Mindfulness Based Interventions and Their Efficacy

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CHAPTER 4 MINDFULNESS AND SOCIAL ANXIETY

Although the efficacy of cognitive behavioural therapy has been demonstrated in the treatment of social anxiety disorder (Heimberg et al., 1990; Heimberg et al., 1993; Hope et al., 1995) mindfulness-based interventions may offer a valuable alternative. Changes to attention, decentering, emotional and behavioural regulation, as well as self-compassion could have implications for the array of cognitive processes that maintain social anxiety. Since mindfulness does not include a cognitive restructuring component it could be disseminated by non-clinical instructors in a brief cost-effective format that is applicable to a broad range of consumers. This chapter describes ways in which mechanisms of mindfulness may result in positive outcomes for socially anxious individuals and reviews recent studies of mindfulness based-treatment interventions for individuals with social anxiety disorder.

Changes to Attentional Processing and Social Anxiety

Mindfulness aims to foster awareness of all experience in the present moment including internal mental events and external contextual experiences in the environment. Since social anxiety is associated with increased self-focussed attention then a technique that helps individuals manage their attention and develop an increased awareness of their environment may reduce distress associated with social anxiety. Furthermore, since mindful attention is directed at the present moment then being mindful should lead to decreased rumination and reduce pre and post-event processing which may exacerbate distress. Finally, since mindful attention is balanced then it should counter both under and over-engagement attention to social threat which is characteristic of social anxiety.

Decentering and Social Anxiety

Adopting a decentred perspective of mental experiences may support socially anxious individuals to better manage characteristic judgement and interpretation biases. Perceiving thoughts as mental events that are distinct from the self, may allow them to be consideredfrom an objective perspective. As a result conviction in the reality of socially anxious thoughts may reduce, along with associated distress.

Emotional and Behavioural Regulation and Social Anxiety

An intervention which facilitates emotion regulation could support socially anxious individuals to better manage their anxiety, by recognising it for what is, experiencing it without avoidance and consequently becoming desensitized to it through exposure. In addition, if mindful awareness supports individuals to adopt a decentred approach to their biased interpretations and cognitions, they may respond to these differently, either by altering thoughts, or by directing attention away from unhelpful thoughts. Mindfulness techniques such as focussed breathing might provide socially anxious individuals with an emotion regulation strategy which differs from usual habitual responses, for example directing attention at the breath rather than engaging in ruminative thought patterns. This alternative strategy might also reduce distress. Increased behavioural regulation would mean that socially anxious individuals would be more likely to engage in behaviours that aligned with their values. To the extent that these values included social participation then participants might engage in more social activity and alter habitual responses of social avoidance.

Self-Compassion and Social Anxiety

Self-compassion may arise from the generalisation of mindful acceptance of experience to acceptance of self. Increased self-compassion would counter socially anxious tendencies to be critical of one‟s social behaviour. A reduction in self-critical cognitions associated with social anxiety would most likely be associated with reduced anxiety related distress.

