**1.7. The relationship between trait mindfulness and social anxiety**

Some researchers have started to examine the effects of mindfulness on social anxiety. Previous studies have reported that trait mindfulness is negatively correlated with self-reported social anxiety, and trait mindfulness has a direct effect on social anxiety [36, 37]. Kocovski et al. also indicated that trait mindfulness predicts subsequent changes in social anxiety and that social anxiety predicts subsequent change in trait mindfulness [38]. Recent studies have provided relationships among trait mindfulness, social anxiety, and maintaining factors of social anxiety as mechanism of mindfulness on social anxiety. According to Clark and Wells and Rapee and Heimberg [8, 9], self-regulation of attention, avoidance behavior, and negative cognition are the factors that maintain SAD social anxiety disorder (SAD).

Noda et al. showed that trait mindfulness affects social anxiety through self-regulation of attention, avoidance behavior, and fear of negative evaluation by others in negative cognition,


**Table 1.** Main techniques and simple features of mindfulness training.

while Schmertz et al. reported that trait mindfulness impacts on social anxiety via cost/probability bias in negative cognition [37, 39]. Moreover, Okawa et al. showed that trait mindfulness affects social anxiety via rumination in negative cognition [40]. **Figure 1**, based on the earlier research, provides a mechanism for assessing the impact of mindfulness on social anxiety. This indicates that trait mindfulness affects social anxiety through maintaining various factors. Based on this research, it is considered that an increase in trait mindfulness would be not only effective for social anxiety but also for its maintenance factors. Research such as this supports the conclusion that trait mindfulness is strongly related to social anxiety symptoms.

Additional treatment studies of MT for SAD patients have been conducted. Previous research has reported that MT is effective in treating social anxiety symptoms [41, 42]. A therapeutic intervention program that includes MT is called Mindfulness-Based Intervention (MBI). MBI for SAD includes Mindfulness-Based Stress Reduction (MBSR), Mindfulness-Based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT), and Mindfulness and Acceptance-based Group Therapy (MAGT).

## **1.8. Mindfulness-based stress reduction**

higher levels of well-being [30]. Coffey et al. found that the improvement of trait mindfulness has been found to positively influence mental health [31]. The improvement of trait mindfulness also negatively impacts on anxiety, depression, and negative cognition [31, 32]. To enhance levels of trait mindfulness, mindfulness training (MT) can be used. MT includes body scan, gentle mindful yoga exercises, sitting meditation, walking meditation, eating meditation, among others (**Table 1**). MT is effective for improving stress, stress reactivity,

Some researchers have started to examine the effects of mindfulness on social anxiety. Previous studies have reported that trait mindfulness is negatively correlated with self-reported social anxiety, and trait mindfulness has a direct effect on social anxiety [36, 37]. Kocovski et al. also indicated that trait mindfulness predicts subsequent changes in social anxiety and that social anxiety predicts subsequent change in trait mindfulness [38]. Recent studies have provided relationships among trait mindfulness, social anxiety, and maintaining factors of social anxiety as mechanism of mindfulness on social anxiety. According to Clark and Wells and Rapee and Heimberg [8, 9], self-regulation of attention, avoidance behavior, and negative cognition

Noda et al. showed that trait mindfulness affects social anxiety through self-regulation of attention, avoidance behavior, and fear of negative evaluation by others in negative cognition,

**1.7. The relationship between trait mindfulness and social anxiety**

are the factors that maintain SAD social anxiety disorder (SAD).

**Table 1.** Main techniques and simple features of mindfulness training.

anxiety, and depression [30, 33–35].

