AIMING TO FULLY UNDERSTAND HOW WE HEAL: TREATMENT AND
ASSESSMENT PROTOCOL DEVELOPMENT FOR CLINICAL RESEARCH ON
PERFORMANCE-SPECIFIC SOCIAL ANXIETY DISORDER.
by
STEPHANIE E. HALL

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR
THE DEGREE OF MASTER OF ARTS
in
THE FACULTY OF GRADUATE STUDIES
Graduate Counselling Psychology Program

We accept this thesis as conforming to the required standard
……………………………………………….
Dr. Richard Bradshaw, Ph.D.; Thesis Supervisor
……………………………………………….
Dr. Marvin McDonald, Ph.D.; Co-Supervisor
……………………………………………….
Dr. Bill Acton, Ph.D.; Third Reader

TRINITY WESTERN UNIVERSITY
August 2017
© Stephanie Hall

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ABSTRACT
The purpose of this project was to develop innovative assessment and treatment protocols for
clinical research on performance-specific Social Anxiety Disorder (SAD). The initial step was to
conduct an investigation of OEI (Observed and Experiential Integration; a trauma-root-focused
therapy) and BRAIN (Breathing, Relaxation, Autogenics, Imagery, and grouNding; a traumasymptom-focused therapy) on performance-specific SAD. Similarities between trauma and
anxiety symptoms suggest that there can be a traumatic cause to SAD (Calamaras, Anderson,
Tannenbaum, & Zimand, 2014; Erwin et al., 2006; Stein, Walker, & Forde, 1996; Wild,
Hackmann, & Clark, 2008). This was a pilot test to explore the assessment and treatment
protocols as they related to specificity and sensitivity of measures. Descriptive analyses in this
pilot study revealed connections between treatment types and symptom processes which were
activated. Symptoms can be distinguished as: (a) narrow spectrum symptoms, such as speaker
confidence and public speaking behaviour; (b) psychophysiological symptoms, such as
electrodermal activity; or (c) broad spectrum symptoms, such as general anxiety and depression.
In this pilot study, both trauma-root-focused and trauma-symptom-focused treatments resulted in
improvements in: (a) narrow spectrum symptoms of speaker confidence and public speaking
behaviour. Additionally, in response to trauma-root-focused treatment: (a) broad spectrum
symptoms improved and (b) psychophysiological activation associated with past traumatic social
experiences was alleviated (Porges, 2007; van der Kolk, 2001, 2002; van der Kolk, B. A.,
Hopper & Osterman, 2001). As a result of this study, it is suggested that diverse types of
measurements (including self-report, behaviour sampling, and psychophysiological measures),
will be helpful for understanding (a) broad spectrum, (b) narrow spectrum, and (c)
psychophysiological symptoms. The potential traumatic origin for performance-specific SAD

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was supported by results of the descriptive analyses in this study. The findings of this study will
also be useful for establishing measurement parameters for clinical research on social anxiety. If
these patterns continue to be supported by additional research, such results will help: (a) those
with performance-specific SAD, (b) clinicians, and (c) future clinical researchers.

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TABLE OF CONTENTS
ABSTRACT.................................................................................................................................... ii
TABLE OF CONTENTS…………………………………………………………………………iv
LIST OF TABLES ....................................................................................................................... viii
LIST OF FIGURES ....................................................................................................................... ix
CHAPTER 1: INTRODUCTION ................................................................................................... 1
CHAPTER 2: LITERATURE REVIEW ........................................................................................ 5
Social Anxiety Disorder (Social Phobia) with Performance-Only Specifier ............................................5
Comorbidity ..........................................................................................................................................5
Impact of Performance-Specific Social Anxiety Disorder....................................................................7
Anxiety Treatments ...................................................................................................................................8
Behaviour Therapy ................................................................................................................................8
Exposure Therapy Theory ...................................................................................................................10
Cognitive Therapy ...............................................................................................................................13
Exposure Therapy versus Cognitive Therapy .....................................................................................13
Cognitive Behaviour Therapy .............................................................................................................14
Mindfulness- and Acceptance-Based interventions ............................................................................15
Trauma Informed Treatment for Social Anxiety Disorder ......................................................................19
Current Trauma Treatments ....................................................................................................................21
Comparison of treatments used to treat trauma...................................................................................22
Trauma focused Exposure Therapy ....................................................................................................23
Eye Movement Desensitization and Reprocessing .............................................................................24
Alternative Treatments Used in This Study ............................................................................................25

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Observed and Experiential Integration ....................................................................................................26
Theoretical background .......................................................................................................................27
Observed and Experiential Integration techniques .............................................................................33
Observed and Experiential Integration research .................................................................................34
BRAIN .....................................................................................................................................................36
BRAIN techniques ..............................................................................................................................36
Relaxation Treatment research ............................................................................................................40
Summary .............................................................................................................................................41
Rationale .............................................................................................................................................41
Research Questions .................................................................................................................................42

CHATPER 3: METHODS ............................................................................................................ 43
Participants ..............................................................................................................................................43
Instruments ..............................................................................................................................................44
Intake assessments ..............................................................................................................................44
Dependent Variable Measures ............................................................................................................50
Self-report. ..........................................................................................................................................51
Behavioural assessment. .....................................................................................................................53
Psychophysiological assessments .......................................................................................................53
Procedure .................................................................................................................................................56
Recruitment .........................................................................................................................................56
Intake ...................................................................................................................................................56
Pre-Treatment and Post-Treatment assessments .................................................................................57
Treatment ............................................................................................................................................59
Observed and Experiential Integration (OEI) ....................................................................................60
Breathing, Relaxation, Autogenics, Imagery, and grouNding ............................................................61

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Interview .............................................................................................................................................63
Analysis ...................................................................................................................................................63

CHAPTER 4: RESULTS .............................................................................................................. 64
Preliminary Analysis ...............................................................................................................................64
Research Questions 1-3 ...........................................................................................................................65
Self report measures ............................................................................................................................66
Behavioural measures .........................................................................................................................70
Psychophysiological measure .............................................................................................................71
Results Summary .....................................................................................................................................73

CHAPTER 5: DISCUSSION........................................................................................................ 76
Reflections on Innovation in Protocol Design and Theory Application .................................................76
Protocol design ....................................................................................................................................76
Application of trauma theory ..............................................................................................................77
Broad and narrow spectrum symptoms ...............................................................................................79
Recommendations for Additional Protocol Development and Research ................................................80
Conclusion ...............................................................................................................................................82

REFERENCES ............................................................................................................................. 84
APPENDIX A: Research Design Diagram ................................................................................. 100
APPENDIX B: Polyvagal Theory Diagram ............................................................................... 101
APPENDIX C: Polyvagal Theory Applied to OEI Treatment Diagram .................................... 102
APPENDIX D: Polyvagal Theory Applied to BRAIN Treatment Diagram .............................. 103
Appendix E: A Conceptual/Theoretical Summary of OEI ......................................................... 104
APPENDIX F: Participant Background Information ................................................................ 108

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APPENDIX G: Dissociative Experiences Scale ........................................................................ 111
APPENDIX H: Personal Report of Confidence as a Speaker ................................................... 117
APPENDIX I: Trauma Scene Form ........................................................................................... 119
APPENDIX J: EEG and EDA Protocol ..................................................................................... 121
APPENDIX K: Timed Behavioural Checklist ........................................................................... 122
APPENDIX L: Recruitment Poster ........................................................................................... 123
APPENDIX M: Informed Consent Form .................................................................................. 124
APPENDIX N – Palm Electrode Placement ............................................................................... 129
APPENDIX O: OEI Power Point Information .......................................................................... 130
APPENDIX P: OEI Homework Exercises ................................................................................ 134
APPENDIX Q: Helpful Aspects of Therapy Questionnaire (HAT) .......................................... 136
APPENDIX R: BRAIN Power Point Information ..................................................................... 140
APPENDIX S: BRAIN Techniques........................................................................................... 145
APPENDIX T: Credibility of Treatment Questionnaire ............................................................ 150
APPENDIX U: Post-Treatment Interview ................................................................................. 151
APPENDIX V: Descriptive Statistics ......................................................................................... 153
APPENDIX W: Treatment and Assessment Protocol Development for Performance Specific
Social Anxiety Disorder based on Symptom Type and Treatment Strategy. ............................. 155

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LIST OF TABLES
TABLE 1: Measurement Reliability…………………………………..……………...………..65

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LIST OF FIGURES
FIGURE 1: Beck Depression Inventory ANOVA Plot…………...……………………………..68
FIGURE: 2 Beck Anxiety Inventory ANOVA Plot………………………………………...…...69
FIGURE: 3 Electrodermal Activity Post-Treatment ANOVA Plot……………………………..73

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CHAPTER 1: INTRODUCTION
Imagine standing on a stage. In front of you is a full auditorium of eager listeners waiting
to hear a dynamic speech. Does your heart race? Do your palms sweat? Does the first line of
your speech leave your mind, as you worry about losing your place or forgetting your speech? If
your answer is “yes” to any of these questions, you are not alone. Community surveys report
that up to one-third of people experience anxiety related to public speaking (Kessler, Stein, &
Berglund, 1998; Stein, Walker, & Forde, 1996).
The fear of negative evaluation by others is at the core of performance-specific Social
Anxiety Disorder (SAD; American Psychological Association, 2013). SAD is the broader
anxiety disorder under which public speaking anxiety (PSA) falls. This type of social anxiety
shows itself most in public speeches or performances, but can be evident in places such as
classes, meetings, or social engagements. There are many physiological, emotional, and
behavioural responses to this fear, including: worry, anxiety, nervousness, sweating, shaking, or
dizziness. These fears and physiological responses are usually associated with (a) worries about
other people noticing the nervousness, or (b) fear of embarrassment (Calamaras, Anderson,
Tannenbaum, & Zimand, 2014).
Researchers have sought to understand the impact of performance-specific SAD. In a
cluster analysis, PSA was found to be the most common subtype within three subtypes of SAD:
(a) generalized, (b) non-generalized, and (c) specific phobia, including PSA (Furmark, Tillfors,
Stattin, Ekselius, & Fredrikson, 2000). Public speaking fears made up 40% of the social phobia
group. Mannuzza et al. (1995) found that PSA co-occurred in 88% of participants with
Generalized Social Anxiety, and 79% of those suffering from non-generalized Social Phobias.
The magnitude of this problem warrants exploration regarding effects of PSA.

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Calamaras et al. (2014) found that those with performance-specific SAD had lower
income, more unemployment, and less education. Stein et al. (1996) found similar implications
of anxiety related to public speaking in a community sample. Those who reported PSA had
lower incomes, higher rates of unemployment, and less education. Half of these individuals had
only PSA and no comorbid anxieties. These correlations do not confirm that PSA caused these
negative outcomes, but subjective interview findings by Stein et al. support the limiting influence
of such fears on ability to pursue educational, career, social, and other major goals. The
collection of these findings supports a reciprocal effect, and constitutes sufficient reason to
research and develop effective treatments for performance-specific SAD. Treatments for
performance-specific SAD will help individuals achieve their educational and employment
potentials.
Many approaches have been used to treat SAD. These include: Cognitive Behavioural
Therapy, Exposure Therapy, combined Exposure Therapy and Cognitive Restructuring, and
mindfulness- and acceptance-based therapy. There may, however, be merit in using trauma
treatments to treat such anxiety, as results of several studies suggest that anxiety disorders can be
traced back to childhood abuse or socially traumatic events, leading to symptoms similar to those
of Posttraumatic Stress Disorder (PTSD). Erwin et al. (2006) found that more than 95% of their
sample of patients with SAD reported past traumatic events. Of this group, 78% reported that
these traumatic experiences caused symptoms of avoidance, re-experiencing, or hyperarousal
lasting more than three months. Wild, Hackmann, and Clark (2008) found that memory rescripting of socially traumatic memories helped individuals with SAD. Participants were less
likely to accept the beliefs which arose from their memories, and had lower anxiety scores during
visualizations of their feared social situations than those in a control group. Results of these

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trauma-informed studies of anxiety reveal the contribution of prior trauma to the development of
later anxiety disorders, suggesting that trauma treatment may be a helpful approach for
performance-specific SAD.
Two types of treatments were used to address the traumatic aspect of performancespecific SAD in this study. The first is Observed and Experiential Integration (OEI; Bradshaw,
Cook, & McDonald, 2011) which focuses on treating the traumatic root (original traumatic
experience or cause) of the anxiety. The second is a mindfulness, relaxation, and grounding
protocol known as BRAIN (Breathing, Relaxation, Autogenics, Imagery, and grouNding) based
on techniques described by Davis, Eshelman, and McKay (1995) and Dennison and Dennison
(1986, 1994). This treatment focuses on neutralizing the symptoms of trauma as they arise. The
purpose in using these two types of treatment is to see how they differently effect how
participants experience changes in their performance-specific SAD.
OEI is a new treatment for psychological trauma (Bradshaw, Cook, & McDonald, 2011).
This approach has been subjected to two randomized controlled trials (Bradshaw, McDonald,
Grace, Detwiler, & Austin, 2014; Bradshaw et al., 2017) and found to be an effective treatment
for PTSD. OEI has been used in hundreds of thousands of hours of clinical practice over a
period of 20 years (R. A. Bradshaw, personal communication, June 15, 2015). Within these
hours, OEI has been used successfully to treat performance-specific SAD which manifested as
public speaking anxiety, usually in 1-3 sessions. To follow up these promising clinical
observations, this study constitutes the first formal investigation of OEI to treat SAD.
BRAIN helps users to calm their bodies and minds when faced with stressors or when
practicing mindfulness (Davis, Eshelman, & McKay, 1995). The main ways this treatment
works with the physiological trauma symptoms is through: (a) diaphragmatic breathing, (b)

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progressive muscular relaxation, (c) autogenics, (d) imagery, and (e) grounding. There is some
evidence this treatment can help individuals cope with their current trauma symptoms (Taylor et
al., 2003).
This study was an initial effort to see how a trauma-root focused and a trauma-symptomfocused treatments interacted with performance-specific SAD. This pilot study was designed to
prepare research guidelines and assessment protocols for future research investigating factors not
addressed by current theories of social anxiety. The main reasons for this pilot study were to
assess sensitivity and specificity of measures, given the heavy response demand of multiple
complex measures in this study (Appendix A).
Different dimensions of assessments were used to see how treatments affected the
symptoms of performance-specific SAD. These assessments included: (a) self report, (b)
behavioural, and (c) psychophysiological measures. Such an involved assessment protocol had
the potential for a high response demand on participants. This pilot study increased
understanding of the importance of multimodal assessment despite high response demand.
Readers wanting to view the list and order of assessments used in this study should see Appendix
A.
A further goal of this study was to alleviate performance-specific SAD in participants, so
they could enroll in broader public speaking skill development programs (e.g., Toastmasters) or
at least be more comfortable using skills they currently possess. As these individuals gain public
speaking skills and confidence, they can pursue education, career, and social goals which were
previously unachievable.

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CHAPTER 2: LITERATURE REVIEW
There is a great deal of literature on anxiety symptoms and treatment. Literature regarding
the following topics will be reviewed in this chapter: (a) Social Anxiety Disorder (SAD) with
performance-only specifier, (b) current treatments for SAD, (c) the commonly missed traumatic
aspects of SAD, and (d) current trauma treatments. The following sections of this chapter
describe the treatments used in this study: (a) Observed and Experiential Integration (OEI) and
(b) BRAIN (a grounding and relaxation protocol). The chapter concludes with (a) rationales for
the study, (b) objectives, (c) hypotheses, and (d) research questions.
Social Anxiety Disorder (Social Phobia) with Performance-Only Specifier
Social Anxiety Disorder (SAD) is the broad term for a group of fears related to social
situations (American Psychological Association, 2013). The diagnostic criteria for SAD
according to the DSM-5 is: (a) fear about social situations (one or more) where there is fear of
scrutiny by others; (b) fear of acting in a way which will show anxiety symptoms; (c) the
situation always prompts this fear response; (d) contexts which would cause this anxiety are
avoided; (e) the fear/anxiety is greater than the threat of the actual event; (f) the anxiety, fear, or
avoidance is present for at least six months; (g) this fear/anxiety causes clinically significant
distress; (h) the symptoms cannot be explained by use of a substance; (i) the symptoms cannot be
better explained by another disorder; and (j) any other medical conditions are clearly unrelated to
the cause of symptoms. This can be further specified by performance-only, in which the fears
are specifically connected to speaking or performing in public.
Comorbidity. There are mixed reports on whether performance-specific SAD is less
comorbid with other disorders than more general social fears, or if it is equally comorbid. If this
subtype is less comorbid, it becomes a perfect subtype to study for treating a pure form of

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anxiety. Each of the following two paragraphs address one article on comorbidity of
performance-specific SAD. Authors of the first article found performance anxieties to be less
comorbid while the authors of the next article reported both to be comorbid with depression and
more general anxiety symptoms.
Kessler et al. (1998) described the incidence of, and distinctions between, public speaking
anxieties and anxieties about other social situations. Data analyzed in the study were collected as
part of the National Comorbidity Survey (n = 8,098) which had: (a) an age range of 15-54 years,
(b) an 82.4% response rate, and (c) sociodemographic variables. The researchers used the
Composite International Diagnostic Interview to assess for Social Phobia (SP). They evaluated
interviewees for SP by asking participants to share their fears or avoidances of six situations: (a)
using a washroom away from home, (b) speaking in public, (c) eating or drinking in public, (d)
writing while someone watches, (d) talking to someone when you do not have something to say,
and (e) talking when in front of a small group. Data analyses revealed two subtypes: (a)
speaking fears, and (b) more expansive social fears. Those who had general social fears usually
had many comorbid social fears (usually of the performance or interaction variety), while onethird of those with speaking fears reported speaking fears in isolation. This subtype showed
much less comorbidity with other DSM-III-R disorders when compared to the general social fear
subtype. More recent references were sought to further substantiate this division; however, there
is a marked paucity of PSA literature since the mid-1990s. The authors found that 35.8% of
respondents had pure speaking fears, which is much higher than the 8.5% who had only one of
any of the other social fears in the survey. This supports the contention that speaking fears are
less comorbid than other social anxieties.
Knappe et al. (2011) also explored social phobia subtypes in terms of clinical (avoidance,

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age of onset, comorbidities, impairments) and vulnerability factors (behavioural inhibition,
parental rearing, and parental psychopathology). Using the Munich-Composite International
Diagnostic Interview they studied a population sample (n = 3,021; aged 14-24 years) for more
than ten years. They found two subtypes of social fears: (a) interaction, and (b) performance
fears (such as PSA). Both types of fears are associated with high levels of avoidance,
comorbidity with depression or anxiety, and impairment. The weighted percentage of
participants who reported fear of speaking in front of others was 24.8%. The authors also found
that parental (multigenerational) anxiety disorders were positively associated with performancerelated social fears (such as public speaking anxiety) but this association was less evident in
those with isolated social phobias. Whether or not performance-specific SAD is equally or less
comorbid than more general social anxiety, this subtype of SAD does appear to have an impact
on the lives of those who struggle with this anxiety.
Impact of Performance-Specific Social Anxiety Disorder. Considering the potential for
limited comorbidity, one may be quick to disregard the impact of a performance-only social
anxiety, but there are several areas of life which can be greatly effected by such a fear. Stein et
al. (1996) studied the prevalence, and repercussions, of social phobia in a community sample of
499 people residing in Winnipeg, Manitoba. Thirty-four percent of the sample reported high
anxiety when speaking to large audiences. Anxious thoughts reported included: (a) “doing or
saying something embarrassing (64%); (b) “having one’s mind go blank” (74%), (c) “being
unable to continue talking” (63%); (d) “saying foolish things or not making sense” (59%); and
(e) “trembling, shaking, or showing other signs of anxiety” (80%). If the diagnostic criteria for
social phobia in the DSM-IV were applied to the data, within the group reporting public speaking
fears: (a) 7% said such fears interfered with their abilities to find jobs, get new jobs, or be

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selected for better jobs; (b) 4% said this interfered with their normal social interactions; (c) 14%
said such fears interfered with their education; and (d) 17% reported their anxiety-related to
public speaking interfered with major areas of their lives. If the criteria for social phobia were
broadened to include all those with anxiety related to large group public speaking, 31% said that
fear had caused them significant distress. They also found those with significant public speaking
anxiety had less lucrative employment, and less education, than those without. The fact that
individuals have reported performance-specific SAD impacted their lives, should lead to inquiry
about the best ways to treat SAD.
Anxiety Treatments
There are many treatments being used currently to treat anxiety. Some of the common
treatments for social anxiety are: (a) behaviour therapy (particularly exposure), (b) cognitive
behaviour therapy (CBT), (c) cognitive behaviour group therapy (CBGT), and (c) mindfulness
and acceptance-based treatments. Theory and research on these common types of treatment are
presented in the following sections.
Behaviour Therapy. The focus of Behaviour Therapy (BT) is to change behaviour by
decreasing the occurrence of maladaptive behaviours, and increasing adaptive behaviours
(Antony & Roemer, 2011). Behaviours are seen as (a) functional, and (b) resulting from
reinforcement or punishment. Within this view, behaviours are seen as a result of the
individual’s interaction with environment, and not an intrinsic part of the individual. The focus
of BT is not on early life experiences which may have contributed to the current problems but,
instead, focuses on changing the current interactions with the environment. Therapy is done
using a direct approach where the therapist may give suggestions and advice. The role of the
client is to actively engage in treatment by practicing behavioural techniques in, and out of,

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sessions. Clients are active partners in therapy. Given of the role of clients, and the nature of
these techniques, the goal is for the clients to become their own therapists.
Classical Conditioning. Classical Conditioning (CC) and extinction of fears involves
several stages (Bouton, 2002; Hofmann, 2008). First, a stimulus is paired with an aversive
unconditioned stimulus (US) until the first stimulus becomes the conditioned stimulus (CS+; a
phase known as classical conditioning). A stimulus which is never paired with the aversive
stimulus remains a safe stimulus. The CS+ signals the US and will eventually independently
cause the fear response, known as the conditioned response (CR). When exposure to the CS+
happens repeatedly in the absence of the US the CR will discontinue. This process is known as
extinction. This does not mean the connection between the CS and US is gone completely, but
rather, replaced by a different response pattern based on the new context.
Operant Conditioning. In Operant Conditioning (OC), the strength, frequency, and form of
behaviour is influenced by the consequences (Beck & Weishaar, 2014). Reinforcement and
punishment are the two forces which influence OC. There are two types of reinforcement: (a)
positive reinforcement is when a behaviour is followed by a desired reward and (b) negative
reinforcement is when is when a behaviour causes an unwanted stimulus to be removed. There
are also two types of punishment: (a) positive punishment is when an aversive stimulus follows
the behaviour and (b) negative punishment is when a behaviour is followed by the removal of an
desired stimulus. In OC, behaviour is viewed as the result of punishment or reward.
Other concepts relevant to OC (Beck & Weishaar, 2014) include: (a) extinction, (b)
discrimination learning, and (c) generalization. Extinction is said to be occurring when
behaviour ceases to occur because the desired consequence has not occurred as a result.
Discrimination Learning is said to be occurring when behaviour is reinforced in a certain

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situation but not in another situation. This can lead the individual to behave differently in
different situations. Generalization is said to be said to be occurring when a behaviour occurs in
a situation other than the context in which it was learned. Extinction, discrimination learning,
and generalization add intricacies to OC.
Two-factor model of fear development and maintenance. Classical conditioning or
operant conditioning alone do not explain the maintenance of anxiety responses to conditioned
stimuli, thus a two-factor model was developed (Mowrer, 1960). The proponents of this theory
posit that fears are developed through classical conditioning and maintained through operant
conditioning. Operant behaviours responsible for this maintenance are escape and avoidance.
These behaviours allow negative reinforcement (removal of feared stimuli) and therefore the
behaviours continue because there is no chance for clients to face prolonged or repeated
exposure to the CS in relaxed or safe ways. There are, however, limitations such as difficulty
distinguishing between CS and UCS in natural environments. Sometimes habituation (gradual
reduction of reactivity due to exposure over time) is considered by some to be a better
explanation for behavioural improvement than extinction (i.e., extinction learning/inhibitory
learning; Jaycox, Foa, & Morral, 1998). Some critics go further and suggest emotional
processing could improve this model (Foa & Kozak, 1986; Foa & McNally, 1996).
Exposure Therapy Theory. There are two key features of contemporary exposure
therapy (ET). The first is that clients need to be engaged with anxiety-causing stimuli repeatedly
or for prolonged periods of time (Abramowitz, 2013). After several exposures, responses may
decline. The second key feature of ET requires that clients engage in behaviours other than their
usual fear responses (Barlow, Allen, & Choate, 2004). These features can be shown in the
intervention known as Systematic Desensitization (SD).

