476867

research-article2013
CPXXXX10.1177/2167702613476867Goldin et al.Changes in Positive Self-Views

Empirical Article
Clinical Psychological Science

Changes in Positive Self-Views Mediate the 1(3) 301­–310

© The Author(s) 2013
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DOI: 10.1177/2167702613476867

Social Anxiety Disorder cpx.sagepub.com

Philippe R. Goldin1, Hooria Jazaieri1, Michal Ziv1, Helena

Kraemer2, Richard G. Heimberg3, and James J. Gross1
1
Department of Psychology, Stanford University, Stanford, California; 2Department of Psychiatry, Stanford Medical School, Stanford,
California; and 3Department of Psychology, Temple University, Philadelphia, Pennsylvania

Abstract
Social anxiety disorder is thought to be characterized by maladaptive self-views. This study investigated whether (a) patients
with social anxiety disorder (n = 75) differ at baseline from healthy controls (n = 43) in negative and positive self-views,
(b) cognitive-behavioral therapy (CBT) for social anxiety disorder versus wait-list control produces statistically and clinically
significant changes in negative and positive self-views, (c) changes in self-views mediate the effect of CBT on social anxiety
symptoms, and (d) changes in self-views during CBT related to social anxiety symptoms at 1-year post-CBT. As expected,
patients endorsed more negative and fewer positive self-views than healthy controls at baseline. Compared to wait-list control,
CBT yielded statistically and clinically significant changes, specifically, fewer negative and more positive self-views. Mediational
analysis indicated that increased positive (but not reduced negative) self-views mediated the effect of CBT on social anxiety
reduction. Correlational analyses determined that increased positive self-views were associated with social anxiety symptom
reduction at 1-year post-CBT.

Keywords
social anxiety, self-view, self-referential, cognitive-behavioral therapy, meditation

Received 10/12/12; Revision accepted 1/8/13

Social anxiety disorder (SAD) is highly prevalent (with a life- self-referential evaluations that generate negative emotions,
time prevalence of 12.1%; Kessler et al., 2005), has an early disrupt emotion regulation, and interfere with social self-
onset (Otto et al., 2001), and has a high rate of persistence that efficacy and performance (Spurr & Stopa, 2002).
is well predicted by symptom severity and comorbid mood Hofmann (2007) suggested that, on an intrapersonal level,
disorders (Blanco et al., 2011). Individuals with SAD experi- social fears may be related to an internal discrepancy among
ence distressing levels of social fear, humiliation, and embar- competing self-views. The notion of multiple possible selves
rassment (Stein & Stein, 2008), which can lead to significant refers to dynamic aspects of the self-concept, including moti-
impairment in social, educational, and occupational function- vation, distortion, and momentary and enduring change
ing (Schneier et al., 1994; Stein & Kean, 2000) and thus cre- (Markus & Nurius, 1986). These different versions of the self
ate a substantial personal as well as a societal burden (Acarturk are thought to vary in accessibility across time and may be
et al., 2009; Patel, Knapp, Henderson, & Baldwin, 2002). modified with training. Moscovitch, Orr, Rowa, Reimer, and
Cognitive-behavioral models of social anxiety (Clark & Antony (2009) argued that, on an interpersonal level, the core
Wells, 1995; Heimberg, Brozovich, & Rapee, 2010) highlight difficulty in SAD is not social situations and others’
the important role played by maladaptive self-views, exag- evaluations per se but, rather, aberrant views of the social self
gerated self-focus, and distorted interpretations in generating
and maintaining heightened social anxiety. Individuals with
Corresponding Author:
SAD tend to view themselves as socially awkward, inade- Philippe R. Goldin, Department of Psychology, Jordan Hall, Bldg. 420,
quate, or flawed. These negative self-views are thought to Stanford, CA 94305-2130
trigger exaggerated self-focused attention that can lead to E-mail: pgoldin@stanford.edu
302 Goldin et al.

