Journal of Cognitive Psychotherapy: An International Quarterly

Volume 20, Number 1 2006

Mindfulness and Task Concentration

Training for Social Phobia: A Pilot Study
Susan M. Bogels, PhD
G. F. V. M. Sijbers, MA
Marisol Voncken, PhD
Maastricht University
Maastricht, LB, The Netherlands

A new treatment for social phobia is evaluated: mindfulness training and task concentration
training. The treatment consisted of nine sessions of 45-60 minutes and was administered
individually. Nine severely socially phobic patients participated. No changes in complaints
were observed during the waiting-list period. One patient withdrew during the treatment.
Results show that treatment was well accepted and highly effective in reducing social phobia,
and results were maintained at a 2-month follow-up. Effects of the treatment were most pronounced on Fear of Negative Evaluation and on the self-ideal discrepancy. Attention as well
as cognitive changes may be responsible for the effectiveness. Explanations for the effects and
clinical implications are discussed.
Keywords: mindfulness; Task Concentration Training; social phobia; attention
urrent models of social phobia assume that attention processes are crucial in the maintenance of social phobia (e.g., Clark & Wells, 1995; Hartman, 1983; Hope, Gansler, &
Heimberg, 1989). Three types of attention processes have been found to maintain social
fears: hypervigilance, attentional avoidance, and heightened self-focused attention (for a recent
review of the empirical evidence of these processes in social phobia, see Bogels & Mansell, 2004).
First, social phobic patients scrutinize their environment and themselves for possible signs of
danger (e.g., a frown, an imminent blush), which is called hypervigilance. Second, they avoid
spending prolonged attention to external and internal aspects of social interaction (e.g., avoiding eye contact, avoiding looking in the mirror). Third, they are excessively self-focused, that is,
they see themselves through the eyes of others and become objects rather than subjects in a social
situation. These three processes of attention may interact and together or separately maintain
social phobia in the following ways. First, patients do not process adequately external and internal information that may disconfirm their negative social beliefs. Second, patients' awareness of
their fear, arousal, and possible flaws in their performance is heightened. Third, these attention
processes may even increase arousal and nervous appearance and interfere with satisfactory
social behavior (e.g., listening), thereby confirming patients' fear of negative evaluation.
Task concentration training (TCT) is a new intervention developed to directly intervene in
these maladaptive attention processes (Bogels, Mulkens, & de Jong, 1997; Mulkens, Bogels & de
Jong, 1999). The goal of TCT is to learn to redirect attention away from the self and to the task

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Mindful Concentration Training for Social Phobia