Studies of Mindfulness and Social Anxiety

A review of the literature using systematic review principles revealed that relatively few studies have systematically evaluated the efficacy of mindfulness interventions for people with social anxiety. A search through Psychinfo and Medline databases was conducted using the following search terms: Social Anxiety or Social Phobia, and Mindfulness. Studies were included if they were published in a peer review journal and excluded if they were unpublished dissertations or theses. A total of six studies met the criteria. Only one of these studies (Bogels, Sijbers, & Voncken, 2006) was published at the onset of the current research.
Bogels, Sijbers, & Voncken (2006) evaluated a combined mindfulness and task concentration training (TCT) technique for this group. Participants were trained in mindfulness to develop awareness of themselves and their anxiety, and then subsequently trained in task concentration, which encouraged them to direct attention outside of themselves to aspects of the social setting. The intervention was conducted over nine therapy sessions. The combined approach was found to be effective in a sample of 9 participants with social anxiety disorder. However the efficacy of attentional strategies like TCT has been demonstrated previously in treating social anxiety (Wells et al., 1997) and it is not clear what effect a mindfulness only approach might have.
Koszycki, Benger, Shlik and Brawejin (2007) randomized 53 patients with social phobia to CBGT for social anxiety or MBSR. They found that, although both interventions led to similar improvements in mood, functioning and quality of life, participants in the CBGT group had significantly lower scores on measures of social anxiety. The authors concluded that, although MBSR may have some benefit to sufferers of SAD, CBGT remained the treatment of choice for social anxiety. Nonetheless, positive outcomes observed in this study suggest that another mindfulness-based intervention could be useful with this group. MBSR is a relatively intensive intervention and the benefits of a brief mindfulness intervention are not yet known. Koszycki and colleagues suggest that mindfulness training may be a useful adjunct to CBGT. A briefer mindfulness intervention may be particularly useful.
Kokovscki, Fleming and Rector (2009) conducted a feasibility study of Mindfulness and Acceptance-Based Group Therapy (MAGT) for social anxiety with a sample of 42 individuals with social anxiety disorder. MAGT is a recently developed 12 week approach incorporating elements of MBCT and ACT. Significant reductions in social anxiety, depression and rumination, and increases in mindfulness and acceptance were reported post-intervention. These results are limited however by the lack of a comparison group. In addition, the intervention also included ACT exercises (e.g., clarifying goals and values, interoceptive exposure). It is not clear therefore which aspects of the observed results related specifically to mindfulness training.
Piet, Hougaard, Hecksher, and Rosenberg (2010) conducted a randomized controlled trial of MBCT and a group-based CBT intervention in a sample of 26 individuals with social anxiety disorder. Participants were randomized into two groups and the study utilised a crossover design so that both groups received both treatments in reverse order. Both interventions led to reductions in social anxiety, and there was no significant difference between the effect size of either CBT (d = 1.15) or MBCT (d = 0.78) interventions. This suggests that both interventions were comparably effective, however the authors note that a significant difference may have been apparent if a larger sample group had been used. Once again, MBCT is a relatively intensive intervention incorporating aspects of CBT with Mindfulness training. It is not clear from this study what effect a brief mindfulness only intervention may have had.
Goldin, Ramel and Gross (2009) conducted an fMRI study of individuals with social anxiety disorder before and after completing an MBSR course. The study investigated the hypothesis that mindfulness training would lead to reductions in self-referential processing so that habitual tendencies to be critical of the self would be reduced. The authors reported an increase in positive self-views and a decrease in negative self-views post-intervention. This change in self-views occurred in conjunction with increased activity in neural areas associated with attention, and decreased activity in areas associated with self-processing and language processing. The authors suggested that this pattern of neural activity may reflect a reduction in narrative and conceptual processing of the self, allowing the possibility of greater experiential self-processing. Experiential processing of the self would allow sociallyanxious individuals to process social experiences in a more objective way, less impacted by conceptualised understandings of themselves as social objects.