and the exposing of negative self-attributes to others. Stopa change in negative and positive self-views compared to nor-
(2009) identified several self-related factors that may contrib- mative HC data. We expected that increases in positive and
ute to social fears, including maladaptive self-related content reductions in negative self-views during CBT would mediate
(i.e., self-concepts), structure (i.e., how information about the the effect of CBT versus WL on social anxiety symptoms. We
self is stored and retrieved), and processes (i.e., how attention further expected that increases in positive and reductions in
is allocated to self-relevant information). negative self-views would be related to social anxiety symp-
Research to date has emphasized the role of negative self- tom reduction at 1-year post-CBT.
views, their relationship to social fears and avoidance, their
function in maintaining SAD, and their malleability during
clinical treatments for SAD (Anderson, Goldin, Kurita, & Method
Gross, 2008; Goldin, Manber-Ball, Werner, Heimberg, &
Participants
Gross, 2009; Hofmann, Moscovitch, Kim, & Taylor, 2004).
However, more recent theoretical models have highlighted Patients were seeking treatment for SAD and met criteria per
the importance of considering positive self-views, in addition the Diagnostic and Statistical Manual of Mental Disorders,
to negative self-views, in the context of SAD (Heimberg et fourth edition (American Psychiatric Association, 1994), for
al., 2010). Key questions raised by these newer models a principal diagnosis of generalized SAD based on the
include (a) whether and how clinical interventions for SAD Anxiety Disorders Interview Schedule for the DSM-IV–
might modify negative and positive self-views and (b) how Lifetime version (ADIS-IV-L; DiNardo, Brown, & Barlow,
such changes might relate to treatment outcome. A small 1994). In the context of an RCT and of the 436 individuals
number of intervention studies suggest that, when broadly assessed for eligibility (see Consolidated Standards of
construed, self-views may be modified in patients with SAD Reporting Trials diagram in Goldin et al., 2012), 110 were
following cognitive-behavioral group therapy (Hofmann et administered the ADIS-IV-L in person to determine whether
al., 2004), exposure (Hofmann, 2000), video feedback with they met diagnostic inclusion and exclusion criteria. After 35
cognitive preparation (Orr & Moscovitch, 2010), and mind- patients were excluded owing to not meeting diagnostic crite-
fulness-based stress reduction training (Goldin, Ramel, & ria (n = 26) or incomplete baseline assessments (n = 9), the
Gross, 2009). remaining 75 patients were randomly assigned to either
One particularly efficacious intervention for SAD is cogni- immediate CBT for SAD (n = 38) or a WL group (n = 37),
tive-behavioral therapy (CBT), which can be administered in who were offered CBT after the waiting period. After account-
group (Heimberg & Becker, 2002) or individual formats ing for dropout from CBT (n = 6, 16%) and WL (n = 5, 14%),
(Clark, 2001). Individual CBT, as developed by Hope and col- as well as incomplete data at post-CBT (n = 5) and post-WL
leagues (Hope, Heimberg, Juster, & Turk, 2000), has been (n = 6), we assessed 43 HC participants for comparison to
shown to be an effective treatment for SAD (Goldin et al., patients with SAD. Participants in this study are the same par-
2012; Ledley et al., 2009). Cognitive-behavioral models of ticipants as reported in Goldin et al. (2012) and Boden et al.
SAD have long suggested that successful CBT for SAD should (2012).
result in adaptive changes in self-views (Rapee & Heimberg, Because participants were part of a larger functional mag-
1997). However, few studies have examined the impact of netic resonance imaging study, they had to pass a magnetic
CBT on negative and positive self-views in the context of a resonance safety screen and be right-handed as assessed by
randomized controlled trial (RCT) or investigated whether the Edinburgh Handedness Inventory (Oldfield, 1971), and
changes in self-views mediate the effects of CBT on SAD out- they were excluded for current pharmacotherapy or psycho-
comes or relate to longer-term clinical improvement. therapy, past CBT, history of neurological or cardiovascular
Our goals in the present study were to investigate whether disorders, and current psychiatric disorders other than SAD,
(a) patients with SAD would differ at baseline from healthy generalized anxiety disorder, agoraphobia without a history
controls (HCs) in negative and positive self-views, (b) CBT of panic attacks, or specific phobia. HCs had to have no his-
for SAD versus random assignment to a wait-list control tory of Axis I psychiatric disorders as assessed by the
(WL) would produce statistically and clinically significant ADIS-IV-L.
changes in negative and positive self-views, (c) changes in
self-views would mediate the effects of CBT on social anxi-
Procedure
ety symptom severity, and (d) changes in self-views during
CBT would be related to social anxiety symptom reduction at HCs were recruited via electronic bulletin boards and assessed
1-year post-CBT. We expected that, compared to HCs, only once. Patients were recruited for an RCT of CBT for
patients with SAD would endorse more negative and fewer SAD through clinician referrals and Web-based community
positive social traits as self-descriptive. We also expected listings. After they passed a telephone screening, they com-
that, compared to WL, CBT would result in fewer negative pleted the ADIS-IV-L during a face-to-face interview. After
and more positive self-views, as well as clinically significant completing all baseline assessments, patients were randomly
Changes in Positive Self-Views 303

