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

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 improving social anxiety symptoms than traditional CBT is demanded.

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 strong mental burden.

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.

We propose the following procedure as the most appropriate combination of mindfulness and exposure for SAD. First, MT is conducted. Through MT patients will be persuaded to increase their awareness of experiences such as negative cognition, social anxiety, trembling, and sweating in social situation, and then it leads to accept these experiences. As a result, negative cognition, social anxiety, and fear of physical response are alleviated. The effect of maintaining factors on social anxiety would be reduced. Therefore, the mental burden of patients to exposure would reduce, and these effects may prevent patients from avoiding and dropping-out exposure. In addition, maintaining mechanism of social anxiety would improve. This shows that MT could prevent relapse and recurrence following therapy.

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Second, exposure is reinforced. Through exposure the therapist encourages patients to face anxiety in social situations. They should notice their experience in facing social situations. And they may understand the differences in their experience between preexposure and postexposure situations. Exposure thus produces a significant reduction in social anxiety [54]. Because social anxiety would be improved by MT, exposure after MT may be more effective for improving social anxiety and maintaining the effect of treatment than exposure alone.