at hand (e.g., a conversation), as a way of coping with social anxiety. TCT was found to be highly effective for subclinical (advertisement-recruited) "socially phobic persons" {n = 26) with fear
of blushing as the main complaint, and more effective in reducing their dysfunctional beUefs about
blushing than exposure alone (Mulkens, Bogels, de Jong, & Louwers, 2001). In line with this.
Wells and Papageorgiou (1998) found that exposure plus focusing attention outward more effectively reduced social anxiety than exposure alone in 8 patients with social phobia. The combination of TCT and cognitive therapy was extremely effective for social phobic patients (n = 65) with
fear of blushing, trembling, sweating, and freezing as the more important complaints; effect sizes
reached 2.5 (Bogels, in press).
Mindfulness-Based Stress Reduction (MBSR) training (Kabat-Zinn, 1990) is another type of
attention training, providing systematic training in mindfulness meditation as a self-regulatory
approach to facilitate adaptation to medical illness, stress reduction, and emotion management
(for a review of the effects of MBSR, see Bishop, 2002). MBSR training was effective for a group
of patients with mixed anxiety disorders (Kabat-Zinn et al., 1992), and results were maintained
at a 3-year follow-up (Miller, Fletcher, & Kabat-Zinn, 1995). Mindfulness-based cognitive therapy
(MBCT), an attention approach developed from MBSR training that also incorporates aspects of
cognitive therapy, was effective for patients with recurrent depression (Segal, Williams, & Teasdale,
2002). The MBCT approaches of Kabat-Zinn (1990) and Segal and associates (2002) resemble
TCT in some ways: Patients are first made aware of attention processes and how they influence
feelings and behaviors, and patients are trained to focus fully on all aspects of a situation and
themselves rather than selectively to attend to negative belief-related aspects (hypervigilance),
avoid prolonged attention, and see themselves through their mind's eye.
In addition to the similarities between MBCT and TCT training, mindfulness training is also
distinctively different from TCT and may offer components of treatment that complement TCT
for social phobia to develop into a stand-alone treatment. First, TCT only claims to offer a coping technique for dealing with socially anxious situations, whereas mindfulness training is more
a "way of living." Second, TCT is directed to application in the situation, that is, patients should
focus their attention externally during difficult social situations, whereas mindfulness training
gives more of an answer to ex ante and ex post rumination, that is, wherever the mind wanders,
direct it back to the anchor (e.g., breath). Third, mindfulness training provides up to 1 hour of
formal meditation exercises per day (Segal et al., 2002), which is thought to make patients less
stressed on a daily basis. Such stress reduction may have several beneficial effects on GSP, such
as a higher threshold of fearfulness, a related reduction of worry about appearing anxious
because of less actual anxiety, and better coping with new problems. Fourth, mindfulness training has a strong focus on nonjudgmental observation and accepting difficulties as they are, rather
than trying to change them. Acceptance of anxiety and physical responses like blushing is offen
extremely difficult for social phobic patients, and a nonaccepting attitude may interfere with the
process of change or produce relapse. Mindfulness training promises to promote a more accepting attitude towards social fears and symptoms, which will facilitate change and prevent relapse.
Although highly effective cognitive-behavioral treatments now exist that also focus on changing attention processes, such as like Clark and associates' (2003), we wanted to develop a treatment that solely intervenes in attention processes. Such an approach allows for a direct test
of current attention models maintaining social phobia. Moreover, it would be interesting to investigate whether solely changing attention processes would reduce negative cognitive biases, which
are thought to be the core of social phobia. Moreover, since attention training requires less verbal
and rational skill from patients, it may be effective for simpler patients. In addition. Wells (2000)
stated that treatment should change the metacognitive processes rather than the content of cognitive schemes. Attention approaches like mindfulness and TCT offer the promise of intervening at
this metacognitive level. Finally, in the long term, patients may no longer apply more complex
cognitive techniques, such as Socratic questioning, whereas the simple skill of redirecting attention externally may stay with them.

Bogels et al.

35

We developed a combined treatment consisting of mindfulness training and TCT, as a standalone for patients witb social pbobia, consisting of five sessions of mindfulness training, tbree
sessions of TCT, and an evaluation session. Tbere seems to be a paradox of tbe goal of mindfulness, tbat is, to be fully aware of all aspects of a situation and tbe self, including anxiety, and tbe
goal of TCT, tbat is, to focus attention outward ratber tban inward. Tbis issue is related to anotber potential paradox in socially pbobic patients' attention problems, namely, patients are botb
byperaware and avoidant of social cues. Tbe approacb we developed taugbt patients to first
become fully aware of all aspects of a situation and tbe self (including anxiety), wbicb is consistent witb tbe mindfulness approacb. Once tbey bave developed tbe ability to be fully aware, tbis
awareness would include being aware of bow tbe mind is constantly drawn to negative self-focused
attention. Tben, tbe transition to TCT, tbat is, to outwardly focused attention instead of selffocused attention in social situations, was made.
Tbe goal of tbe present study is to investigate tbe developed combined approacb of mindfulness and TCT as a stand-alone treatment for social pbobia. Five tberapists were trained in tbe
procedures, and tbey treated 10 patients witb social pbobia. Effects of tbe treatment on social anxiety, attention processes, cognitions, and self-ideal discrepancies were investigated.

