanding can be facilitated in the early stages of therapy by conducting a functional analysis, in which precise information is gathered on every patient's: (a) feared stimulus (defined here, as elsewhere [e.g., Barlow, 2002], as the precise focus or object of the patient's anxiety or that which the patient perceives as being "dangerous"); (b) feared consequences (defined as that outcome or set of outcomes that the patient is afraid will transpire if the feared stimuli are confronted); (c) fear triggers and contexts (defined as the cues, contexts, and situations that are associated for the patient with his or her feared stimuli and, therefore, likely to trigger feelings of anxiety and use of avoidance behaviors); and (d) fear-related avoidance, escape, and safety behaviors (defined as the emotional action tendencies in which a patient engages to try to prevent the occurrence of feared consequences)."

Moscovitch argues ... pretty convincingly to my mind ... that "the precise focus or object of the patient's anxiety" isn't negative evaluation by others, loss of social rank/status, or embarrassment.  He suggests that these are all more "feared consequences" .  He goes on to state "Thus, to answer our central question regarding the feared stimulus in social phobia, the empirical evidence cited above converges with clinical observation to suggest that individuals with social phobia are uniquely and primarily concerned about characteristics of self that they perceive as being deficient or contrary to perceived societal expectations or norms.  According to this conceptualization, certain attributes of self are the focus of concern in social phobia in the same way that physical sensations are the focus of concern or fear in panic disorder and intrusive thoughts are the focus of concern or fear in OCD.  Accordingly, negative evaluation, rejection, embarrassment, and loss of social status are consequences that individuals with social phobia fear will occur if those self-attributes are exposed for scrutiny by critical others.  Whether a particular situation is thought of as being threatening depends crucially upon the nature of each patient's feared self-attributes and whether the patient believes he or she will be successful at concealing such attributes from public exposure. It follows from these premises that safety behaviors are self-protective, self-concealment strategies that serve the intended function of preventing the public exposure and criticism of feared self-attributes. The types of safety behaviors that are used by each patient depend on the specific self-attributes that are the focus of concern."   In his paper "The negative self-portrayal scale: Development, validation, and application to social anxiety", Moscovitch argues that these fears about exposed "deficient attributes" typically occur in three general areas - "Social competence" (for example around being seen as "boring", "stupid" or "socially awkward"), "Physical appearance" (for example fears around being seen as "physically unattractive", "unfashionable" or "ugly") and "Signs of anxiety" (for example fears around being seen as "sweating", "stuttering" or "blushing").  Interesting territory.  He has developed the "Negative self-portrayal scale (NSPS)" (PDF file and Word doc) to help clarify the particular concerns of individual social anxiety sufferers.

The next post in this sequence is "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: more on avoidance, social skills & compassion (5th post)".