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Systematic desensitization involves exposing clients to progressively more anxietyprovoking stimuli in their imaginations while sustaining relaxed states (Davison, 1968). Starting
with muscle relaxation may help them to get into relaxed states as they start systematic
desensitization. This process helps clients to use anxiety cues (such as muscle tension or other
somatic responses) to know when to use alternative behaviours which are incompatible with
anxiety (such as relaxation techniques).
There are many ways exposure therapy can be used. These include: (a) imaginal exposure,
(b) in vivo exposure, (c) informal exposure, (d) interoceptive exposure, (e) cue exposure, and (f)
virtual reality exposure. These types of exposure are explained in the following sections.
Imaginal exposure. Imaginal exposure requires clients to imagine stressful stimuli to
create non-threatening associations with feared stimuli (Farmer & Chapman, 2016). This can be
used in three different conditions: (a) when in vivo (live) exposure is too difficult, (b) when a
client’s imagination is vivid enough to invoke an emotional response, and (c) before in vivo
exposure.
Prolonged exposure is a type of imagined exposure where clients recount their traumatic
experiences in great detail so they can face events without their traumatic-stress conditioned
responses (Farmer and Chapman, 2016). This enables clients to learn new associations with their
memories while in safe environments, because the memories are not inherently dangerous (Foa
& Rothbaum, 1998).
In vivo exposure. In vivo exposure involves letting clients face anxiety-provoking stimuli
in real life (Farmer & Chapman, 2016). This can be done: (a) in a natural environment, (b) at
home, or (c) in the therapist’s office.
Informal exposure. Informal exposure is when clients are exposed to feared stimuli in

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informally during therapy (Farmer & Chapman, 2016). This is most often useful when clients
are avoiding certain emotional responses because of maladaptive coping patterns. Therapists
typically begin by explaining how exposure will help clients reach their goals. Therapists then
describe when and how exposure will be used. Finally, therapists may address exposure as the
need arises in following sessions.
Interoceptive exposure. Interoceptive exposure helps clients to engage and recognize their
bodily sensations (Farmer & Chapman, 2016). This type of exposure especially helps when
clients fear certain sensations, such as those associated with panic attacks. This can include fear
of dizziness, in which case clients may spin until they are dizzy and come to realize they no
serious consequences will result.
Cue exposure. Cue exposure is primarily used with addiction-based struggles because
certain cues can prompt substance use. In the case of cue exposure, the response is blocked in
the presence of some cue related to the substance or behaviour. In classical conditioning terms,
the conditioned stimulus (e.g., substance-based cue) is presented while restricting the client’s
ability to engage in the conditioned response (e.g., taking the substance).
Exposure using virtual reality. Virtual reality exposure therapy (VRET) involves facing
feared stimuli using technology. VR can be accessed using computers, head-mounted
technologies, or even a fully immersive environment (Kim, Rosenthal, Zielinski, & Brady,
2014). The advantages of VR exposure include the ability to: (a) expose clients to situations
which may not be possible using in vivo exposure, (b) expose clients to stimuli without leaving a
therapist’s office, and (c) precisely control the stimuli. Promising results have been found in
meta-analyses on VR for treatment of various anxiety disorders. VRET treatment groups show
greater reductions in anxiety than do wait-list (control condition) groups, and VRET treatment

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groups show maintenance of improvements during follow-up periods (Opris et al., 2012).
Additionally, VRET treatment groups show larger effect sizes than non-treatment (control)
conditions (Powers & Emmelkamp, 2008).
Cognitive Therapy. Cognitive Therapy (CT) is a system of strategies and techniques
based in the theory that processing information is very important in survival (Beck & Weishaar,
2014). The main systems involved are: (a) cognitive, (b) behavioural, (c) affective, and (d)
motivational. Each of these systems are made up schemas. Cognitive Schemas are what people
think of: (a) themselves, (b) others, (c) their goals, (d) their expectations, (e) their memories, (f)
their fantasies, and (g) their previous learning. CT views disorders as a result of certain schemas,
or biases, when incorporating new information into their lives. There are underlying core
beliefs, known as cognitive vulnerabilities, which contribute to the development of these
schemas. Previously, CT theorists saw cognitive schemas as causative of changes in other
systems. Current CT theorists conceptualize all the previously mentioned systems as functioning
together and impacting each other; this is known as a mode.
Exposure Therapy versus Cognitive Therapy. Ougrin (2011) conducted a meta-analysis
comparing Cognitive Therapy (CT) and Exposure therapy (ET) for treating anxiety disorders.
Articles chosen were randomized controlled studies comparing the efficacy of CBT and ET for
treating Posttraumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), Panic
Disorder (PD), and Social Phobia (SP). These 20 articles were gathered from Psych INFO,
EMBASE, and MEDLINE and included articles from first date available to May 2010. Most
interesting to the current study, Ougrin found a statistically significant difference between
treatments for SP. CT was more effective than ET in both short term outcomes (Z = 3.72, p =
0.0002) and long-term outcomes (Z = 3.28, p = 0.001). Considering the application of trauma

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informed research and practice in the current study, the results about PTSD outcomes are also
worth noting. There were no significant differences between treatment outcomes for PTSD. A
correction to this meta-analysis was published by Ebrahim and Bance (2012) finding some
statistical errors in Ougrin’s analysis. These authors found a medium effect size for treatment of
SP with CT and a modest effect size for ET. Cohen’s d criteria used for assessment of effect
sizes were: a) 0.2 is a small effect, b) 0.5 is a medium effect, and c) 0.8 is a large effect.
Ebrahim and Bance concluded, however, that their assessment did not greatly change the main
interpretation of Ougrin’s work.
Cognitive Behaviour Therapy. Cognitive therapy is often used in conjunction with
behaviour therapy in work with anxiety, thus leading to the new umbrella title Cognitive
Behaviour Therapy (CBT). CBT uses strategies to help the client become aware of his or her
behaviours, reactions, and thoughts. The focus is upon changing problematic thinking and
behaviour patterns (Sheldon, 2011). Psychoeducation is used to help clients become aware of
why their specific issues occur and to help them understand how CBT works. The importance of
psychoeducation is to draw clients’ awareness to how their thoughts, behaviours, and emotions
interact (Friedberg & McClure, 2002). Skill building may be used to help the client identify their
unhelpful cognitions and learn to challenge those cognitions to make more positive and accurate
assessments in their everyday lives (Miller, Short, Garland, & Clark, 2010). Relaxation training
is often implemented to help individuals cope with peaks in anxiety (or other symptoms; Barrett,
Lowry-Webster, & Turner, 2000). CBT is also used with exposure therapy to help clients face
their anxieties (Craske & Barlow, 2007). This combination of cognitive and behavioural
interventions is intended to help clients learn to manage their thoughts and behaviours, so they
gain more stability and control over their emotions.

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CBT is usually a short-term treatment for 10-12 sessions. Because of the short-term nature
of the treatment, clients often leave therapy with residual symptoms (Sheldon, 2011). Clients are
able to take the tools and techniques learned in therapy into their real life activities. The goal of
CBT is to help the client learn techniques to manage their own treatment and therapeutic work
after they leave formal therapy. CBT can be done via individual or group therapy sessions.
Cognitive Behaviour Group Therapy meta-analysis. Wersbe, Sijbrandij, and Cuijpers
(2013) conducted the first meta-analysis to assess the effectiveness of Cognitive Behaviour
Group Therapy (CBGT) on Social Anxiety Disorder (SAD). Eleven studies were gathered from
PubMed, Cochrane, PsychINFO, and Embase. Every one of these studies were randomized
controlled studies in which the participants were diagnosed with SAD and given CBGT in
comparison to a control group. The authors suggest the overall quality of these studies was
moderate. The effect size resulting from the meta-analysis suggested a 0.53 (95% COI: 0.330.73) difference between the CBGT and control conditions in favour of CBGT. The CBGT
condition showed a moderate, yet significant, effect in the treatment of SAD in the meta analysis
even though individual studies had effect sizes ranging from 0 (no effect size) to 1 (a large effect
size). The authors reported that heterogeneity of values ranged between low and moderately
high within all the analyses. The authors suggest future research be done comparing these group
therapies for SAD to control conditions.
Mindfulness- and Acceptance-Based interventions. Mindfulness and Acceptance, while
two different concepts, are often used together. Mindfulness came from Buddhist tradition while
acceptance came from Christian teachings (Brown, 1987). The definitions and theories of these
concepts are useful to understand more about how these two concepts work individually and can
be integrated together in psychotherapy.

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Being mindful involves self-regulating your attention to the experiences of the present
moment in a non-judgemental, accepting way (Bishop et al., 2004). A well known definition of
mindfulness is “the awareness that emerges through paying attention on purpose, in the present
moment, and non-judgementally to the unfolding of experience moment to moment” (KabatZinn, 2003, p. 145). Mindfulness involves three main aspects (Shapiro et al., 2006): a) intention,
which is a curiosity into what values motivate the practice of mindfulness; b) attention, actively
noticing the experiences of the present moment; and c) attitude, which is how one pays attention
to the present moment. The main attitudes which should be applied during the attention process
are: (a) patience, (b) non-judging, (c) openness, (d) non-striving, (e) trust, (f) acceptance, and (g)
“letting go” (Kabat-Zinn, 1990). The Buddhist practice of mindfulness also emphasizes
gentleness, loving-kindness, curiosity, and non-reactivity. Mindfulness has the potential to help
regulate stress by calming various physiological systems, by allowing a greater connectedness
between the mind and body (Schwartz, 1984, 1990). This connection can increase the ability for
self-regulation and the ability to restore order to physiological systems, which will improve
emotional and physical well being. A mindful way of interacting with the present helps prevent
in-the-moment concern over future and past.
Acceptance is considered a way to reach spiritual freedom, by using acceptance to deal
with the struggles intrinsic to human life (Brown, 1987). The practice of acceptance allows you
to become present and open, to let go of the struggle with painful internal experiences (Brach,
2004). It is worth noting this does not mean one should stay in destructive situations but, rather,
by becoming aware of these situations, one can become more capable of leaving such situations
(Follette & Hazlett-Stevens, 2016). Acceptance may help clients to deal with what they may
become aware of during mindfulness.

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Mindfulness Based Interventions: A meta-analysis. A meta-analysis was conducted on
the effectiveness of mindfulness-based interventions (MBIs) for treatment of diagnosed Anxiety
or Depression (Strauss, Cavanagh, Oliver, & Pettman, 2014). The authors conducted this metaanalysis because they questioned whether standard MBI practices would be of benefit to those
who have symptoms meeting diagnostic criteria. Their main four concerns were that: (a)
attending to current thoughts and feelings with acceptance may be difficult for those with anxiety
(Eaves & Rush, 1984; Strauss, Cavanagh, Oliver, & Pettman, 2014); (b) attending to thoughts
and feelings without perseverating on them could be difficult because of the tendency to
perseverate on anxious thoughts and feelings (Barnhofer & Crane, 2009; Borkovec, Alcaine, &
Behar, 2004; Borkovec & Roemer, 1995; McLaughlin & Hoeksema, 2011; Mogg, Bradley, &
Williams, 1995; Muris, Roelofs, Rassin, Franken, & Mayer, 2005; Nolen-Hoeksema, 2000); (c)
the concentration and motivational difficulties usually experienced by those struggling with
anxiety may make mindfulness a difficult state to achieve (Barnhofer et al. 2009; Eysenck,
Derakshan, Santos, & Calvo, 2007; Haslam, Atkinson, Brown, & Haslam, 2005); (d) brief
therapy, as is usually the case for MBI, may not be sufficient for treating anxiety. This meta
analysis was conducted to discern whether or not the authors’ concerns were supported.
Twelve studies on MBIs for anxiety or depression were included with a sample size of 578
participants. The best effects were seen for depressive symptoms but not for anxiety symptoms.
There was not statistically significant improvement for those with confirmed anxiety disorders or
for anxiety symptoms from the full-range of studies. The authors suggest professionals be
careful when using MBIs for clients with anxiety disorders where anxiety symptoms are the
target.
Mindfullness- and Acceptance-Based interventions: Meta-analysis. Vollestad, Nielsen,

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and Nielsen (2012) conducted a systematic review and meta-analysis into studies using
mindfulness- and acceptance-based interventions (MABIs) for participants with Panic Disorder
(PD), Social Anxiety Disorder (SAD), and Generalized Anxiety Disorder (GAD). They found
19 eligible studies and conducted a meta-analysis of within-group pre- to post-treatment effects.
Their results had Hedges’ g effect sizes of 1.08 and 0.85 for anxiety and depression symptoms,
respectively. They went further to assess the controlled studies which yielded a Hedges’ g of
0.83 for anxiety symptoms and 0.72 for depression symptoms. They assessed and found no
significant moderating effects for things such as intervention type, design, treatment dosage, or
patient. The authors did note, however, that differing effect sizes warrant adding specific types
of psychotherapeutic interventions to mindfulness training. They also found individual therapy
to be more advantageous than group therapy. They conclude that MABIs are effective at
reducing anxiety symptoms and the associated depressive symptoms.
A more recent study was conducted looking at mindulness- and acceptance-based
treatments (MABTs) for Social Anxiety Disorder (SAD) specifically (Norton, Abbott, Norberg,
& Hunt, 2014). The authors conducted a systematic review of 9 studies assessing MABTs for
SAD in PsychoInfo, Medline, PubMed, and Cochrane Central Register of Controlled Trials. The
authors of this review found significant improvements in symptoms as a result of treatment with
MABTs but the benefits were equal to, or less than, the benefits from Cognitive Behavioural
Therapy (CBT). The authors of this review note that some of the studies had methodological
weaknesses and risks of bias, while others were uncontrolled or had small sample sizes. While
there are indications that MABTs can reduce SAD symptoms, the outcomes should be accepted
and applied with caution until future research can be done.

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Trauma Informed Treatment for Social Anxiety Disorder
Thus far, the treatments reviewed in this chapter have included (a) cognitive, (b)
behavioural, (c) current physiological calming, and (d) acceptance based aspects of SAD. At
first glance this seems like a thorough approach to treatment. There are, however, still aspects
which may not be addressed by those treatments.
Erwin et al. (2006) studied responses to very stressful social situations, of 45 participants
with Social Anxiety Disorder (SAD). Those individuals had experiences which did not meet the
criteria for posttraumatic stress disorder (PTSD) according to the DSM-IV. The researchers
were particularly interested in the occurrence of symptoms usually associated with PTSD, such
as the frequency of avoidance, re-experiencing, and hyperarousal. Such responses were found to
be very common. Over one third of the sample would be diagnosed with PTSD if their traumatic
events had met the criteria in the DSM-IV. A total of 94% of those participants reported that
their symptoms had occurred for more than 3 months. Results of studies have shown that social
interaction and public speaking are often associated with elevated systolic blood pressure
(Turner, Beidel, & Larkin, 1986) and increased heart rate (Ost, Jerremalm, & Johansson, 1981)
but Erwin et al. (2006) suggested that hyperarousal symptoms, such as those for PTSD Criterion
D (irritability, sleep difficulties, hypervigilance, concentration difficulties, and exaggerated
startle response) were the more extensive, and potentially impairing, symptoms. The authors
explained the combination of emotional and cognitive avoidance responses to memories of these
socially traumatic events. Results of this study suggest that memories of these past traumatic
events impacted those with SAD as much as current or anticipated future performances or social
situations. The vividness of these social memories suggests that they are pervasive, even though
they are in the past, much like other traumatic memories. As a result, the authors suggest that

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treatments for PTSD should be used to treat SAD. They endorse cognitive-behavioural and
exposure treatments, but question whether these treatments can access all aspects of fear
memories.
Wild et al. (2008) did a study to check the effectiveness of re-scripting early memories of
unpleasant social experiences. This was an early study (n = 11), with two sessions given a week
apart. The first, a control session, involved discussion of participants’ memories and images
without modification. The next was an experimental session, with cognitive restructuring and an
imagery re-scripting procedure intended to update and conceptualize memories. No changes
were found for the control session but the experimental session caused improvements in: (a)
negative beliefs; (b) fears of negative evaluation; (c) levels of image/memory distress and
vividness; and (d) social anxiety. The authors suggested that re-scripting these unpleasant social
memories (associated with negative self-images) could help in the treatment of social phobias.
The results of these studies reveal how SAD can have symptoms similar to those associated with
trauma, and suggest that treatment of those social traumas could be treated successfully with
trauma therapies.
These traumatic ties to anxiety bring a fundamental psychological concept to mind; this
concept is transference. Transference is described as the “experience of impulses, feelings,
fantasies, attitudes, and defenses with respect to a person in the present which do not
appropriately fit that person but are a repetition of responses originating in regard to significant
persons of early childhood, unconsciously displaced onto persons in the present” (Greenson &
Wexler, 1969, p. 28). These transference experiences can cause substantial difficulty in
interpersonal relationships (Wolitzky, 2011). Since past experiences can trigger negative
transference reactions, individuals with public speaking anxiety may experience such

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transference reactions with those listening to them speak (i.e., audience members).
A study by Wieser, Pauli, Reicherts, and Mühlberger (2010) assessed neurological activity
in anticipation of a public speech. The researchers found larger N170 amplitudes on
electroencephalogram assessments when participants saw angry faces, and smaller N170
amplitudes when they saw happy or neutral faces. They used early posterior negativity to check
for motivated attention, and found motivated attention to be higher when participants viewed
angry faces as opposed to happy or neutral faces for those in a public speaking group. They
concluded that public speaking fears can change the way participants process faces, particularly
angry faces. This heightened negative response to angry faces could be an aspect of transference
associated with disturbing past experiences.
Each of these studies contributes possible extensions beyond standard anxiety research
protocols, including (a) broader traumatic criteria, (b) processing of past traumatic social
experiences, and (c) negative transference reactions. These ties to traumatic antecedents of
anxiety constitute reasons to consider current treatments for trauma and their potential for
helping those who struggle with performance-specific SAD.
Current Trauma Treatments
A trauma informed approach to treating SAD requires examination of current trauma
treatment efficacy. Many treatments are used to treat trauma but few are especially designed to
work with the underlying sources of traumatic symptoms. Some of these treatments are: (a)
Exposure Therapies, (b) EMDR, (c) CBT, and (d) Present-Centered Therapies (PCT). The
following literature reviews are meta-analyses of the aforementioned treatments for treating
trauma. The first is a review of a complex study comparing trauma treatments to the other types
of treatments. Next is a meta-analysis of Trauma Focused Exposure Therapy followed by a

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meta-analysis examining the effectiveness of EMDR. Each of these reviews will provide more
context for the current treatments for trauma.
Comparison of treatments used to treat trauma. Tran and Gregor (2016) conducted a
meta-analysis comparing several bona fide psychotherapies for treatment of Post-Traumatic
Stress Disorder (PTSD). The authors defined “bona fide” treatments as those which met the
following criteria: (a) administered by a trained therapist who considered the therapeutic
relationship when adjusting the treatment, (b) administered face-to-face, and (c) satisfying
criteria provided by the author, as follows. Treatment descriptions in each study needed to meet
two of four set criteria: (a) references to the theoretical approach used, (b) description of
psychological processes, (c) references to treatment manuals, and (d) descriptions and references
to the active ingredients of the treatments. The authors conducted this analysis because previous
analyses had suggested Exposure Therapies (ET), Cognitive Behaviour Therapies (CBT), trauma
focused Cognitive Behavioural Therpaies (TFCBT), and Eye Movement Desensitization
Reprocessing (EMDR), are of similar effectiveness while non-trauma focused therapies (i.e.
hypnotherapy, psychodynamic therapy, or supportive therapy) showed inconsistent results (1121). Eligibility criteria included: (a) randomized controlled trials (RCTs), (b) comparisons of at
least two bona fide therapies, (c) treatments doses lasting at least two sessions, (d) adult
participants, (e) PTSD diagnoses based on the DSM criteria at the time of each study (DSM-III
and DSM-IV for the studies included), and (f) severity of the symptoms assessed with either a
clinical rating or self-report. They found 22 randomized control trials with a total of 1,694
patients.
Treatments included in this study included: (a) Exposure Therapies, (b) Prolonged
Exposure, (c) combined Exposure and Prolonged Exposure Therapies, (d) EMDR, (e) CBT, and

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(f) Present-Centered Therapies (PCT). The PCT interventions included such treatments as
Rogerian client centered work like (a) present-centered, (b) psychoeducative, and (c) problem
solving. CBT clinicians were permitted to use, but not to depend on, certain techniques from
other therapies. Treatments were coded as (a) trauma-focused (TF), or (b) not-trauma-focused
(NTF). TF treatment were required to focus specifically on traumatic event memories and
subsequent appraisals.
Results of the studies were analyzed to see which therapies were most efficacious for
treatment of PTSD. Treatments showed similar results in clinical significance and dropout rates.
The treatments which focused on trauma did show greater efficacy than those which were NTF
but this result did not quite reach significance (p = .095). The TF treatments did appear more
effective when working with PTSD symptom severity at post-treatment, and at first and second
follow-ups. Similar efficacy was found for (a) exposure therapies, (b) prolonged exposure, (c)
CBT, and (d) TFCBT. The authors did note, however, that these results could be due to low
quality studies being included in the analysis. When they excluded the studies which seemed to
be a low quality the prolonged exposure and exposure therapies showed an advantage in
treatment of PTSD symptoms at the post-treatment assessment. The results showed that PCTs
were slightly less helpful for PTSD symptom severity at the post-treatment and follow-up
assessments. These results showed that many of these bona fide treatments had similar efficacy
but, when studies with a questionable quality were removed, exposure and prolonged exposure
had a stronger impact on PTSD symptoms.
Trauma focused Exposure Therapy. Modern technology has provided new ways to treat
Post-Traumatic Stress Disorder (PTSD). Of these new technological resources, Virtual Reality
has become very applicable to exposure therapy. Some meta-analyses have compared the use of

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traditional exposure therapy and virtual reality exposure therapy. The following review is a
meta-analysis to address this comparison.
DiMauro (2014) conducted a meta-analysis which compared the effectiveness of traditional
cognitive-behaviour-based exposure therapy versus virtual reality exposure therapy (VRET) for
treatment of PTSD. In this meta-analysis, the authors compared pre- and post-treatment effect
sizes and interactions across 26 articles. Article inclusion criteria included: (a) aged at least 18
years and diagnosed with PTSD, (b) standardized diagnostic measures (e.g., ClinicianAdministered PTSD Scale, Symptom Scale-Interview, or Posttraumatic Diagnostic Scale), (c)
treatments provided face-to-face (rather than online or over the phone), and (d) distinct treatment
groups. Articles were selected from PsychArticles and Psychinfo. The first set of articles
included 15 articles on traditional therapies for PTSD and were found using key words of “Posttraumatic Stress Disorder,” “Posttraumatic Stress Disorder,” or “PTSD,” paired with the words
“exposure therapy,” “In Vivo exposure,” “prolonged exposure,” “imagined exposure,” and
“flooding.” The second set of 6 articles was regarding VRET. Search words included
“Posttraumatic Stress Disorder,” “Post-traumatic Stress Disorder,” or “PTSD” along with
“Virtual Reality.” The results were insignificant, though showing a trend towards significance (p
< .05), with findings supporting traditional exposure therapy over VRET. The authors suggest
that a larger database of studies may have rendered significant results.
Eye Movement Desensitization and Reprocessing. Davidson and Parker (2001)
conducted a meta-analysis comparing Eye Movement Desensitization and Reprocessing
(EMDR) with other therapies. The researchers collected 34 studies from various databases over
select years: (a) Medline and PsychINFO from 1988 to April 2000; and (b) Current Contents
from 1997 to March 2000. Keywords used in these searches were EMDR and eye movement

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desensitization and reprocessing. The focus of this meta-analysis was to compare participants
across conditions: (a) participants treated with EMDR; (b) participants treated with treatments
other than EMRR; and (c) participants who did not receive treatment. They broke these
conditions down into seven categories with the first being a within-subjects comparison between
pre-post EMDR assessment scores. The remaining six categories compared EMDR to: (a) no
treatment, (b) Cognitive Behaviour Therapy or in vivo exposure, (c) exposure (without in vivo),
(d) eyes fixed desensitization reprocessing (EFixDR, in which the eye moment aspect of EMDR
is left out of the EMDR treatment protocol), and (e) other dismantling designs (OthDism, when
the EMDR protocol was used with the omission of one specific aspect while eye movement was
used), (f) nonspecific treatments (e.g., biofeedback, active listening, applied relaxation, but no
therapies in which anxiety provoking stimuli were presented). The results of analysis showed
EMDR was effective when: (a) post-treatment EMDR group assessment results were compared
to pre-treatment EMDR group (within-participant comparisons), and (b) when EMDR posttreatment measure was compared with untreated controls. EMDR was not, however, shown to
be more effective than exposure therapies, EFixDR, or OthDism. This meta-analysis suggests:
(a) EMDR is effective in treating trauma but that the exact protocol may be unnecessary; and (b)
EMDR may not be more effective than other uses of exposure.
Alternative Treatments Used in This Study
Two treatments with different approaches were used in this study to treat performancespecific SAD. The first treatment, Observed and Experiential Integration, addressed the
underlying traumatic experiences of SAD, borrowing from a variety of theories to develop a
holistic approach. The second treatment was a grounding and relaxation protocol, known as
BRAIN, which addressed immediate coping with trauma symptoms present in performance-

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specific SAD. The logic for using these two types of treatments was to compare the treatment of
underlying trauma (trauma-root-focused treatment) with the treatment of current trauma
symptoms (symptom-focused treatment).
OEI and BRAIN were chosen for this study because they work with the neurobiological
correlates of anxiety and trauma found in the fight-and-flight response (Porges, 2007). As seen
in this literature review, many types of treatment used for anxiety interact with this group of
symptoms as behavioural or cognitive, which does not necessary draw upon the insights from
trauma therapy. OEI and BRAIN interact with deeper level emotional responses and therefore
work with the body’s natural response to fear (activated by the limbic system) instead of trying to
work against the natural fear response. A cognitive or behavioural approach is more likely to try
to override the natural fear response by struggling to regain cognitive control (reengaging the
cortex of the brain) without calming the limbic system. OEI and BRAIN engage with the the
client based on what their brain is doing in the moment and allow for dissipation of the fear
response so the cortex is emotionally safe to reengage.
See Appendix B for a diagram of how the polyvagal theory of fear response occurs and to
Appendix C and Appendix D to see how OEI and BRAIN interact with this fear response. It is
worth noting that it is very hard to act in a cognitive way after the ventral vagal break is off and
even harder once the freeze response has occurred. It is even difficult to use the BRAIN
techniques after the freeze response has occurred but there are several OEI techniques which can
still be applied at that point. These diagrams show how these different techniques are able to
engage with the various stages of fear response.
Observed and Experiential Integration
In the previous sections, mainstream treatments for public speaking anxiety were

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reviewed. In contrast, this section constitutes a theoretical and technical review of a treatment
that has never before been used to treat performance-specific SAD in a formal study. Observed
and Experiential Integration (OEI) was selected as one of the two treatments used in this study
because it has been shown to reduce trauma-related anxiety symptoms (Bradshaw, McDonald,
Grace, Detwiler, & Austin, 2014). In light of those research findings, it was postulated that OEI
would also help to process posttraumatic aspects of social anxieties, as mentioned previously
(Erwin et al., 2006; Wild et al., 2008). OEI has been used in hundreds of thousands of hours of
clinical practice over a period of 21 years (R. A. Bradshaw, personal communication, June 15,
2015). Within these hours, OEI has been used to successfully treat public speaking anxiety,
usually in 1-3 sessions. To follow up these promising clinical observations, this study constitutes
the first formal investigation of OEI to treat performance-specific SAD, using short term
treatment (7 sessions). In this section, the theoretical background and development of OEI are
outlined. In addition, OEI techniques are reviewed, along with studies in which OEI has been
used as a trauma treatment.
Theoretical background. OEI is a theoretically integrated treatment. Gold and Stricker
(2006) described several types of integration: (a) Assimilative Integration, (b) Technical
Eclecticism, (c) Common Factors, and (d) Theoretical Integration. In this section readers will
also learn how each of these types of integration was used in the development of OEI.
Furthermore, Bradshaw has compiled a description of OEI through other theoretical
lenses. The main theoretical lenses he has summarized are combinations of
Behavioural/Neurobiological and Psychoanalytic/Psychodynamic. Many treatments are
presented through their own theoretical lenses with little regard to what they are missing from
other ways of approaching the presenting problem. In this summary, Bradshaw explains how

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OEI addresses many of the mechanisms of change described by Behavioural, Neurobiological,
Psychoanalytic, and Psychodynamic theorists. OEI encompasses most of the mechanisms
inherent in therapies discussed earlier in this document. This summary can be seen in Appendix
E.
Assimilative integration. At the heart of OEI is Experiential Psychotherapy (Bradshaw et
al., 2011). This aspect is closely related to Accelerated Experiential Dynamic Psychotherapy
(Fosha, 2002). The Therapist is constantly tuning into clients’ expressions on a second-bysecond basis, while giving them directives according to OEI theory. The client is also practicing
Focusing (Gendlin, 1984), by paying attention to slight affective and somatic states and shifts,
while following the therapist’s directions. Focusing is at the foundation of OEI, from an
experiential perspective.
Relational Psychoanalytic Therapy is then applied, as each therapist interacts with microlevel expressions of clients, which are contingent on eye movements and facial expressions
clients have during treatment. This micro-level process is combined with empathic reflections
from therapists, across sessions. As these comments coincide with experiences of clients, each
therapist is able to join with his or her client and build relationships of understanding (Bradshaw
et al., 2011).
Negative reactions to the faces of therapists were noted during the development of OEI
Switching (i.e., alternate left and right monocular covering). This reaction constitutes negative
transference. Distortions clear as clients “switch” (Bradshaw et al., 2011).
There are some similarities in the neurobiological aspects of OEI and Schiffer’s Dual Brain
Psychology (Schiffer, 1998). He noticed differences in emotional states when light was blocked
from both eyes with the exception of the right or left lateral visual fields. He described these

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shifts as either “irrational” (similar to the id) or “rational” (similar to the ego). Similarly, OEI
involves alternate monocular covering. This technique, in combination with several others
described in the OEI Techniques section of this document, “neurologically activates, dissipates,
and shifts perceptions through repeated applications” (Bradshaw et al., 2011, p. 111).
Technical eclecticism. Some techniques were integrated without adoption of underlying
theories. One of these techniques, guided eye movements and bilateral stimulation (both
auditory and tactile) resulted in Glitch Massaging techniques (Bradshaw et al., 2011). Another
technique borrowed without theoretical acceptance is ‘lazy eights’ from Educational Kinesiology
(Brain Gym; Dennison & Dennison, 1986, 1994). This technique was adapted, to become the
OEI technique known as “Sweeping”, which is only used for resolving somatic symptoms such
as drowsiness, headaches, tingling, dizziness, numbing, and visual disturbances (Bradshaw et al.,
2011). A third technique involves use of a balance board, to help counteract loss of balance
associated with dissociation, by providing instant feedback to clients that they are “tuning out”.
Common factors approach. Common factors across many effective psychotherapies are
incorporated into OEI, which contribute to the effectiveness of this treatment. These include:
empathic attunement, insight, self-awareness, and hope. The most important of these factors is
empathic attunement. In agreement with Greenberg (2008), OEI therapists believe the use of
emotion is also very important. OEI involves use of empirically-supported, emotion-focused
change processes. All five of Greenberg’s principles of change in the affective domain are
incorporated in OEI: “Increasing emotional awareness, facilitating emotional expression,
improving emotion regulation, promoting greater reflection on emotion, and transforming
emotion with the activation or presentation of alternate emotion(s)” (Bradshaw et al., 2011, p.
115).