METHOD

Participants
We planned to treat 10 patients witb tbis experimental approacb to learn about more and less
effective parts of tbe treatment and to assess tbe effects. Tbe first 10 patients witb a primary diagnosis of social pbobia, wbo were referred to tbe Ambulant Mental Healtb Centre in Maastricbt
for treatment and met inclusion criteria, were offered mindfulness training and TCT. Inclusion
criteria were a primary diagnosis of social pbobia and being willing and able to spend at least 1
bour per day on tbe bomework assignments. None of tbe patients refused treatment based on
tbis latter demand. Exclusion criteria were substance dependence, psycbotic disorder, acute suicidal bebavior, and borderline personality disorder. Patients wbo used medication for social pbobia bad to stop medication before tbe start of tbe assessment, or keep tbe medication constant
until tbe follow-up assessment. Patients were screened using tbe Structured Clinical Interview for
tbe DSM-IV (SCID-I) (First, Spitzer, Cibbon, & Williams, 1997; Groenestijn, Akkerbuis, Kupka,
Scbneider, & Nolen, 1999) as well as tbe Structured Clinical Interview for DSM-IV (Axis II) personaHty disorders (First, Spitzer, Cibbon, Williams, & Benjamin 1994; Weertman, Arntz, &
Kerkbofs, 2000) by clinicians wbo were extensively trained in tbese semistructured interviews
and bad comprebensive experience in diagnosing patients witb anxiety and personality disorders.
Diagnoses were cbecked in staff meetings. Tbe interrater reliability of tbe SCID bas been demonstrated in previous researcb (e.g., Zanarini & Frankenburg, 2001). Patients signed an informed
consent form.
Of tbe 10 patients, 1 completed tbe treatment, but could not be reacbed for tbe assessments
after treatment. Of tbe 9 remaining patients, 6 men and 3 women (mean age = 32.4, SD = 12.1, [20,
53]), 8 met criteria for tbe generalized type. Tbe mean duration of tbeir social pbobia was more
tban 18 years (M = 221.3 montbs, SD 166.9, [60, 572]), tbeir mean education level was 8.3 (SD =
2.1, [5, 11], wbere 5 = lowest level of professional education and 11 = university education). One
of tbem lived witb a partner; 7 lived alone; 1 lived vtb parents. Two patients used antidepressant
medication, wbicb tbey kept constant during tbe waiting-list period, treatment, and follow-up.
Four patients bad a bistory of prior treatments for tbeir social pbobia: group tberapy ( - 2), counseling (n = 2), bebavior tberapy (n = 1), and psycbomotor tberapy ( = 1). One patient did not
work because of tbe social pbobia; 4 worked; 4 studied. Eigbt patients bad comorbid Axis I disorders: depressive disorder (n = 7), dystbymic disorder (n = 2), alcobol dependence in full remission
{n - 1), and bypocbondriasis {n = 1). Tbree patients bad Axis II disorders: avoidant personality

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Mindful Concentration Training for Social Phobia

disorder (n = 2), depressive personality disorder ( = 1), and obsessive-compulsive personality disorder {n- 1).

Design
In order to assess whether time alone would improve their symptoms, we used the waiting-list
period itself as a measure. Patients had to wait at least 1 month (and most longer) before they could
start treatment, so a waiting list assessment was carried out as soon as informed consent was
obtained. Within 1 week before the start of treatment, patients completed a pretest. At the end
of 2-month treatment, a post-test was done, followed by 2 months in which no further treatment
was given. Then, a follow-up test was carried out, followed by an evaluation session with the
therapist. All questionnaire assessments were regularly administered on computer.

Assessments
General Social Phobia. To assess aspects of social phobia, we used the brief version of the Fear
of Negative Evaluation scale (FNE) (Leary, 1983) and the Social Phobia Subscale of the Social
Phobia and Anxiety Inventory (SPAI) (Bogels & Reith, 1999; Turner, Beidel, Dancu, & Stanley,
1989). The clinical cut-off point for the Dutch SPAI, based on data of Bogels and Reith (1999) is
89. Moreover, at follow-up, the SCID-I interview was readministered to check whether patients still
met the criteria for GSP.
Cognitions. Cognitions related to social phobia were measured with firstly, the Social
Phobic Belief scale (SPB), a 15-item questionnaire measuring the conviction of negative beliefs
related to social phobia, that is, negative assumptions about the self, others, and conditional
beliefs (Bogels, 2005). The reliability and discriminant validity of the SPB has been demonstrated in previous research (e.g., Voncken, Bogels, & De Vries, 2004). Second, the conviction of negative beliefs concerning showing bodily symptoms (blushing, trembling, svireating) was measured
with the Negative Belief Subscale of the Blushing, Trembling, and Sweating Questionnaire (BTSQ), which consists of 54 negative beliefs about bodily symptoms. The BTS-Q is a reliable and valid
instrument (e.g., Bogels & Reith, 1999).
Attention. The following attention measures were applied. First, state self-focused attention
was measured with the Self-Focused Attention (SFA) Scale (Bogels, Alberts, & de Jong, 1996),
which consists of the subscales SFA on Arousal (e.g., "In the presence of other people, I'm constantly focusing on . . . 'whether my heart is beating'.") and SFA on Performance (e.g., "In the presence of other people, I'm constantly focusing on . . . 'how well I take part in the conversation'.").
Factor analysis confirmed the existence of two factors as well as a reliable total score (Bogels et al.,
1997). The subscales Public and Private Self-Consciousness of the Self Consciousness Scale (SCS)
(Bogels, Alberts, & de Jong, 1996; Fenigstein, Scheier, & Buss, 1975) were administered to assess a
dispositional tendency to be aware of oneself, privately or publicly.
General Psychopathology. Possible changes in general psychopathology were measured
with the Symptom Check List (SCL-90) (Arrindell & Ettema, 1986; Derogatis, 1977). The SCL-90
consists of the subscales Generalized Anxiety, Agoraphobia, Depression, Somatic Complaints,
Obsessive Compulsive Behavior, Social Sensitivity and Mistrust, Hostility, Sleeping Problems,
and Other Problems.
Self-Other-Ideal. We measured the view of self and perceived others' view of the self, and
ideal self, as well as discrepancies between view of self and ideal self, using the Self-Other-Ideal
Questionnaire (Miskimins, Wilson, Nicolas-Braucht, & Berry, 1971). This questionnaire measures
15 aspects of functioning that seem relevant to social phobia: smart and skilled; creative and original; physically attractive; successful in life; fit for many professions; friendly and warm; preference to be YfiXh others; good contacts with other gender; socially skilled; worried about others;
happy; relaxed; self confident; capable of dealing with personal problems; alert and active.

