Be/m. Res. Thu. Vol. 23. No. 6. pp. 651-657. 1985 0005-7967/85 $3.00 + 0.00

Printed m Great Britam. All rights reserved Copyright ec 1985 Pergamon Press Ltd

EXPOSURE AS A TREATMENT FOR SOCIAL PHOBIA:

SOME INSTRUCTIVE DIFFICULTIES

GILLIAN BUTLER

Oxford University Department of Psychiatry, Wameford Hospital, Headington, Oxford OX3 7JK, England

(Receined 13 March 1985)

Summary-The main rules guiding the application of exposure to the treatment of simple phobias and agoraphobia are described, together with the four principal difficulties that came to attention when these rules were applied to the treatment of social phobia. These difficulties were: (i) specifying graduated and repeatable tasks: (ii) prolonging exposure; (iii) securing adequate engagement during exposure; and (iv) dealing with the cognitive aspects of social phobia. Solutions to these difficulties are described and illustrated from case material collected during the treatment of 45 socially-phobic out-patients. The discussion considers the implications of these solutions both for the treatment of other conditions and for understanding the processes involved in exposure.

INTRODUCTION

The most effective treatment for phobias is exposure (cf. Emmelkamp, 1982). For optimal effectiveness exposure should be graduated, repeated and prolonged, and practice tasks should be clearly specified [see, for example, Mathews, Gelder and Johnston (1982)]. According to Borkovec and Sides (1979) it should also be ‘functional’, i.e. provoke symptoms of anxiety, and de Silva and Rachman (198 1) add that the procedure may not be effective if the patient is not ‘engaged’ or is not sufficiently active.

These guiding rules have been derived from research over many years on the treatment of simple phobias and of agoraphobia. They are guiding rules, not scientific principles because, as Rachman (1983) reminds us “neither the role nor the underlying mechanisms of ( ) exposure to the feared situation or stimulus, are well understood”. Because they are rules not principles it is not certain whether they can be applied more widely than to the simple phobic and agoraphobic cases from which they were derived.

Butler, Cullington, Munby, Amies and Gelder (1984) applied these rules to the treatment of social phobia. In order to evaluate a relatively pure form of exposure they specifically excluded all instructions about how to manage symptoms of anxiety. This procedure focused attention on a number of ways in which social phobias differ from other phobias, and revealed certain difficulties in the application of exposure to this disorder. The principal difficulties were:

1. Tasks could not always be clearly specified in advance, repeated or graduated because social situations are variable and unpredictable.

2. Many social situations have an intrinsic time limit and cannot be prolonged. Entering a room. saying good morning or buying a drink are examples of such situations.

3. Social phobics often appear to avoid relatively few situations; they may continue to go to work or to other places where they will meet people, and may be forced to do some things that provoke anxiety. However, this continued exposure is not apparently beneficial, as the problem frequently persists despite it.

4. Thoughts and attitudes seem to play a central role in the maintenance of social phobias. Social phobics are generally preoccupied with the impression they make on others and suppose this to be negative. Exposure (without anxiety management) provides no information about evaluation and so it ignores an important aspect of the problem. Exposure alone might therefore be less effective for social than for

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other phobias. Thoughts that accompany agoraphobia. for instance about fainting, going mad or losing control, appear to subside during exposure. This may be because exposure provides information that these disasters do not occur. and therefore tends to correct the ideas.

These differences between social and other phobias make it difficult to organize treatment in a way that closely follows the guiding rules referred to above. Despite this. the clinical trial reported

by Butler et al. (1984) showed that patients with social phobia improved significantly when treated with exposure alone and retained this improvement for 6 months after treatment had ended. In the present paper each of the difficulties listed above will be discussed in turn and solutions to them will be described and illustrated from cases treated during the trial. Consideration is also given to the implications of these solutions for: (i) the treatment of other conditions; and (ii) for understanding the processes involved in exposure.

THE DIFFICULTY OF SPECIFYING GRADUATED AND REPEATABLETASKS

For agoraphobic patients it is quite easy to arrange exposure along a hierarchy. The patient decides at what level in the hierarchy to begin, and starts repeated and prolonged practice at that point, moving up or down the hierarchy according to the amount of anxiety experienced and the rate of change. The situations can be clearly described, and are amenable to Guttman scaling (Johnston, Johnston, Wilkes, Burns and Thorpe, 1984). There is inter-individual consistency in the order of task difficulty and individual hierarchy items fit naturally together so that progress with one item serves as preparation for the next.