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Theoretical integration. When a trauma response is triggered, blood flow to the left
dorsolateral prefrontal cortex is reduced, causing difficulty in coherent and clear speech (Rauch
et al., 1996). Other symptoms of trauma, such as dissociative experiences, panic attacks, and
flashbacks, are not accessed easily through words because they emanate from subcortical areas
of the brain (limbic and paralimbic regions; see van der Kolk, 2002). Along with these
neurobiological principles, other theoretical mechanisms have been included in OEI to address
neurobiological and behavioural aspects of clients’ experiences.
Neuro-activation and microattunement during trauma processing. During OEI
treatment, mirror neurons are activated in therapists and they experience the emotions of their
clients to a limited extent (known as “embodied simulation”). Gallese, Eagle, and Migone
(2007) suggest that this experience helps clients to see their emotions in the faces of their
therapists and, in turn, to “experience the modulation and containment of such states” (p. 160).
If therapists notice and comment on the slightest movements in the eyes and facial expressions of
clients while they are experiencing emotional changes, those clients will feel more connected
with their therapists. This attunement helps each client develop secure attachment with his or her
therapist.
Classical Conditioning of sensory, emotional, and cognitive responses. Classical
conditioning can occur with sensory stimuli such as sights, smells, somatic sensations, tastes, and
sounds to amygdalar and hypothalamic-pituitary-adrenal (HPA) axis activation (van der Kolk,
2001; Yehuda, 1997, 2002). People are triggered by both external discriminative stimuli, and
internal cues like racing heartbeat, shortness of breath, and lightheadedness caused by
amygdaloid arousal (Barlow, Allen, & Basden, 2007). OEI does not rely exclusively (or even
primarily) on exposure to extinction. Treatment involves having clients use the OEI technique of

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Switching, during which they expose the eye associated with the most somatoaffective intensity
to light, for one to five seconds (to as short a duration as half a second in extremely intense
cases). By these means, intensity can be dissipated by Switching (alternately covering the eyes).
Neuro-activation and microattunement (NAMA) are considered the primary processes of change
in OEI (Bradshaw et al., 2014).
Incorporation of polyvagal theory. All three levels of human response (according to
polyvagal theory; Porges, 2007) are addressed in OEI (Bradshaw et al., 2011). According to this
theory, humans respond in a hierarchy of three levels of neurobiological activation. The top
level (referred to as “Social Engagement”) involves the ventral vagal complex when it is not
adrenalized (i.e., when the “brake” is “on”). In this state, the larynx, pharynx, bronchi, lungs,
esophagus, and heart) are relaxed. The next level of response involves activation of the
sympathetic branch of the autonomic nervous system (also known as the “fight or flight”
response). When the ventral vagal “brake” is “off”, these structures are adrenalized. Finally, in
the third level of response, if the “fight or flight” response cannot sufficiently dissipate a threat,
the Dorsal Vagal Complex (“freeze” response) is activated. This involves organs below the
diaphragm (e.g., stomach and intestines) but also restricts bronchi, lungs, and airway, and slows
the heart. This final response is often triggered by hypoxia or perceived lack of oxygen.
Porges (2007) describes implications of polyvagal theory for psychotherapy. This theory
is relevant for clinical practice with OEI. He posits that, in order to shift clients from defensive
responses (e.g., dorsal vagal and ventral vagal “brake off” states) back to the relaxed state of
social engagement (ventral vagal, “brake on”), the nervous system must (a) assess risk, and (b)
inhibit primal limbic system structures which manage fight, flight, and freeze behaviours. In
individuals with extensive histories of psychological trauma (abuse and neglect), threat is over-

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generalized. By this means, their neuroception (unconscious assessment of safety or threat) is
distorted. During the neuroception process, feature detectors within the temporal cortex are
activated (which recognize familiar faces, voices, and hand movements). Depending on these
assessments, limbic activity is either enhanced (threat) or suppressed (safety). In most cases, the
nervous system is able to evaluate risk (neuroception) and causes appropriate neurophysiological
responses for the context. Safe situations result in relaxed limbic structures, allowing calm states
and social engagement. If, however, the environment is mismatched with nervous system
appraisals, individuals may engage in fight, flight, or freeze responses, making social
engagement and communication extremely difficult. There are OEI techniques to address all
three levels postulated in polyvagal theory, and distorted perceptions can be corrected with OEI.
Coactivation of sympathetic and parasympathetic responses, and tonic immobility.
Rothschild (2006) recognized polyvagal theory but suggested that the “freeze” response
triggered during trauma processing was more likely due to coactivation of sympathetic and
parasympathetic branches of the autonomic nervous system. She posited that coactivation could
explain why some clients experience hyperarousal and numbing at the same time. OEI treatment
permits clients to achieve release from such states, not only in sessions but between sessions.
Ocular proprioception, multisensory memory, and stimulated psychophysiological
schemas. Intricate information about the movements and locations of the eyes, relaxation or
constriction of the intraocular muscles, and positions of the eyelids is sent to the brain by large
numbers of proprioceptive neutrons in extra- and intra-ocular muscles (Batini, Buisseret,
Lasserre, & Toupet, 1985; Donaldson, 2000; Dutton, 2003). Specialized ocular muscle
components (“multiply innervated muscle fibers”) have palisade endings, implying they employ
proprioception to control slow, gradual movements and contractions (Buttner-Ennever, 2006,

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2008). The Glitch Massage technique in OEI involves noting the types and speeds of eye
responses (Bradshaw et al., 2011). There are several intra-ocular muscles: those which control
the thickness and curvature of the lenses, and those which dilate and constrict the pupils
(Buttner-Ennever, 2006, 2008). The last group of muscles involved are the extra-ocular muscles
which move the eyelids, known as levator palpebrae superioris. All of these muscles and
neurons work together to make movement-related associations.
According to OEI theory, specific movement patterns and distances (of objects) from the
eyes, and resultant eye movement and lens focusing, can become classically conditioned to
specific amygdalar states and HPA axis arousal (Bradshaw et al., 2011). Specific eye positions
can be accessed while clients relive (i.e., somatoaffectively recall) events with which they are
associated. This can be done intentionally, using multisensory imaginal visualization. By
guiding a client’s eye(s) into and through points which have been conditioned to traumatic
events, symptoms of intensity or numbing can be dissolved. Often, simply having a client cover
his or her dominant eye can reduce intensity (or at least change the emotion) and this difference
is profound and observable enough to engage the client in the process.
Observed and Experiential Integration techniques. In this section the five main
techniques of OEI will be described (Bradshaw et al., 2011). The main techniques are: (a)
Switching, (b) Tracking and Massaging glitches, (c) Sweeping, (d) Glitch Holding with Bilateral
Stimulation, and (e) Release Points.
Switching. Switching involves alternate monocular covering of the left and right eyes
while thinking of distressing memories or disturbing symptoms. This technique can be used for
(a) titrating intensity associated with traumas, (b) reducing dissociative artefacts (e.g., loss of
balance, dizziness, drowsiness, visual distortions, or headaches), and (c) detecting and resolving

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negative transference reactions.
Tracking for glitches and Glitch Massaging. While tracking for glitches, clients think
about traumatic memories or disturbing symptoms and track a stimulus (such as a therapist’s
fingers) across one or both visual fields. When hesitations, blinking, or skipping (i.e., “glitches”)
are seen in eye movements, the therapist “massages” them by guiding one or both eyes back and
forth or toward and away from the eyes until they move smoothly and emotions are dissipated.
Sweeping. The Sweeping technique is a combination of Switching and Tracking, used to
reduce dissociative artefacts (headaches, visual distortions or occlusions, drowsiness, etc.).
Glitch Holding with Bilateral Stimulation. Glitch Holding with Bilateral Stimulation is
useful for resolving “visual splitting” (i.e., when one eye seems focused on a stimulus while the
other “wanders”). The therapist holds the client’s eyes in the “glitch” (usually in the upper
visual fields) while the client engages in rapid alternate tapping of his or her left and right
shoulders.
Release points. Knowing that there was a “most intense point” in the “most intense” eye
(i.e., a glitch in the dominant eye), Bradshaw looked for (and found) the “least intense point” in
the “least intense” (non-dominant) eye: a “peaceful spot” in the non-dominant visual field.
These points have now been identified, and are used to help release core trauma symptoms such
as throat constriction, nausea, and bronchoconstriction.
Observed and Experiential Integration research. Bradshaw et al. (2017) completed an
18-month randomized clinical trial with 25 female sexual assault survivors who had developed
posttraumatic stress disorder (PTSD). Three treatments were used: (a) Cognitive Processing
Therapy (CPT-R), a therapy involving cognitive restructuring and behavioural exposure; (b)
OEI; and (c) a control treatment comprised of calming and grounding techniques, known by the

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acronym BRAIN (Breathing, Relaxation, Autogenics, Imagery, and grouNding). Several types
of measurements were used at pre-treatment, post-treatment, 3-month follow-up, 6-month
follow-up and final time periods: (a) quantitative, (b) qualitative, and (c) psychophysiological
assessments. Assessors were blind to group assignments (treatment conditions), and participants
were randomly assigned to one of the three groups. All three groups showed significant
reductions in PTSD symptom severity between pre-treatment and post-treatment assessments.
Significant differences between the groups were found at the 3-month follow-up, at which time,
OEI was more effective than BRAIN. All groups showed increases in PTSD symptoms at the 6month follow-up, likely a result of having no treatment for 6 months, other than calming and
grounding techniques. There was then a cross-over for a second round of treatments. Once
again, significant improvements were found equally among the groups. At the final assessment,
75% of the participants reported that OEI was most effective for reducing their PTSD symptoms.
In addition, many participants reported that CPT was helpful for reducing self-blame, shame, and
guilt. The authors surmised that OEI was at least as helpful as CPT, and that all three treatments
were effective for treating PTSD symptoms.
Bradshaw, McDonald, Grace, Detwiler, and Austin (2014) conducted a pilot study
comparing OEI to a delayed treatment control. The Clinician-Administered PTSD Scale (CAPS)
and the Impact of Event Scale-Revised (IES-R) were used as dependent measures. Script-driven
symptom provocation was used to activate symptoms for assessment purposes. Ten participants
diagnosed with PTSD (3 male, 7 female) received three 1-hour sessions of OEI “Switching”.
Participants in the OEI treatment group showed greater improvement than those in the control
group in terms of reduction of PTSD symptoms. The delayed treatment group later received the
same treatment. Nine of the ten participants no longer met the criteria for PTSD at the end of the

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study. This RCT portion of this study was later supplemented by a qualitative 2-year follow up.
The follow-up included 8 of the 10 original participants and all participants reported that OEI
treatment was important in their paths to recovery. Several participants clearly described details
of how OEI helped their individual recoveries.
BRAIN
BRAIN (Breathing, Relaxation, Autogenics, Imagery, and grouNding) was the alternative
treatment used in this study because relaxation techniques have been found to be helpful for
coping with trauma symptoms (Taylor et al., 2003), even though previous research findings have
not indicated major impact of relaxation techniques on SAD with the performance only specifier
(Alstrom et al., 1984; Wolpe, 1995). Much of the research on relaxation and PSA did not
involve either mindfulness or grounding techniques. BRAIN protocol was chosen to represent
relaxation and grounding treatments because this collection of techniques is particularly robust
and has been found to be effective for reducing posttraumatic stress symptoms (Bradshaw et al.,
2017). The range of procedures included in BRAIN address both physiological and cognitive
aspects of psychological trauma.
BRAIN techniques. Descriptions of the main techniques in the BRAIN protocol are
provided in the following sections. The techniques (which are represented by the acronym
BRAIN) are: Breathing, Relaxation, Autogenics, Imagery, and grouNding.
Diaphragmatic breathing. “Belly breathing” shifts respiration out of the chest to the
diaphragm and the abdominal muscles, thereby deepening and lengthening the breath. This
prevents hyperventilation, shortness of breath, breath-holding, and fainting. Participants are
instructed to: (a) place one hand on their abdomens and the other on their chests, (b) close their
eyes and breath in through their noses, and (c) notice how much more their abdominal hands rise

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than their chest hands. Participants do this for 5-10 minutes at a time. “Sighing” when exhaling
increases relaxation. Self-statements such as “Breath in relaxation” and “Breath out tension”
while inhaling and exhaling facilitate deeper states of relaxation. The diaphragm creates a
vacuum in the lungs, pulling in more oxygen than thoracic breathing that involves raising the
shoulders and expanding the ribcage.
Progressive muscular relaxation. Muscle tension increases in response to traumatic
experiences. Such tension can be triggered situationally or remain more constant. Increased
awareness of the difference between relaxed and tense muscles helps participants recognize
when they are becoming distressed and need to apply relaxation techniques. Progressive
muscular relaxation involves guiding participants through major muscle groups, requiring them
to tense muscles for 5-7 seconds, and then release the tension for 20-30 seconds (only the
relaxation component is used once participants can differentiate tense from relaxed muscles.
Major muscle groups include: (a) hands, forearms, and biceps; (b) head, face, throat, and
shoulders; (c) chest, stomach, and lower back; and (d) thighs, buttocks, calves, and feet. These
techniques require practice to consistently reduce muscle tension, and pair relaxation with
exhalation.
Autogenics. This set of mental suggestions helps participants relax their bodies, by
activating the parasympathetic division of the autonomic nervous system (ANS). The ANS
controls smooth muscles, which include internal organs, arteries, veins, and capillaries. The
sympathetic branch of the ANS becomes more active after traumatic experiences, to maintain
vigilance (i.e., the “fight or flight” response). Autogenics activates the opposite branch (i.e., the
parasympathetic or “relaxation” division) of the ANS.
Autogenics involve slow, relaxed, respiratory-synchronized self-talk. The five statements

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are: (a) “My breathing is deep and slow”, (b) “My heartbeat is slow and regular”, (c) “My hands
and arms are warm and heavy”, (d) “My feet and legs are warm and heavy”, and (e) “My
forehead is cool and dry”. This self-talk activates vasodilation (i.e., expansion of blood vessels),
in the extremities, making hands, arms, feet, and legs feel warm and heavy.
Imagery. Positive multisensory moving imagery helps participants to replace distressing
images in their minds with calming pictures. This involves vividly recalling relaxing, safe
places, usually in nature (e.g., a tropical beach, garden, lake, river, forest, mountain, or country
road). Many find it helpful to imagine protection around the setting to keep it safe (e.g., high
rock cliffs, a patrolling lion, a large Plexiglas dome, etc.). Such imagery is combined with
abdominal breathing, progressive muscular relaxation, and autogenics. Typical prompts include
statements that encourage participants to engage their sensory memories, such as: (a) “Notice
what you see…”; (b) “What do you hear…”, (c) “Pay attention to what you feel in your body…”,
(d) “Become aware of what you smell…”, and (e) “Imagine your favourite taste…”. The easiest
combination of techniques to practice together is imagery with autogenics: “As each wave rolls
in on the shore, it is perfectly timed with your breathing (exhaling). The sun warms your hands
and arms, feet and legs; Your hands and arms are so warm, and so heavy. There is a gentle
breeze with a beautiful fragrance, blowing over your forehead and through your hair; Your
forehead is cool and dry…”
Grounding. Grounding helps to reconnect participants to their immediate experiences
(rather than regretting the past or fearing the future). Those with past traumas often focus on
past concerns, and worries about the future. The goal of grounding is to help clients be more inthe-moment. This practice should be applied several times a day. There are several ways to
increase grounding, described in the following paragraphs. These techniques include: (a) sensate

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focus, (b) Cook’s Hookups, and (c) Cross Crawl.
Sensate focus. During this exercise, participants become more aware of their senses.
Focusing on them, one at a time, increases their ability to therapeutically dissociate from anxietyinducing past or future events. These exercises should be done for 12-15 minutes a day to allow
sufficient time for participants to tune in to their bodies, one sense at a time.
Hearing – Participants are guided to focus on sounds in the room. They may be
encouraged to close their eyes or look down at the floor, and focus only on what they hear. The
goal is to note what is happening in the moment and not worry about the future or the past.
Seeing – Participants are guided to notice what they can see around the room (or in
nature, if they are outside). The instruction is to find and focus upon colours, objects, pictures,
or people that are most comforting.
Touching – Participants are encouraged to touch different textures near to where they are
sitting or standing, to draw their attention to the current moment. Noticing the comfort of a chair
cushion, the coolness of a metal table, or the firmness of the ground can provide distraction at the
least, and comfort (fur, feathers, fabric) at best.
Tasting – Most participants find that this sense is helpful for distracting them from states
of distress. Carrying and using gum, favourite candies, or snacks when anxious, facilitates
therapeutic dissociation. Participants are instructed to take several minutes to notice various
aspects of taste and texture, to draw their attention away from distressing thoughts or emotions.
Smelling – This sense is closely associated with emotions due to the anatomical
proximity of the olfactory bulbs (projecting back from the nose) to the left and right amygdalae
(in the limbic system, within the midbrain). This is why smells facilitate immediate recall of
emotions (both negative “triggers”, and positive “reminders”). Participants are encouraged to

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take note of what smells prompt calm, peaceful, or positively energizing emotions. Typically,
scented oils come in four broad categories: florals, woods, spices, and citrus fragrances.
Cook’s Hookups. The left brain hemisphere controls the right side of the body, and the
right brain hemisphere controls the left side of the body. This fact is the basis for two additional
grounding techniques that are included in the BRAIN protocol. A left-right imbalance in
affective arousal can causes numb (“stuck”) or aroused (“stirred up”) states. These exercises
involve crossing the arms and legs. In Cooks Hookups, participants are instructed to sit in chairs
with their legs crossed (one perpendicular to the other, resting the top leg across the lower thigh
of the other one). At the same time, they are instructed to cross their arms just above the wrist
(and rest their hands on the top leg at mid-calf).
Cross-crawl. Participants are instructed to touch their left hands (or elbows) to their right
calves (or knees), and then repeat the process on the other side, while standing or sitting (lifting
knees when standing). This facilitates hemispheric integration, and tactile reconnection to the
present moment. When participants dissociate they lose connections to body awareness in space,
losing their balance. During cross-crawl, participants are forced to stay connected while
balancing on one leg at a time (alternating sides). In addition, the elements of touch and sound
that occur when hands contact legs facilitate in-the-moment body awareness.
Relaxation Treatment research. Taylor et al. (2003) conducted a study comparing
Exposure Therapy, Eye Movement Desensitization and Reprocessing (EMDR), and Relaxation
Treatment to treat posttraumatic stress disorder (PTSD). These treatments resulted in similar
outcomes in terms of: (a) symptom reduction, (b) symptom severity, and (c) impact on
hyperarousal or numbing symptoms. Relaxation and Exposure therapies showed stronger results
than EMDR as evidenced by: (a) larger reductions in re-experiencing and avoidance, (b) faster

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improvements, and (c) greater numbers of participants who no longer met the diagnostic criteria
for PTSD. In addition, in a study of women with PTSD as a result of sexual assault(s),
Bradshaw et al. (2017) reported that administration of the BRAIN protocol resulted in equivalent
reductions in PTSD symptoms to OEI and Cognitive Processing Therapy (CPT-R) from Pre- to
Post-Treatment assessments (although results for BRAIN faded by the 3-month follow-up, while
results for OEI and CPT-R were not only sustained but improved). In light of these positive
findings regarding application of BRAIN (or other Relaxation Skill Treatment) protocol, this
collection of techniques was chosen as the alternative treatment for the present study. It was
hoped that the BRAIN protocol would reduce SAD social trauma symptoms as well.
Summary
Performance-specific SAD is very common and can disrupt the desired futures of those
who struggle with this specific phobia. Many treatments have been used but few of those treat
psychophysiological hyperarousal caused by past traumatic social experiences. The treatments
applied in this study address the commonly missed aspect of trauma in anxiety. BRAIN focuses
on the surface trauma symptoms and OEI addresses the root of the trauma. Using a trauma-rootfocused treatment along side a trauma-symptom-focused treatment provided information on how
such different trauma treatments impact social anxiety.
Rationale
The purpose of this study is to see what type of measurements show changes in
performance-specific SAD symptoms as a result of trauma based treatments. Several types of
treatment are regularly used to treat SAD but these may well neglect the potential traumatic root
of the disorder. Two types of trauma treatments were chosen for this study: (a) OEI, to treat the
traumatic root of the anxiety; and (b) BRAIN, to treat the traumatic symptoms of the anxiety.

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Different dimensions of assessment are required to understand the full impact of trauma
treatments on the trauma based symptoms of performance-specific SAD. The dimensions of
assessment chosen for this study were based on the (a) emotional, (b) behavioural, and (c)
psychophysiological symptoms of SAD. The three measurement categories selected were: (a)
self report, (b) behavioural, and (c) psychophysiological. Results of this study provided
information about the utility of these measures to assess traumatic symptom changes due to
trauma treatment for performance-specific SAD.
Research Questions
The purpose of this project was to develop innovative assessment protocols for clinical
research on performance-specific SAD. The initial step was to conduct an investigation of OEI
(a trauma-root-focused therapy) and BRAIN (a trauma-symptom-focused therapy) on
performance-specific SAD. This was a pilot test to explore the assessment and treatment
protocols as they related to specificity and sensitivity of measures. The purpose of this study
leads to the following questions:
1) Which groups of measures (self-report, behavioural, or psychophysiological) display
large effect sizes in response to treatment (sensitivity)?
2) Which group of measures show sensitivity across time?
3) Which groups of measures (self-report, behavioural, or psychophysiological) display
different patterns of effect when compared between the treatment groups (specificity)?
These research questions will allow for evaluation of the research protocols used in this
project. The viability of these research protocols can be further demonstrated in future research,
in which hypotheses associated with specific clinical interventions are explored.

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CHATPER 3: METHODS
Participants
There were 9 participants in this pilot study. Original recruitment resulted in 14
participants but 4 dropped out for personal reasons early in the study (2 before treatment started
and 2 shortly after treatments started). This left 10 participants, one of whom fell well behind in
her treatment schedule, as a result of family relocations associated with contract work, and
eventually was withdrawn from the study. Effect size results for potential confounding
background factors were small when compared to the effect sizes of the observed treatment
effects. The background variables examined to explore comparability of groups were: sex,
gender, age, ethnicity, culture, religious affiliation, level of education, and occupation. The form
used to gather background information can be seen in Appendix F. The pattern of background
factors cannot be described for each participant without compromising the anonymity of
participants but a general description of the participants included in this study is as follows: (a)
six cisgender females and three cisgender males; (b) six participants were Caucasian, two were
East Indian, and one identified as biracial; (c) one participant completed grade 10, one
participant had completed high-school/GED, three participants had some post-secondary
education, and four participants had some level of graduate education.
A small sample size allows for detailed examination of key features of this clinical
research protocol. While a small sample does not provide statistical power, this pilot study
design allows for descriptive examination for selection of treatments and measures for future
research. Physiological assessment frequently involves small sample sizes due to response
demands on participants and intensive demands on research team members.

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Instruments
Measures were used at (a) Intake, (b) Pre-Treatment, and (c) Post-Treatment stages of the
study. Measures used to screen participants at Intake will be described first, followed by
instruments used at Pre- and Post-Treatment stages. Finally, Supplementary measures used to
monitor participant anxiety and depression will be described. Together, this collection of
assessments provides a rich database for each participant.
Intake assessments. Intake measures were chosen to screen for participant suitability.
Since the study involved only short term treatment (7 sessions), participants were assessed for
severe and comorbid disorders. Applicants were chosen for the study if their intake assessment
scores did not reflect comorbid disorders, or conditions more severe than performance-specific
SAD. Short term treatment was considered more appropriate for less severe conditions. Intake
was also used to determine whether or not self-reported PSA was present sufficiently to justify
entrance to the study. Measures used at intake included: (a) Severity Measure for Social Anxiety
Disorder (Social Phobia) – Adult; (b) Severity Measure for Generalized Anxiety Disorder –
Adult; (c) Severity of Posttraumatic Stress Symptoms – Adult; (d) Beck Depression Inventory II;
(e) Dissociative Experiences Scale; and (f) Personal Report of Confidence as a Speaker. These
assessments and their cut-off points are described in the following section.
Severity Measure for Social Anxiety Disorder (SMSAD; Social Phobia) - Adult. This
measure consists of 10 items to assess (screen for) severity of social anxiety (phobia) in adults,
over the previous 7 days (American Psychiatric Association, 2015a). The measure was designed
for screening and follow up (i.e., to assess the status of previously-diagnosed social anxiety).
Items involve ratings on 5-point scales, with: (a) 0 = never, (b) 1 = occasionally, (c) 2 = half of
the time, (d) 3 = most of the time, and (e) all of the time. Scores can range from 0 to 40: Higher

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scores reflect more severe social anxiety. The total score is then reduced to an average item
score by dividing the raw total score by the number of items. This allows severity to be
expressed on a 5-point scale: (a) 0 = none, (b) 1 = mild, (c) 2 = moderate, (d) 3 = severe, or (e) 4
= extreme. During DSM-5 field trials these measures were found to be reliable. The total score
is not calculated if 3 or more items are not answered. If only 1 or 2 items are unanswered a
prorated score is calculated, dividing the total score by the number of items answered. The
Cronbach alpha coefficient was used to assess internal consistency. In the current study, the
Cronbach alpha coefficient for this measure was .90.
To be included in this study participants needed to score below a 2. If they scored 2 or
higher, their file was reviewed by Dr. Richard Bradshaw (a registered psychologist with 35 years
of experience) to decide whether results of the full battery of assessments indicated that
applicants would be good candidates for the study.
Severity Measure for Generalized Anxiety Disorder (SMGAD) - Adult. This measure
consisted of 10 items to assess severity of Generalized Anxiety Disorder (GAD) in adults during
the previous 7 days (American Psychiatric Association, 2015b). Like the Social Anxiety
screening measure described above, this instrument was designed for screening and follow up
(i.e., to assess the status of GAD symptoms before and after clinical treatment).
Items constitute 5-point scales, with: (a) 0 = never, (b) 1 = occasionally, (c) 2 = half of
the time, (d) 3 = most of the time, or (e) all of the time (American Psychiatric Association,
2015a). Scores can range from 0 to 40: Higher scores reflecting more severe generalized
anxiety. The total score is then reduced to an average item score by dividing the raw total score
by the number of items. This allows severity to be expressed on a 5-point scale as: (a) 0 = none,
(b) 1 = mild, (c) 2 = moderate, (d) 3 = severe, or (e) 4 = extreme. This instrument was found to

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be reliable in DSM-5 field trials. Total score should not be calculated if 3 or more items are not
answered. If only 1 or 2 items are unanswered a prorated score is calculated by dividing the total
score by the number of items which were answered. Cronbach’s alpha coefficient was used to
assess internal consistency in the current study, resulting in a coefficient of .73.
To be included in this study participants needed to score below 2. If they scored 2 or
higher, their file was reviewed by Dr. Bradshaw to decide whether results of the full battery of
measures indicated they constituted good candidates for the study.
Severity Measure for Posttraumatic Stress Symptoms (SMPSS-A) – Adult. This
measure consists of 9 items to assess for the severity of Posttraumatic Stress in adults during the
previous 7 days (American Psychiatric Association, 2015c). Like the Social Anxiety and
General Anxiety measures described above, this was designed for screening and follow up (i.e.,
to assess the status of PTSD symptoms before and after clinical treatment).
Items constitute 5-point scales, with: (a) 0 = not at all, (b) 1 = a little bit, (c) 2 =
moderately, (d) 3 = quite a bit, or (e) extremely (American Psychiatric Association, 2015c).
Total scores can range from 0 to 36: Higher scores indicating greater severity of Posttraumatic
Stress. The total score is then reduced to an average item score by dividing the raw total score
by the number of items. This allows severity to be expressed on a 5-point scale as: (a) 0 = none,
(b) 1 = mild, (c) 2 = moderate, (d) 3 = severe, or (e) 4 = extreme. This measure was found to be
reliable in DSM-5 field trials. The total score should not be calculated if 3 or more items are not
answered. If only 1 or 2 items are unanswered a prorated score can be calculated by dividing the
total score by the number of items which were answered. Cronbach’s alpha coefficient was used
to assess internal consistency and in the current study, this coefficient was .79.