Bogels et al.

37

Patients rate each item on a 0-100 Visual Analogue Scale in which 0 represents the most negative and 100 the most positive outcome. All items are rated first with respect to the actual self,
then with respect to the way the participants think others perceive them, andfinallywith respect
to how they ideally want to be. The 15 items are thus presented three times. Self-ideal discrepancy is calculated by subtracting the ratings on self from ideal. Since we were not aware of earlier
publications of the psychometric properties of this scale for a socially phobic population, we
assessed its homogeneity in the present sample, which was satisfactory, that is, alpha values were
.89 for view of self, .93 for perceived others' view of self, and .78 for ideal self.

Therapists
Five therapists, two men and three women, with varying levels of experience in cognitivebehavioral treatment for social phobia, conducted the therapies. Mark Williams, one of the developers of MBCT, provided initial training in mindfulness during a 2-day workshop. In addition
to this introduction, each undertook his or her own meditation training in a therapist group,
supervised by the second author, who has long experience with meditation. The first two authors,
who had the most experience with mindfulness training, treated the first 3 patients with the three
less experienced therapists serving as co-therapist, in order to make them more familiar with
mindfulness training. The remaining 7 patients were then treated by the less experienced therapists without a co-therapist.

Treatment
Treatment consisted of 9 sessions. The first 5 sessions were almost identical to the first 5 sessions
of MBCT described by Segal and associates (2002), and all the handouts were translated. Four
modifications were made from the original sessions. First, we deleted any cognitive therapy,
because we wanted to assess the effects of "pure" attention training, without cognitive therapy,
on social phobia. Second, we removed the parts about depression and rephrased them into ones
about social phobia. Third, we rephrased group exercises into individual exercises and leff out the
parts that were only applicable in a group format, because our treatment was given in an individual format. Fourth, since our treatment sessions were much shorter (45-60 minutes) than treatment sessions of group-based MBCT, we had to shorten the exercises as well as the evaluative
discussions. In session 6 to 8, task concentration training was given. Session 9 was comparable to
the last session (8) of the MBCT of Segal and associates (2002). We give a short description of
the content of each session, and a more extensive description of the task concentration sessions,
because these are not described in Segal and associates (2002).
Session 1: Automatic Pilot The rationale for mindfulness training and TCT is explained.
Most of the day we are occupied with our thoughts and feelings. This is normally not a problem,
but if these thoughts and feelings are negative, we can become self-focused and ruminate. This
wandering to our thoughts and feelings is an automatic process. In a social situation that is stressful for you, for example a party, you will automatically focus on your feelings of nervousness, on
how you think you come across, and what you think others will think of you. While your mind is
wandering to such issues, you are not really at the party. This has many negative consequences:
you will continue feeling anxious, you will respond in an automatic way to reduce your anxiety
(e.g. avoiding, withdrawing), which is often not helpful, and you will not discover what others
really think of you, and what is really going on in the situation, because you do not attend to the
situation. In the training you will learn to be more aware and to be in the here and now. This will
make your life more interesting, lively, and thereby fulfilling. Being in the here and now implies
that you will face your problems and learn to accept your anxiety rather than fighting against it.
Fighting against anxiety will increase anxiety and other negative feelings. Once you start accepting your anxiety, you will learn to recognize early signals of anxiety better and be more prepared

38

Mindful Concentration Training for Social Phobia

to cope with them in a conscious way. In this training you will also learn to focus on your task and
your environment, rather than on yourself, during difficult social situations. If you concentrate on
the task at hand, you will be less (aware of) anxiety, be more open to what is actually going on,
and it might even help you perform better. What we ask from you is to practice one hour per day,
this is really important. If you are not able to make that space in this period of your life, it is better not to follow this treatment now.

