5. Future direction

objectively after the speech tasks. The results showed that there was a significant interaction (group times) on self-perception. In addition, the VW + CI group showed significantly higher ratings for self-perception than the VW group after watching the video. These findings suggest that cognitive intervention before video feedback is an important factor in enhancing the effects of video feedback. Moreover, just watching videos has only a limited effect on

Shirotsuki has described a 23-year-old man named A with SAD [48] who was treated with VF. A was helping the family business by working in their factory as a self-employed person. At the factory, he was often required to communicate with customers about repairing their products. A felt excessive anxiety on these occasions. Because of his anxiety, he often spoke fast and could not sufficiently express what he intended to say. Therefore, he avoided talking with customers as much as possible. He was also taking the prescription medications Paroxetine and Landsen. A CBGT program was conducted for A on eight occasions to treat his SAD. Psychological education was given in the first therapy session; exposure focused on speech, cognitive restructuring, and video feedback (VF) were conducted at the second, third, and fourth sessions, respectively; and exposure using conversation settings, cognitive restructuring, and VF were conducted at the fifth, sixth, and seventh sessions, respectively.

After making a speech for the first time, A had the following impression; "I thought it would be all right to make a speech even in front of an audience if the topic were pre-decided. However, somehow, I became awkward and felt I might be the worst speaker." After implementing the program, he thought "It seems like I am improving, but cannot feel the improvement." Video feedback was given during the fourth therapy session. "A" seemed rather nervous about observing the videos, similar to the other participants. After the observation, he thought "I was not as bad as I thought I would be." Regarding his speech, he thought "I could make the speech rather smoothly because I was relaxed. I will also do my best in the future." This case study suggests that A felt confident about his own behavior as a result of VF. After finishing the CBCT program, A was able to talk to people that he was acquainted with without excessive feelings of tension. He could also become involved with first-time customers

Shirotsuki et al. have presented another case study that illustrated the treatment process of a SAD patient who participated in a CBGT program and was reinstated in his former office after treatment [49]. The patient was in his 40s and was feeling difficulties about working in his office because it had a negative environment. He was also afraid of his colleagues because they often reproached him. As a result, he gradually became uncomfortable in the office. Moreover, he became scared of getting involved with people because he was afraid that he might make others feel unpleasant. Furthermore, he thought that he might be smelling bad. His depressive symptoms increased, and as a result, he took a leave of absence and attended therapy to treat his anxiety and depression. A CBGT program was initiated because his anxiety about

improving self-perceptions about speech tasks.

70 Cognitive Behavioral Therapy and Clinical Applications

4. Case examples

without being too defensive.

Firstly, it is important to clarify the influence of factors interfering with VF. Certain studies have reported the effect of negative self-images and interpretations. Individuals with SAD and highly socially anxious people often provoke negative self-images before conducting video feedback. These cognitions might interrupt the shift in their thoughts to an objective and balanced view. Shirotsuki suggested that highly socially anxious people might have negative and positive interpretations about their appearance on video, which might interfere with the efficacy of VF sessions [50]. In addition, high social anxiety results in negative interpretation about social information. When conducting video feedback, activated negative interpretation biases interrupt receiving neutral information from video images. Certain studies have suggested that estimated social cost was activated by watching video images. Therefore, the relationship between these cognitions and SAD symptoms needs to be examined in the future.

Secondly, conducting VF with individuals having SAD would burden the participants because they feel uneasy and strange about themselves. In clinical settings, it is often said, "It is very hard to watch myself." They feel uncomfortableness about viewing their video because some people watch only negative information on the videos and remember a negative image. It is necessary to reduce this burden to improve the effectiveness of VF. Future studies need to identify effective interventions for reducing the psychological burden of VF.

In Figure 2, the psychological process during VF sessions is described. After conducting social tasks, highly socially anxious individuals and individuals with SAD have negative self-images. These images lead to focusing on negative information during video watching. Therefore, they become unable to change their negative self-perceptions and as a result continue to maintain

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Figure 2. Psychological process in video feedback.

their previous self-image. On the other hand, they can prepare appropriately before watching the video and develop an objective self-image. This is expected to make them receptive to receiving objective information during video feedback.

Research on interventions that are conducted before and after VF sessions suggests that it is important to conduct cognitive preparations before VF. Second, mindfulness-based psychotherapy could improve the efficacy of VF as suggested by research on the efficacy of mindfulness-based psychotherapy for SAD symptoms. Conducting mindful breath training and mediation before VF affects improvements in self-perceptions. Additionally, the burden of VF might be mediated by mindfulness training. Third, Internet-based CBT programs that include video feedback techniques could be developed. Internet-based CBT is an effective treatment modality in spite of certain difficulties. CCBT consist of complete self-help and clinician-guided treatment programs. In most cases, it is important to assist the participants during exposure or video feedback sessions. By using Internet services (e.g., Skype or web camera), video feedback could be easily given during Internet-based CBT.