assigned to immediate CBT or WL using Efron’s biased coin whether the word consisted of upper- or lowercase letters.
randomization procedure (Efron, 1971), which promotes Each of the four trial types (two conditions by two valences)
approximately equal sample sizes throughout the duration of included five blocks. Each block consisted of a fixation cross,
the clinical trial. Patients in the WL and CBT completed the a prompt (either “Describes ME?” or “UPPER case?”), and
same measures. Patients received CBT at no cost and were five adjectives of the same valence presented one at a time for
not paid to participate. All participants provided informed 3 s each. We decided not to use neutral adjectives (as a com-
consent in accordance with the Institutional Review Board at parison condition), because there were few that could not be
Stanford University. misconstrued as positive or negative by a patient with SAD.
Stimulus order included a random sequence of block types and
a random sequence of five words within each block. Patients
Measures
pressed buttons to indicate whether or not a word was self-
To measure severity of social anxiety symptoms, we used descriptive or appeared in uppercase letters.
the 24-item Liebowitz Social Anxiety Scale–Self-Report
(LSAS-SR; Fresco et al., 2001; Liebowitz, 1987), which con-
Individual CBT for SAD
sists of questions that assess social interaction situations (11
items) and performance situations (13 items). A 4-point CBT was delivered with the Managing Social Anxiety: A
Likert-type scale is used for ratings of fear and avoidance for Cognitive-Behavioral Therapy Approach, the first edition of a
situations during the past week (0 = none and never; 3 = manualized treatment protocol, which included a therapist
severe and usually, respectively). Ratings are summed for a guide (Hope, Heimberg, & Turk, 2006) and a client workbook
total LSAS-SR score (range = 0–144). The LSAS-SR has (Hope et al., 2000) and consisted of 16 individual 1-hour ses-
good reliability and construct validity (Rytwinski et al., sions (except for the first in-session exposure session, which
2009), and its internal consistency (Cronbach’s alpha) was lasted 1.5 hours) administered over 4 months. The treatment
excellent in this study (SAD patients = .91, HCs = .93). covered five major components: (a) psychoeducation and ori-
To measure the potential confound of social desirability, entation to CBT; (b) cognitive restructuring skills; (c) gradu-
we administered the 10-item Marlowe-Crowne Social ated exposure to feared social situations, within session and
Desirability Scale (Crowne & Marlowe, 1960). The instru- as homework; (d) examination and modification of core
ment consists of true-false items with four reverse-coded beliefs; and (e) relapse prevention and termination. Further
items, with higher scores reflecting a greater tendency to give details are available elsewhere (Hope et al., 2000; Hope et al.,
a socially desirable response. It has shown adequate internal 2006; Ledley et al., 2009).
consistency and reliability (Crino, Svoboda, Rubenfeld, & All four study therapists had to achieve proficiency in
White, 1983). implementing CBT with training cases prior to treating study
participants. All CBT therapists were trained by and had
weekly group supervision with Dr. Heimberg, an expert in
Self-referential encoding task CBT for SAD and one of the principal developers of the CBT
The self-referential encoding task (SRET; Derry & Kuiper, protocol. To assure treatment adherence, every therapy ses-
1981) is considered an information-processing measure of sion was digitally recorded and rated for adherence based on
self-schema. Stimuli consisted of 25 positive and 25 negative the Cognitive-Behavioral Therapy for Social Anxiety
social trait adjectives from the Affective Norms of Emotion Disorder: Therapist Adherence Scale (Hope et al., 2006), and
Words database (Bradley & Lang, 1999), balanced (all ps > we determined that each therapist was rated as “in protocol.”
.51) on (a) word frequency (positive adjectives = 40.5, nega- For methodological details, see Goldin et al. (2012).
tive adjectives = 33.6), (b) number of letters (positive adjec-
tives = 6.9, negative adjectives = 7.2), (c) arousal (positive
Statistical analyses
adjectives = 5.54, negative adjectives = 5.43; 1 = low, 9 =
high), and (d) valence (deviation from neutral: positive adjec- For the baseline comparison, we conducted between-group t
tives = 2.66, negative adjectives = 2.58; 1 = most negative, 5 = tests on positive and negative self-endorsement on the SRET.
neutral, 9 = most positive), based on the 9-point Self- For the RCT, we conducted a 2 × 2 repeated-measures analy-
Assessment Manikin rating system (Lang, 1980). sis of variance (ANOVA)—Group (CBT, WL) × Time (pre-
The SRET was programmed with Eprime software treatment, posttreatment)—of positive and negative
(Schneider, Eschman, & Zuccolotto, 2002) to be exactly 5 self-endorsement to determine the effect of CBT on self-
minutes and 39 seconds. Each adjective was presented twice, views. We report effect sizes as Cohen’s d (Cohen, 1988) and
once in each of two conditions. The self-referential condition as partial eta squared (ηp2; Pierce, Block, & Aguinis, 2004).
assessed self-focused social-evaluative processing. Case iden- For the RCT, we also report effect sizes as success rate differ-
tification was used as a comparison condition to control for ence (SRD), defined as the difference between the probabili-
reading negative and positive adjectives while determining ties that a randomly chosen patient from CBT will have a
304 Goldin et al.