The practice tasks of the 45 social phobics in the trial under discussion were examined, and for only 5 patients could the tasks be ordered into graduated, continuous hierarchies of this kind. For these 5, anxiety focused on a relatively specific social situaton such as eating, drinking or speaking in public. For the rest there was no natural hierarchy, and little reason for believing that practising an easy item would enable the patient to deal better with harder ones. Indeed most task lists contained such apparently disparate items as having a haircut, entering a canteen, using a dictaphone, picking up a drink and talking to colleagues at work about leisure activities. Such lists, can be more appropriately regarded as problem lists than hierarchies in that it was not usually possible to predict the order of task difficulty. Thus for some patients it was easier to go to the pub alone; for others going with a friend was easier; some were more anxious during conversations, others during silences; some were more anxious talking to strangers, others talking to intimate friends; some were more anxious when making eye-contact, others when looking away; some more anxious speaking first, others when waiting for someone else to start the conversation. Moreover, the same person may need to practise apparently opposite tasks in different situations. Thus social hierarchies are discontinuous and vary widely between individuals. In this way they differ from agoraphobic hierarchies, and pose more problems for exposure.

One solution is to construct separate hierarchies for each situation listed, and to work on these separately. However, in many cases this procedure is neither efficient nor practical. For example, in the case of having a haircut, it is quite easy to practise approaching barbers’ shops or sitting in front of mirrors. but there is a limit to the number of times hair can be cut, or a person can enter a barbers without having a haircut.

A second solution, of a kind mentioned by Wolpe (1973), is to find a common theme of relevance to the individual, for example if the person is anxious in the barbers and in a pub, the theme might be carrying on a conversation with a relative stranger, but for another person it might be remaining seated for a time dictated by the behaviour of someone else. Whatever the theme it is intended to direct attention to what seem to be the important elements of the situation, and to provide a hierarchical structure around which to organize subsequent practice. In effect this solution shifts the focus of practice away from overt social aspects of the difficult situations towards covert cognitive aspects associated with the central fear of negative evaluation.

A third solution involves placing strong emphasis on the amount of practice required while paying less attention to the difficulty of each task. In the trial discussed here patients were requested

Exposure as a treatment for social phobia 6.53

to practise for 1 hr each day, if necessary practising many different tasks, some of which might be extremely brief (e.g. greeting someone), others relatively lengthy (e.g. attending a club meeting). In the same week several aspects of social interaction producing different amounts of anxiety were often practised. So at any one time practice tasks might be taken from a wide section of the hierarchy although patients were advised that whenever possible they should attempt easier tasks before harder ones. Sometimes a series of tasks could be related by a common theme but sometimes they could not. Patients complied with this form of treatment, carrying out a mean of 8.6 hr of practice each week, and phobias improved. This suggests that for social phobics the duration, frequency and variety of practice may be more important than strict organization in a hierarchy with exact repetition of individual tasks.

DIFFICULTIES IN PROLONGING EXPOSURE

It has been suggested that prolonged exposure is desirable because it allows patients to learn that if they stay in fear-provoking situations long enough, fear will subside and new associations will develop between those situations and calmer feelings. Prolonged exposure also changes the behaviour through which patients learn that escape brings relief of anxiety.

Many social situations are too brief to allow these processes to operate effectively. However brief situations, for example entering crowded rooms, making enquiries or signing cheques, can be frequently repeated. For a substantial proportion of the weeks that they were in treatment at least a quarter of the patients practised some tasks that lasted less than 1 min. Self-report suggests that these short tasks were helpful. This may be because even brief social tasks are sufficient to disconfirm expectations, for example of being rejected, though more prolonged exposure would be needed to disconfirm the agoraphobic expectation of panicking.

CONTINUED EXPOSURE WITHOUT ANY LESSENING OF THE SOCIAL PHOBIA

At the start of treatment about three-quarters of patients reported regularly entering situations that predictably provoked their symptoms. Examples include an insurance saiesman who continued to approach new clients, a telephone engineer who continued his work repairing faults in private houses and an accountant who never avoided answering the telephone, drinking coffee with his colleagues or using the dictating machine. The encounters with phobic situations did not lead to any reductions in symptoms and the problem in treatment was to find a way of making this continued exposure effective.

