**1.5. Video feedback**

**1.3. Exposure**

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related to daily situations.

improvement of SAD symptoms.

**1.4. Cognitive biases**

Exposure technique is one of the best ways to deal with SAD symptoms. In the treatment of SAD, in vivo exposure often has been used. In exposure therapy, the following approaches are involved: psychological education about exposure, development of anxiety hierarchy worksheets, specifying exposure settings, execution of exposure, and anxiety assessment before and after exposure. In psychological education, participants learn in advance the characteristics of anxiety and what will be conducted in exposure therapy. They need to sufficiently

Through developing an anxiety hierarchy worksheet, the situation of anxiety and the degree of anxiety in each situation become clear. Through setting discussion in concrete situations, problems are shared between the therapist and client. The first aim of exposure therapy is to reduce anxiety. Social settings tend to change in the condition where anxiety feelings are high. For example, speech situations usually finish in a few minutes. Participants tend to finish the situation with high anxiety, which leads to avoidance behaviors in the next anxiety situation. It is important to properly expose themselves to each anxiety situation repeatedly. Exposure therapy is often conducted during a treatment session (regardless of inside or outside of the treatment institutions) or in an actual setting as homework. Though imagined exposure is also effective, when exposure in real life can be used, this can be

There are some types of information-processing biases in SAD. Attentional biases, interpretation biases, memory biases, and cost/probability biases are often modified in bias modification. The effects of cognitive restructuring have been indicated through various studies. For example, Clark et al. [19] indicated the following as intervention targets of cognitive therapy: (1) attention, or an increase in attention and reduction in observation of others and making association with others' responses; (2) recognition of physiological responses, or the use of incorrect inner information that causes excessively negative ideas about how others think of the self; (3) safety behaviors (avoidance), or the excessive use of explicit or implicit safety behaviors; and (4): information-processing biases, or the processing of information before and after an issue. They thus compared the effects of cognitive therapy and exposure + applied relaxation therapy. The results indicated the high impact of cognitive therapy on improving SAD symptoms, indicative

The research on the treatment of SAD has thus focused on the effectiveness of using cognitive therapy techniques to change specific cognitions or thought patterns [14, 18, 19]. However, SAD treatment research has also focused on the reduction of cost and probability bias. Foa et al. [20] reported that the reduction of cost bias strongly predicted the reduction of SAD symptoms. Rapee et al. [14] showed that a change in cost bias was highly related to a decrease in the severity of SAD symptoms using a group CBT (CBGT) program. Shirotsuki et al. [21] suggested that repeated exposure and reduction of cost bias may have an effect on the

of the effectiveness of the intervention in cognition characteristic of SAD.

understand the nature of psychological burden when implementing the therapy.

Video feedback (VF) is one of the important and effective techniques in most CBT treatment programs. Individuals with SAD try to watch their video before receiving sufficient cognitive preparation. Clark et al. [18] reported a high impact from individual CBT. This program consisted of developing with patients a personal set of safety behaviors and a self-focused attention experiment: shifting the focus of attention to the social situation. In video feedback sessions, individuals with SAD watch their actual social tasks, which are public speaking and conversation. They often recognize their performance is worse than actual performance. Therapists try to change the discrepancy between subjective and objective perceptions of social performance. VF involves providing individuals with video playback of their social performance following their participation about social task, such as a public speech or a oneon-one conversation [22]. High socially anxious and individuals with SAD watch the real situation through recorded video. Video feedback involves video recording socially anxious individuals while they are trying a social task, that is, a speaking task or conversation. It is anticipated that review of the recording corrects distorted self-evaluations, including the underestimation of social skills [23].

Though video feedback sessions are effective, it is necessary to consider that participants might have a resulting psychological burden. Shirotsuki [24] indicated the effects of the interpretation of video images: when watching video images, sometimes, participants cannot perceive themselves objectively owing to their negative interpretation of the video images, which reduces the self-evaluation of their performance. It is considered important to try to make participants watch video images objectively before the session.

#### **1.6. Mindfulness**

In recent years, researchers and clinicians have developed intervention programs that include mindfulness. Mindfulness is defined as "paying attention in a particular way—on purpose, in the present moment and nonjudgmentally" [25]. Bishop et al. [26] distinguished two components of mindfulness. The first component is "self-regulation of attention." Self-regulation of attention is observing and attending to the changing field of thoughts, feeling, and sensations from moment to moment. This leads to a feeling of being very alert to what is occurring in the here-and-now [26].

The second component is "orientation to experience." Orientation to experience is an attitude of openness, acceptance, and curiosity about the present moment. Experiential avoidance which is the opposite concept of orientation to experience is at the heart of all psychological distress [27]. It is to avoid one's own experience such as thought, feeling, cognition, behavior, and sense of body. Experiential avoidance is reduced by increasing the mental state of orientation to experience; as a result, psychological distress improves [28].

Many researchers have found relationship between trait mindfulness and mental health criteria. Baer et al. showed that trait mindfulness was negatively correlated with alexithymia, dissociative activities, difficulties in emotion regulation, and neuroticism [29]. Higher levels of trait mindfulness predict lower levels of anxiety, depression, and negative cognition, and 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, anxiety, and depression [30, 33–35].

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

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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

Acceptance-based Group Therapy (MAGT).

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

**1.8. Mindfulness-based stress reduction**