Recently Goldin and Gross (2010) conducted a follow up fMRI study of socially anxious MBSR completers exploring emotional reactions and regulation in response to negative self-beliefs. Participants were instructed to engage in either breath-focussed attention or a distraction task (counting backwards) in response to a negative self-belief. Post intervention participants reported lower levels of social anxiety, depression and rumination, and higher levels of self-esteem. During breath-focussed attention they also reported less negative emotion in response to negative self-beliefs and presented with reduced activation of the amygdala, a brain region involved in emotion, and increased activity in brain regions involved in attention. The authors concluded that MBSR may reduce emotional reactivity whilst enhancing emotion regulation. The results of both of these studies are limited once again however by the lack of any comparison group. As a result it is not clear whether the changes observed are specific effects of mindfulness training. In addition these studies tested specific hypotheses about mindfulness mechanisms, that they would reduce self referential processing and reactivity to negative beliefs, and did not explore other possible mechanisms (e.g., self compassion).
Overall these studies suggest that various forms of mindfulness training ranging from 8 to 12 sessions in duration generate positive outcomes for individuals with social anxiety. These outcomes include reductions in social anxiety, depression, rumination and increases in life satisfaction. Results of these studies also suggest that mindfulness may result in enhanced attention, reduced self-referential processing and reduced reactivity to negative beliefs.
All of the studies reported utilised relatively intensive multi-component mindfulness interventions. Where interventions included aspects of CBT (Piet et al., 2010) or ACT (Kocovski et al., 2009) it is not clear whether outcomes observed relate to mindfulness training, ACT or CBT components of the intervention. Similarly, as MBSR incorporates training in a variety of mindfulness-oriented exercises it is not possible to assess different influences of each of these exercises on any outcomes observed. That is, it is not clear what impact yoga exercises may have had on outcomes relative to body scanning, mindful-eating or mindful-breathing tasks. None of the studies published to date demonstrate the impact of brief mindfulness training in a single mindfulness exercise. A brief mindfulness intervention would have the advantage of being a portable and accessible form of training. This sort of therapy might be particularly useful for socially anxious individuals who, as a result of social anxiety, may find it difficult to engage in more elaborate therapies that require greater social interaction and more prolonged attendance.
Several of these studies did not include a comparison group and therefore it is not clear whether outcomes observed related specifically to mindfulness or to some other element of the intervention (Bogels et al., 2006; Goldin & Gross, 2010; Goldin et al., 2009; Kocovski et al., 2009). The two studies that did utilise a comparison group compared an intensive mindfulness-based therapy to CBT. While these studies provide evidence regarding the efficacy of intensive mindfulness-based interventions relative to CBT the comparison of multi-component interventions means it is not possible to ascertain which aspects of which intervention led to which outcomes. Information on the effective components of treatment interventions is necessary in establishing new treatment protocols (Doss, 2004).
Social anxiety is maintained by over and under-engagement of attention, biased interpretation of social experiences and a self-critical perspective of one‟s social behaviour. This information processing style results in both anxious emotions and behavioural avoidance. Mindfulness may reduce both distress and avoidance associated with social anxiety by promoting; balanced attention, objective information processing, improved emotional and behavioural regulation and reduced self-criticism. In establishing the efficacy of mindfulness as an intervention for social anxiety research should consider not only treatment outcomes for social anxiety overall but for each of these hypothesised mechanisms. In this way, research may establish not only whether or not mindfulness is effective, but also how it generates these effects. Once mechanisms of change are better understood these can be furtherexamined through additional research programmes which aim to enhance and refine the overall treatment protocol (Doss, 2004).
Comparisons of brief interventions that use a single treatment modality allow the effectiveness of this treatment modality, and related mechanisms, to be investigated. To establish whether outcome effects relate to the intervention specifically it is essential that the intervention group is compared to a comparison group. Comparisons with other treatment interventions, matched for factors such as duration and frequency of contact, allow the efficacy or treatment specific components to be established.
For this reason, several studies investigating the effective components of mindfulness interventions have utilised relaxation interventions as comparison groups (Feldman et al., 2010; Jain et al., 2007). Although mindfulness and relaxation share similarities, the primary difference between them is that in relaxation the goal is for the individual to change the nature of their experience by inducing a state of physical relaxation. When practicing mindfulness, the intention is not to change anything, but simply to increase awareness of current experience. By including a relaxation condition it is possible for specific effects arising from mindfulness training to be observed (Feldman et al., 2010; Jain et al., 2007)
If studies utilise a treatment comparison condition only, it is not possible to know whether the effects observed are actually any better than doing nothing at all. For this reason a no-intervention condition (e.g., wait-list control groups) can provide useful information about whether outcome effects observed may arise over time irrespective of any intervention.