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To be included in this study participants needed to score below 2. If they scored 2 or
higher, their file was reviewed by Dr. Bradshaw to decide whether results of the full battery of
measures showed them to be good candidates for the study.
Beck Depression Inventory II. Due to high rates of comorbidity between anxiety and
depression (Beck, Steer, & Brown, 1996) the Beck Depression Inventory II (BDI-II) was used to
screen for respondents with high levels of depression (or suicidal risk). Those with moderate or
high scores (levels of depression) on the BDI-II were not included in the study. Referrals to
counselling services were available for those who may have been at risk of suicide (assessment
as outlined in the BDI manual; no candidates were found to be suicidal) and for respondents who
reported “moderate” (or higher) depressive symptoms on the BDI-II.
The BDI-II is comprised of 21 items, which respondents ranked on 0-3 scales (Beck et
al., 1996). Ordinal scale interpretations are: (a) 0 = no more than usual, (b) 1 = more than usual,
(c) 2 = much more than usual, or (d) 3 = all the time. A total score of: (a) 0-9 is considered
“minimal” depression, (b) 10-19 is considered “mild” depression, (c) 20-29 is considered
“moderate depression, and (d) 30-63 is considered “severe”. While these scores suggest levels
of depression, it is important to note that the BDI-II is not a diagnostic tool, but rather a reference
point for the current experience of depressed mood. A clinical assessment by a qualified mental
health professional is required for diagnoses such as Major Depressive Disorder.
The BDI-II has strong psychometric properties. Coefficient alpha for the BDI-II was .92
for 500 outpatients and .93 for 120 college students (Beck et al., 1996). Test-retest reliability
was assessed in a sample of 26 outpatients between first and second therapy sessions one week
apart. The test-retest correlation coefficient was .93. Convergent and discriminant validity for
the BDI-II has also been assessed. Convergent validity is shown in a positive correlation (r =

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.37, p < .001) between the BDI-II and the Scale for Suicide Ideation (SSI; Beck, Kovacs, &
Weissman, 1979) and between the BDI-II and the Beck Hopelessness Scale (BHS; Beck & Steer,
1988; r = .68). Both of these measures were shown to positively correlate with depression
(Beck, Epstein, Brown, & Steer, 1988; Beck & Steer, 1988). In comparison to the Hamilton
Rating Scale for Depression (HRSD) and the Hamilton Rating Scale for Anxiety (HRSA), the
BDI correlates more highly with the HRSD (r = .71) than the HRSA (r = .47; Hamilton, 1959;
Riskind, Beck, Brown, & Steer, 1987). Together, these findings support the reliability and
validity of the BDI-II. Cronbach’s alpha coefficient was used to assess internal consistency. In
the current study, Cronbach alpha coefficients were: (a) .87 at Intake, (b) .86 at Pre-Treatment,
and (c) .84 at Post-Treatment.
To be included in this study participants needed BDI-II scores less than 19. If they
scored 19 or higher, their file was reviewed by Dr. Bradshaw to decide whether results of the full
battery of assessments showed them to be good candidates for the study.
Dissociative Experiences Scale (DES). This measure was used to assesses dissociative
experiences of respondents by instructing them to rate percentages of time (0%-100%) they
experienced various dissociative symptoms, on visual analogue scales (cross hatches on lines;
Appendix G; Carlson & Putman, 1993, 2015). All item percentages are added together and
divided by the number of items (28). Although there are no clear diagnostic cut-offs, scores
between 19.2 and 30 may be associated with borderline personality disorder, acute PTSD, or
severe anxiety disorders. Scores greater than 36 suggest some form of Dissociative Disorder,
and scores greater than 48 warrant further testing for Dissociative Identity Disorder (DID).
Actual levels of dissociation can be much higher than indicated by the results of this assessment,
because some respondents lack self-awareness regarding their own dissociation. Cronbach’s

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alpha coefficient was used to assess internal consistency in the current study, and the coefficient
was .82.
To be included in this study, participants needed DES scores less than 30. If they scored
30 or higher, their file was reviewed by Dr. Bradshaw to decide whether results of the full
battery of measures showed them to be good candidates for the study. See Appendix G for item
content and layout for this instrument.
Personal Report of Confidence as a Speaker (PRCS). To be included in this study,
participants had to score higher than 15 on this measure. A cut-off of 16 was chosen because
this was the point used for determining the clinical sample reported by Paul (1966) during
development of a shortened form of this instrument, although other researchers have used
different cut-off scores (Gatchel, Hatch, Maynard, Turns, & Taunton-Blackwood, 1979; Jones,
Philips, & Rieger, 1995). The original PRCS consisted of 104 items (Gilkinson, 1942) but was
shortened by Paul (1966) due to difficulty using the instrument for screening. The shortened
PRCS consists of 30 questions related to feelings of confidence as a speaker during respondent’s
most recent public speaking experiences. Items are answered true or false (Appendix H).
Higher scores indicate greater severity of PSA.
Paul (1966) had two normative groups: (a) a clinical sample, and (b) a non-clinical
sample. The clinical sample had 98 subjects, and resulted in a mean score of 20.6 with a
standard deviation of 3.31. The mean and standard deviation for the non-clinical sample (n =
523) were 11.6 and 5.9, respectively. Philips, Jones, Rieger, and Snell (1997) conducted a study
to develop norms for the PRCS with 1109 college students. They considered: (a) age, (b) gender
(697 women, 412 men), (c) race (752 Caucasians, 316 African Americans, and 41 other races),
and (c) academic grades, in the evaluation of the PRCS scores. They found no main or

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interaction effects for age, gender, or race. The mean score was 14.24 and the standard deviation
was 7.76. These findings suggest that age, race, and gender do not significantly affect levels of
public speaking anxiety using the PRCS.
Daly (1978) found high internal consistency (Cronbach’s alpha = .91) and positive
correlations between the PRCS and other speech and social anxiety measures (r = .52 to .97).
From a behavioural perspective, Tarico, van Velzen, and Altmaier (1986) found that poor speech
performance was associated with higher scores on the PRCS. Cronbach’s alpha coefficient was
used to assess internal consistency in the current study, and the coefficients were: (a) .81 at
Intake, (b) .81 at Pre-Treatment, and (c) .92 at Post-Treatment.
Dependent Variable Measures
In this section, measures used to assess dependent variables are described (some of which
were described in the previous section). Assessment types used in this study included: (a) selfreport measures, (b) psychophysiological assessments, and (c) behavioural analyses.
The rationale for using all three types of evaluation (self-report, psychophysiological, and
behavioural) arises from research findings suggesting that subjective accounts of emotional
experiences alone are not as reliable, complete, or accurate as multimodal assessments which
include physiological measures (Orr & Roth, 2000). Davidson (1998), in agreement with Orr
and Roth (2000), went on to say that it is crucially important that both subjective and objective
measures be included in future studies, to build stronger evidence for assessment validity. Lang
(1988) listed three main ways to measure emotional experiences: (a) overt reactions, (b) selfreport, and (c) physiological changes. Since many symptoms of public speaking anxiety are
associated with physiological arousal such as sweating, shaking, or dizziness (Calamaras et al.,

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2014), it seemed logical to include physiological measures. In light of the research findings and
arguments mentioned, all three types of assessment were included in this study.
Self-report. Three self-report measures were used to asses both broad and narrow
spectrum symptoms. Broad versus narrow categorization is decided based on how closely the
given symptoms are clustered to the core presenting issue (performance-specific SAD). Broad
spectrum symptoms assessed were general Anxiety and Depression. The narrow spectrum
symptom was confidence as a speaker. These assessments are described in the following
sections.
Personal Report of Confidence as a Speaker. The assessment used to monitor selfreported levels of speaker confidence was the Personal Report of Confidence as a Speaker (Paul,
1966). This was the same assessment used during the intake process, and described under Intake
Assessments, above (view instrument in Appendix H).
Beck Depression Inventory II (BDI-II). The assessment used to monitor self-reported
levels of depressive symptoms was the Beck Depression Inventory II (Beck, Steer, & Brown,
1996). This was the same assessment used during the intake process, and described under Intake
Assessments, above.
Beck Anxiety Inventory (BAI). As mentioned, this measure was used to monitor anxiety
in participants at each assessment time to determine whether outside treatment was warranted
due to severity of symptoms. The BAI consists of 21 items describing symptoms of anxiety
(Beck & Steer, 1993). These symptoms are rated on 4-point scales from 0 to 3, as follows: (a) 0
= “not at all,” (b) 1 = “mildly; it did not bother me much,” (c) 2 = “moderately; it was very
unpleasant, but I could stand it,” (d) 3 = “severely; I could barely stand it”. Symptoms listed are
“Numbness and tingling,” “Wobbliness in legs,” “Feeling hot,” “Unable to relax,” “Dizzy or

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lightheaded,” “Fear of the worst happening,” “Heart pounding or racing,” “Terrified,”
“Unsteady,” Feelings of choking,” “Nervous,” “Hands trembling,” “Fear of losing control,”
“Shaky,” “Difficulty breathing,” “Scared,” “Fear of dying,” “Indigestion or discomfort in
abdomen,” “Face flush,” “Faint,” and “Sweating (not because of heat).”
This self-administered test takes 10 minutes to complete. Total score ratings are: (a) 0-7
= minimal anxiety, (b) 8-15 = mild anxiety, (c) 16-25 = moderate anxiety, or (d) 26-63 = severe
anxiety. Reliability of the BAI has been examined in several studies. Beck et al. (1988) found
high internal consistency with a Cronbach alpha coefficient of .92. Fydrich et al. (1990) found
an even higher alpha coefficient of .94 for internal consistency reliability. Test-retest reliability
was assessed with a subsample of 83 outpatients (Beck et al., 1988) tested one week apart,
resulting in a correlation of .75.
Several types of validity have been explored for the BAI. The content of the BAI
matches the outline for diagnosing patients with anxiety disorders (specifically, panic and
generalized anxiety disorders). Much like other anxiety scales (Gotlib & Cane, 1989), the BAI
has also been found to have moderate correlations with depression scales, such as the Beck
Depression Inventory (r = .50, p < .001; Fydrich et al., 1990) and the Hamilton Psychiatric
Rating Scale for Depression - Revised (r = .25, p < .05; Hamilton, 1960). The BAI is not
significantly correlated with the Beck Hopelessness Scale (Beck & Steer, 1988) which measures
negative attitudes regarding the future. These type of symptoms are more related to depression
and less with anxiety (Beck, 1967, 1976; Beck & Emery, 1985). Cronbach’s alpha coefficient
was used to assess internal consistency and, in the current study, the coefficients were .57 at PreTreatment and .72 at Post-Treatment.

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Behavioural assessment.
Timed Behavioural Checklist (TBC). This measure was used to assess performance
aspects of PSA. This checklist was adapted in several ways. Clevenger and King (1961)
developed this measure, although the length of the checklist made it difficult to use for clinical
work (i.e., outside of research studies). The instrument was shortened by Paul (1966), and
further amended by Henry (2003). The initial pool of items for the present study was drawn
from Henry’s list of 20 behavioural displays of public speaking anxiety, which are assessed in
30-second intervals over the first two minutes of a speech task. Two additional symptoms were
added to the checklist (see items 21 and 22 in Appendix K). Immediately prior to this study, all
22 categories were examined using pilot speech samples. Collection and analysis of pilot data
was done to: (a) select categories which were a better fit for this application, and (b) identify a
small number of behavioural observation categories that could be most reliably assessed, to
clarify and focus the procedure. These analyses yielded five items with high inter-rater
reliability and clinical utility. Items which were retained are 3, 5, 7, 20, and 22. Criteria that
were considered when determining item utility were: (a) patterns of inter-rater agreement, (b)
likelihood of the behaviours being observable in video recordings of speeches, and (c) ease of
use by observers (raters). Each rater’s total counts of the five behaviours for all intervals were
averaged across two raters to achieve a total TBC for each speech task.
Psychophysiological assessments. Many symptoms of PSA are associated with
activation of the limbic system (Calamaras, Anderson, Tannenbaum, & Zimand, 2014), as
described in polyvagal theory (Porges, 2007). In this study, limbic system activation was
assessed via Electrodermal Activity (EDA) measurement. In the following paragraphs,

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rationales and procedures for using EDA to measure limbic system activation assessments are
outlined.
Script Driven Symptom Provocation (SDSP). This assessment procedure is based on
bioinformational theory, in which it is suggested that the brain stores traumatic memories which,
in turn, cause psychophysiological responses. Personal meanings and emotional reactions
behind traumatic stimuli can be intentionally triggered (Lang, Levin, Miller, & Kozak, 1983;
Levin, Cook, & Lang, 1982). Though often applied in laboratory studies of PTSD for veterans
(Pitman et al., 1987; Pitman, Orr, Forgue, Altman, de Jong, & Herz, 1990) SDSP has been
applied in studies of anxiety disorders (Levin et al., 1982; Pitman et al., 1990). More recently,
SDSP has been applied to study: (a) emotional and cognitive activity associated with PTSD
before and after OEI Switching (Grace, 2003), (b) psychobiology and psychopharmacology of
PTSD (van der Kolk, 2001), and (c) positron emission tomography following childhood sexual
abuse-based PTSD (Shin et al., 1999).
SDSP was used to ensure consistency in measurement of anxiety over time. The
procedure started by having participants summarize their most intense emotional and physical
reactions associated with PSA using a standardized procedure (van der Kolk, Hopper, &
Osterman, 2001) and reporting form (Traumatic Scene Form; Hopper & van der Kolk, 2001).
Next, individualized scripts were created and recorded (50-60 second audio files) for each
participant. Finally, these recordings were played for participants during certain EDA
assessments, to assess the impact of triggering prior to, and following, treatment. The Traumatic
Scene form, which participants completed for individualized script creation, can be seen in
Appendix I. Participants’ reactions to their scripts were measured via EDA assessments.

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According to polyvagal theory (Porges, 2007), limbic system structures are activated in
response to stressful stimuli. EDA changes as limbic system activity increases during the “fight
or flight” response (Schwartz & Andrasik, 2003). A pattern of EDA when recorded scripts were
played for participants provided information about their reactions to PSA-related traumatic
events. EDA has been shown to be a sensitive measurement of sympathetic nervous system
arousal in response to mental stress, including arousal associated with recollection of upsetting
events (Neumann & Blanton, 1970). Galvanic Skin Response (GSR, now known as
Electrodermal Activity, or EDA) is extremely sensitive to transitory emotions and mental events
(Schwartz & Andrasik, 2003). Brown (1974) found EDA to be more responsive to mental events
than either Electromyography (electrical activity from muscle movement or tension) or
Thermography (measurement of skin temperature; Neumann & Blanton, 1970). The protocol for
EDA assessments can be seen in Appendix J.
The palm of the hand contains up to 2000 sweat glands in every square centimeter
(Schwartz & Andrasik, 2003). When these glands are activated, they can each send microelectrical signals along pathways between the deeper, more conductive layers of skin and the
skin surface. Skin conductance can be measured by applying two electrodes to the skin to
monitor sweat gland activity. When voltage is applied, a circuit is formed and an electric current
will flow. Resistance of the skin is dependent on the number of glands that are open. Such
resistance will affect the magnitude of the current (according to Ohm’s law).
Because EDA is associated with arousal, flat or low response patterns are not adaptive for
humans (Schwartz & Andrasik, 2003). Persistent minimal arousal, inattentiveness, and flattened
affect are neither healthy nor adaptive. There are times when minimal arousal is beneficial, such
as during relaxation, but there are also times when greater stimulation should occur. An example

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of a time when increased arousal is beneficial is when one is confronted with a novel stimulus:
One needs to be able to recognize and respond to stimuli appropriately. Once an individual has
oriented to a stimulus, arousal should return to a baseline level. People sometimes react to
stimuli in an overly-sensitive manner (i.e., out of proportion to the threat of the stimulus). Such
overreactions require more energy, which results in increased physical tension. In light of these
findings, the goal of treatment in this study is to optimize EDA levels in participants, reducing
over-reactive responses to public speaking.
Cronbach’s alpha coefficient was used to assess internal consistency. Calculations were
run using the 3 EDA baseline activities (see Appendix J). In the current study, Cronbach’s alpha
coefficients were .92 at Pre-Treatment and .99 at Post-Treatment.
Procedure
Recruitment. Recruitment was done on a small scale for this initial pilot study through
several methods, including: (a) word of mouth through representatives of a Department of
Counselling Psychology and through local Toastmasters leaders, (b) a series of three community
presentations, and (c) posters throughout the Greater Vancouver and Fraser Valley regions of
British Columbia. The poster can be seen in Appendix L. The most successful form of
recruitment was word of mouth in the community, followed by the presentations.
Intake. The intake process consisted of informed consent and several self-report
assessments to determine whether respondents fit the criteria described in the Intake Assessment
portion of this document. This session began with the informed consent process. Each
participant was provided with (a) a document describing the study, and (b) a discussion of both
the treatments and assessments in the study. The informed consent document can be seen in

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Appendix M. Participants signed the document if they were interested in entering the study.
After informed consent was complete, intake assessments commenced.
The order in which the assessments were given was: (a) Personal Report of Confidence as
a Speaker (Paul, 1966), (b) Severity Measure for Social Anxiety Disorder (Social Phobia) –
Adult (American Psychiatric Association, 2015b), (c) Severity Measure for Generalized Anxiety
Disorder – Adult (American Psychiatric Association, 2015a), (d) Severity of Posttraumatic Stress
Symptoms – Adult (American Psychiatric Association, 2015c), (e) Beck Depression Inventory II
(BDI-II) (Beck et al., 1996), and (f) Dissociative Experiences Scale (Carlson & Putman, 2015).
These assessments were used together to determine whether each individual would be a good fit
for the study. If participants met criteria for inclusion in the study, they completed the Traumatic
Scene Form (see Appendix I) which would later be used for Script Driven Symptom Provocation
assessment. Those who did not meet the criteria were referred to other community counselling
services.
Pre-Treatment and Post-Treatment assessments. There were two parts to each
assessment, and both parts were administered at Pre- and Post-Treatment evaluations.
Part one. The first part of each evaluation began with self-report instruments, and
proceeded to baseline EDA assessments.
Self-report. Participants were given three self-report instruments to complete. These
included: (a) BDI-II, (b) BAI, and (c) Severity of Posttraumatic Stress Symptoms – Adult (SPSSA) during which participants were asked to consider a socially traumatic (typically, a public
speaking) situation. The BAI and BDI were given according to the manualized instructions. The
SPSS-A was given according to manualized instructions except that the event listed for the
traumatic experience did not need to satisfy “Criterion A” for Posttraumatic Stress Disorder

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according to the Diagnostic and Statistical Manual of Mental Disorders (DSM; American
Psychiatric Association, 2013). Instead, a social criterion was used. Participants were prompted
to think of socially traumatic events with the following prompt: “Was there a time you felt hurt
in a group setting in one (or more) of the following ways: (a) Feeling rejected & criticized, (b)
Feeling humiliated & embarrassed, or (c) Feeling deceived & betrayed?” After choosing their
stressful experience participants were asked to write a sentence describing the situation, and to
indicate the approximate date when the experience occurred. They then completed the SPSS-A
according to manualized instructions. Results of analyses of this assessment are not reported in
the present report. After these self-report measures were completed, participants were escorted
to the psychophysiological laboratory where the next phase of the assessment would occur.
Baseline psychophysiological assessment. The next phase of the assessment involved a
baseline EDA assessment at locations E1 and E2 (see Appendix N; Scheirer, Picard, Tilbury, &
Farringdon, 2002). It should be noted that EEG data were collected at the same time, but were
not included in this thesis. The protocol for the baseline EDA assessment can be found in
Appendix J.
Part two. The second part of each evaluation consisted of three components. The first
involved Script Driven Symptom Provocation (SDSP) with EDA measurements, followed by
behavioural assessment during a speech task, and finally, a brief self-report (PRCS).
Script driven symptom provocation with psychophysiological assessment. This
psychophysiological measurement involved assessment at the same two EDA locations as the
baseline. After a brief (1 minute) baseline, the audio recording of the individualized trauma
script played for the participant and their EDA reactions were recorded. This 1-minute trauma

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script time was followed by a final minute of assessment time with no further trauma stimuli.
The protocol for this assessment can be seen in Appendix J.
Behavioural assessment. The Timed Behavioural Checklist (TBC) was used to assess
behavioural aspects of public speaking anxiety. The assessment consisted of video-recording
five consecutive 30-second periods (during a 3-minute speech task) for later analysis of
behavioural measures of public speaking anxiety. These behaviors were coded from video
recordings by two trained observers (trained and assessed together to maximize consistency of
measurement). Total TBC scores incorporated reports averaged across observers, resulting in
more objective measurements of PSA.
Participants were asked to stand at the front of a classroom and present 3-minute
speeches on alphabetical topics provided to the two observers. The topic for the Pre-Treatment
assessment had to start with the letter “P”. The topic for the Post-Treatment assessment had to
start with the letter “C”. The full TBC can be found in Appendix K.
Self-report. The final phase of the assessment was to complete the PCRS. This
assessment was administered immediately after the speech task, so that participants would be
rating their levels of confidence during a very recent speech.
Treatment. There were two treatments used in the study. The first treatment was
Observed and Experiential Integration (OEI; a trauma-root-focused treatment) and the alternative
treatment was Breathing, Relaxation, Autogenics, Imagery, and grounding (BRAIN; a traumasymptom-focused treatment). OEI will be described first. Finally, results of the Credibility of
Treatment Questionnaire will be reported, which was used to determine whether participants’
expectations, or perceptions, of effectiveness for each treatment likely affected their treatment
outcomes.

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Observed and Experiential Integration (OEI)
Information session. The information session for OEI involved a PowerPoint
presentation and a video demonstration of Dr. Bradshaw using OEI to treat public speaking
anxiety. Information presented in the PowerPoint presentation can be seen in Appendix O. A
homework sheet for OEI was also provided, to help participants remember techniques they could
use at home between sessions. This handout can be seen in Appendix P.
Treatment. Those in the OEI Group received seven 1-hour session of OEI treatment (at
the times outlined in the design, presented in Figure 1). Treatments were conducted by Level II
certified OEI clinicians. There were two female Masters-level counselors and one male
Doctoral-level psychologist. The psychologist had over 35 years of clinical experience and codeveloped OEI. The psychologist led the OEI psychoeducational sessions for all participants.
One of the Masters-level clinicians had over 12 years of experience. The other Masters-level
clinician had over three years of experience. Treatment included all five OEI treatment
techniques: Switching, Sweeping, Glitch Massaging, Release Points, and Glitch Holding with
Bilateral Stimulation (Bradshaw et al., 2011). Each session started with discussion of elements
of public speaking that provoked the most negative intensity (subjective anxiety) in each
participant. Such intensity could include: anger, fear, shame, sadness, and/or somatic
experiences. Multisensory expansion with imagery was used to help participants identify, and
connect with, their anxiety. Once each participant had a target (or event) clearly in his/her mind
associated with somatoemotional intensity, the therapist would begin applying the OEI
Switching technique. The therapist then tracked through the participant’s visual field(s) using
either (a) typical Glitch Tracking (based on therapist observation) or “Track-to-Target” (based on
participant’s subjective report of affect or sensation). As described in Bradshaw et al. (2011),

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these “glitches” in eye movement (blinking, squinting, halting, or skipping of eye movement) are
often connected with distinct emotional or physical experiences. The Sweep technique was used
when necessary to dissipate dissociative artefacts (headaches, drowsiness, etc.) if they arose and
did not dissipate sufficiently with OEI Switching.
Helpful Aspects of Therapy questionnaire. Immediately after each treatment session,
participants completed the Helpful Aspects of Therapy (HAT) questionnaire to assess what they
found to be most helpful or hindering during the treatment session on that day. The HAT
consists of seven questions: (a) four short-answer questions, (b) two multiple-choice questions,
and (c) an option to briefly describe any outstanding treatment events. A copy of this form can
be found in Appendix Q. Results of this inventory are not included in this thesis report.
Breathing, Relaxation, Autogenics, Imagery, and grouNding
Information session. The information session for BRAIN involved a PowerPoint
presentation and a video demonstration of Dr. Bradshaw using BRAIN techniques with a client
to reduce public speaking anxiety. The PowerPoint presentation can be seen in Appendix R.
Treatment. The content of BRAIN sessions included tools and techniques that
participants could use both at home, and before public speaking tasks, to reduce their stress and
promote relaxation. The main techniques included in this collection of techniques are: (a)
diaphragmatic breathing, (b) progressive muscular relaxation, (c) autogenics, (d) imagery, and
(e) grounding techniques. Readers will find an overview of BRAIN techniques in Appendix S.
These treatments were conducted by the same clinicians who administered the OEI treatment.
The Psychologist co-developed the BRAIN protocol. The Psychologist led the BRAIN
psychoeducational sessions for all participants. Both Masters-level clinicians were trained by the

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Psychologist. Consultations occurred to address treatment fidelity for this clinical team
throughout the study (initially every two days and later on a weekly basis).
Helpful Aspects of Therapy questionnaire. Immediately after treatment, participants
completed the HAT questionnaire to assess what they found to be most helpful or hindering
during the treatment session for the day. As mentioned above, this form consists of seven
questions: (a) four short-answer, (b) two multiple-choice, and (c) one open-ended, to briefly
describe any outstanding treatment-related events (see Appendix Q). Results of this inventory
are not included in this thesis report.
Credibility of Treatment Questionnaire (CoTQ). This measure consists of 6 items, on
which participants provided ratings of each of the two therapies in the study on 10-point scales,
immediately following their 2-hour information and demonstration sessions. These questions
assess credibility and expectancy for improvement (Borkovec & Nau, 1972). It should be noted
that in the larger study from which this thesis emerges, all participants received both therapies
(including information sessions and CoTQs). In this way, comparisons in perceptions of the two
therapies were possible to determine for this thesis. The purpose of the questionnaire in this
study was to determine whether differential expectancies of success likely impacted treatment
outcomes. The CoTQ can be seen in Appendix T. Results of the CoTQ suggest that there were
no differences in how participants saw the two therapies (in terms of credibility or expectancy of
success).
A paired-samples t-test was used to assess differences in how credible participants saw
the two treatments. There was no significant difference between the therapies: OEI (M = 43.89,
SD = 4.70) and BRAIN (M = 44.33, SD = 4.56), t(8) = -.36, p = .73 (two-tailed). The difference
between means was .44 with a 95% confidence interval from -3.32 to 2.43. The eta squared

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statistic (.02) indicates there is a small effect size. This clearly suggests that different
expectations for the success of the treatments did not play significant roles in treatment outcome.
Interview. After the Post-Treatment assessment, participants were interviewed by Dr.
Marvin MacDonald. The purpose of this interview was to add depth and understanding
regarding the subjective experiences of participants, with hopes of understanding how the
treatments impacted them. Questions used in this interview can be seen in Appendix U. Results
of these interviews are beyond the scope of this thesis project but will be reported in future
publications.
Analysis
A pilot study design with a small sample size allows for descriptive examination for
selection of measures for future research. In this study, parametric analysis was chosen to
describe the relationships among interval-level variables. The interval-level variables used were:
(a) established self-report measures (PRCS, BAI, and BDI-II), (b) frequency of behaviour in the
performance tasks (TBC), and (c) a physiological component of anxiety (EDA). Because the
low power prevented inferential analysis, effect size descriptions were used to guide evaluation
of protocol performance in this pilot study.
Measures were evaluated for utility based on the principals of sensitivity and specificity
(Sox, 1986). For the purposes of the present study, the definition of sensitivity is the proportion
of accurate positive indicators of an index state (high anxiety). Specificity is defined as the
proportion of accurate negative indicators of an index state (low anxiety). The results of
parametric analysis to descriptively evaluate sensitivity and specificity will help develop stronger
protocols for future studies.