When asked to describe this regular exposure many patients became aware that they were not fully ‘engaged’ in the anxiety-provoking activities, and spontaneously reported using a kind of ‘internal avoidance’. For example a man who became anxious when eating or drinking in public said that the rule he learned during treatment .was ‘don’t pretend you’re not where you are’. Another said that his problem was ‘internal avoiding’. The reported purpose of the attempted disengagement was to reduce symptoms, rather in the way that distraction is supposed to reduce symptoms. However in these cases symptoms persisted, possibly because ‘internal avoiding’ refers to dissociation from external rather than internal cues, Attending to internal cues may maintain symptom monitoring while preventing full exposure.

As the guiding rules of exposure indicate that full engagement is necessary, attempts were made to obtain it. Three solutions were found.

(if The first was to use a detailed ‘syntactical’ ~reuk~own of social interaction like that used in social-skills training (e.g. Argyle, Bryant and Trower, 1974; Trower, Bryant and Argyle, 1978). Patients were encouraged to practise specific elements of social interaction such as active listening skills, making appropriate eye-contact or introducing topics of conversation. It was difficult for patients to disengage while carrying out these behaviours. At the start of treatment most people were unaware of the elements of social interaction and needed instructions, but most patients already had the relevant skills and did not need social-skills training before they could start practising. In addition social-skills analysis helped in defining specific practice tasks which could sometimes be arranged in a hierarchy; in this way it also contributed to the solution of the first

654 GILLIAN BUTLER

problem mentioned above. For example, particular listening skills such as non-verbal signs of attention, appropriate use of eye-contact or of verbal reflections can be practised successively and then linked with speaking skills to create a graded series of tasks. They also engage the patient more fully by providing a new way of thinking about those fear-provoking situations that were not avoided, and a method of breaking them down into smaller units. An example of the value of social-skills analysis is provided by a young, unconfident trainee chef who seemed ill at ease in most social situations, and worried that he was being criticized or ridiculed. Social-skills analysis showed that although he listened to others, he avoided talking even though his speaking skills were adequate. Practice tasks included listing possible topics of conversation using non-verbal indications that he wanted to speak, speaking up and not mumbling, initiating conversations etc. The insurance salesman mentioned above avoided remaining silent and felt responsible for the progress of any social interaction. Appropriate practice tasks for him included more listening than speaking skills.

A more complex example shows how the social-skills analysis may help patients identify some of the more manageable constants (or relevant themes), in the social situations that they do not avoid but continue to fear. A young man experienced severe anxiety when unable to keep his various roles separate, for instance when talking about leisure activities at work, or about the construction industry in the pub. Meeting a friend from college while mending his motorbike provoked intense anxiety. He referred to these as ‘clashing situations’. His anxiety was reduced by using a variety of speaking, listening and other non-verbal social tasks. These tasks, which helped him to think of the clashing situations in a new way, were chosen because they could be applied irrespective of situation and topic of conversation. They provide some practice consistency while recognizing the need for adaptation. improvisation and flexibility dictated by the complex nature of social situations.

Practice tasks of this kind were intended to ‘engage’ the individual more fully in difficult

situations. However, they may also have other functions. They may counteract avoidance of elements of social interaction that patients were not aware of avoiding, or enable patients intentionally to use the social skills that they were not aware of possessing. If patients possess appropriate skills but become too anxious to perform them the social-skills analysis may increase engagement by reminding them of a sequence of actions. Such tasks may also distract attention from anxiety-provoking aspects of situations (either the presence of particular threatening individuals, or the occurrence of physiological symptoms), thus allowing anxiety to subside during

exposure. (ii) The second element that helped patients to benefit from continuing exposure was the

instruction to be an actioe rather than a passive participant in situations that provoke anxiety, or to initiate difficult interactions. The particular difficulty, highlighted by the problem of disen- gagement, is that the behaviour of social phobics changes or contaminates the situations they fear. Agoraphobia does not change the nature of supermarkets in the way that social phobia changes the nature of conversation. The difficulty is to arrange exposure to an uncontaminated interchange. The instruction to initiate provided one means of doing this. For example. many social phobics find it difficult to start or to carry on a conversation. The difficulty becomes acute if others are waiting for them to speak, since attention is focused upon them and they are likely to interpret such attention as critical. In this situation social phobics usually suffer in silence. However, according to the social-skills analysis asking a question focuses the attention of listeners away from the questioner and onto the person who is expected to reply. So questions were frequently used as practice tasks. Using appropriate eye-contact provides another example and shows that as well as counteracting a typically contaminating type of avoidance, the instruction to initiate combines well with the fine analysis of social behaviour mentioned above.