CHAPTER 1 INTRODUCTION 
CHAPTER 2 SOCIAL ANXIETY
Overview
Social Anxiety Disorder
Prevalence of Social Anxiety Disorder
Impact of Social Anxiety Disorder
Social Anxiety in the General Population
Etiology of Social Anxiety
Genetic and Biological Factors
Infant Temperament
Attachment Style
Childhood Abuse
Cognitive Models of Social Anxiety
Rapee and Heimberg’s Model
Key Features of Cognitive Models
Cognitive Behavioural Treatments
CHAPTER 3 MINDFULNESS
Overview
Definitions of Mindfulness
Mindfulness Based Interventions and Their Efficacy
Mindfulness Based Stress Reduction
Mindfulness Based Cognitive Therapy
Dialectical Behaviour Therapy
Acceptance and Commitment Therapy
Summary
Proposed Mechanisms of Mindfulness
Changes to Attentional Processing
Decentering
Emotional and Behavioural Regulation
Self Compassion
Summary
CHAPTER 4 MINDFULNESS AND SOCIAL ANXIETY
Changes to Attentional Processing and Social Anxiety
Decentering and Social Anxiety Emotional and Behavioural Regulation and Social Anxiety
Self Compassion and Social Anxiety
Studies of Mindfulness and Social Anxiety
CHAPTER 5 PURPOSE OF THE CURRENT RESEARCH
CHAPTER 6 METHODOLOGICAL OVERVIEW
CHAPTER 7 STUDY PHASE 1: SURVEY TO ESTABLISH INCLUSION CRITERIA
Method
Participants
Measure: The Fear of Negative Evaluation Scale
Procedure
Results and Discussion
CHAPTER 8 STUDY PHASE 2: PILOT TESTING OF RCT PROTOCOLS AND MATERIALS
Assessment of the Mindfulness and Relaxation Audio Recordings
Pilot Study of the RCT Protocol and Measures
Results
CHAPTER 9 STUDY PHASE 3: ONLINE SCREENING OF INTERESTED POTENTIAL PARTICIPANTS
Method
Participants
Procedures
Measures
Analytical Strategy
Results
Correlations Between Measures
Comparisons of Scale Scores for Demographic Groups
Comparisons of Scale Scores and Age for Respondents With and Without
Yoga, Meditation and Martial Arts Experience
Comparisons of Qualifying Respondents Who Did and Did Not Choose to
Participate in the RCT
Discussion
CHAPTER 10 STUDY PHASE 4: RANDOMIZED CONTROLLED TRIAL OF MINDFULNESS INTERVENTION FOR SOCIAL ANXIETY – METHODOLOGY
Participants
Design
Interventions
Mindfulness Condition
Relaxation Condition
Control Condition
Measures
Mindful Attention Awareness Scale
Stroop Task
Thought Conviction
Trait Meta-Mood Scale
Self-Statements During Public Speaking Scale
Procedure
Overview
Training Session
Experimental Session
Analytical Strategy
CHAPTER 11 STUDY PHASE 4: RESULTS
Baseline Measures
Correlations Between Measures at Baseline
Practice Log Data
Changes in Mindfulness Over Time
Mindful Attention Awareness Scale
Self-Compassion Scale – Mindfulness Subscale
Changes in Anxiety Over Time
Fear of Negative Evaluation Survey
Between Groups Comparisons of Anxiety Post Intervention
Heart Rate and Blood Pressure
Anxiety Symptom Ratings
Decentering
Emotion and Behavioural Regulation
Self Compassion
Effectiveness and Acceptability of the Interventions
Summary
CHAPTER 12 DISCUSSION
Changes to Mindfulness
Changes to Social Anxiety
Changes to Potential Mechanisms of Mindfulness
Decentering
Emotion and Behavioural Regulation
Self Compassion
The Acceptability and Utility of Brief Mindfulness Training
Limitations of the Study
Implications and Future Directions
Conclusion

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Mechanisms of Mindfulness and the Treatment of Social Anxiety: A Randomized Controlled Trial of Brief Mindfulness Training for Socially Anxious Adults