In the remainder of the session two exercises are done. The first exercise is eating a raisin
mindfully, that is, focusing on its appearance (shape, colors, shades), how it feels, how it smells,
and finally how it tastes. In the second exercise, the "body scan," patients focus on all aspects of
their body one after the other. The homework assignments consist of the body scan and conducting of routine activities, including eating in a mindful way.
Session 2: Dealing With Barriers. The session starts with body scan practice, followed by
practice review and homework review. Then, a sitting meditation is done, mindfulness of breath.
Patients are taught to focus their full attention on this normally automatic activity. Homework
consists of the body scan, mindfulness of the breath, conducting another routine activity with full
awareness, and filling in the "pleasant event calendar." In this calendar, patients register everyday one event that made them feel pleasant (e.g., looking at the sky), in order to become fully
aware of all aspects of that feeling (emotion, bodily sensations, muscular activity, thoughts).
Session 3: Mindfulness of Breath. The session starts with a short "hearing" exercise. In this
exercise, patients focus on all the sounds, without giving labels to them ("car"). A sitting meditation (mindfulness of breath and body), practice review, and homework review follow. Afterwards
a 3-minute breathing space is allowed. In this exercise, patients learn to take a "break" by first
focusing on where their attention is (thoughts, feelings, sensations), then focusing on breath, and
finally broadening awareness to the body and the environment. Homework consists of the sitting
meditation, a 3-minute breathing space, andfillingin the event calendar, now focusing on unpleasant (social) events. The purpose is to become fully aware of all aspects of such unpleasant feelings,
including fear related to social situations (e.g., emotions, sensations, muscular activity, thoughts)
Session 4: Staying Present. The session starts with a short "seeing" exercise, in which patients
focus on everything they see looking out of a window, without labeling ("a tree"). Then, a sitting
meditation is done, including awareness of breath, body, but also sounds, and then thoughts, and
practice and homework are reviewed. The 3-minute breathing space as a strategy for coping with
(social) stress is introduced. Homework consists of sitting meditation and 3-minute breathing
space as a regular exercise and to cope with social anxiety.
Session 5: Allowing/Letting Be. The session starts with a sitting meditation centered on awareness of breath, body, sounds, and thoughts. The patients are invited to think about a difficult
social situation (e.g., an embarrassing event) during practice to note its effect on the body. After
the practice and homework review, acceptance versus fighting against anxiety is introduced, and
followed by a 3-minute coping breathing space. Homework consists of sitting meditation, 3 minutes regular and coping breathing space.
Session 6: Task-Focused Attention. After a short sitting meditation and review of homework, task-focused attention is introduced. We continue with a listening exercise in which
instructors tell a 2-minute story about their vacation while instructors and patients sit with their
backs against each other so that no eye contact takes place. Patients are instructed to concentrate
on the story ("task"). After 2 minutes patients estimate the percentage of their attention that they
devoted to themselves, the task, and the environment while listening, and they then summarize
the story. In addition, patients estimate the percentage of the story that they were able to summarize, and so does the instructor. This procedure is continued, every new exercise growing more
complex: first, eye contact takes place; next, patients distract themselves by thinking about blushing, for example, and finally, a story about social anxiety is presented. The effect of the more

Bogels et al.