(iii) the third method used to help patients secure engagement was the instruction to provoke

symptoms of anxiety. This was particularly useful either when patients could not find enough tasks to practise or when they were improving and experienced less anxiety. For example a man who sweated distressingly when in company was able to increase his practice by moving away from the open window, wearing an extra sweater or accepting hot food and drink. A woman who was fast improving decided to raise a controversial point in a meeting. At later stages in treatment exposure can be extended by taking cognitive action such as deciding to tolerate occasional silences or by

Exposure as a treatment for social phobia 655

adopting a willingness to wait for a cue from others, for instance in deciding where to sit, when to pick up a drink or what to talk about.

FEAR OF NEGATIVE EVALUATION

The last problem mentioned at the beginning of this paper was that social phobias involve an important cognitive element, the fear of negative evaluation, i.e. a fear of what other people may be thinking. This suggests that social phobia might be resistant to treatment by exposure which does not include a cognitive element. Although social phobics can be asked to approach situations in which they expect to be evaluated negatively, one cannot arrange, grade or repeat exposure to the critical thoughts of others. Nor indeed would this necessarily be helpful since, in fact, other people seldom think these thoughts. Fear of negative evaluation is more likely to be reduced by a demonstration that it does not occur than by exposure to criticism. Brief practice tasks might achieve this aim. For example when a phobic patient smiles when greeting someone and receives a smile in return expectations of negative evaluation might be discontinued. However, our results suggest that exposure alone does not produce a substantial or lasting effect on the fear of negative evaluation.

In contrast, anxiety management did reduce the cognitive aspects of social anxiety. The measures of fear of negative evaluation and social avoidance and distress (Watson and Friend, 1969) changed significantly in the subgroup of patients treated with anxiety management as well as exposure. Those receiving exposure without anxiety management did not improve on these measures during treatment, nor during the 6-month follow-up period. Although they improved on the main measures of social phobia more of them requested further treatment during the following year (40% vs 0%). So the attempts to adapt exposure to this difficult group did not succeed in overcoming this problem. The results suggest that it may not be necessary to do so in order to make immediate gains, but it may be necessary to do so if the patient is to feel less susceptible to the critical thoughts of others. If this thought pattern does not change then the patient is likely to continue to ask for help.

DISCUSSION

Exposure as adapted here for social phobics conformed to the requirement that it should be confined to tasks that were feared and/or avoided, and that formed a part of normal social interaction. It was also effective. However, it did not generally conform to the requirements that tasks should be graduated, repeated and prolonged, and non-specific instructions to initiate interaction or to provoke symptoms were also given. To conform to the further requirement that patients should be engaged in the tasks, three procedures were used, one of which employed the syntax of social behaviour developed for work on social skills. So it is possible to obtain good results with social phobics using a version of exposure which, theoretically, is less than optimal. The implications of this finding for the treatment of other conditions are discussed next.

The Implications for the Treatment of Other Conditions

In the treatment of simple phobias and agoraphobia frequency and variety of practice may also be more important than the strict hierarchical organization and exact repetition of tasks. In addition the value of very brief exposure may have been underestimated in treating these disorders, though it may take longer to disconfirm agoraphobic patients’ expectations of losing control than social phobics’ fears of social rejection, and the problem of disengagement should probably be tackled systematically. It is likely that in clinical practice this more flexible approach to exposure is often used.

The modified version of exposure can also be used in the treatment of generalized anxiety, even though avoidance is less consistent in these cases and it is not usually possible to construct a hierarchy. Patients can be instructed to approach that variable set of events that provokes their symptoms. This may mean that exposure cannot be planned in advance or graded. Instead the patient is prepared to respond to symptoms with approach rather than withdrawal irrespective of situation, and may need to be warned about the possibility of disengagement.