response preferable to a randomly chosen patient from WL. completer data were used to ensure temporal precedence. We
SRD ranges from 1 (if every patient treated with CBT has a used Pearson-product correlation coefficients to determine if
clinically preferable response to every patient in the WL) to there was an association between CBT-related changes in
−1 (if the reverse is true), with null value equaling 0. If the self-views and changes in social anxiety symptom severity
assumptions underlying Cohen’s d apply, then SRD is from pretreatment to 1-year post-CBT.
2Φ(d/√2) – 1, where Φ(d/√2) is the standard normal distribu-
tion function.
Results
To analyze clinically significant change, we used the
methods described by Jacobson and Truax (1991) to deter- Preliminary analyses
mine if treatment has moved a patient from the dysfunctional
to functional range. Their method C (Jacobson, Roberts, Patients with SAD and HCs did not differ significantly (all
Berns, & McGlinchey, 1999) uses the baseline mean and ps > .18) in gender, age, education, ethnicity, and marital sta-
standard deviation of the clinical patient sample and a norma- tus (Table 1). Patients in the CBT and WL groups also did not
tive sample to compute a cutoff score to determine whether a differ in gender, age, education, ethnicity, marital status, cur-
posttreatment score is more typical of the normative sample rent or past Axis I comorbidity, and past psychotherapy or
than the patient sample. Specifically, this determines whether pharmacotherapy (all ps > .05). The two groups also reported
a patient has moved to the normal control side of the halfway similar age at symptom onset (M ± SD: CBT = 13.2 ± 7.9, WL
point between two standard deviations from the patient mean = 13.0 ± 6.1 years; t = 0.16) and years since symptom onset
and two standard deviations from the normal control group. (CBT = 20.4 ± 11.1, WL = 20.3 ± 12.9 years; t = .02).
Chi-square analysis was conducted to determine whether the To rule out baseline differences in self-views, between-
proportion of patients demonstrating clinically significant group t tests of patients with SAD who were randomly
change differed following CBT and WL. assigned to (but had yet to begin) CBT or WL revealed no
For the mediation analysis, we investigated whether between-group differences on self-endorsement of positive
changes in positive and negative self-views separately medi- self-views (p > .18) or negative self-views (p > .37). To rule
ated the effect of CBT (vs. WL) on social anxiety symptoms. out the possibility of a social desirability response bias on
We implemented the MacArthur approach to mediation anal- self-report measures, we examined the relationship of the
ysis (Kraemer, Kiernan, Essex, & Kupfer, 2008), using a lin- Marlowe-Crowne Social Desirability Scale and endorsement
ear model including the main effects of treatment group (G) of self-views. In the CBT group, we found no significant rela-
and mediator (M) and the G × M interaction. G, the treatment tionships between the scale and baseline SRET negative self-
group assigned at baseline, was coded as 0.5 and −0.5. The endorsement (r = .15, p > .37) and positive (r = .01, p >.97).
prechange to postchange in M temporally followed G, and the Similarly, in the WL group, we found no significant relation-
outcome variable (O) was measured after treatment comple- ships between the scale and baseline SRET negative self-
tion. M was centered at zero (i.e., its value at baseline) to endorsement (r = –.28, p > .13) and positive (r = .34, p > .07).
make the standardized coefficient beta values (β) more inter-
pretable. Then we determined that G and M were correlated
Baseline results for patients versus HCs
and that in the linear model, either the main effect of M or the
interactive effect of G × M was statistically significant. The For positive self-views, a between-group t test revealed that,
mediator effect size is the difference between the overall compared to HC, patients with SAD had fewer positive self-
effect size of G on O and the effect size, if the connection views: SAD, M = 43.7%, SD = 24.2; HC, M = 88.0%, SD =
between G and M were somehow severed. Only treatment 12.1; t(112) = 11.15, p < .001, ηp2 = .53, Cohen’s d = 2.18,