39

complex (social anxiety-inducing) elements is typically that patients become more self-focused
at first, but are able to refocus on the task after some exercise. Each listening exercise is repeated
until at least 51% of attention is on the task. Homework consists of sitting meditation, using one
or a combination of the forms that were taught so far, and task concentration in social but non- or
only mildly threatening situations, for example, a blushing phobic patient having a phone conservation, in which the task is to listen withfiallattention to what the other person is saying and
summarize it afterwards in writing.
Session 7: Flexibility ofAttention. After a short sitting meditation and review of homework,
we teach patients in this sessionfiexibilityof attention, that is, to direct their attention to and away
from stress. We achieve this by starting a pleasant activity, then think about a sociaUy stressful
event, and then redirect attention to the task, the pleasant activity. In addition, we practice task
concentration in increasingly more stressful social situations, for example, walking along a bus
stop and first focusing on the directions of the busses, and then observing all people who are waiting for the busses. Homework consists of sitting meditation, fiexibility of attention in nonsocially
stressful situations (e.g., walking though a quiet forest and paying attention to all aspects of the
forestvisual, olfactory, auditory, kinestheticone at a time, as well as to one's body while walking, and then integrated attention to all aspects together), flexibility of attention in more stressful
situations, and task concentration in increasingly more stressful social situations.
Session 8: Task-Focused Attention in Increasingly More Difficult Situations. After a short
sitting meditation and review of homework, task concentration is practiced in threatening personal social situations in session, by some role-plays and in vivo exercises, hierarchically building
up. The steps in practicing TCT in threatening situations are (1) Where is the patient's attention
usually focused in this particular situation? (2) What is the task? (3) Where should attention be
focused, given the task? On what else? (4) Situation is practiced with task-focus; and (5) Exercise
is evaluated in terms of percentage of task focus. For more details on TCT, see Bogels and associates (1997).
Session 9: Preparing for the Future. The last session starts with a short meditation exercise
and review of homework. Then, we review the whole therapy and evaluate progress. We discuss
how to best continue mindfulness and task concentration practice, and patients write down their
plans for practice in the next 2 months, which are discussed and linked to positive reasons for
continuing practicing. Advice for daily mindfulness and task concentration is given.
Patients were encouraged to confront threatening social situations only after session 7 in
order to apply task concentration in situations more fearful.

RESULTS

Stability and Effect of Waiting List Period

The average waiting period was about 2 months, comparable to the period of treatment. All measures were very stable, with correlations between waiting-list and pretest assessment ranging from
.71 to .97 ips < .01). There was no improvement during the waiting-list period; all paired f tests
comparing waiting-list with pretest were not significant. Therefore, the possible effects observed
during the treatment period cannot be explained by the effect of time and assessment alone.

Drop-Outs
One patient withdrew during the treatment, after 4 sessions, because he found the treatment too
vague, although he thought he was much improved, and he did complete further assessments.
The 10th patient finished the treatment, but did not show at the assessments and could not be

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Mindful Concentration Training for Social Phobia

reached. Because this patient was much improved, according to the therapist, we could not apply
a last-assessment-carried-forward approach, hecause this approach assumes no change. Therefore,
this patient was excluded from the analyses.

Treatment Compliance
In order to assess how much time patients actually spend on doing homework assignments,
patients had to fill in each week the average numher of hours per week that they spend doing
homework. The average time spent on homework was 3.5 hours (SD = 1.3) per week. This is half
of the time that we advised (1 hour per day).