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CHAPTER 4: RESULTS
Preliminary Analysis
This pilot study was designed with a small sample size to allow for descriptive
examination for selection of measures for future research. Parametric analysis was chosen to
describe the relationships among interval-level variables. Assumptions of normality,
homoscedasticity (homogeneity of variance), and reliability underlie inferential and descriptive
parametric analyses.
Reliability (internal consistency) was assessed using Cronbach’s Alpha for psychometric
instruments used in this study (PRCS, SMSAD-A, SMGAD-A, SPSS-A, DES, BDI-II, EDA,
BAI) and psychophysiological assessments. These coefficients can be seen in Table 1.
Normality for each instrument (at each administration) was assessed using the
Kolmogorov-Smirnov test of normality. Normality was assessed for each 1-minute activity
during EDA assessments. All assessments satisfied the assumption of normality except: (a) PreTreatment script-driven EDA; (b) Post-Treatment BDI; and (c) Post-Treatment baseline EDA.
Logarithm or Square Root transformations were applied to these variables, resulting in
satisfaction of the normality assumption in each case. Since the assumption of normality was not
met for the BDI-II at Post-Treatment, a Square Root transformation was applied to both PreTreatment and Post-Treatment scores. After transformation the Post-Treatment distribution of
BDI-II scores met the assumption of normality according to the Kolmogorov-Smirnov test.
To check the equality of error variance (homoscedasticity), Levene’s Test was used.
Every administration of each instrument satisfied the assumption of homoscedasticity (p > .05).
Box’s Test for equality of covariance matrices was also used, and it was apparent that no data
violated this assumption.

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Table 1
Measurement Reliability
Intake

Pre-treatment

Post-treatment

PRCS

0.81

0.81

0.92

SMSAD-A

0.9

-

-

SMGAD-A

0.73

-

-

SPSS-A

0.79

-

-

DES

0.82

-

-

BDI-II

0.87

0.86

0.84

EDA

-

0.92

0.99

BAI

-

0.57

0.72

Note: The full titles for each measurement are as follows, the: (a) PRCS is Personal Report of Confidence as a
Speaker, (b) SMSAD-A is Severity Measure for Social Anxiety Disorder (Social Phobia) – Adult, (c) SMSAD-A is
Severity Measure for Generalized Anxiety Disorder – Adult, (d) SPSS-A is Severity of Posttraumatic Stress
Symptoms – Adult, (e) DES is Dissociative Experiences Scale, (f) BDI-II is Beck Depression Inventory II, and (g)
BAI is Beck Anxiety Inventory. The (a) EDA and BAI were not administered during the Intake process and (b) the
SMSAD-A, SMGAD-A, SPSS-A, and DES were not administered during Pre-Treatment or Post-Treatment
assessments.

Many of the assumption checks are tied to the practice of inferential statistics.
Descriptive analyses will rely on conventional uses of effect size descriptions: (a) .14 and greater
are large effects, (b) .06 to .13 are medium effect, and (c) .05 and lower are small effects (Cohen,
1988).
Research Questions 1-3
The research questions address (a) treatment effects, (b) time effects, and (c) specificity
effects. These effects are explored for all the measures in the treatment protocol. Each category
of measures is presented below in the sequence of: (a) self-report, (b) behavioural, and (c)
psychophysiological. Descriptive statistics for each measure are presented in Appendix V. After

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the overall ANOVA results are presented for each measure, implications for research questions 1
to 3 are summarized.
Self report measures. The self report measures examined in this study were: (a)
Personal Report of Confidence as a Speaker (PRCS), (b) Beck Anxiety Inventory (BAI), and (c)
Beck Depression Inventory II (BDI-II).
In addition to the narrow spectrum assessments (those closely associated with
performance-specific Social Anxiety Disorder [SAD]) used in this study, two broad spectrum
symptom patterns were assessed: Depression and Anxiety were assessed using the Beck
Depression Inventory II and the Beck Anxiety Inventory, respectively. Anxiety and depression
are very common in mental health and clinical work settings in general. Both are also evident in
research findings that show high prevalence rates and considerable comorbidity with specific
phobias like performance-specific SAD (American Psychiatric Association, 2013). In light of
such comorbidity, the BDI-II and BAI were included in this study. Of greatest interest was the
impact of OEI on broad spectrum symptoms.
Personal Report of Confidence as a Speaker (PRCS). Mixed between-within subjects
ANOVA (2 X 2) was conducted. The interaction effect between time and group was small and
nonsignificant, Wilk’s Λ = .97, F (1, 7) = .25, p = .633, η2 = 0.034. There was a large main
effect for time, Wilk’s Λ = 0.39, F (1, 7) = 10.78, p = .013, η2 = .606, and it was so large that is
also happened to be statistically significant even in the small sample. Participants in both groups
showed reductions in self-reported PSA from Pre- to Post-Treatment (approximately 5 points for
OEI and 6 points for BRAIN). There was a negligible group main effect, F (1, 7) = .13, p =
.731, η2 = .018. There was a large effect size for the within subjects main effect but effect sizes
for between subjects and interaction effects were very small. Both treatments have the same

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impact on the confidence as a speaker of the participants. These scores show increasing
confidence for all participants.
Beck Depression Inventory II (BDI-II). Results for both non-transformed and
transformed scores are provided to show the robustness of results despite the presence of
skewness and/or kurtosis. Similar results were obtained for both versions of the analysis.
Untransformed scores analysis. A mixed between-within subjects ANOVA (2 X 2) was
conducted using untransformed BDI-II scores. The interaction effect between time and group
was large, Wilk’s Λ = .29, F (2, 7) = 17.17, p = .0.004, η2 = .710, and it was so large that it also
happened to be statistically significant, even in the small sample. There was a moderate effect
for time which was non-significant, Wilk’s Λ = 0.87, F (1, 7) = 1.07, p = .335, η2 = .133. There
was a large between-subjects effect which was non-significant, F (2, 7) = 2.57, p = .153, η2 =
.268. Refer to Figure 1 for a visual plot of these relationships.
Transformed Scores Analysis. A mixed between-within subjects ANOVA (2 X 2) was
conducted using square root transformed variables of both Pre- and Post-Treatment BDI scores.
There was a large interaction effect between time and group, Wilk’s Λ = .36, F (2, 7) = 12.7, p =
.0.009, η2 = .644, and it was so large that it also happened to be statistically significant, even in
the small sample. There was moderate effect for time which was non-significant, Wilk’s Λ =
0.87, F (1, 7) = 1.06, p = .338, η2 = .131. There was a large between-subjects effect which was
non-significant, F (2, 7) = 1.91, p = .210, η2 = .214. Figure 1 adequately describes the
interaction effect for the transformed scores as well.

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Figure 1. Beck Depression Inventory II (BDI-II) ANOVA Plot for changes from PreTreatment to Post-Treatment assessments for the (a) Observed and Experiential Integration
(OEI) and and (b) Breathing, Relaxation, Autogenics, Imagery, and grouNding (BRAIN).
Beck Anxiety Inventory (BAI). A mixed between-within subjects ANOVA (2 X 2) was
conducted. There was a large interaction effect between time and group which was nonsignificant at conventional alpha levels, Λ = .58, F (1, 6) = 4.42, p = .080, η = .424. If, however,
we used an alpha level of .1 (suggested by Stevens [1996] for small sample sizes), this effect
becomes significant. There was a moderate effect for time which was non-significant, Λ = 0.92,
F (1, 6) = .56, p = .484, η = .085. There was a large between-subjects effect which was nonsignificant, F (1, 7) = 5.418, p = .059, η = .475. Between group differences did not mask clinical
effects in this sample, and this pattern may well hold for future samples.

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Figure 2. Beck Anxiety Inventory plot of cell means for changes from Pre-Treatment to
Post-Treatment assessment times for the (a) Observed and Experiential Integration (OEI) and
and (b) Breathing, Relaxation, Autogenics, Imagery, and grouNding (BRAIN).
Self report summary. The research questions refer to: (a) interaction effect, (b)
sensitivity to change over time, and (c) specificity. Some self-report measures showed greater
sensitivity and specificity than others. As a whole, the self-report measures did show utility in
understanding the impact of these two treatments for this population.
The three self-report measures were the: (a) PRCS, (b) BDI-II, and (c) the BAI. The
PRCS shows no sensitivity to differential treatment effects. The PRCS did show that confidence
reflects sensitivity to change over time. The PRCS did not, however, show specificity as both
treatments addressed the confidence based symptoms assessed by this measure. The BDI-II
shows strong sensitivity to differential treatment effects. Time effects for the BDI-II show up for

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the two treatment groups in different directions. The BDI-II showed specificity by
demonstrating a beneficial impact of the trauma-root-focused treatment while the traumasymptom-focused treatment actually showed a sensitization effect. Similarly, the BAI shows
strong sensitivity to differential treatment effects. Time effects for the BAI show up for the two
treatment groups in different directions. The BAI showed specificity by revealing a beneficial
impact of the trauma-root-focused treatment while the trauma-symptom-focused treatment
actually showed a sensitization effect. The PRCS tends to show similar patterns for the traumaroot-focused and trauma-symptom-focused treatments. On the other hand, the BDI-II and the
BAI tend to show the differential effects of the two types of treatment. The depression and
anxiety symptoms show positive responses to the trauma-root-focused treatment while the
confidence measure shows beneficial results of both the trauma-root-focused treatment and the
trauma-symptom-focused treatment.
Behavioural measures. The behavioural measure used in this study was the Timed
Behavioural Checklist (TBC).
Timed Behavioural Checklist. A mixed between-within subjects ANOVA (2 X 2) was
conducted. There was no interaction effect between time and group, Wilk’s Λ = 1.00, F (2, 7) =
.00, p = .976, η2 = 0.000. There was a large effect for time, Wilk’s Λ = 0.33, F (1, 7) = 14.56, p
= .007, η2 = .675, and it was large enough that it also was statistically significant in the small
sample. All participants showed reduced scores on the TBC, indicating lower levels of
performance-specific SAD behaviours. There was a moderate between-subjects main effect
which was non-significant, F (1, 7) = .1.09, p = .332, η2 = .134.
In summary, the TBC showed no sensitivity to differential treatment effects. The TBC
did show sensitivity to change over time. As can be seen in the descriptive statistics in Appendix

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V, there were approximately 14 point drops in mean scores for both the OEI and BRAIN groups
from Pre- to Post-Treatment. The TBC showed a lack of substantial specificity, because the
TBC tended to show similar patterns for the trauma-root-focused and trauma-symptom-focused
treatment groups.
Psychophysiological measure. The psychophysiological assessment used in this study
was electro dermal activity (EDA). Baseline level of EDA was compared to a script driven
symptom provocation (SDSP) condition level of EDA.
Electrodermal Activity (EDA). A mixed between-within subjects ANOVA (2 X 2) was
conducted. Baseline data and SDSP data analysis was conducted for each of two time periods
(Pre-Treatment and Post-Treatment). Two ANOVA analyses were run on the EDA data: (a) PreTreatment baseline EDA in comparison to Pre-Treatment SDSP EDA, and (b) Post-Treatment
baseline EDA in comparison to Post-Treatment SDSP EDA. Results of these two ANOVA
procedures were descriptively compared. The OEI group showed less psychophysiological
increase than did the BRAIN group, from baseline to SDSP at Post-Treatment. This pattern was
not present at the pre-treatment assessment time.
Pre-treatment EDA results. A Mixed between-within subjects ANOVA (2 X 2) was used
to evaluate the impact of OEI and BRAIN on EDA levels across two conditions (baseline and
SDSP). There was no interaction effect between triggering and group, Wilk’s Λ = .99, F (1, 7) =
.154, p = .702, η2 = .014. There was a large effect for triggering, Wilk’s Λ = .70, F (1, 7) = 4.75,
p = .052, η2 = .302, nearly meeting conventional significance levels. Both groups showed
increased EDA activity when the trauma script was played. There was no between-subjects
effect, F (1, 7) = .13, p = .725, η2 = .012. These results suggest that (a) both groups responded to

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the trigger with increased EDA levels, and (b) the groups did not differ in how they reacted to
the Pre-Treatment SDSP condition.
Post-treatment EDA results. A mixed between-within subjects ANOVA (2 X 2) was
used to evaluate the impact of OEI and BRAIN on EDA levels across two conditions (baseline
and SDSP). There was a large interaction effect between triggering and group which was nonsignificant, Wilk’s Λ = .77, F (2, 7) = 2.36, p = .163, η2 = .228 (See Figure 3). The 23% effect
size is large, but not statistically significant because of the low power of the test with this small
sample. This pattern shows a tendency for the OEI group to increase less (from baseline) in
response to SDSP than the BRAIN group at Post-Treatment. There was a large main effect for
triggering, Wilk’s Λ = .56, F (1, 7) = 6.41, p = .035, η2 = .445, and it was so large, that is also
happened to be statistically significant, even in the small sample. Participants showed increased
EDA levels from baseline when triggered with SDSP. There was a moderately large betweensubjects effect which was non-significant, F (2, 7) = 2.11, p = .184, η2 = .209. Descriptively, it is
helpful to see this pattern displayed in the plot below (Figure 1).
Psychophysiological measurement summary. The research questions have been
presented in a specific order. (a) Research question one refers to the treatment effect of OEI
when compared to BRAIN. This question is answered by the descriptive comparison of the pretreatment analysis to the post-treatment analysis. Since the OEI group showed less sensitivity to
SDSP at post-treatment but not a pre-treatment assessment, the contrast between these two
analyses suggest that EDA measures can detect differential treatment effects. (b) Research
question two examines sensitivity to change over time of treatment effects. EDA is a sensitive
measure to triggering (SDSP) effects for both treatment groups. (c) Research question three
exams specificity between the treatment groups. The pre-treatment EDA analysis does not

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suggest any specificity between BRAIN and OEI. This simply shows the groups were similar in
response to the SDSP condition at pre-treatment assessment. The post-treatment assessment
shows specificity between groups since the OEI group displayed reduced reactivity to SDSP.
Thus the EDA measure seems capable of demonstrating specificity since the lack of specificity at
pre-treatment contrasted with the specificity evident at post-treatment.

Figure 3. Plot of cell means for Electrodermal Activity (EDA) changes from Baseline to
Script Driven Symptom Provocation (SDSP) for two groups at Post-Treatment assessment time:
(a) Observed and Experiential Integration (OEI) and (b) Breathing, Relaxation, Autogenics,
Imagery, and grouNding (BRAIN).
Results Summary
The self-report, behavioural, and psychophysiological measures showed utility in
understanding how both the trauma-root-focused and the trauma-symptom-focused treatment

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groups shaped the symptoms of performance-specific Social Anxiety Disorder. Different
measures focused on different processes addressed in treatment and thus displayed different
patterns of sensitivity and specificity. The various processes measured with these assessments
are: (a) confidence, (b) depression, (c) general anxiety, (d) speaking behaviour, and (e)
psychophysiological arousal. These can be separated into three categories of processes: (a)
narrow spectrum symptoms, (b) broad spectrum symptoms, and (c) psychophysiological
symptoms. Narrow spectrum symptoms are: (a) speaking confidence, and (b) speaking
behaviour. Broad spectrum symptoms are: (a) depression and (b) anxiety. The
psychophysiological symptom was EDA. The focused of treatment (trauma-root-focused versus
trauma-symptom focused) impacted which processes were activated for change.
The self-report measures displayed this differentiation clearly. The confidence measure,
PRCS: (a) did not show differential sensitivity to treatment, (b) was sensitive to time, and (c) did
not show specificity because both treatments affected confidence in the same way. The BDI-II
showed: (a) high differential sensitivity to treatment; (b) time sensitivity for the two groups, in
light of the differential sensitivity in the interaction (research question 1) shown by contrasting
directions for the two treatment groups; and (c) high specificity because OEI activated a process
of treatment which impacted depressive symptoms which BRAIN did not activate. The BAI
showed: (a) high sensitivity to treatment, (b) differential time sensitivity for the two groups, and
(c) high specificity because OEI addressed a process of treatment which impacted anxious
symptoms which BRAIN did not address. These measures give a great deal of information about
how self-report assessments show how treatments impact various symptom processes.
The behavioural measure, TBC, showed: (a) low sensitivity to differential treatment
effects, (b) high sensitivity for time, and (c) low specificity because both treatments activated

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behavioural processes. The moderate between groups effect size (13%) might be worth
exploring in future research if this strength of relationship is replicated.
The psychophysiological results, Electrodermal Activity (EDA), were shown through a
comparison of two analyses: (a) pre-treatment comparison of reactivity for the two treatment
groups and (b) a post-treatment comparison of reactivity for the two treatment groups. The
comparison of the pre-treatment and post-treatment results showed (a) differential treatment
effects, the pre-treatment analysis showed no differential reactivity between treatment groups but
the post-treatment groups demonstrated a decrease in reactivity in the OEI group. The
comparison of the pre-treatment and post-treatment results showed (b) a strong sensitivity for
time for both groups. The comparison of the pre-treatment and post-treatment results showed (c)
specificity through a shift from a non-specific pattern of triggering at pre-treatment while
specificity at post-treatment showed through decreased levels of triggering for the OEI group.
The significance of the results pattern becomes clearer when displayed in Appendix W.
There appear to be broad spectrum symptoms, narrow spectrum symptoms, and
psychophysiological symptoms. The two types of treatment (trauma-symptom-focused versus
trauma-root-focused) are presented using concentric circles associated with the processes
activated by the respective treatments. The trauma-root-focused treatment activates processes
beyond the scope of the processes activated by the trauma-symptom-focused treatment. Note
that self-report instruments fell both within the trauma-root-focused treatment and the traumasymptom-focused treatment. It is important to recognize the value of using multiple types of
assessment to encompass broad and narrow spectrum symptom change as a result of various
treatment methods.

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CHAPTER 5: DISCUSSION
This project constitutes a contribution to previous knowledge in the areas of (a) protocol
development for clinical research in performance-specific Social Anxiety Disorder (SAD), (b)
application of trauma theory and treatments used in this study, and (c) added understanding of
narrow versus broad spectrum symptom change. Finally, recommendations will be made for
further protocol development for clinical research on SAD which addresses psychophysiological
activation.
Reflections on Innovation in Protocol Design and Theory Application
Protocol design. Protocol development is important for emerging directions in clinical
research, to guide researchers’ choices of treatment models and assessment procedures. In this
study, the focus for protocol development for clinical research in performance-specific SAD was
the interaction between treatment type and symptom processes that were activated. Examining a
range of measurement strategies showed how different treatments activated different processes
for our participants. The diagram in Appendix W displays the integration of these principles.
Patterns of results revealed connections between treatment types and which symptom
processes were activated. The diagram in Appendix W shows this pattern of interconnections.
Symptoms can be distinguished as: (a) narrow spectrum symptoms, such as speaker confidence
and public speaking behaviour (light grey); (b) psychophysiological symptoms, such as
electrodermal activity (medium grey); and (c) broad spectrum symptoms, such as general anxiety
and depression (darker grey). The two treatment types employed in this study are represented in
the figure by concentric circles, where the trauma-root-focused treatment (solid line) includes
items within the trauma-symptom-focused circle (dashed line). As shown in the results and
displayed in the diagram in Appendix W, the trauma-symptom-focused treatment seemed to

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activate processes of (a) speaker confidence and (b) speaking behaviour. These processes were
also activated by the trauma-root-focused treatment. In addition to those processes, the traumaroot-focused treatment activated movement (toward improvement) of the processes of: (a)
electrodermal activation in response to a trigger, (b) general anxiety, and (c) depression. In
response to trauma-root-focused treatment: (a) broad spectrum symptoms improve and (b)
psychophysiological activation associated with past traumatic social experiences is alleviated.
Diverse types of measurements, such as self report, behaviour sampling, and
psychophysiological measures, will be helpful in understanding broad spectrum, narrow
spectrum, and psychophysiological symptoms.
Application of trauma theory. Innovative applications of trauma treatments were
implemented in this study for reducing anxiety symptoms. The similarity of trauma and anxiety
symptoms suggested a traumatic root to performance-specific SAD (Calamaras, Anderson,
Tannenbaum, & Zimand, 2014; Erwin et al., 2006; Stein, Walker, & Forde, 1996). This
relationship was supported by the descriptive analyses in this study. All participants in the study
reported memories of socially traumatic events, which left them feeling: (a) rejected and
criticized, (b) humiliated and embarrassed, and/or (c) deceived and betrayed. All but one of
these traumatic experiences related directly to public speaking. The connection between trauma
and anxiety suggests the utility of applying trauma theory and treatment for performance-specific
SAD (Erwin et al., 2006).
It is worth noting that the different trauma treatments activated different symptoms
processes. The assessments in this study showed utility in differentiating between a trauma-rootfocused treatment and a trauma-symptom-focused treatment. Descriptive analysis of the
assessments for the trauma-root-focused treatment group showed improved: (a) speaker

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confidence, (b) public speaking behaviour, (c) EDA reactivity, (d) general anxiety, and (e)
depression. The trauma-symptom-focused treatment descriptive analyses results showed
improved: (a) speaker confidence and (b) public speaking behaviour. It would appear different
treatment foci impact which processes are activated for improvement. The trauma-root-focused
treatment seemed to impact processes which lay at a deeper level of emotional experience
(Porges, 2007; van der Kolk, 2001, 2002; Yehuda, 1997, 2002). The impact of OEI, the traumaroot-focused treatment, on electrodermal activation indicates the hyperarousal and hyper
activation responses to triggers are decreased after treatment. This coincides with the polyvagal
theory of physiological activation to threat, which appears out of context in traumatized
individuals. This treatment may allow clients to live life with less physiological fear and to
lower their baseline levels of anxiety and trauma.
The connection between trauma and anxiety, supported through descriptive analyses of
this study, contributes to trauma-informed research and clinical practice. Anxiety can be as
crippling as trauma, stopping many people from living the lives they desire. The similarity
between trauma and anxiety symptoms is important when considering treatment for individuals
with anxiety. If this obvious similarity is neglected, clients may not receive the necessary
treatment. Anxiety reduction is multifaceted, including physiological, cognitive, behavioural,
and emotional changes. Therapists will miss a large aspect of anxiety if treatment neglects the
physiological impact of socially traumatic events (Porges, 2007; van der Kolk, 2001, 2002;
Yehuda, 1997, 2002). In addition to other mechanisms of change, OEI addresses
neurobiological (sympathetic and parasympathetic nervous system) arousal, including emotional
and psychophysiological sequelae of socially traumatic memories (see Appendix E for a more
thorough presentation of how OEI incorporates other theoretical mechanisms of change). This

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frees clients, so they can better access and use their higher-order thinking capacities during
public speaking and other performance tasks. It is hypothesized that this integration of limbic
and cortical functioning could empower clients to heal in more comprehensive ways.
Broad and narrow spectrum symptoms. Reduction in depression (BDI-II scores) for
the OEI group was interesting, considering that reductions in BDI-II scores were not found in a
previous OEI study (Williams, Bradshaw, McDonald, & Blake, 2006). Two differences in OEI
treatment protocols may explain this disparity in findings: First, only three hours of OEI
treatment were administered in the Williams et al. study whereas seven hours of OEI were
provided in the current study. Depression may be a peripheral symptom which does not change
until (a) longer treatment has occurred, or (b) the central symptoms have been addressed.
Secondly, in the Williams et al. study, a highly manualized version of OEI treatment was used,
targeting treatment of each participant’s specific sexual assault traumas. In the current study,
OEI treatment was targeted on a broader range of experiences identified by participants. Rather
than keeping treatment exclusively focused on public speaking targets, therapists were instructed
to let participants guide their sessions, with targets that spontaneously emerged from focusing on
their negative emotions and intense physiological experiences associated with performancespecific SAD. Treatment with a highly manualized form of OEI to address narrow spectrum
symptoms (sexual assault traumas, in the Williams et al. study) would be expected to show
improvement in targeted narrow spectrum symptoms (as was the finding in the Williams et al.
study). Less tightly targeted OEI treatment in the current study resulted in reductions of both
narrow spectrum (behaviour and self-reported confidence) and broad spectrum (depression and
anxiety) symptoms.

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Recommendations for Additional Protocol Development and Research
This portion of the discussion is provided to delineate parameters of the study and to
make suggestions for future research on performance-specific SAD. The elements addressed
are: (a) sampling methods, (b) psychophysiological assessments, (c) broad spectrum symptom
patterns, and (d) treatment targets. Following these, will be suggestions regarding how these
elements can be used together to inform future research design.
The sample size was intentionally small to permit pilot testing of the complex design and
assessment processes implemented in this project. The purpose of the small size was to
determine what adjustments would be necessary in both assessment and treatment protocols for
future studies. No attempt was made to collect a sample from a large geographical catchment
area, thereby limiting the generalizability of results to a larger population. Participant samples in
future research studies should be large enough to support statistical inference with adequate
power, and selected from wide geographical regions. Broadening the recruitment area and
increasing sample size will improve the generalizability of findings. The decisions on sample
size for this study allowed for descriptive analysis of the data to provide information for protocol
design in future research.
Exploration of EDA assessment revealed rewarding applications for future research
involving psychophysiological correlates of anxiety. This strategy could be an innovative way to
gain more comprehensive understanding of symptom patterns in future research.
Psychophysiological assessment also permitted documentation of reductions in triggered
emotional reactions (reactivity), which would not have been possible with self-report or
behavioural observations (at least not at the same level of measurement sensitivity).