Table 1. Demographics of Patients and Healthy Controls, n (%)

Variable SAD HC Test

2
Men 39 (52.0) 23 (53.4) χ = 0.07
Age, yearsa 33.5 ± 8.9 33.8 ± 9.8 t = 0.21
Education, yearsa 16.8 ± 2.3 17.4 ± 2.0 t = 1.34
White 43 (57.3) 25 (58.1) χ2 = 0.41
Marital status χ2 = 0.78
Single, never married 46 (63.0) 21 (48.8)
Married/with partner 24 (32.9) 21 (48.8)
Divorced, separated, widowed 3 (4.1) 1 (2.3)

Note: SAD = patients with social anxiety disorder (n = 75); HC = healthy controls (n =
43). All comparisons were nonsignificant (p > .05).
a
Mean ± standard deviation.
Changes in Positive Self-Views 305

mean between-group difference = 44.3, 95% confidence 65], and no change in the WL group, ∆ positive self-view =
interval [36.4, 52.2]. For negative self-views, compared to 7.04; t(25) = 1.72, p > .10. For clinically significant change,
HC, patients had more negative self-views: SAD, M = 49.4%, the Jacobson and Truax method C determined that positive
SD = 26.5; HC, M = 3.4%, SD = 9.1; t(112) = 11.01, p < .001, self-views greater than 85% was a cutoff for determining that
ηp2 = .52, d = 2.14, mean between-group difference = 46.0, a patient moved from dysfunctional to the functional range.
95% confidence interval [37.7, 54.3]. Chi-square analysis determined that, compared to WL, CBT
resulted in a higher proportion of patients who achieved clini-
cally significant change in positive self-views (CBT = 48.3%,
CBT versus WL effects on self-views WL = 10.0%; χ2 = 10.59, p < .001).
A 2 × 2 × 2 repeated-measures ANOVA of self-views—Group
(CBT, WL) × Valence (positive, negative) × Time (pretreat- Negative self-views. A 2 × 2 repeated-measures ANOVA of
ment, posttreatment)—resulted in a significant three-way negative self-views—Group (CBT, WL) × Time (baseline,
Group × Valence × Time interaction effect, F(1, 51) = 14.67, posttreatment)—resulted in main effects of time, F(1, 51) =
p < .001, ηp2 = .22, d = 1.07, and a significant interaction 9.19, p = .004, ηp2 = .15, and group, F(1, 51) = 14.93, p <
of Group × Time, F(1, 51) = 15.41, p < .001, ηp2 = .23, d = .001, ηp2 = .23, qualified by a group by time interaction, F(2,
1.10. 51) = 11.19, p = .002, ηp2 = .18, d = .94, SRD = .72 (Fig. 1).
Follow-up paired t tests showed CBT-related decreased nega-
Positive self-views. A 2 × 2 repeated-measures ANOVA on tive self-views, ∆ negative self-views = −25.34; t(26) = 4.97,
positive self-views—Group (CBT, WL) × Time (baseline, p < .001, ηp2 = .49, d = 1.39, and no change in WL group, ∆
posttreatment)—resulted in significant effects of time, F(1, negative self-views = 1.25; t(25) = 0.20, p > .84. For clini-
51) = 36.18, p < .001, ηp2 = .41, and group, F(1, 51) = 11.17, cally significant change, the Jacobson and Truax method C
p = .002, ηp2 = .18, qualified by a significant Group × Time determined that negative self-views less than 6% was a cutoff
interaction, F(2, 51) = 12.21, p < .001, ηp2 = .19, d = .97, for determining that a patient moved from dysfunctional to
SRD = .70 (Fig. 1). Follow-up paired t tests showed pre- to the functional range. Chi-square analysis determined that,
post-CBT increases in positive self-views, ∆ positive self- compared to WL, CBT resulted in a higher proportion of
view = 27.22; t(26) = 6.68, p < .001, ηp2 = .63, d = 2.61, mean patients who achieved clinically significant change (CBT =
within-group difference = 46, 95% confidence interval [27, 31.0%, WL = 3.0%; χ2 = 25.78, p < .001).