Results of Treatment
On the SPAI a significant reduction from pretest to post-test was observed, f(8) = 3.9, p < .01,
which was maintained over time, that is, from pretest to follow-up, f(8) = 3.4, p < .01. High-end
state criteria indicated that at post-test 4 of the 9 patients were helow the Dutch cut-off point for
social phohia (< 89) (Bogels & Reith, 1997), and at follow-up 5 of the 9 patients were helow the
cut-off. The SCID-I interview at follow-up revealed that 7 of the 9 patients did not meet the criteria for social phohia any longer. On the FNE, a significant reduction was found from pretest to
post-test, f(8) = 2.9, p = .01, as well as from pretest to follow-up, t(8) - 3.7, p < .01.
On the cognitive measures, a significant change from pre- to post-test was observed, t{8) =
2.0, p < .05, for general social phohic hehefs (SPB), and t(8) = 2.5, p < .05, for negative beliefs
about hlushing, trembling, and sweating. Cognitive changes were maintained at follow-up, f(8)
= 2.7, p < .05, and t(8) = 2.5, p < .05, respectively.
On the attention measures, significant improvements were observed from pre- to post-test,
for SFA f(8) = 2.3, p < .05, for SCS-pub t(8) = 2.2, p < .05, but for SCS-priv no pre- to post-test
change was observed, t{8) = .4. From pretest to follow-up, the reduction on SFA and on SCS-pub
were maintained, f(8) = 3.5, p < .01, and f(8) = 3.1, p < .01, respectively. Moreover, the pretest
to follow-up contrast revealed a significant improvement on SCS-priv, t(8) - 2.6, p < .05.
On the Self-Other-Ideal questionnaire, a significant reduction in the self-ideal discrepancy
was observed from before to after, f(8) = 5.8, p < .001, which was maintained at follow-up, t(8)
= 4.7, p = .001. This reduction was due to increased self-image, t(8) = -3.5, p < .01, maintained
at follow-up f(8) = -2.7, p < .05, effecting a horderline significantly reduced ideal image, t(8) =
1.6, p =.07, which persisted at follow-up ((8) = 2.3, p < .05. At post-test no significant reduction
in perceived others-about-self image was noted, f(8) = -1.2., ns. However, at follow-up a significant reduction of perceived others-about-self image occurred, t(8) = -3.1, p < .01.
On general psychopathology (SCL-90) no reduction took place from pre to post, f(8) = .5,
ns, however, the difference from pretest to follow-up was significant, (= 1.9, p < .05.
Effect sizes were computed for all dependent variables at the different time contrasts,
according to the Cohen (1988) d statistic (Mp,, - Mp^J/SD^^^^^^, where SD^^^^^^ = ^[(SDpJ +
SDpos,^)/2]. Effect sizes immediately after the treatment were large (> .8) for the social phobia
symptoms measures (i.e., SPAI and FNE) (Table 1). At follow-up effect sizes were large for the
social phobia symptoms measures, but also for reduction in conviction of SPB, for self-focused
attention, and for the self-ideal discrepancy. Moreover, medium effect sizes were observed for
SCS-pub and for the conviction of negative beliefs related to blushing, trembling, and sweating
(BTS-Q) at follow-up.
Of the 9 patients, 6 did not receive further treatment after the 2-month follow-up, because
they felt that they were sufficiently improved or had learned enough to cope with their social fears.
Three patients received fiirther treatment for social phobia, all cognitive-behavioral therapy.

Bogels etal.

TABLE L

41

EFFECTS OF MINDFULNESS AND TASK CONCENTRATION TRAINING AFTER TREATMENT AND

AT 2-MONTH F O L L O W - U P 1=OR 9 PATIENTS

Pretest
M
SD

Posttest
M

SD

FoUow-Up I Effect Size Effect Size

M
SD Posttest FoUow-Up

Social phobia symptoms

SPAI
128.25 27.16 101.08 35.93 93.24 42.69
36.67 8.93 28.33 11.10 23.44 11.31
FNE
Cognitions
SPB
62.87 16.33 50.76 23.23 43.42 23.26
58.25 26.18 49.81 26.35 41.59 25.14
BTS-Q
Attention
23.22 8.57 18.11 11.04 14.89 11.53
SFA
19.44 4.36 17.33 5.34 16.22 5.78
SCS-Pub
SCS-Priv
23.11 7.25 22.44 6.17 19.44 6.78
General psychopathology
171.44 62.85 166.00 68.73 147.33 53.91
SCL-90
Self-other-ideal
48.30 16.76 54.68 17.14 59.89 18.06
Self
53.95 20.35 57.50 22.91 64.33 17.16
Other
Ideal
90.38 4.35 88.02 7.56 84.76 10.79
Ideal-self
42.09 18.93 33.23 19.60 24.88 18.90

0.85
0.83

0.98
1.30

0.60
0.32

0.97
0.65

0.52
0.43
0.10

0.82
0.63
0.52

0.08

0.41

0.38
0.16
0.38
0.46

0.67
0.55
0.68
0.91

DISCUSSION
The present study investigated mindfulness and TCT as a short (9-session), stand-alone treatment in 9 patients with severe social phobia. Following are the results.
1.
2.
3.
4.

The treatment is well accepted by patients.

The treatment is effective in reducing social phobia in the short term.
Effects are maintained after 2 months, and patients further improve in this period.
Effects of the treatment are most pronounced on fear of negative evaluation, social phobic
beliefs, and on reducing the self-ideal discrepancy.

