Exposure as a treatment for social phobia: Some instructive difficulties

The main rules guiding the application of exposure to the treatment of simple phobias and agoraphobia are described, together with the four principal difficulties that came to attention when these rules were applied to the treatment of social phobia. These difficulties were: (i) specifying graduated and repeatable tasks; (ii) prolonging exposure; (iii) securing adequate engagement during exposure; and (iv) dealing with the cognitive aspects of social phobia. Solutions to these difficulties are described and illustrated from case material collected during the treatment of 45 socially-phobic out-patients. The discussion considers the implications of these solutions both for the treatment of other conditions and for understanding the processes involved in exposure.