CBT
WL
100
∗∗ ∗
90

80

70
Self-Endorsement%

60

50

40

30

20

10

0
Pre-Positive Post-Positive Pre-Negative Post-Negative

Fig.1. Self-endorsement pre– and post–cognitive-behavioral therapy versus wait-list control in

patients with social anxiety disorder.
*p < .005. **p < .001.
306 Goldin et al.

Table 2. Change in Positive Self-Views Mediating the Effect of self-views were ignored—is now nonsignificant, indicating
Cognitive-Behavioral Therapy on the Severity of Social Anxiety complete mediation. For negative self-views, the linear
Symptoms regression, F(3, 50) = 4.49, p = .007, R2 = .20, demonstrated
Liebowitz Social Anxiety neither a main effect of M (p > .10) or an interaction of G × M
Scale–Self-Report b SE β p (p > .66).
To investigate the specificity of the findings, we tested
Intercept 67.01 3.95
whether changes in social anxiety symptoms mediated the
Group –1.55 7.89 –.035 .85
effect of CBT on positive self-views. For positive self-views,
Positive self-views –0.30 0.14 –.31 .03
the linear regression, F(3, 50) = 10.19, p < .001, R2 = .39,
Group × Positive Self-Views –0.41 0.27 –.25 .14
showed only partial mediation characterized by a main effect
of M (pre- to postchange in social anxiety symptoms; β =
–.36, p = .026) and a main effect of G (treatment group; β =
Self-views mediation of effects of CBT on .59, p = .003). Thus, the mediator did not reduce the effect of
social anxiety treatment group to nonsignificance. For negative self-views,
the linear regression, F(3, 50) = 8.49, p < .001, R2 = .32, dem-
As shown above, group assignment (G) at baseline to CBT onstrated neither a main effect of M (p > .06) nor an interac-
versus WL was associated with differential change in positive tion of G × M (p > .43).
and negative self-views satisfying the first criterion for show-
ing mediation. For positive self-views, the linear regression, CBT-related changes in self-views and
F(3, 50) = 5.24, p = .003, R2 = .23, demonstrated a main effect
long-term outcome
of M (pre- to postchange in positive self-endorsement) but no
interaction of G × M on post-CBT/WL social anxiety symp- We also examined whether pre- to post-CBT changes in self-
toms (LSAS-SR; Table 2, Fig. 2). Thus, the final criterion for views were related to changes in social anxiety symptoms
mediation is satisfied. Moreover, the treatment effect on from pretreatment to 1-year post-CBT. We found that
change in social anxiety—shown significant when positive increased positive self-views were associated with decreased

CBT Linear (CBT)

WL Linear (WL)

120
Social Anxiety Symptom Severity Post-CBT/WL

100

80

y = –0.09x + 68
R ² = 0.01
60

40
y = –0.50x + 66
R ² = 0.22
20

0
–30 –20 –10 0 10 20 30 40 50 60 70 80 90 100
Pre-to-Post Change in Positive Self-View
Fig. 2. Association of pre- to postchanges in positive self-endorsement and post–cognitive-
behavioral therapy/wait-list social anxiety symptom severity.
Changes in Positive Self-Views 307