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The BDI-II and BAI should clearly be used at intake, and in all subsequent assessments,
along with measurements of narrow spectrum symptoms. These instruments showed promise for
detecting group differences in broad spectrum symptom patterns. It will be valuable for future
clinical practice and research to assess how, and why, OEI impacts broad spectrum symptoms
like depression and anxiety.
In this study, OEI treatment was not tightly targeted at Public Speaking Anxiety stories.
This could be seen as a limitation, if researchers were only considering narrow spectrum (PSA)
symptoms. Results of this study, however, support continued therapist flexibility to deliver
client-centered OEI treatment: Such treatment resulted in improvements for both narrow
spectrum (behaviour and self-reported confidence) and broad spectrum (depression and anxiety)
symptoms.
Future OEI treatment in research studies should be administered (a) in a variety of
contexts, (b) at different levels of target specificity, and (c) with variations in treatment dosage
and scheduling. In some future OEI studies, sessions could be more tightly focused on
performance-specific SAD targets to more intensively treat narrow spectrum symptoms. This
could involve: (a) target redirection by therapists, (b) script-driven symptom provocation in
sessions, and/or (c) virtual reality exposure. In other future studies, OEI target specification
should permit participant-directed target selection allowing treatment to reduce broad spectrum
symptoms along with the narrow spectrum symptom change. When applying less stringent
target selection, therapy duration may need to be increased to permit clients to work through
more trauma-root-based experiences. More general treatment which begins with the “person-asa-whole” will likely facilitate processing of core early traumas. After those core traumas have
been addressed, participants may naturally return to narrow spectrum symptom targets, or

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reduction in narrow spectrum symptoms may occur alongside the trauma processing, as was the
case in this study. Variations in targeting and duration of OEI treatment will reveal more
precisely how OEI affects symptoms.
These suggestions for future research will improve: (a) generalizability of findings; (b)
potency of treatment; and (c) assessment of the effects of OEI on broad spectrum, narrow
spectrum, and psychophysiological symptoms. Continued research on OEI will provide greater
insight regarding how this treatment can best be used to help clients in therapy.
Conclusion
The findings of this study will be useful for establishing key parameters for development
of clinical research for social anxiety. These innovative approaches to clinical research on social
anxiety address psychophysiological activation. There is clear support for application of trauma
treatment to treatment of performance-specific SAD. If these patterns continue to be supported
by additional research this will help: (a) those with performance-specific SAD, (b) clinicians,
and (c) future researchers. Both OEI and BRAIN were effective in improving the performancespecific SAD symptoms of speaker confidence and speaking behaviour. After treatment,
psychophysiological (EDA) assessments revealed that the OEI group was less reactive to
triggered reminders of social traumas than the BRAIN group. More stringent therapeutic focus
on performance-specific SAD targets during OEI treatment may lead to superior outcomes in
terms of narrow spectrum symptoms while less tightly targeted treatment may allow for greater
reductions in broad spectrum symptoms like depression and general anxiety alongside narrow
spectrum symptom improvement. The findings of this study will be beneficial for enhancing
assessment and treatment protocols in future clinical research for performance-specific SAD.

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Based on community survey results, there is potential to help the one-third of the
individuals in the general population who experience performance-specific SAD (Kessler, Stein,
& Berglund, 1998; Stein, Walker, & Forde, 1996). Research indicates that those with
performance-specific SAD have higher unemployment rates, lower incomes, and lower
education levels than those who do not (Calamaras, Anderson, Tannenbaum, & Zimand, 2014).
These findings suggest that treatment for performance-specific Social Anxiety Disorder will help
people to reach their vocational, financial, and educational goals and, in turn, make contributions
to society.

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REFERENCES
Abramowitz, J. S. (2013). The practice of exposure therapy: Relevance of cognitive-behavioral
theory and extinction theory. Behavior Therapy, 44(4), 548-58.
Alstrom, J. E., Nordlund, C. L, Persson, G., Hording, M., & Ljungqvist, C. (1984). Effects of
four treatment methods on social phobia patients not suitable for insight-oriented
psychotherapy. Acta Psychiatrica Scandinavica, 70, 97-110.
American Psychiatric Association (2013). Diagnostic & statistical manual of mental disorders,
5th edition (DSM-5). Washington, DC: American Psychiatric Publishing.
American Psychiatric Association. (2015a, July 7). Severity measure for social anxiety disorder
(social phobia) - Adult. Retrieved from
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures
American Psychiatric Association. (2015b, July 7). Severity measure for generalized anxiety
disorder - Adult. Retrieved from http://www.psychiatry.org/practice/dsm/dsm5/onlineassessment-measures
American Psychiatric Association. (2015c, July 7). Severity of posttraumatic stress symptoms –
Adult. Retrieved from http://www.psychiatry.org/practice/dsm/dsm5/online-assessmentmeasures
Antony, M. M., & Roemer, L. (2011). Behavior therapy. Washington DC: American
Psychological Association.
Barlow, D. H., Allen, L. B., & Basden, S. L. (2007). Psychological treatments for panic
disorders, phobias, and generalized anxiety disorder. In P. E. Nathan & J. M. Gorman
(Eds.), Treatments that work (3rd ed., pp. 351–394). New York: Oxford University Press.
Barlow, D. H., Allen, L. B., & Choate M. L. (2004). Toward a unified treatment for emotional

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

85

disorders. Behavior Therapy, 35(2), 205–230.
Barnhofer, T., & Crane, C. (2009). Mindfulness-based cognitive therapy for depression and
suicidality. In F. Didonna (Ed.), Clinical handbook of mindfulness (pp. 221-244). New
York: Springer.
Barnhofer, T., Crane, C., Hargus, E., Amarasinghe, M., Winder, R., & Williams, J. M. (2009).
Mindfulness-based cognitive therapy as a treatment for chronic depression: A preliminary
study. Behaviour Research & Therapy, 47, 366–373.
Barrett, P., Lowry-Webster, H., & Turner, C. (2000). Friends for children group leader manual
(2nd ed.). Australia: Academic Press.
Batini, C., Buisseret, P., Lasserre, M. H., & Toupet, M. (1985). Does proprioception of the
extrinsic eye muscles participate in equilibrium, vision and oculomotor action? Annales
d’Oto-laryngologie et de Chirurgie Cervico Faciale, 102, 7–18.
Beck, A. T. (1967). Depression: Causes and treatment. Philadelphia: University of Pennsylvania
Press.
Beck, A. T. (1976). Cognitive therapy and the emotional disorders. New York: International
University Press.
Beck, A. T. & Emery, G. (1985). Anxiety disorders and phobias: A cognitive perspective. New
York, NY: Basic Books.
Beck, A. T., Epstein, N., Brown, G., & Steer, R. A. (1988). An inventory for measuring clinical
anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56,
893-897.
Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal intention: The scale or
suicide ideation. Journal of Consulting and Clinical Psychology, 47(2), 343-352.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

86

Beck, A. T., & Steer, R. A. (1988). Manual for Beck hopeless scale. San Antonio, TX: The
Psychological Corporation.
Beck, A. T., & Steer, R. A. (1993). BAI: Beck Anxiety inventory: Manual. San Antoni, TX: The
Psychological Corporation.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory: Manual (2nd ed.).
San Antonio, TX: The Psychological Corporation.
Beck, A. T. & Weishaar, M. E. (2014). Cognitive therapy. In D. Wedding, & R. J. Corsini (Eds.),
Current psychotherapies. Belmont, CA: Brooks/Cole.
Borkovec, T. D., Alcaine, O., & Behar, E. (2004). Avoidance theory of worry and generalized
anxiety disorder. In R. G. Heimberg, C. L. Turk, & D. S. Mennin, (Eds.). Generalized
anxiety disorder: Advances in research and practice (pp. 77–108). New York: Guilford
Press.
Borkovec, T. D., & Nau, S. D. (1972). Credibility of analogue therapy rationales. Journal of
Behaviour Therapy & Experimental Psychiatry, 3, 257-260.
Borkovec, T. D. & Roemer, L. (1995). Perceived functions of worry among generalized anxiety
disorder subjects: Distraction from more emotionally distressing topics? Journal of
Behavior Therapy and Experimental Psychiatry, 26, 25–30.
Bouton, M. E., (2002). Context, ambiguity, and unlearning: Sources of relapse after behavioral
extinction. Biological Psychiatry, 52(10), 976– 986.
Bradshaw, R. A., Cook, A., & McDonald, M. J. (2011). Observed & experiential integration
(OEI): Discovery and development of a new set of trauma therapy techniques. Journal of
Psychotherapy Integration, 21(2), 104-171.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

87

Bradshaw, R. A., McDonald, M. J., Grace, R., Detwiler, L., & Austin, K. (2014). A randomized
clinical trial of Observed & Experiential Integration (OEI): A simple, innovative
intervention for affect regulation in clients with PTSD. Traumatology, 20(3), 161-171.
http://dx.doi.org/10.1037/h0099401
Bradshaw, R. A., McDonald, M. J., Williams, K., Ndunda, S. K., Lauder, J., Heinrichs, K., . . .
Allard, D. (2017). Quantitative and qualitative findings from an 18-month RCT for PTSD
following sexual assault in women: Observed & experiential integration (OEI) versus
cognitive processing therapy-revised (CPT-R). Manuscript in preparation.
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J.… Devins, G.
(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science
and Practice, 11, 230–241.
Brach, T. (2004). Radical acceptance: Embracing your life with the heart of a Buddha. New
York, NY: Bantam Press.
Brown, B. (1974). New mind, new body: New directions for the mind. New York: Harper &
Row.
Brown, R. M. (1987). The essential Reinhold Niebuhr: Selected essays and addresses. New
Haven, CT: Yale University Press.
Buttner-Ennever, J. A. (2006). The extraocular motor nuclei: Organization and functional
neuroanatomy. Progress in Brain Research, 151, 95–125. doi:10.1016/S00796123(05)51004 –5
Buttner-Ennever, J. A. (2008). Mapping the oculomotor system. Progress in Brain Research,
171, 3–11. doi:10.1016/S0079-6123(08)00601–8
Calamaras, M. R., Anderson, P. L., Tannenbaum, L., & Zimand, E. (2014). Public speaking

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

88

anxiety. In L. Grossman, S. Walfish, L. Grossman, & S. Walfish (Eds.), Translating
psychological research into practice (pp. 253-258). New York, NY: Springer.
Carlson, E. B., & Putnam, F. W. (1993). An update on the dissociative experiences scale.
Dissociation, 6(1), 16-27.
Carlson, E. B., & Putnam, F. W. (2015). Dissociative experiences scale-II. Retrieved from
http://www.emdrhap.org/content/wp-content/uploads/2014/07/VIII-F_DES-II.pdf
Clevenger, T. J., & King, T. R. (1961). A factor analysis of the visible symptoms of stage fright.
Speech Monographs, 28, 296-298. doi:10.1080/03637756109375328
Craske, M., & Barlow, A. (2007). Mastery of your anxiety and panic (4th ed.): Therapist guide.
New York: Oxford University Press.
Cohen, J. (1988). Statistical power analysis for the behavioral sciences. Hillsdale, NJ: Earlbaum.
Daly, J. A. (1978). The assessment of social-communication anxiety via self-reports: A
comparison of measures. Communication Monographs, 45, 204-18.
Davidson, R. J. (1998). Anterior electrophysiological asymmetries, emotion, and depression:
Conceptual and methodological conundrums. Psychophysiology, 35, 607-614.
Davidson, P. R., & Parker, K. H. (2001). Eye movement desensitization and reprocessing
(EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305316. doi:10.1037/0022-006X.69.2.305
Davis, M., Eshelman, E.R. & McKay, M. (1995). The relaxation & stress reduction workbook
(4th ed.). Oakland, CA: New Harbinger Publications.
Davison, G. C. (1968). Systematic desensitization as a counterconditioning process. Journal of
Abnormal Psychology, 73(2). http://dx.doi.org/10.1037/h0025501
Dennison, P. E., & Dennison, G. E. (1986). Brain gym: Simple activities for whole brain

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

89

learning. Ventura, CA: Edu-Kinesthetics.
Dennison, P. E., & Dennison, G. E. (1994). Brain gym: Teacher’s edition (rev. ed.). Ventura,
CA: Edu-Kinesthetics.
DiMauro, J. (2014). Exposure therapy for posttraumatic stress disorder: A meta-analysis.
Military Psychology, 26(2), 120-130. doi:10.1037/mil0000038
Donaldson, I. M. (2000). The functions of the proprioceptors of the eye muscles. Philosophical
Transactions of the Royal Society of London Series B, Biological Sciences, 355, 1685–
1754.
Dutton, G. N. (2003). Cognitive vision, its disorders and differential diagnosis in adults and
children: Knowing where and what things are. Eye, 17, 289–304.
Eaves, G. & Rush, A. J. (1984). Cognitive patterns in symptomatic and remitted unipolar major
depression. Journal of Abnormal Psychology, 93, 31–40.
Ebrahim, S., & Bance, S. (2012). Correcting and interpreting the effect of cognitive therapy
versus exposure in anxiety disorders. BioMed Central Psychiatry, 12, 202.
Erwin, B. A., Heimberg, R. G., Marx, B. P., & Franklin, M. E. (2006). Traumatic and socially
stressful life events among persons with social anxiety disorder. Journal of Anxiety
Disorders, 20(7), 896-914. doi:10.1016/j.janxdis.2005.05.006
Eysenck, M. W., Derakshan, N., Santos, R., & Calvo, M. G. (2007). Anxiety and cognitive
performance: Attentional control theory. Emotion, 7, 336–353.
Farmer, R. F., & Chapman, A. L. (2016). Exposure-based interventions. In R. F. Farmer, & A. L.
Chapman, Behavioral interventions in cognitive behavior therapy: Practical guidance for
putting theory into action (2nd ed., pp. 269-299). Washington, DC, US: American
Psychological Association. doi:10.1037/14691-009

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

90

Foa, E. B. & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective
information. Psychological Bulletin, 99(1), 20-35. http://dx.doi.org/10.1037/00332909.99.1.20
Foa, E. B. & Rothbaum, B. O. (1998). Treating the trauma of rape: Cognitive-behavioral
therapy for PTSD. New York: Guilford Press.
Foa, E. G. & McNally, R. J. (1996). Mechanism of change in exposure therapy. In R. M. Rapee
(Ed.), Current controversies in the anxiety disorders. New York: Guilford Press.
Follette, V. M., & Hazlett-Stevens, H. (2016). Mindfulness and acceptance theories. In J. C.
Norcross, G. R. VandenBos, D. K. Freedheim, B. O. Olatunji, J. C. Norcross, G. R.
VandenBos, ... B. O. Olatunji (Eds.), APA handbook of clinical psychology: Theory and
research, Vol. 2 (pp. 273-302). Washington, DC, US: American Psychological
Association. doi:10.1037/14773-010
Fosha, D. (2002). The activation of affective change processes in AEDP (accelerated experiential-dynamic psychotherapy). In F. W. Kaslow & J. J. Magnavita (Eds.), Comprehensive handbook of psychotherapy: Vol. 1. Psychodynamic/object relations (pp. 309–
344). New York: Wiley.
Friedberg, R., & McClure, J. (2002). Clinical practice of cognitive therapy with children and
adolescents: The nuts and bolts. New York: Guilford.
Furmark, T., Tillfors, M., Stattin, H., Ekselius, L., & Fredrikson, M. (2000). Social phobia
subtypes in the general population revealed by cluster analysis. Psychological Medicine,
30, 1335–1344.
Fydrich, T., Dowdall, D., & Chambless, D. L. (1990). Aspects of reliability and validity for the
Beck anxiety inventory. Paper presented at the National Conference on Phobias, and

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

91

Related Anxiety Disorders, Bethesda, MD.
Gallese, V., Eagle, M. N., & Migone, P. (2007). Intentional attunement: Mirror neurons and the
neural underpinnings of interpersonal relations. Journal of the American Psychoanalytic
Association, 55, 131–176. doi:10.1177/00030651070550010601
Gatchel, R., Hatch, J., Maynard, A., Turns, R., & Taunton-Blackwood, A. (1979). Comparison of
heart rate biofeedback, false biofeedback, and systemic desensitization in reducing
speech anxiety: Short- and long-term effectiveness. Journal of Consulting and Clinical
Psychology, 47, 620-622.
Gendlin, E. T. (1984). Focusing (rev. ed.). New York: Bantam Books.
Gilkinson, H. (1942). Social fears as reported by students in college speech classes. Speech
Monographs, 9, 131-160.
Gold, J., & Stricker, G. (2006). An overview of psychotherapy integration. In G. Stricker &
J. Gold (Eds.), A casebook of psychotherapy integration (pp. 3–16). Washington, DC:
American Psychological Association.
Gotlib, I. H., & Cane, D. B. (1989). Self-report assessment of depression and anxiety. In P. C.
Kendall & D. Watson (Eds.), Anxiety and depression: Distinctive and overlapping
features (pp. 131-169). New York: Academic Press.
Grace, R. (2003). An exploration of trauma-specific frontal lobe brainwave activity and
posttraumatic symptomatology before and after the application of a specific bilateral
stimulation and integration technique. (Unpublished master’s thesis). Trinity Western
University, Langley, British Columbia, Canada.
Greenberg, L. S. (2008). Emotion and cognition in psychotherapy: The transforming power of
affect. Canadian Psychology, 49(1), 49–59.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

92

Greenson, R. R., & Wexler, M. (1969). The non-transference relationship in the psycho-analytic
situation. The International Journal of Psycho-Analysis, 50, 27–39.
Hamilton, M. (1959). The assessment of anxiety states by rating. British Journal of Medical
Psychology, 32, 50-55.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurobiology, Neurosurgery, and
Psychiatry, 23, 56-61.
Haslam, C., Atkinson, S., Brown, S. S., & Haslam, R. A. (2005). Anxiety and depression in the
workplace: Effects on the individual and organisation (a focus group investigation).
Journal of Affective Disorders, 88, 209-215.
Henry, J. R. (2003). The effects of brief ruminating, distracting, and mindfulness interventions
on public speaking anxiety. Dissertation Abstracts International, 64, 2920.
Hofmann, S. G., (2008). Cognitive processes during fear acquisition and extinction in animals
and humans: Implications for exposure therapy of anxiety disorders. Clinical Psychology
Review, 28(2), 199–210.
Hopper, J. W., & van der Kolk, B. A. (2001). Retrieving, assessing, and classifying traumatic
memories: A preliminary report on three case studies of a standardized method. Journal
of Aggression, Maltreatment, and Trauma, 4(2), 33-71.
Jaycox, L. H., Foa, E. B., & Morral, A. R. (1998). Influence of emotional engagement and
habituation on exposure therapy for PTSD. Journal of Consulting and Clinical
Psychology, 66(1), 185-192. http://dx.doi.org/10.1037/0022-006X.66.1.185
Jones, G. Philips, G., & Rieger, E. (1995). Effects of cardiac awareness, public speaking anxiety,
and physiological “priming” on state-trait anxiety (state) and feelings of apprehension.
Psychophysiology, 32 (Suppl.), S43.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

93

Kabat-Zinn, J. (1990). Full catastrophe living. New York, NY: Bantam Books.
Kabat-Zinn, J. (2003). Mindfulness-based interventions in context: Past, present, and future.
Clinical Psychology: Science and Practice, 10, 144–156. http://
dx.doi.org/10.1093/clipsy.bpg016
Kessler, R. C., Stein, M. B., & Berglund, P. (1998). Social phobia in the national comorbidity
study. American Journal of Psychiatry, 155, 613-619.
Kim, K., Rosenthal, M. Z, Zielinski D. J., & Brady, R. (2014). Effects of virtual environment
platforms on emotional responses. Computer Methods and Programs in Biomedicine,
113(3), 882–893.
Knappe, S., Beesdo-Baum, K., Fehm, L., Stein, M. B., Lieb, R., & Wittchen, H. (2011). Social
fear and social phobia types among community youth: Differential clinical features and
vulnerability factors. Journal of Psychiatric Research, 45(1), 111-120.
doi:10.1016/j.jpsychires.2010.05.002
Lang, P. J. (1988). What are the data of emotion? In V. Hamilton, G. H. Bower, & N. H. Frijda
(Eds.), Cognitive perspectives on emotion and motivation (pp. 173-191). New York:
Kluwer Academic/Plenum Press.
Lang, P. J., Levin, D. N., Miller, G. A., & Kozak, M. J. (1983). Fear behavior, fear imagery, and
the psychophysiology of emotion: The problem of affective-response integration.
Journal of Abnormal Psychology, 92, 276-306.
Levin, D. N., Cook, F. N., & Lang, P. J. (1982). Fear imagery and fear behavior:
Psychophysiological analysis of clients receiving treatment for anxiety disorders.
Psychophysiology, 19, 571-572.
Mannuzza, S., Schneier, F. R., Chapman, T. F., Liebowitz, M. R., Klein, D. F., & Fyer, A. J.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

94

(1995). Generalized social phobia: Reliability and validity. Archives of General
Psychiatry, 52, 230–237.
McLaughlin, K. A. & Hoeksema, S. (2011). Rumination as a transdiagnostic factor in depression
and anxiety. Behaviour Research and Therapy, 49, 186-193.
Miller, L. D., Short, C., Garland, E. J., & Clark, S. (2010). The ABCs of CBT (Cognitive
Behavior Therapy): Evidence-based approaches to child anxiety in public school settings.
Journal of Counseling & Development, 88, 432-439. Retrieved from
http://ezproxy.library.ubc.ca/login?url=http://search.proquest.com.ezproxy.library.ubc.ca/
docview/762466878?accountid=14656
Mogg, K., Bradley, B. P., & Williams, R. (1995) Attentional bias in anxiety and depression: The
role of awareness. British Journal of Clinical Psychology, 34, 17-36.
Mowrer, O. H. (1960). Learning theory and the symbolic processes. Hoboken, NJ, US: John
Wiley & Sons.
Muris, P., Roelofs, J., Rassin, E., Franken, I., & Mayer, B. (2005). Mediating effects of
rumination and worry on the links between neuroticism, anxiety and depression.
Personality and Individual Differences, 39, 1105-1111.
Neumann, E., & Blanton, R. (1970). The early history of electrodermal research.
Psychophysiology, 8(4), 463-474.
Nolen-Hoeksema, S. (2000). The role of rumination in depressive disorders and mixed anxiety/
depressive symptoms. Journal of Abnormal Psychology, 109, 504-511.
Norton, A. R., Abbott, M. J., Norberg, M. M., & Hunt, C. (2014). A systematic review of
mindfulness and acceptance-based treatments for social anxiety disorder. Journal of
Clinical Psychology, 71(4), 283-301. doi:10.1002/jclp.22144

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

95

Opriş, D., Pintea, S., García-Palacios, A., Botella, C., Szamosközi, Ş., & David, D. (2012).
Virtual reality exposure therapy in anxiety disorders: A quantitative meta-analysis.
Depression and Anxiety, 29(2), 85-93. doi: 10.1002/da.20910
Orr, S. P., & Roth, W. T. (2000). Psychophysiological assessment: Clinical applications for
PTSD. Journal of Affective Disorders, 6, 225-240.
Ost, L. G., Jerremalm, A., & Johansson, J. (1981). Individual response patterns and the effects of
different behavioral methods in the treatment of social phobia. Behaviour Research and
Therapy, 19, 1–16.
Ougrin, D. (2011). Efficacy of exposure versus cognitive therapy in anxiety disorders:
Systematic review and meta-analysis. BioMed Central Psychiatry, 11(200), 1-12.
doi:10.1186/1471-244X-11-200
Paul, G. (1966). Insight versus desensitization in psychotherapy: An experiment in anxiety
reduction. Palo Alto, CA: Stanford University Press.
Phillips, G. C., Jones, G. E., Rieger, E. R., & Snell, J. B. (1997). Normative data for the personal
report of confidence as a speaker. Journal of Anxiety Disorders, 11(2), 215-20.
Pitman, R. K., Orr, S. P., Forgue, D. F., Altman, B., de Jong, J. B., & Herz, L. R. (1990).
Psychophysiologic responses to combat imagery of Vietnam veterans with posttraumatic
stress disorder vs. other anxiety disorders. Journal of Abnormal Psychology, 99, 49-54.
Pitman, R. K., Orr, S. P., Forgue, D. F., de Jong, J. B., & Claiborn, J. B. (1987).
Psychophysiological assessment of posttraumatic stress disorder imagery in Vietnam
combat veterans. Archives of General Psychiatry, 44, 970-975.
Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74, 116–143.
Powers, M. B. & Emmelkamp, P. M. G. (2008). Virtual reality exposure therapy for anxiety

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

96

disorders: A meta-analysis. Journal of Anxiety Disorders, 22(3). 561-569.
Rauch, S. L., van der Kolk, B., Fisler, R. E., Alpert, N. M., Orr, S. P., Savage, C. R.,…Pitman,
R. K. (1996). A symptom provocation study of posttraumatic stress disorder using
positron emission tomography and script-driven imagery. Archives of General
Psychiatry, 53, 380–387.
Riskind, J. H., Beck, A. T., Brown, G., & Steer, R. A. (1987). Taking the measure of anxiety and
depression: Validity of the reconstructed Hamilton scales. Journal of Nervous and Mental
Disease, 175(8), 474-479.
Rothschild, B. (with Rand, M. L.). (2006). Help for the helper: The psychophysiology of
compassion fatigue and vicarious trauma. New York: Norton.
Scheirer, J. C., Picard, R. W., Tilbury, N., & Farringdon, J. (2002). Sensing and display of skin
conductivity. Cambridge, MA: Massachusetts Institute of Technology.
Schiffer, F. (1998). Of two minds: The revolutionary science of dual-brain psychology. New
York: Free Press.
Schwartz, G. E. (1984). Psychobiology of health: A new synthesis. In B. L. Hammonds & C. J.
Scheirer (Eds.), Psychology and health: Master lecture series Vol. 3 (pp. 149–193).
Washington, DC: American Psychological Association.
Schwartz, G. E. (1990). Psychobiology of repression and health: A systems approach. In J.
Singer (Ed.), Repression and dissociation: Implications for personality theory,
psychopathology, and health (pp. 405–434). Chicago, IL: University of Chicago Press.
Schwartz, M. S., & Andrasik, F. (2003). Biofeedback: A practitioner’s guide. New York:
Guilford Press.
Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mindfulness.

RESEARCH PROTOCOL DEVELOPMENT FOR SAD

97

Journal of Clinical Psychology, 62, 373–386. http://dx.doi. org/10.1002/jclp.20237
Sheldon, B. (2011). Cognitive-behavioural therapy: Research and practice in health and social
care (2nd ed.). New York: Routledge.
Shin, L. M., McNally, R. J., Kosslyn, S. M., Thompson, W. L., Rauch, S. L., Alpert, N. M., …
Pitman, R. K.. (1999). Regional cerebral blood flow during script-driven imagery in
childhood sexual abuse-related PTSD: A PET investigation. American Journal of
Psychiatry, 156, 575-584.
Stein, M. B., Walker, J. R., & Forde, D. R. (1996). Public speaking fears in a community sample:
Prevalence, impact on functioning, and diagnostic classification. Archives of General
Psychiatry, 53(2), 169-174.
Stevens, J. (1996). Applied multivariate statistics for the social sciences (3rd ed.). Boston:
Houghton Mifflin.
Strauss, C., Cavanagh, K., Oliver, A., & Pettman, D. (2014). Mindfulness-based interventions for
people diagnosed with a current episode of an anxiety or depressive disorder: A metaanalysis of randomized controlled trials, PLOS One, 9(4).
Tarico, V. S., van Velzen, D. R., & Altmaier, E. M. (1986). Comparison of thought-listing rating
methods. Journal of Counseling Psychology, 33(1), 81-3.
Taylor, S., Thordarson, D. S., Maxfield, L., Fedoroff, I. C., Lovell, K., & Ogrodniczuk, J.
(2003). Comparative efficacy, speed, and adverse effects of three PTSD treatments:
Exposure therapy, EMDR, and relaxation training. Journal of Consulting and Clinical
Psychology, 71(2), 330-338. doi:10.1037/0022-006X.71.2.330

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Tran, U. S. & Gregor, B. (2016). The relative efficacy of bona fide psychotherapies for posttraumatic stress disorder: A meta-analytical evaluation of randomized controlled trials.
BioMed Central Psychiatry, 16(266). doi: 10.1186/s12888-016-0979-2
Turner, S. M., Beidel, D. C., & Larkin, K. T. (1986). Situational determinants of social anxiety in
clinical and nonclinical samples: Physiological and cognitive correlates. Journal of
Consulting and Clinical Psychology, 54, 523–527.
van der Kolk, B. A. (2001). The psychobiology and psychopharmacology of PTSD. Human
Psychopharmacology of Clinical Experience, 16, 49–64.
van der Kolk, B. A. (2002). Beyond the talking cure: Somatic experiences, subcortical imprints
and the treatment of trauma. In F. Shapiro (Ed.), EMDR as an integrative psychotherapy
approach: Experts of diverse orientations explore the paradigm prism (pp. 57–83).
Washington, DC: American Psychological Association.
van der Kolk, B. A., Hopper, J. W., & Osterman, J. E. (2001). Exploring the nature of traumatic
memory: Combining clinical knowledge with laboratory methods. Journal of Aggression,
Maltreatment, and Trauma, 4(2), 9-31.
Vøllestad, J., Nielsen, M. B., & Nielsen, G. H. (2012). Mindfulness- and acceptance-based
interventions for anxiety disorders: A systematic review and meta-analysis. British
Journal of Clinical Psychology, 51(3), 239-260. doi:10.1111/j.2044-8260.2011.02024.x
Wersebe, H., Sijbrandij, M., & Cuijpers, P. (2013). Psychological group-treatments of social
anxiety disorder: A meta-analysis. Plos ONE, 8(11), doi:10.1371/journal.pone.0079034
Wild, J., Hackmann, A., & Clark, D. M. (2008). Rescripting early memories linked to negative
images in social phobia: A pilot study. Behavior Therapy, 39(1), 47-56.
doi:10.1016/j.beth.2007.04.003

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Williams, K. (2006). A comparative experimental treatment outcome study: Female survivors of
sexual assault suffering from posttraumatic stress disorder, depression, and traumarelated guilt – Self-report and psychophysiological measures (Unpublished master’s
thesis). Trinity Western University, Langley, B.C.
Wolitzky, D. L. (2011). Psychoanalytic theories of psychotherapy. In J. C. Norcross, G. R.
VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim
(Eds.), History of psychotherapy: Continuity and change (2nd ed., pp. 65-100).
Washington, DC: American Psychological Association. doi:10.1037/12353-003
Wolpe, J. (1995). Reciprocal inhibition: Major agent of behavior change. In W. T. O'Donohue &
L. Krasner (Eds.), Theories of behavior therapy: Exploring behavior change (pp. 23-57).
Washington, DC: American Psychological Association. doi:10.1037/10169-002
Yehuda, R. (1997). Sensitization of the hypothalamic-pituitary-adrenal axis in posttraumatic
stress disorder. Annals of the New York Academy of Sciences, 821, 57–75.
doi:10.1111/j.1749– 6632.1997.tb48269.x
Yehuda, R. (Ed.) (2002). Treating trauma survivors with PTSD. Washington, DC: American
Psychiatric Publishing.