120 Anxiety Disorders - From Childhood to Adulthood

MBSR was developed by Kabat-Zinn [43]. It is the most well-known MBI and has gained empirical support in the treatment of psychological symptoms. The protocol of MBSR is composed of MT. Previous research has shown that MBSR is effective for treating stress, anxiety, depression symptoms, improving self-regulation, and the purpose of life [34, 44]. Goldin and Gross [41] conducted MBSR for SAD patients. Individuals (N = 16) diagnosed with SAD participated in 8 weekly 2.5 h sessions of MBSR. The main components of treatment were mindfulness meditation techniques such as breath-focused attention, body scan-based attention to the transient nature of sensory experience, shifting attention across sensory modalities, open

**Figure 1.** The mechanism of mindfulness on social anxiety.

monitoring of moment-to-moment experience, walking meditation, and eating meditation. As a result, MBSR showed significant reduction in self-reported social anxiety symptoms and negative cognition (η<sup>2</sup> p = .59 on the Liebowitz Social Anxiety Scale; η<sup>2</sup> p = .53 on the Rumination Style Questionnaire) and significant improvement in self-reported self-esteem (η<sup>2</sup> p = .51 on the Rosenberg Self-Esteem Scale). In another study, individuals (N = 22) diagnosed with SAD participated in 8 weekly 2.5 h sessions of MBSR and an all-day meditation retreat for MBSR [42]. The MBSR produced significant reductions in self-reported social anxiety symptoms effect size (ES) = 1.48 on the Liebowitz Social Anxiety Scale-Fear; ES = 1.40 on the Liebowitz Social Anxiety Scale-Avoidance).

thoughts and feelings, and acceptance of social anxiety exercises. Kocovski et al. conducted MAGT for SAD patients [51]. Individuals (N = 53) diagnosed with SAD participated in 12 weekly 2 h sessions of MAGT. Consequently, the MAGT results showed significant reductions in self-reported social anxiety symptoms (*d* = 1.32 on the Social Phobia Inventory). In another study [52], individuals (N = 29) diagnosed with SAD participated in 12 weekly 2 h sessions of MAGT. As a result, the MAGT produced significant prepost improvements with high ESs (1.00 on the Liebowitz Social Anxiety Scale, 1.09 on the Social Phobia Scale, and 1.03 on the Social Interaction Anxiety Scale). From the earlier research, MBI appears to be an effective intervention for SAD, with generally large effect sizes on social anxiety symptoms.

Cognitive Behavior Therapy and Mindfulness-Based Intervention for Social Anxiety Disorder

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**2.1. The possibilities in the combination of mindfulness and exposure for the** 

improving social anxiety symptoms than traditional CBT is demanded.

The most well-known and effective psychological treatment for individuals with SAD is cognitive behavioral therapy (CBT). However, although CBT has been found to be efficacious in reducing social anxiety, there are patients who do not achieve clinically significant improvement following CBT [17]. According to Leichsenring et al., remission rates were nearly 40% for CBT [53]. Thus, the development of intervention protocols that are more effective for

Exposure, which is a key ingredient of most CBT, is effective for improving social anxiety symptoms [54]. But, it is indicated that exposure tend to be avoided and dropped by patients [55]. According to Van Velzen et al., 34.4% of patients with SAD dropped-out from exposure programs [56]. In another study by Hofmann, the attrition rate of exposure group therapy was 21% [23]. From the above, it is considered that exposure is an intervention that carries with a

The crucial factor causing patients with SAD to avoid and drop-out from exposure is experiential avoidance, which is based on thoughts, feelings, cognition, behavior, and sensation in the body in social situations. Experiential avoidance is a disturbance factor in the effective treatment of exposure, promoting the maintenance of anxiety [55]. By enhancing mental state of mindfulness, we would be promoted to increase awareness of one's experience and to accept what we are currently experiencing. Thereby, experiential avoidance is reduced [44], and willingness enhanced [55]. These findings suggest that incorporating MT into exposure for treatment of SAD may prevent patients from avoiding and dropping-out exposure. The combination of cognitive approach and exposure is thus more effective for improving social anxiety symptoms than only exposure [54]. Because MT seeks to reduce negative cognition [41, 47], and to enhance decentering and change cognitive flexibility [44], it functions as an approach that changes negative cognition. In addition, MT brings the improvement of selfregulation to our attention [41]. The low self-regulation of attention is core maintaining factors of social anxiety [8]. These findings suggest that the combination of MT and exposure may be more effective for improving social anxiety symptoms than traditional exposure therapy.

**2. Future direction**

**treatment of SAD**

strong mental burden.