severity of social anxiety symptoms (LSAS-SR) at 1-year Mediators of treatment outcome for SAD have begun to be
post-CBT, r(32) = –.35, p < .05. Decreased negative self- identified. These include decreases in probability bias for
views, however, were not associated with decreased severity negative social events (Smits, Rosenfield, McDonald, &
of social anxiety symptoms at 1-year post-CBT, r(32) = .20, Telch, 2006), self-focus, estimated probability and estimated
p > .27. cost of negative social events, safety behaviors (Hoffart,
Borge, Sexton, & Clark, 2009), anticipated aversive social
outcomes (Hofmann, 2004), interpersonal core beliefs (Boden
Discussion et al., 2012), and increases in cognitive reappraisal self-
This study found that CBT reduced negative and increased efficacy (Goldin et al., 2012). The present study adds to our
positive self-views and that increased positive (but not understanding of the mechanisms of change in CBT by dem-
reduced negative) self-views mediated the effect of CBT on onstrating that changes in positive (but not negative) self-
social anxiety symptom reduction, as well as predicted social views fully mediated the effect of CBT on reduction of social
anxiety symptom reduction at immediate CBT and 1-year anxiety symptom severity.
post-CBT. Mediator specificity was indicated by (a) an increase in
As expected, compared to HC, patients with SAD at base- positive self-views from pre- to post-CBT and no change
line showed a maladaptive profile of self-views, character- from pre- to post-WL, (b) no evidence that changes in nega-
ized by few positive and many negative self-endorsements. tive self-views mediated the effect of CBT on social anxiety
This pattern converges with prior reports of maladaptive self- symptoms, (c) no evidence that changes in social anxiety
views in SAD (Goldin et al., 2009; Hofmann et al., 2004) and symptoms or the interaction of treatment group by changes in
more generally with self-critical cognitive styles that reflect a social anxiety fully mediated the effect of CBT on positive or
fundamental cognitive diathesis in anxiety and mood disor- negative self-views, and (d) pre- to post-CBT changes in pos-
ders (Moscovitch, Hofmann, Suvak, & In-Albon, 2005). itive (but not negative) self-views being associated with
Importantly, the effect size for differential positive (ηp2 = .53) reduced social anxiety symptom severity immediately after
and negative (ηp2 = .52) self-views in patients with SAD ver- CBT and at 1-year post-CBT. These results highlight the clin-
sus nonanxious HCs showed an equivalent degree of distor- ical significance of enhancement of positive self-views (and
tion. This means that individuals with SAD have fewer not just reduction in negative self-views) during CBT and
positive and more negative self-views than do nonclinical suggest different functions for negative and positive self-
individuals. views in SAD.
Compared to WL, CBT resulted in significant enhance- These findings highlight the importance of assessing self-
ment of positive and reduction of negative self-views (pre- to views in SAD and investigating how self-views are modified
post-CBT change in self-endorsement: positive = 27% and by CBT (and other clinical interventions). Understanding the
negative = −25%). This indicates that CBT affects not only rate of change in self-views during treatment might elucidate
negative but also positive self-concepts. However, when specific subgroups of patients with SAD. For example, there
viewed through the lens of clinically significant change, CBT might be subgroups who fail to show significant enhancement
was more effective in moving positive self-views (48%) than in positive self-views, which might lead clinicians to modify
negative self-views (31%) into the normative range. a portion of their interventions to focus on this domain of self-
Prior RCTs of clinical treatments have examined negative, views. This could be as simple as having patients reflect, after
but not positive, self-referential thoughts and self-views each fear exposure, on positive self-attributes and describe
(Hofmann et al., 2004). The present findings add to our under- them verbally or in writing to elucidate and reinforce positive
standing of the effects of CBT for SAD, suggesting that cog- self-views. This might be valuable information for both the
nitive restructuring and exposure to feared social situations clinician and the client to record and track over time. It might
modifies at least two aspects of self-processing (positive and also be important for clinicians to help patients understand
negative self-views) but that the impact on positive self-views that positive and negative self-views may change at different
may be more clinically meaningful than previously consid- rates during treatment. Furthermore, a more nuanced appre-
ered. Moscovitch and colleagues (2009) found that positive ciation of self-views may facilitate the effectiveness of cogni-
self-views (based on ratings of 13 self-attribute dimensions) tive restructuring during exposure. Additionally, it will be
were related to higher levels of certainty and importance in important to determine whether and how group experience
HCs. It may be the case that as patients with SAD shift after facilitates changes in positive and negative self-views,
CBT into the normative range for positive self-views, they, morale, and behavior.
like HCs, regard these positive self-views as more definitive The use of multiple assessments of self-views during treat-
and relevant to their well-being (than the changes in negative ment (inside and outside of therapy sessions) could be used
self-views). If so, this suggests that changes in positive self- (a) to direct attention in patients to their self-concepts,
views may be even more meaningful and effective than especially in patients who do not regularly engage in self-
changes in negative self-views. reflection, and (b) to notice when and where specific
308 Goldin et al.