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APPENDIX A: Research Design Diagram
Please note that this diagram includes research design aspects which are beyond the scope of this
thesis document but which will be included in future reports on this data.

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APPENDIX B: Polyvagal Theory Diagram

101

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APPENDIX C: Polyvagal Theory Applied to OEI Treatment Diagram

102

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APPENDIX D: Polyvagal Theory Applied to BRAIN Treatment Diagram

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Appendix E: A Conceptual/Theoretical Summary of OEI
Prepared by

Dr. Rick Bradshaw
(February 2017)
______________________________________________________________________________
Observed and Experiential Integration (OEI) can be considered from a number of
theoretical perspectives (Bradshaw, Cook, & McDonald, 2011). In this brief review, the major
theoretical lenses through which OEI can be understood are presented, starting with a
Behavioural/ Neurobiological lens, because it is so foundational to understanding how and why
OEI “works”.
Behavioural/Neurobiological
It is believed that interoceptive states associated with amygdaloid arousal become
classically conditioned with relative states of tension in the extraocular and intraocular muscles
of trauma survivors (including the left and right levator palpebrae superioris muscles which raise
and lower the eyelids). This is achieved through the mechanism of ocular proprioception.
Proprioceptive neurons, which exist in large numbers and high densities in the muscles of the
eyes and the neck, send messages back to the brain indicating the relative positions and
movements of the eyes. Intraocular muscles that constrict and dilate the pupil, and adjust tension
in the lenses of the eyes, send messages that indicate whether people or objects were approaching
or moving away (and the distances from the eyes of those people and objects) at the times trauma
survivors were most overwhelmed (i.e., in states of amygdaloid arousal).
When trauma survivors revisit the times in their lives when they were most overwhelmed
(i.e., when their bodies were adrenalized) by thinking about the faces of people, scenes or places,

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and even somato-affective states, their eyes typically respond by blinking, halting, or skipping in
response to movement sequences guided by therapists. In this way, clients and their therapists
can identify movement patterns, locations in the visual fields, and distances from the eyes, that
are now (and were then, during traumas) associated with physical and emotional intensity. By
guiding the eyes in directions opposite to those associated with the original traumas, typically the
intensity that patients experience diminishes in a matter of minutes or hours (depending on how
early and how intense these experiences were).
In the 68-page foundational article on OEI (Bradshaw, Cook, & McDonald, 2011), other
neurobiological mechanisms are suggested for the remaining four sets of OEI techniques.
Psychoanalytic/Psychodynamic
The neurobiological/behavioural foundation of OEI theory is supplemented by
assimilation of a number of psychoanalytic/psychodynamic concepts. Recently, there have been
entire psychotherapies based on exploration and resolution of transference reactions. One
evidence-based therapy for treatment of patients with personality disorders is known as
“Transference-Focused Psychotherapy” (Yeomans, Clarkin, & Kernberg, 2002). It is based on
years of theoretical work by object relations therapist Otto Kernberg (Clarkin, Yeomans, &
Kernberg, 1999; Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989; Koenigsberg,
Kernberg, Stone, Appelbaum, Yeomans, & Diamond, 2000).
During early applications of OEI, it was discovered that many patients with early and
severe abuse and neglect manifested negative transference reactions toward their therapists.
These can be detected by having patients simply cover one of their eyes and look at the therapist,
and then switch to cover the other eye and compare their perceptions of the therapist. It is not
unusual, particularly in patients with personality disorders, to see major differences in the visual

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perceptions that clients have of their therapists, depending on which I is covered. Typically, this
manifests as differences in perceived physical distance from the therapist, and/or differences in
appearance of the therapist (e.g., critical and angry with one eye open, but accepting and warm
with the other eye open). In extreme cases, the therapist may appear to have no face with one
eye open, or to appear as if she or he is a past abuser).
Therapeutically, the great benefit of OEI is that these negative transference reactions can
usually be quickly resolved in a matter of minutes, simply by continuing to switch between
covering the left and right eyes. This procedure has been extended to couples therapy, and even
to resolution of distorted body image with mirror work for patients afflicted with eating
disorders.
It is certainly not difficult to appreciate the value of such procedures, as they improve the
therapeutic relationship (i.e., remove perceptual distortions that prevent experiences of trust and
caring with the therapist). So much research has been done that clearly demonstrates the
centrality of therapeutic rapport to treatment outcome (explaining approximately 65% of the
variance in treatment outcome). One of the primary researchers and writers associated with this
foundation in psychotherapeutic effectiveness is John Norcross (2010).

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References
Bradshaw, R. A., Cook, A., & McDonald, M. J. (2011). Observed & experiential integration
(OEI): Discovery and development of a new set of trauma therapy techniques. Journal of
Psychotherapy Integration, 21(2), 104-171.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (1999). Psychotherapy for borderline
personality. New York: J. Wiley and Sons.
Kernberg, O. F., Selzer, M. A., Koenigsberg, H. A., Carr, A. C., & Appelbaum, A. H. (1989).
Psychodynamic psychotherapy of borderline patients. New York: Basic Books.
Koenigsberg, H. W., Kernberg, O. F., Stone, M. H., Appelbaum, A. H., Yeomans, F. E., &
Diamond, D. D. (2000). Borderline patients: Extending the limits of treatability. New
York: Basic Books.
Norcross, J. C. (2010). The therapeutic relationship. In Duncan, B. L., Miller, S. D., Wampold,
B. E., & Hubble, M. A. (Eds.). The heart and soul of change: Delivering what works in
therapy (2nd ed.), (pp. 113-141). Washington, DC: American Psychological Association.
http://dx.doi.org/10.1037/12075-004
Wieser, M. J., Pauli, P., Reicherts, P., & Mühlberger, A. (2010). Don't look at me in anger!
Enhanced processing of angry faces in anticipation of public speaking. Psychophysiology,
47(2), 271-280. doi:10.1111/j.1469-8986.2009.00938.x
Yeomans, F. E., Clarkin J. F., & Kernberg, O. F. (2002). A primer of transference-focused
psychotherapy for the borderline patient. Northvale, NJ: Jason Aronson.

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APPENDIX F: Participant Background Information
The following information is to provide descriptive data about the participants in this study.

1) What is your sex? Please circle.

Male

Female

2) What is your gender (if different from above)?

3) What is your Age? Please write your date of birth (month/day/year) as well.

4) What is your Ethnicity?

5) What is your Culture?

6) What is your religious affiliation?

7) What is your highest level of education? Please circle.

___ Less than Grade 10

___ Bachelors Degree

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___ Completed Grade 10

___ Masters Degree

___ High School Graduate or GED

___ Ph. D, Doctorate, M.D.

___ Some College/Associate Degree/Diploma

___ Other: _____________

8) What is your occupation?

9) Are you currently taking any medication? Please list below, including purposes.

______________________________________________________________________________

______________________________________________________________________________

10) Have you ever been hospitalized for mental health reasons? __________________

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Electroencephalographic Information
The following information will provide direction for the psychophysiological assessments.
1) Dominant hand (circle)?

Right

Left

2) Dominant eye (circle)?

Right

Left

3) Nasion to Inion measurement?

_______________

4) 50% of this for Nasion to Cz _______________
5) 10% of 3) above (for 10-20) _______________
6) 2 x 5) above (20% of 3) above

_______________

---------------------------------------------------------------------------------------------------------------------

(Please Tear off This Portion of the Page and Refer to it Before Assessments)

During electroencephalographic assessments, it is important for the electrodes (sensors on scalp)
to make good contact. For this reason, please avoid use of hair sprays and gels on assessment
days.

In addition, please avoid drinking beverages or eating foods that contain caffeine (coffee, tea,
chocolate) for 2 hours before assessments.

Thank you for your cooperation with these procedures.

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APPENDIX G: Dissociative Experiences Scale
Eve Bernstein Carlson, Ph.D.

Frank W. Putnam, M.D.
DIRECTIONS

This questionnaire consists of twenty-eight questions about experiences that you may have in
your daily life. We are interested in how often you have these experiences in your daily life. It
is important, however, that your answers show how often these experiences happen to you when
you are not under the influence of alcohol or drugs. To answer the questions, please determine
to what degree the experience described in the question applies to you and mark the line with a
vertical slash at the appropriate place, as shown in the example below.
Example:
0% l…......................................................./...........................................................l 100%

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Date:________________ Age: _________________ Sex: M F ______________
1. Some people have the experience of driving a car and suddenly realizing that they don’t
remember what has happened during all or part of the trip. Mark the line to show what
percentage of the time this happens to you.
0%.......................................................................................100%
2. Some people find that sometimes they are listening to someone talk and they suddenly
realize that they did not hear part or all of what was said. Mark the line to show what
percentage of the time this happens to you.
0%......................................................................................100%
3. Some people have the experience of finding themselves in a place and having no idea
how they got there. Mark the line to show what percentage of the time this happens to
you.
0%......................................................................................100%
4. Some people have the experience of finding themselves dressed in clothes that they don’t
remember putting on. Mark the line to show what percentage of the time this happens to
you.
0%......................................................................................100%
5. Some people have the experience of finding new things among their belongings that they
do not remember buying. Mark the line to show what percentage of the time this happens
to you.
0%.......................................................................................100%
6. Some people sometimes find that they are approached by people that they do not know
who call them by another name or insist that they have met them before. Mark the line to
show what percentage of the time this happens to you.
0%.......................................................................................100%
7. Some people sometimes have the experience of feeling as though they are standing next
to themselves or watching themselves do something and they actually see themselves as
if they were looking at another person. Mark the line to show what percentage of the
time this happens to you.
0%.......................................................................................100%

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8. Some people are told that they sometimes do not recognize friends or family members.
Mark the line to show what percentage of the time this happens to you.
0%.......................................................................................100%
9. Some people find that they have no memory for some important events in their lives (for
example, a wedding or graduation). Mark the line to show what percentage of the time
this happens to you.
0%.......................................................................................100%
10. Some people have the experience of being accused of lying when they do not think that
they have lied. Mark the line to show what percentage of the time this happens to you.
0% ……………………………………………………… 100%
11. Some people have the experience of looking in a mirror and not recognizing themselves.
Mark the line to show what percentage of the time this happens to you.
0% ……………………………………………………….100%
12. Some people have the experience of feeling that other people, objects, and the world
around them are not real. Mark the line to show what percentage of the time this happens
to you.
0% ……………………………………………………….100%
13. Some people have the experience of feeling that their body does not seem to belong to
them. Mark the line to show what percentage of the time this happens to you.
0% ………………………………………………………..100%
14. Some people have the experience of sometimes remembering a past event so vividly that
they feel as if they were reliving that event. Mark the line to show what percentage of the
time this happens to you.
0%......................................................................................100%
15. Some people have the experience of not being sure whether things that they remember
happening really did happen or whether they just dreamed them. Mark the line to show
what percentage of the time this happens to you.
0%................................................................................100%
16. Some people have the experience of being in a familiar place but finding it strange and
unfamiliar. Mark the line to show what percentage of the time this happens to you.
0%................................................................................100%

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17. Some people find that when they are watching television or a movie they become so
absorbed in the story they are unaware of other events happening around them. Mark the
line to show what percentage of the time this happens to you.
0%................................................................................100%
18. Some people find that they become so involved in a fantasy or daydream that it feels as
though it were really happening to them. Mark the line to show what percentage of the
time this happens to you.
0%................................................................................100%
19. Some people find that they sometimes are able to ignore pain. Mark the line to show
what percentage of the time this happens to you.
0%.................................................................................100%
20. Some people find that they sometimes sit staring off into space, thinking of nothing and
are not aware of the passage of time. Mark the line to show what percentage of the time
this happens to you.
0%.................................................................................100%
21. Some people sometimes find that when they are alone they talk out loud to themselves.
Mark the line to show what percentage of the time this happens to you.
0%....................................................................................100%
22. Some people find that in one situation they may act so differently compared with another
situation that they feel almost as if they are two different people. Mark the line to show
what percentage of the time this happens to you.
0%....................................................................................100%
23. Some people sometimes find that in certain situations they are able to do things with
amazing ease and spontaneity that would usually be difficult for them (for example,
sports, work, social situations, etc.). Mark the line to show what percentage of the time
this happens to you.
0%..................................................................................100%
24. Some people sometimes feel that they cannot remember whether they have done
something or have just thought about doing that this (for example, not knowing whether
they have just mailed a letter of have just thought about mailing it). Mark the line to
show what percentage of the time this happens to you.
0%.................................................................................100%

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25. Some people find evidence that they have done things that they do not remember doing.
Mark the line to show what percentage of the time this happens to you.
0%.................................................................................100%
26. Some people sometimes find writings, drawings, or notes among their belongings that
they must have done but cannot remember doing. Mark the line to show what percentage
of the time this happens to you.
0%...............................................................................100%
27. Some people sometimes find that they hear voices inside their head that tell them to do
things or comment on things they are doing. Mark the line to show what percentage of
the time this happens to you.
0%...............................................................................100%
28. Some people sometimes feel as if they are looking at the world through a fog so that
people and objects appear far away or unclear. Mark the line to show what percentage of
the time this happens to you.

0%..........................................................................100%

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To score: Add percentages from all the questions together and divide by 28.
If score is > 25 < 40 = BPD range.
If score is > 40 = DID (MPD) range.
But …. Actual dissociation could be much higher than reported due to client’s lack of awareness
re: his/her own dissociation. In these cases you will usually see evidence of in it the oral
administration.

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APPENDIX H: Personal Report of Confidence as a Speaker
This instrument is composed of 30 items regarding your feelings of confidence as a speaker.
After each question there is a “true” and “false.” Try to decide whether “true” or “false” most
represents your feelings associated with your most recent speech, then put a circle around the
“true” or “false.” Remember this information is completely confidential and will not be made
known to any professors. Work quickly and don’t spend much time on any one question. Your
first impression is what counts.
T

F

I look forward to an opportunity to speak in public.

T

F

My hands tremble when I try to handle objects during a speech.

T

F

I am in constant fear of forgetting my speech.

T

F

Audiences seem friendly when I address them.

T

F

While preparing for a speech I am in a constant state of anxiety.

T

F

At the conclusion of a speech I feel that I have had a pleasant
experience.

T

F

I dislike to use my body and voice expressively.

T

F

My thoughts become confused and jumbled when I speak before an
audience.

T

F

I have no fear facing an audience.

T

F

Although I am nervous just before getting up to give a speech.

T

F

I face the prospect of making a speech with complete confidence.

T

F

I feel that I am in complete possession of myself while speaking.

T

F

I prefer to have notes with me in case I forget my speech.

T

F

I like to observe the reactions of my audience to my speech.

T

F

Although I talk fluently with friends I am at a loss for words when
giving a speech.

T

F

I feel relaxed and comfortable while speaking to an audience.

T

F

Although I do not enjoy speaking in public I do not particularly dread it.

T

F

I always avoid speaking in public if possible.

T

F

The faces of the audience are blurred when I look at them.

T

F

I feel disgusted with myself after trying to address a group.

T

F

I enjoy preparing a talk.

T

F

My mind is clear when I face an audience.

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T

F

I am fairly fluent.

T

F

I perspire and tense all the while I am speaking before an audience.

T

F

My posture feels strained and unnatural when speaking to an audience.

T

F

I am fearful and tense all the while I am speaking before a group.

T

F

I find the prospect of speaking before a group mildly pleasant.

T

F

It is difficult for me to calmly search my mind for the right words to
express my thoughts in front of a group.

T

F

I am terrified at the thought of speaking before a group.

T

F

I have a feeling of alertness in facing a group.

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APPENDIX I: Trauma Scene Form
(for Script-Driven Symptom Provocation)
We would like you to write a description of the most traumatic event you have experienced in
your life associated with public speaking. We may ask you more detail about this experience
later.
If you find it difficult to think of something to write, it may help to close your eyes and imagine
yourself back in the situation. Try to generate the same sensations and feelings that you
experienced at the time. While the image is vivid in your memory, jot down the details of the
scene and the sensations you experienced at the time. Also, on the next page are bodily
experiences you may have had; please circle any that apply.
Describe the traumatic situation. Include such details as when it happened (age and date), where
you were, who was there (names), what you were doing, how things looked, what you heard,
what you were feeling, etc. Please do not guess or include anything about which you are not
positive.
Please write things in the order they happened, and include bodily sensations from the next page
at the appropriate times (turn the page to that first). Continue your description on the reverse
side of this page if necessary.

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Listed below are a number of bodily sensations that people may experience in various
situations. Please circle all of the responses that you experienced in the situation you
described, and include several in your description.

heart stops

feel tense all over

jittery

feel relaxed all over

butterflies in stomach

calm

tension in forehead

cramps in stomach

clenched fist

constriction in chest

tension in back

breath faster

shallow breathing

breath slower

grit my teeth

pant

clenched jaw

feel relaxed all over

stomach is in a knot

gasping for air

heart skips a beat

laboured breathing

tension in the arms

feel restless

nauseous

feel tense all over

head pounds

tension in forehead

tightness in the face

hands trembling

heart pounds

heart beats slower

heart races

heart quickens

feel sweaty

palms are clammy

beads of perspiration

sweat pours out

feel warm

clenched fist

tension in back

grit my teeth

clenched jaw

feel hot all over

tension in the arms

flushed face

eyes water

body feels heavy

eye twitches

eyes burn

tightness in the face

hands trembling

eyes wide open

whole body shakes

blood rushing to head

arms & legs warm and relaxed

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APPENDIX J: EEG and EDA Protocol

Electroencephalogram and Electrodermal Activity Assessment Script
The exact sequence of recording sites and activities, in the Electroencephalogram and
Electrodermal ActivityAssessment script, are as follows. All measurements within each task are
gathered during the same one minute period the task runs. Each assessment is 3 minutes in total.
Baseline Assessment
Task 1
Channel C: C4: Eyes Open (1 minute)
Channel D: T4: Eyes Open (1 minute)
Channel E: E1 & E2: Eyes Open (1 minute)
Task 2
Channel C: C4: Eyes Open (1 minute)
Channel D: T4: Eyes Open (1 minute)
Channel E: E1 & E2: Eyes Open (1 minute)
Task 3
Channel C: C4: Eyes Open (1 minute)
Channel D: T4: Eyes Open (1 minute)
Channel E: E1 & E2: Eyes Open (1 minute)
Symptom Provocation Assessment
Task 1
Channel C: C4: Eyes Open (1 minute)
Channel D: T4: Eyes Open (1 minute)
Channel E: E1 & E2: Eyes Open (1 minute)
Task 2
Channel C: C4: Eyes Open (1 minute), play Script Driven Symptom Provocation Audio Track
Channel D: T4: Eyes Open (1 minute), play Script Driven Symptom Provocation Audio Track
Channel E: E1 & E2: Eyes Open (1 minute), play Script Driven Symptom Provocation Audio
Track
Task 3
Channel C: C4: Eyes Open (1 minute)
Channel D: T4: Eyes Open (1 minute)
Channel E: E1 & E2: Eyes Open (1 minute)

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APPENDIX K: Timed Behavioural Checklist
Behaviour Observed

Time Period
1

1) Paces
2) Sways
3) Shuffles feet
4) Knees tremble
5) Extraneous arm/hand motion
6) Arms rigid
7) Hands restrained
8) Hand tremors
9) No eye contact
10) Face muscles tense
11) Face “deadpan”
12) Face pale
13) Face Flush
14) Moistens lips
15) Swallows
16) Clears throat
17) Breathes heavily
18) Perspires
19) Voice quivers
20) Speech blocks or stammers
21) Rate changes
22) Topic Changes
Total:

2

3

4

5

6

7

8

Σ

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APPENDIX L: Recruitment Poster

123

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APPENDIX M: Informed Consent Form
Confidence to be Heard: An efficacy pilot study using Observed and Experiential Integration
(OEI) for the treatment of anxiety related to public speaking

Investigators
Stephanie Hall
MA Counselling Psychology Program
Trinity Western University
Dr. Richard Bradshaw
MA Counselling Psychology Program
Trinity Western University
Mihaela Launeanu
MA Counselling Psychology Program
Trinity Western University
Dr. Marvin McDonald
MA Counselling Psychology
Program
Trinity Western University
Todd Dutka
Department of Psychology
Trinity Western University
Andria Weiser
PhD Clinical Psychology Program
Antioch University
Michele Gruenhage
Bestmarriages.ca
Laverna Wilk
Bestmarriages.ca
Dr. Julie Lane
School Psychologist
Maple Ridge School District
Ya-Chun Chi
MA Counselling Psychology Program
Trinity Western University

Hannah Calayan
Undergraduate Psychology Student
Trinity Western University

Purpose of the Project
Public speaking anxiety is exceptionally common, affecting one third of the population in
community surveys (Kessler, Stein, & Berglund, 1998; Stein, Walker, & Forde, 1996).
Observed & Experiential Integration (OEI) is a new treatment for psychological trauma
(Bradshaw, Cook, & McDonald, 2011) which has been subjected to two randomized controlled
trials (Bradshaw, McDonald, Grace, Detwiler, & Austin, 2014; Bradshaw, McDonald, Williams
et al., in preparation) and found to be an effective treatment for Posttraumatic Stress Disorder
(PTSD). Another treatment that has been found to be effective for reducing PTSD is referred to
as “BRAIN”, which stands for: Breathing, Relaxation, Autogenics, Imagery, and grounding. In
years of clinical practice, OEI and BRAIN have been used successfully to treat public speaking
anxiety (usually in 1-7 sessions). To follow up these promising clinical observations, this study
constitutes the first formal investigation of OEI to treat public speaking anxiety. Behavioural
(actual public speaking analysis) and psychophysiological (brainwave and skin conductance)
evaluations will supplement self-report (questionnaire and interview) measures.
Procedures
There will be two phases in the project:
1. Treatment #1 – 2-hour small group information/practice session followed by seven individual
sessions;
2. Treatment #2 – 2-hour small group information/practice session followed by seven individual
sessions;
You will be randomly assigned to one of two groups: 1) Treatment #1 first, or 2) Treatment #2
first. You will complete pretreatment, posttreatment I, and posttreatment II assessments. At
each assessment, you will deliver a short (5-minute) prepared speech to a small audience (up to
four people), and the video recordings of those talks will be analyzed for specific behaviours.
During each assessment period, you will also complete two quantitative electroencephalographic
assessments to assess brainwave activity, and two palmar electrodermal activity assessments (a)
when relaxed, and (b) when anticipating giving a short speech. These evaluations simply involve
measuring tiny electrical signals from your scalp and from the palm of one of your hands.
During the evaluations just prior to giving a short speech, you will also listen to a short (50second) audio recording from your own description of an event earlier in your life that was very
stressful and involved public speaking. Assessments will also include paper-and-pencil
questionnaires, and short interviews. Assessments will be delivered by trained individuals who
are unaware of which treatment group you have been assigned to, so it will be very important
during the assessments not to talk about (describe or name) the treatments you have received
with the assessors.

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Confidentiality
Your identity, and all of your scores, will be kept confidential. Only the Investigators and
Research Assistants will have access to this information. The one exception to this assurance
involves attendance at the two 2-hour psychoeducational group sessions which you will attend
with five other participants in the study. Even though all participants are assuring that they will
not disclose the identities of other participants, this cannot be guaranteed by the investigators in
this research study. You may choose to use a pseudonym during that group time if you are
uncomfortable using your own first name. All researchers and research assistants who have
access to your confidential information will sign a confidentiality agreement to keep your
identity and all of your information confidential. All hard copies of data will be kept in a locked
file cabinet in a locked room in a secure (locked at night) building. All digital copies of data will
be stored in a password-protected file on a password-locked computer. After analysis of video
recordings of speech tasks and assessment sessions involving brainwave recording, those video
recordings will be deleted, and your data will only be saved by participant number. The
intention is to keep the data in that form for ongoing analysis over a period of 10 years from
completion of the data collection portion of the study.
Information disclosed in assessment and therapy sessions is confidential, with the following
exceptions: Threat to self (suicide risk); Threat to other (homicide risk and duty to warn);
Suspicion of child abuse; Intent to drive a motor vehicle while intoxicated by alcohol or drugs; or
Intent to have unprotected sexual contact or share IV drug needles, when infected by HIV and/or
diagnosed with AIDS; and court subpoena of records.
Time Commitment
In addition to the phases mentioned above, there are several stages in this study.
The initial stage constitutes the screening process, during which a series of self-report
instruments will be used to decide eligibility for the study. This portion should take roughly an
hour plus any time spent asking questions of, or responding to questions from, Research
Assistants.
Each assessment period will take approximately 4-7 hours, spread over two days.
The group receiving Treatment #1 first, will receive a 2-hour psychoeducational session about
Treatment #1, with time to practice those skills. The group receiving Treatment #2 first, will
receive a 2-hour psychoeducational session about Treatment #2, with time to practice those
skills.
You will then receive seven hours of individual treatment sessions.
A second assessment period will follow, which will include a series of interview questions in
addition to all of the measures used in the pretreatment assessment period.
You will then receive a 2-hour psychoeducational session about the second treatment, followed

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by seven hours of individual therapy with the second treatment (which will differ, depending on
which group you have been assigned to).
Finally, there will be a second posttreatment assessment period, during which you will be asked
a series of interview questions about your views on the therapy you have received, and the other
assessment instruments and procedures from the pretreatment assessment.
At the end of the study, you are encouraged (but not required) to book an appointment with a
research team member for a debriefing meeting. These appointments typically last an hour.
These stages add to a time commitment of 35 hours spread over four months from January 2016
through April 2016.
Potential Discomfort
Since one of the treatments (OEI) involves movement of the eyes, if you suffer from any eyerelated condition that could be aggravated by eye movement (including brain surgery in the area
of the eyes) it will be important to inform your OEI therapist in the study, who can consult with
your ophthalmologist for his/her approval before proceeding with these techniques.
As with any therapy involving assessment or treatment of anxiety or stress, you may experience
psychological distress at some point as you recall events, people, and situations that upset you.
During OEI we try to keep this distress as low as possible (moderate) while still allowing you to
process the traumas that disturb you. You will be asked to focus on those events, or on current
feelings that are distressing, while you have both eyes open, and also while you have each eye
open separately.
During these OEI procedures, people sometimes experience transient symptoms such as
headaches, visual distortions, and stomach or chest tension. These generally fade within 30-60
minutes, and more often within 5 minutes. In addition, it is possible that recall of upsetting
incidents will trigger numbing symptoms, such as feeling drowsy, light-headed, or tingling in
your hands, face, or feet. Again, such symptoms normally subside within 30-60 minutes and
more commonly within 5-10 minutes.
Based on clinical experience, these procedures are effective for reducing anxiety and stress
symptoms. It is reasonable to alleviate the intensity of many of your symptoms in 7 sessions, but
if you have had many previous traumatic experiences, or if you have an extensive mental health
history (e.g., hospitalization, suicidality, or bipolar disorder) you should not expect all of your
psychological symptoms to be gone in such a relatively short course of treatment. For this
reason, it is very important to describe your mental health history, provide contact information
for other health and mental health professionals from whom you have received care recently, and
(at some point early in your treatment) sign a consent form for exchange of information between
providers who may be addressing your psychological symptoms (e.g., psychologist, psychiatrist,
other counsellor, or GP physician.