656 GILLIAN BUTLER

A detailed behavioural analysis similar to that based on the social-skills approach can provide a source of practice tasks for generally anxious patients. For instance those who are overcommitted and permanently busy may be trying to do more than one thing at a time. may not complete one task before starting another or continue to plan what to do next while trying to concentrate on the job in hand. Such people may avoid setting aside time to plan activities. or doing things slowly. Others avoid any disturbance of their daily routines. These people may be helped by learning how to plan activities systematically or by exposing themselves to more flexible schedules.

Implications for the L’nderstanding of‘ E.~posure

Non-reinforced exposure to anxiety-eliciting stimuli is said to be the main agent of change in the psychological treatment of phobias (e.g. Boyd and Levis. 1983). However, the processes involved are not clearly understood. Neither conditioning models, involving explanations in terms of extinction, reciprocal inhibition or counter-conditioning, nor habituation models can account adequately for variations in the success or failure of exposure [see. for example. Wilson (1984) and Williams, Dooseman and Keifield (1984) for recent discussions].

There are two main problems. The first is that exposure has limitations. Few patients are symptom-free at the end of treatment, some may improve and relapse and a few do not respond at all. Also in the investigation discussed above exposure alone did not change important cognitive aspects of social phobia. The second is that neither duration of exposure nor arousal level relates well to outcome.

When discussing the processes involved in recovery, Goldfried and Robins ( 1983) suggest that if performance-based treatments are to be effective there has to be a corresponding change in the patient’s ‘schema’. This is because cognitive biases may limit the assimilation of new information. Cognitive-behavioural and social-learning models of treatment explicitly recognize this and consequently focus on cognitive factors as well as on behavioural tasks. However, it has not yet been shown that these methods lead to better outcomes.

A close look at the procedures involved when social phobics are treated with a relatively ‘pure’ form of exposure suggests that many complex and interrelated factors may contribute to the effectiveness of exposure. In its ‘pure’ state the treatment involves more than non-reinforced exposure to anxiety-eliciting stimuli. Implicit cognitive factors relevant to the interpretation of events and future expectations usually form an integral part of exposure treatment delivered with an active, behavioural, self-help orientation. For example, during discussion of practice therapists help patients to interpret events in an unbiased way. In this way a difficult occasion is seen as a partial success and not as a complete disaster; the failure of another person to smile at the patient may be interpreted as a sign of preoccupation rather than of personal rejection. Also patients are told to expect future fluctuations in social anxiety and prepared to deal with setbacks on their own.

Other implicit cognitive factors were introduced in the investigation under discussion together with solutions to the particular problems posed by social phobics. For example, themes around which practice could be organized frequently related to the fear of negative evaluation, and very brief practice tasks may have been effective because they were at least long enough to disconfirm expectations about being rejected.

Non-cognitive factors also play a part in exposure for social phobics. These include identification of specific skills. breakdown of social events into manageable units which may increase social repertoire and flexibility and practice in the implementation and sequencing of specific skills. Practice probably also increases the range of social experience, knowledge about social events and the number of social skills available. All these factors are likely to increase the patient’s sense of control over difficult situations and self-confidence, and these in turn motivate patients to practise (or not to avoid) entering difficult situations.

When a patient improves, all these factors change. So the social phobic no longer avoids difficult situations, feels rejected, expects to feel uncomfortable or complains of symptoms of anxiety, but instead appears more skillful and confident. It is possible that exposure alone engages all the relevant processes of change. In simple phobias this does apparently happen. But it is also possible to be misled by the relative simplicity of the treatment procedure in simpler cases, and to suppose that the processes of change are correspondingly simple. The number of factors involved in the modified form of exposure used with social phobics suggests this is unlikely. It rather suggests that

Exposure as a treatment for social phobia 657

further work on the processes of change is needed before we are likely to be able to remove the limitations on behavioural treatments for phobic disorders. If cognitive factors play a central role in a patient’s problem, as may also be the case for those generally anxious patients who fear they have or will get a serious illness, these need specifically to be dealt with using techniques other than exposure.

Acknawledgemenrs-The author was supported by a grant from the Medical Research Council of the United Kingdom. I would like to thank Michael Gelder, David Clark and John Marzillier for their helpful comments on an earlier draft

of this article.

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