For a novel treatment, it is first important to know whether patients accept it. When we conducted this pilot study, we had no real knowledge as to whether this treatment would work,
because it was the first time mindfulness training was evaluated for socially phobic patients. We
did know that TCT was a highly effective approach, although it was only evaluated for patients
with fear of showing bodily symptoms as the predominant complaint (Bogels, 2005; Mulkens et
al., 2001), and not for social phobia in general. Therefore, we had to inform the patients about
the unknown effectiveness of the treatment. Despite this information, and despite the considerable time patients had to dedicate to homework, every patient who was offered the treatment
accepted it. Furthermore, the patients complied with the homework assignments, although they
spent less time on homework than we advised (3.5 rather than 7 hours per -week). Still, spending
3.5 hours per week during a period of 8 weeks on homework can be regarded as a considerable
investment. Moreover, withdrawal during the treatment was low (1 patient, 10%).
The short-term effects of the treatment are encouraging. Effect sizes are in the range of those
reported after traditional cognitive-behavioral therapy for social phobia (cf Rodenbaug,
Holaway, & Heimberg, 2004), which is remarkable given that the treatment has fev^^er sessions; it

42

Mindful Concentration Training for Social Phobia

concerned a pilot phase of a highly experimental treatment; and therapists were relatively inexperienced with these techniques. Also, the percentage of patients meeting criteria for high-end state
functioning (i.e., SPAI cut-off < 89) is in the range of longer and established cognitive-behavioral
treatments from our research group (Bogels, 2005; Bogels, Wijts, & Sallaerts, 2006).
The follow-up results are even more encouraging. Patients kept improving during the 2
months afterward in which they received no further treatment, and 7 of the 9 patients are free of
a social phobia diagnosis. Compared to the Dutch SPAI average of GSP patients of 135.9 (Bogels
& Reith, 1999), our participants had a mean SPAI of 93.2. Mindfulness training emphasizes the
importance of continuing the meditation exercises after the treatment as a daily practice, so that
it becomes a way of life. Furthermore, mindfulness training is designed so tbat patients are bighly independent of their therapists, tbat is, tbey receive tapes and written instructions for all exercises. Tbe idea behind tbe treatment that is communicated is tbat wben being more in tbe here
and now, patients tbemselves will discover bow best to respond wben problems recur. Tbe finding tbat patients keep improving after the treatment is consistent witb this self-belp focus.
Witb respect to tbe mechanisms of cbange, on both attention and cognitive measures, significant changes were observed. Note that we removed all cognitive therapy elements from the
protocol, so tbe reduction of negative beliefs cannot be explained by cognitive interventions.
Tbe cbanges in dysfunctional beliefs more likely result from nonbiased and task- ratber tban
self-focused information processing and from reducing attentional avoidance. Interestingly, large
changes were obtained in tbe self-ideal discrepancy. Segal and associates (2002) describe our attention in tbe "doing mode" as devoted to a narrow focus on discrepancies between desired and actual states, thereby empbasizing discrepancy-based processing. In contrast, the focus of the "being
mode" is to accept and allow. In line witb tbis, the shift from doing to being, as was promoted
during the mindfulness training, reduced self-ideal discrepancies.
It is important to note that in the treated group comorbid depressive disorder was overrepresented; 7 patients bad comorbid depression. Since MBCT, on wbicb we largely based tbis treatment, was originally developed for chronically depressed patients, one could argue tbat tbe positive
effect of tbis treatment resulted from cbanges in depression ratber tban cbanges in social anxiety. To test tbis idea, we post-boc analyzed cbanges in the subscale depression of the SCL-90.
Treatment did not produce significant changes in depression from pretest to post-test, f(8) = .7,
ns, and from pretest to follow-up, f(8) = 1.5, ns. Therefore, reducing depression is an unlikely
explanation for the effects of the treatment.
The question of whether mindfulness training or TCT contributed more to tbe effect of
treatment is bard to answer. Our clinical impression was tbat patients benefited from both parts
of the treatment, but we found tbe task-concentration part essential, because it provides patients
tools for coping with anxiety wbile being in a social situation. Based on tbis pilot study, we bave
decided to start TCT earlier in the treatment, at session 4.
We are currently investigating the combined mindfulness and TCT approacb in a larger
treatment outcome study for social pbobia. We now also offer tbe treatment in a group format,
and we have reduced it to 8 sessions. Preliminary results are encouraging.

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Acknowledgments. We would like to thank Mark Williams for sharing his knowledge with us and for his comments on an earlier version of the manuscript. Also, we are grateful to therapists Rene Albers, Stefanie Duijvis,
and Sanne Tinga and research assistants Thamare van Roosmalen, Philippe Jacques, Jill Lobbestael, Joke
Opdenacker, and Essin Demir.
Offprints. Requests for offprints should be directed to Susan M. Bogels, PhD, Department of Medical, Clinical
and Experimental Psychology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
E-mail: Bogels@DEP.Unimaas.nl