self-views are most likely to occur and how they influence time, online self-report and cognitive assessments (e.g.,
social functioning. An additional benefit of multiple assess- smartphone delivered) could be administered throughout
ments of self-views is to increase the probability that changes treatment and for 1-year posttreatment completion. These
in self-views occur and are observed by the patient. This may assessments would measure clinical symptoms as well as pre-
serve as a basis for the patient to experience a potentially pro- viously identified mediators of treatment change. Such stud-
found insight—namely, that self-views are indeed malleable ies might employ a multidimensional neuroimaging approach,
and transient. Such a reappraisal of the nature of self-views including (a) combined functional magnetic resonance imag-
may lead to greater psychological flexibility, enhanced per- ing blood oxygen level–dependent and electroencephalogram
spective taking, and increased expectancy for a positive treat- assessment of self-views and cognitive reappraisal at base-
ment outcome. line, posttreatment, and at 1-year posttreatment and (b) daily
Surprisingly, the findings in this study suggest that smartphone-delivered social fear exposure assessment of
enhancement of positive self-views during CBT may be even self-beliefs and other beliefs, subjective distress, and cogni-
more important than reducing negative self-views in patients tive reappraisal. This measurement approach would allow for
with SAD. This is evidenced by greater clinically significant an examination of the temporal dynamics of change in poten-
change in positive self-views, its role as a mediator of CBT, tial mediators (i.e., mechanisms of change) and how they
and its relationship to longer-term CBT-related improvement relate to one another (i.e., temporally interrelated multiple
in social anxiety symptom severity. If this finding is repli- mechanisms of change) during treatment and follow-up.
cated, then it will be important to develop a better under- Future clinical intervention studies should also be designed
standing of the factors that promote changes in positive to address one of the biggest puzzles today—namely, the
self-views. Equipped with this knowledge, it may be possible question of who benefits from which type of treatment. This
to modify CBT for SAD in ways that explicitly and implic- is the issue of treatment matching. In contrast to the identifi-
itly increase positive self-views. For example, it might be cation of underlying mechanisms of change (i.e., mediators of
helpful to introduce patients to a more complex and compre- treatment response) that can enhance the effectiveness of spe-
hensive notion of self-views. Specifically, this could entail cific interventions, the pretreatment identification of individ-
elucidating that positive and negative self-views reflect dif- ual features (or combinations) that predict treatment response
ferent aspects of the self and that they might change at differ- (i.e., moderators) is essential for the scientific advancement
ent rates, have different functions, and be related to treatment of the clinical treatment of psychological disorders. This
outcome in different ways. One way to enhance awareness of entails recruitment of much larger sample sizes that require
self-views is to have patients briefly rate positive and nega- large multisite studies. Although the ever-advancing technol-
tive self-views at the beginning and end of therapy sessions, ogy to conduct such large-scale studies is in place now, what
as well as before and after in vivo social interactions and is urgently needed is an increased spirit of cooperation and
exposures. Increasing our understanding of the profiles of collaboration across investigators, laboratories, and institu-
adaptive and maladaptive self-views and how they change tions (as well as financial and academic reward contingen-
with treatment in patients with SAD may lead to refined clas- cies) that support and promote such efforts.
sification of individual differences in patients, help direct
case conceptualization, and promote a more customized Declaration of Conflicting Interests
delivery of CBT for SAD. The authors declared that they had no conflicts of interest with
The current study was focused on how patients with SAD respect to their authorship or the publication of this article.
viewed themselves and how CBT affected those self-views.
As our understanding of the mechanisms underlying clini- Funding
cally meaningful changes in self-views develops, it will be This research was supported by a National Institute of Mental Health
possible to more precisely test the role of purported mecha- grant (R01 MH076074) awarded to James J. Gross. Richard G.
nisms in carefully tailored RCTs that enroll participants with Heimberg is the author of the commercially available cognitive-
a broader range of clinical symptoms, compared to current- behavioral therapy protocol utilized in this study. None of the
generation disorder-specific studies. For example, future authors have any biomedical financial interests or potential conflicts
RCTs might employ a temporally fine-grained, multidimen- of interest. Philippe R. Goldin, who is independent of any commer-
sional assessment approach in a sample characterized by a cial funder, had full access to all data in the study and takes respon-
broader range of affective disturbances. Specifically, RCTs sibility for their integrity and the accuracy of their analysis.
might include random assignment to three arms: group CBT,
a comparison treatment with a proposed mechanism of change Note
that differs from CBT (e.g., a pharmacological intervention, ClinicalTrials.gov identifier: NCT00380731.
such as paroxetine or sertraline, or a noncognitive psycho-
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