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Benefits for You
This is an opportunity to work through experiences which cause public speaking anxiety with a
skilled therapist, free of charge. The effects of this study are expected to improve your life by
helping you to process anxiety related to public speaking, and enable you to enter skill-based
programs (like Toastmasters) or to learn public speaking skills. In the long run, this could
improve your employment status, future education, income, and even satisfaction with your own
abilities and goal achievement.
You will also receive training in relaxation and grounding techniques which can help you
manage stress in this, and other areas, of your life.
Further Information
If you have any questions or desire further information with respect to this study, you may
contact Stephanie Hall or one of her associates at stephanie.hall@mytwu.ca.
If you have any concerns about your treatment or rights as a research participant, you may
contact Ms. Sue Funk in the Office of Research, Trinity Western University at 604-513-2142 or
sue.funk@twu.ca.
Even after you consent to participate in this study by signing below, you may choose to stop
doing OEI or any other treatment, at any time, without consequence. In order to withdraw from
the study you must simply notify the Principal Investigator, Stephanie Hall, in writing. Your
signature below affirms that you have read and understood the description of the therapy, and
you willingly consent to the use of these procedures to reduce your posttraumatic distress related
to public speaking anxiety and other anxiety-related problems.
If you withdraw from the study, data collected from you will be stored in the same confidential
way described earlier in this consent form.
Your signature below indicates that you have had your questions about the study answered to
your satisfaction, and have received a copy of this consent form for your own records.
Your signature indicates that you consent to participate in this study, and that your responses
may be put in anonymous form and kept for further use for 10 years, after the completion of this
study.
Name: ________________________________

Date: __________________________

Witness: ______________________________

Date: __________________________

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APPENDIX N – Palm Electrode Placement

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APPENDIX O: OEI Power Point Information
Observed & Experiential Integration (OEI): To Resolve Public Speaking Anxiety
Audrey Cook, MPhil
Rick Bradshaw, PhD
Public Speaking Anxiety Starts with Relational Trauma:
a. Criticism & Rejection
b. Humiliation/Embarassment
i. Presentations in Classes
ii. Recitals & Performances
iii. Team or Club Activities
iv. First Group: Starting School
Now gets triggered:
• Standing up front
• Faces of Many People
• Eyes Looking at You
• Any Performance
• Authority Figures
Trauma Is…
Negative Unexpected Makes You Feel:
Powerless, Confused, or Out of Control
Broca’s Area: Speech Production
Limbic & Paralimbic Structures
• The parts of the brain most involved in producing intense symptoms, like:
• Panic, flashbacks, startle response, nausea, and throat or chest constriction
• Are not directly affected by talking or listening
Limbic System: Midbrain
Anterior Cingulate Gyrus
5 Building Blocks of OEI
Level I Techniques
• Switch
• Sweep
• Release Points
Level II Techniques
• Glitch Hold
• Glitch Massage

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Core Trauma vs Dissociative Artefacts
CORE TRAUMA SYMPTOMS (Fight, Flight, or Freeze)
• Constriction in Throat (Airway)
• Bronchoconstriction in Chest
• Nausea or Queasiness in Stomach
• Racing Heart Rate, Rapid Breathing, Perspiration, Shaking, Fear/Anxiety
*Note that all of these symptoms are experiencedin the core of the body…(hence CORE
DISSOCIATIVE ARTEFACTS (Side Effects of Processing Intensity)
• Headaches & Pressure in the Head
• Visual Distortions, Blocks, & Blurring
• Dizziness, Drowsiness, Loss of Balance
• Tingling & Numbness in the Hands, Face, & Feet
• Yawning
• Sinus Pressure
Video Demo – Public Speaking
• Switching to reduce trauma intensity
• Glitch massage to resolve points of intensity, using the eyes to access past relational traumas
Examples - Transference
• Audience Member Faces
• Group Leaders
• Photographs
• Mirrors
Eye Dominance Check
Arms Length, Two Fingers Vertical, Both Eyes Open
Line up vertical fingers with straight edge in distance
Without moving fingers, close one eye, then open it
Without moving fingers, close the other eye, then open it
Which eye was open when the straight edge was in line?
Many people report: higher levels of shock/fear/anxiety with their dominant eye open higher
levels of sadness/despair/hopelessness with the other eye open
Activity: Try This in Pairs
Transference Check & Clearance
• Proximity: Notice how far away I appear to you
• Appearance: Notice how I look to you (color, expression)
• Body/Emotion: Notice how you feel physically & emotionally
• Cognitive Proj: Notice whether it seems like I’m on your side…
Try sitting, standing, different people (gender, race, age, etc.)
Try moving a small amount closer, further away, diff. angles
Polyvagal Theory: Stephen Porges (2001/2007) 3 Response Levels
Social Connection - Ventral Vagal Brake “On”

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Fight-or-Flight - Ventral Vagal Brake “Off” (SNS)
Freeze - Dorsal Vagal Complex – (DVC)

Coactivation of SNS & PNS
• “Tonic Immobility” = co-activation of Sympathetic & Parasympathetic Nervous Systems
• In “Freeze” response, frequently changing pupil widths and increases in pulse rate from 60-70
to 110-120 ppm
• Childhood sexual abuse = 50%
• Sexual assault victims 35-40 % some immobility
Classical Conditioning of Trauma
Ocular Proprioception: Angle/Direction/Movement Pattern
Proprioceptors = Nerve cells in muscles sending signals to the brain about muscle positioning.
Exist in large numbers and high densities in 6 muscles outside the eyes that control the
movements of each eye & the neck.
Individual cells fire in response to eye movements tracking objects. Curved movements start
from a different area of the brain than straight vertical, horizontal, or diagonal eye movements.
Vertical Location in Visual Fields
Occular Proprioception
String demo
“Like pulling out a sliver”
Ocular proprioception - Distance
Muscles inside the eyes control:
• Curve & thickness of lenses
• Constriction & dilation of pupils.
What you:
• Sense in your body
• Hear
• See
• Smell
• Feel emotionally
Gets associated into patterns that occurred during events, that are recorded in the brain, then
retrieved & re-mapped on muscles when you recall those events – creating “glitches”.

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Live Demo
Therapist will comment on breathing, reddening of eyes (Social Biofeedback, Attunement)
Glitch “massage” w distal pulls & other movement patterns
Resolutions of Intensity with “Switching” & “Glitch Work”:
• “Glitch Work”, like running the water into the sink from the tap
• “Switching”, like pulling the plug and draining the sink of water
Proximal-distal
• Usually massaging toward the eyes triggers abuse
• Sometimes massaging away triggers abandonment
• Track across the visual field until you see a “glitch”
• Then move vertically until you see another halt or skip
• Then pull out of the centre of that “cross-hair” ( + )
• Keep going until you feel a fluttering of the eyes
• There is often a breath release and shoulder drop
• Sometimes there is an emotional release as well
Release Points
Peak Performance & Homework
Use OEI Techniques at Home or at Work --- on Yourself!
• Think about public speaking in front of an audience.
• Focus on the images and sounds in your mind vividly.
• If necessary, talk out loud about the situation you face!
• When you feel physical & emotional intensity, Switch (eyes)
• Stay longer with the eye open that’s LESS INTENSE, then Switch
• Another way: Vividly imagine what you want to be able to do…
• Notice what gets in the way (thoughts, emotions, sensations)
• Focus on those blocks and Switch or do Glitch Work on yourself
More Info on OEI
Visit our Web site for FAQ videos, books, seminars, resources, memberships, Web site listing of
clinicians, research summaries, information on OEI publications
www.sightpsychology.com

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APPENDIX P: OEI Homework Exercises

OEI Homework Exercises
A.
Already Intense & Thinking About Anxiety
— Think about public speaking in front of an audience.
— Focus on the images and sounds in your mind vividly.
— If necessary, talk out loud about the situation you face!
— When you feel physical & emotional intensity, Switch (eyes)
— Stay longer with the eye open that’s LESS INTENSE, then Switch

B.
“Peak Performance” Approach to OEI Targets
— Vividly imagine what you want to be able to do…(verbally fluid, confident)
— Notice what gets in the way of that goal (thoughts, emotions, sensations)
— Focus on those blocks or interferences and Switch or do Glitch Work

— Go back to A. (Above) to pull down the intensity of the interferences
______________________________________________________________________________
_______

Remember…
• When you’re already intense (anticipational anxiety), cover your dominant eye
• Wait until intensity subsides and you get a spontaneous breath release, then…
• Return briefly to the dominant eye (open), feel the intensity and Switch again

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If:
• You get headaches, head pressure, tingling & numbness (hands/face/feet)
Or:
• Visual side effects (blurring, grey or black blobs in visual fields, double vision)
Then:
• Focus on side effects and Switch (eyes) or Sweep (from ears toward nose)

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APPENDIX Q: Helpful Aspects of Therapy Questionnaire (HAT)

Name (pseudonym): _____________________________ Date __________________________

Thank you for taking the time to fill in the information requested on this form. Please note that
you have the right to choose not to share any information that you choose not to share, and the
right to withdraw your participation from this study.

1. Of what happened in this session, what do you feel was the most helpful or important for you?
(By that we mean something that happened in the session. It might be something you said or did
or something the therapist said or did.)

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2. Please explain what made this event helpful/important and what you got out of it.

3. How helpful was this particular event? Rate it on the following scale. (Put an "X" at the
appropriate point; half-point ratings are OK; e.g., 7.5.)

4. About where in the session did this event occur?

5. About how long did the event last?

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6. Did anything else particularly helpful happen during this session?
☐ Yes ☐ No
a) If yes, please rate how helpful this event was:

☐ Slightly helpful

☐ Moderately helpful
☐ Greatly helpful
☐ Extremely helpful

b) Please describe the event briefly:

7.

Did anything happen during the session that might have been hindering or not helpful?
☐ Yes ☐ No
a) If yes, please rate how hindering the event was: ☐ Extremely hindering
☐ Greatly hindering
☐ Moderately hindering
☐ Slightly hindering

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b) Please describe this event briefly:

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APPENDIX R: BRAIN Power Point Information
B.R.A.I.N.
Treatment Techniques for Public Speaking Anxiety
Breathing, Relaxation, Autogenics, Imagery, & grouNding
Breathing
Breath Support
2)Public Speaking = Projection of Your Voice
3)Anxiety = Shortness/Shallowness of Breath
4)Diaphragmatic Breathing = More Oxygen
5)Diaphragmatic Breathing = More Relaxation
Chest (Thoracic) Breathing: Photo Example
Diaphragmatic Breathing: Photo Example
Diaphragmatic Breathing Exercise
• Chest (thoracic) breathing vs. abdominal (diaphragmatic) breathing
• Hand on stomach should rise more than hand on chest
• “breathe in relaxation…breathe out tension”
Progressive Muscle Relaxation
Progressive Muscle Relaxation
Progressive Muscle Relaxation for Public Speaking Requires “Natural” Relaxed Gestures
• “Fight-or-Flight” response causes muscle tension
• Learn to sense the difference between tense muscles and relaxed ones
Muscle Relaxation (Hands): Video Example
Muscle Group Relaxation
• Head, face, throat & shoulders
• Chest, stomach & lower back
• Thighs, buttocks, calves & feet
• Hands, forearms, & biceps
• Tense for 5 sec. Release for 20 sec.
Autogenics
Autogenics = Opposite of Fight/Flight
• Central Nervous System = Brain & Spinal Cord
• Peripheral Nervous System = SNS + ANS
Somatic Nervous System = Voluntary Muscles
Autonomic Nervous System = Involuntary Muscles

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Sympathetic Division - Fight-or-Flight Response
Parasympathetic Division - Relaxation Response
Autogenics (CNS vs ANS): Anatomic Diagram
Sympathetic vs Parasympathetic: Anatomic Diagram of Organs Effected
Autogenics (with Respiratory Synchronization)
• My breathing is deep and slow
• My heartbeat is slow and regular
• My hands and arms are so warm and so heavy
• My feet and legs are so warm and so heavy
• My forehead is cool and dry
Imagery
Positive Mental Imagery = Relaxation
• Positive Multisensory Mental Imagery
What do you see? Hear? Feel in your body?
• Core Person/Safe Place Exercise
Pair Autogenics with Multisensory Imagery
• Create Protection Around the “Safe Place”
Your brain doesn’t know the difference between the real thing (e.g., favourite food) and a mental
image of that thing.
The same response is generated (saliva, etc)
CORE PERSON / SAFE PLACE EXERCISE
(“Visualize the most calm, safe place you have experienced or can imagine”)
Autogenics
• My hands & arms are warm & heavy
• My breathing is deep & slow
• My heartbeat is slow & regular
• My feet & legs are warm & heavy
• My forehead is cool & dry
Multisensory Imagery
• What do you see? (movement, colour)
• What do you hear? (waves, nature)
• What do you feel? (wind, sun, water)
• What do you smell? (fragrance)
• What do you taste? (drink, food)
Images of A Successful Speech
You can also imagine (using all your senses) giving a wonderful speech. See the looks of
emotion on the faces of audience members. Hear the applause when you are done! Walk
through and mentally rehearse every detail, from walking onto the stage, to confidently stepping
down. Olympic athletes use this when preparing for their events (gymnastics, skiing, high

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diving) because it works!
Multisensory Imagery
The brain has motor areas to actually trigger movement of the muscles. It also has pre-motor
areas that organize the movement sequences and help with muscle memory.
There was a champion golfer who was captured as a prisoner of war. He would go through the
18 holes of a golf game each day in his mind. When released, he played better than he had
before he went in!
Grounding
Grounding: Reconnect to the World in the moment
Not worrying about future performances
Sensate Focus – One Sense at a Time
Cook’s Hook-Ups & Cross-Crawl
Restores Hemispheric Balance in Brain
Lowers Distress
Grounding – Sensate Focus
What do you hear?
What do you see?
What do you feel (touch)?
What do you smell?
What do you taste?
Hearing & Seeing
While waiting to get up and speak, just close your eyes and concentrate ONLY on what you hear
(air conditioning, voices, etc).
While sitting in the audience or backstage, find some colour or object (or person) that is calming
and make that your focus.
Tasting & Touching
Take a favourite flavour of gum or hard candy with you and pop some in your mouth while
waiting. Focus your mind completely on the taste and texture.
Feel the arm of the chair you are in. Feel your feet on the floor, or your back against the chair
you are sitting in. Focus ONLY on those sensations --- in the moment!

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Smell - A Magical Sense for Calming
5 senses: (sight, hearing, touch, taste, & smell)
4 of the 5 senses are processed through the Thalamus (sensory processor) first, but…
One sense is processed through the Amygdala (emotion processor) first…SMELL
Brain Image:
Olfactory Bulb Amygdala
Smell = Emotion Processor
Positive Smells Instantly Calm the Emotions
Floral:
• Rose
• Lavender
• Champa
Citrus:
• Lime
• Lemon
• Orange
Wood:
• Cedar
• Pine
• Spruce
Spice:
• Clove
• Cinnamon
• Vanilla
Get Smells!
• Bring a small bottle of scented oil from three groups of smells (floral, citrus, wood)
• Put a few drops on some Kleenex tissue
• Breathe in the fragrance while waiting to give a speech or perform and it will calm your
emotion processor deep in your brain quickly!
Grounding – Cook’s Hook-ups
• Cross left leg over right with right leg perpendicular to the floor.
• Take right hand and grasp shin between knee and ankle.
• Cross left hand and arm over right hand and arm, and grasp shin closer to ankle
You can do this procedure while sitting and waiting to give a speech or perform and it will help

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keep you calm until you go on stage!
No one can tell what you are doing, because it looks like you are just sitting comfortably with
your legs crossed!
Grounding (Cross-Crawl): Photo Example
You can do a subtle version of this while sitting: Just cross your arms on your lap and alternately
tap the insides or backs of your legs just above your knees.
This is so unobtrusive that you can do it any time while you are waiting to get up and speak.
More Information on BRAIN?
The Relaxation & Stress Reduction Workbook by Martha Davis, Elizabeth Robbins Eshleman &
Matthew McKay Oakland, California: New Harbinger Publications
Brain Gym: Simple Activities for Whole Brain Learning by Paul Erlich Dennison & Gail E.
Dennison Edu-Kinesthetics

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APPENDIX S: BRAIN Techniques

Breathing Relaxation Autogenics Imagery GrouNing
Script for All-Participant Audiotape
prepared by

Rick Bradshaw, Ph.D.
recorded by

Marie Amos, M.A. (Cand.)
Before your start your relaxation session, locate the Amos Relaxation Effectiveness Tracking
Chart and enter the numbers for your “Emotional State (Before)”, “Physical State (Before)” and
“Overall Distress Level (Before)” for the current day of the month.

Good times for this relaxation session may be just before or after dinner, or just before bed. Find
a safe, calm, quiet place with the lights dimmed….and a comfortable, warm temperature. You
may want to use scented oils or candles with soothing fragrances. It might be nice to use pillows
or cushions under or around you.

Start by getting into a comfortable position, sitting or lying down. Place your hand on your
abdomen. As you breathe in, allow your abdomen to rise, lifting your hand. As you breathe out,
allow your hand to lower with your abdomen, as it returns to its original position. Continue this
process, inhaling and exhaling deeply. Close your eyes and take a deep breath in. Breathe in
relaxation, and breathe out tension. Allow yourself to sigh gently, as the air flows from your
lungs.

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With each breath, search your body for tension, and melt it away. Allow yourself to sink back
into the chair, couch or bed, feeling the support under you. As you relax, follow your breathing.
Go to the deepest, calmest place inside…

Notice your hands… With each breath release more tension in your hands…now release the
muscles in your forearms…imagine the tension floating off your forearms…and now your
biceps. Let your arms fall to your sides or in your lap, and relax your biceps. Imagine a warm,
flowing current…with each breath, melting more of the tension away…----…soothing and
smoothing the muscles…calming. Now notice the muscles in your head and face…allow the
tension to float up off your forehead and soften the skin around your eyes…Now notice your
jaw. Let it slacken, and allow your mouth to open comfortably and relax.

Next, relax your throat…”Melt away” tension in your throat, neck, and shoulders. Go through
each of these areas, and release more tension each time you exhale…… Let go of the tension in
your face and jaw …Lift the tension off your forehead and face. Llet it slowly melt away from
your neck and shoulders. Let the tension dissolve away. Continue down your body…”letting
go” of tension and “breathing in” relaxation…to your chest…slowly …your stomach…and your
lower back. Finally, release the tension in your lower body…with each breath …Relax and
smooth the muscles… to your feet….Let the tension flow out of your feet. Allow the tension to
flow out of your body, from the top of your head all the way down, and out though your feet.
Let go more…and more…keep releasing tension as you breathe, until you find absolutely no
trace of tension in your muscles.

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Now that you’re deeply relaxed, go in your mind to your own special retreat for relaxation and
rest. It can be indoors or out. You’ll need a private entry or pathway, and it should be peaceful,
comfortable and safe. Create protection around you and over you, in your mind. Try imagining a
large, in the distance. As you spend time in that place, gradually become aware of the sound of
water & wind. Allow the wind and gentle waves to ebb & flow in time with your breathing…
perfectly synchronized with your breathing in…and breathing out…deep, full, relaxing
breaths…Your breathing is deep… and…slow-w-w…and your heartbeat is slow-w-w…and…
regular…

Feel the sun on your skin…If you’re inside, notice the warmth of the room…Your hands…and
arms…are so-o-o warm, and so-o-o heavy…and your feet and legs…so-o-o warm…and so-o-o
heavy…

There’s a gentle breeze… through your hair… through the trees… and over your forehead. Your
forehead…is cool…and…dry-y-y…. A beautiful fragrance is floating on the
breeze…calming…soothing, peaceful…The fragrance takes you back in your mind to a time
when you rested safely…effortlessly…to a place where you were restored and felt fully alive, in
the most positive way…

Continue to spend time in that calm, restful, safe place…breathing in---deeply, and breathing
out---fully. Breathing is deep…and… slow. Heartbeat is slow…and…regular…Notice the
colours & movement in that place. Choosing the most calming, soothing colour…and allowing
that colour to go all through your body, from the top of your head to the tips of your fingers and
toes…..

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As you focus on that color, allow music or sounds to enter your mind that go most naturally
with the soothing colour. Let that music or sound go all through your body, from the top of your
head to the tips of your toes.

Focus on the colour, sound, and calm, confident feeling, and think of an object or shape and
movement that goes with those feelings, thoughts and images. It might be soaring, bubbling, or
moving effortlessly in slow motion…Just focus on that sense of movement, and feel it all through
your body. Also notice the temperature that’s most comfortable.

Your hands…and arms… are so-o-o warm, and so-o-o heavy… …feet and legs…so-o-o
warm…and so-o-o heavy…forehead…is cool…and…dry-y-y…. That beautiful fragrance is
floating on the breeze…calming…soothing…peaceful…

Become aware of all your senses. Notice which sense activates the rest. It might be
colour…sound…movement… shape… temperature…fragrance…or touch. Focus on one of
your senses in your environment right now…what you hear…or see…or textures & temperatures
you feel with your hands…Block out all of the other senses and just focus…second-bysecond…on what you become aware of…as if you’re noticing life “floating gently by” on a
slow-moving river…Feel the support of the chair, couch or bed under you…Feel the weight of
your feet and hands…

Enjoy more time in your safe, special place: The colours, movement, sounds, fragrances and
temperature all combine to create a restful, relaxing experience. Breathing in relaxation, and

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breathing out tension. Consider returning to the room you started your relaxation session
in….gradually, at your own pace. There’s no rush….Start noticing the sounds in the room and
outside….
.
Cross one leg over the other…and then cross your forearms on the leg that is crossed over the
lower leg...holding the shin closest to you with both hands. Remember “Cook’s Hook-ups”.
Allow a deep sense of peacefulness and relaxation to flow over you… calming…
soothing…restoring. Remember those feelings as you come back and continue your day or
evening. Take that relaxation with you…

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APPENDIX T: Credibility of Treatment Questionnaire
Please circle the corresponding number to answer these questions.
6)

How logical does this type of treatment seem to you?

1
2
Not Logical

3

4

5

6

7

8

9

10
Very Logical

2) How confident are you that this treatment will be successful in eliminating the symptoms of
Public Speaking Anxiety?
1
2
Not Confident

3

4

5

6

7

8

9

10
Very Confident

3) How confident would you be in recommending this treatment to a friend who was suffering
from the symptoms of Public Speaking Anxiety?
1
2
Not Confident

3

4

5

6

7

8

9

10
Very Confident

4) If you were suffering from extremely high levels of Public Speaking Anxiety symptoms,
would you be willing to undergo such treatment?
1
2
Not Willing

3

4

5

6

7

8

9

10
Very Willing

5) How successful do you think this treatment would be in decreasing the symptoms of a
different anxiety disorder, such as Social Anxiety?
1
2
3
Not Successful

4

5

6

7

8

9

10
Very Successful

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APPENDIX U: Post-Treatment Interview
Interview Questions for Posttreatment Assessment #1

Ask each participant the following questions1. Printed in bold are the actual words to ask the
participants and italic print gives directions to the interviewer.

Now I am going to ask you some questions about your therapeutic experience and I will be
recording our conversation. Please be honest and give as much detail in response to each
question as you see fit. Do you have any questions before we start? (If they have questions,
answer them, make a mental note of the question(s), then proceed to Question #1; if they have no
questions proceed to Question #1)

1. How are you doing now as compared to when you entered the study?
2. In what way if any was the therapy helpful to you?
3. Did it have any effect on the issues that you wanted to address?
a. If the participant answered yes to #3, ask them: Do you think that the benefits
gained will be lasting?
4. Did the therapy affect anything else?
5. Were you surprised by anything that has happened since you began the study?
6. Do you think you will need more therapy to resolve your public speaking issues?

1

Questions 1-8 are taken directly from Edmond et al. (2004), p. 264. The remaining questions were added for this
project.

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7. What are your thoughts and feelings about your therapist now?
8. How did the therapy that you received in the study compare to other therapy or
counselling that you have received?
9. What did you like or value the most about the therapy you received?
10. What did you dislike or find least valuable about the therapy you received?
11. Either Option “a” or Option “b” is to be used for this question. DO NOT ASK BOTH
OPTIONS!
a. If the participant has mentioned in any of the previous questions anything about
extra-therapeutic factors (relationships, family, overall disposition, etc.) that are
better ask them: Earlier you mentioned _______ (insert the extra-therapeutic
factor they mentioned earlier) Can you tell me more about that?
i. Ask this in follow up to Option “a” Is there anything else that has
affected your life over the last few months besides therapy?
b. If the participant did not mention anything in the previous questions about
positive impacts on extra-therapeutic factors or they only mentioned negative
effects of the therapy, ask them: So far we have been talking about the therapy
you received. Now I would like to ask you a more general question, okay?
Wait for the participant to respond in the affirmative, and then ask them: What
has been helpful for you over the last few months besides therapy?

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APPENDIX V: Descriptive Statistics
PRCS Descriptive Statistics

Pre-treatment

Post-Treatment

Experimental Group

Mean

Std. Deviation

N

OEI

20.60

3.29

5

BRAIN

22.75

6.08

4

Total

21.56

4.53

9

OEI

16.00

6.29

5

BRAIN

16.50

8.19

4

Total

16.22

6.70

9

Experimental Group

Mean

Std. Deviation

N

OEI

6.80

2.49

5

BRAIN

8.25

8.26

4

Total

7.44

5.41

9

OEI

1.80

1.79

5

BRAIN

11.25

6.99

4

Total

6.00

6.10

9

BDI-II Descriptive Statistics

Pre-treatment

Post-treatment

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BAI Descriptive Statistics

Pre-Treatment

Post-Treatment

Experimental Group

Mean

Std. Deviation

N

OEI

7.00

3.94

5

BRAIN

9.33

0.58

4

Total

7.88

3.23

9

OEI

4.20

2.39

5

BRAIN

10.67

2.89

4

Total

6.00

4.10

9

Experimental Group

Mean

Std. Deviation

N

OEI

36.90

10.79

5

BRAIN

43.75

10.28

4

Total

39.94

10.53

9

OEI

23.00

11.42

5

BRAIN

29.63

11.78

4

Total

25.94

11.37

9

TBC Descriptive Statistics

Pre-treatment

Post-treatment

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APPENDIX W: Treatment and Assessment Protocol Development for Performance Specific
Social Anxiety Disorder based on Symptom Type and Treatment Strategy.

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Note: Treatment Activated Processes are presented as concentric circles where one encapsulates
the contents of the other. The Symptom circles represent categories. Each of the measurement
instruments employed in this project are placed in the diagram.