1118349

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BMOXXX10.1177/01454455221118349Behavior ModificationLaposa and Rector

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Behavior Modification

The Impact of Group

2023, Vol. 47(3) 573­–589
© The Author(s) 2022
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DOI: 10.1177/01454455221118349
https://doi.org/10.1177/01454455221118349
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Videotape Exposure in
CBT for Social Anxiety
Disorder

Judith M. Laposa1,2 and Neil A. Rector2,3

Abstract
Video feedback following social anxiety exposures improves self-perceptions.
Clinical studies have not examined whether feedback from group members
has incremental benefit beyond that of viewing the tape itself. Sixty-seven
individuals with social anxiety disorder completed videotaped exposure
during group based cognitive behavior therapy (CBT). After participants
viewed their taped exposure, group members and therapists gave feedback.
Participants completed ratings of anxiety and performance before and
after taping their exposure, after viewing the video themselves, and after
receiving group feedback. Appraisal of social concerns were assessed after
taping, viewing, and group feedback. There were significant improvements
in anxiety, performance, and decreased social concerns across time points.
Comparing only the time points of after viewing and after receiving group
feedback, the same pattern emerged for anxiety, performance, and appraisal
of social concerns, with moderate to large effect sizes. Group feedback led
to ratings that exceeded their own initial evaluation of their video. Video

1
Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health,
Toronto, Ontario, Canada
2
Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
3
Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
Corresponding Author:
Judith M. Laposa, Centre for Addiction and Mental Health, 100 Stokes Street, Toronto,
Ontario M6J 1H4, Canada.
Email: Judith.Laposa@camh.ca
574 Behavior Modification 47(3)

feedback in group CBT that also includes feedback from others may improve
clinical outcomes.

Keywords
video feedback, social anxiety, performance, anxiety, social concerns, group

Introduction
Social anxiety disorder (SAD) is a disorder characterized by marked anxiety
in social situations, and fear of negative evaluation (American Psychiatric
Association, 2013). Cognitive models of SAD hypothesize that when those
with SAD enter social situations, negative beliefs are activated, leading to
perception of danger in social situations. Focus of attention becomes directed
inward on anxious arousal, and/or externally to scan the situation for signs of
disapproval (Wild et al., 2008), and a negative self-image of how they come
across to others is conjured up in their mind’s eye (Voncken et al., 2006,
2010). These in turn contribute to elevations in state anxiety in social situa-
tions (e.g., Clark & Wells, 1995; Rapee & Heimberg, 1997).
Mental imagery is one of the key contributors to the maintenance of SAD
(Wild & Clark, 2011). In comparison to non-clinical participants, those with
SAD have more negative self-imagery before or during social situations that
are anxiety provoking (e.g., Hackmann et al., 1998, 2000). The negative self-
image apparent in those with SAD is distorted, and typically takes the
observer perspective (Hackmann et al., 1998, 2000). It is often based on prior
experience, is generally consistent with their negative beliefs, and interocep-
tive information is used to create the self-representation, based on emotional
reasoning. Negative self-images are thought to prevent incorporation of accu-
rate feedback from others, and instigate self-focused attention and safety
behaviors that exacerbate and maintain anxiety (Clark & Wells, 1995; Rapee
& Heimberg, 1997). Research demonstrates that negative self-image leads to
increased perceived sense of social danger, anxiety, and visibility of anxiety
symptoms (e.g., Hirsch et al., 2003; Stopa & Jenkins, 2007), poorer perfor-
mance (Hirsch et al., 2003), and decreased self-esteem (Hulme et al., 2012).
Video feedback was developed to help those with SAD target their dis-
torted self-image. Salient provoking events have been found to activate nega-
tive self-perceptions (e.g., Rodebaugh & Rapee, 2005). Video feedback
provides an opportunity to compare the image in one’s mind’s eye, versus
that objectively on the screen, thus helping those with social anxiety to exam-
ine the accuracy of their negative appraisals and beliefs about how they come
Laposa and Rector 575

across to others (Clark, 2001, 2005). This is pertinent as individuals with

SAD rate their performance more poorly than objective observers (e.g., Chen
et al., 2010, Furukawa et al., 2009; Rapee & Lim, 1992).
Examination of the utility of video feedback began with trials using taped
speeches with non-clinical samples, which found that video feedback
improves accuracy of self-ratings of performance, particularly among those
with highly distorted negative impression of their performance (e.g., Orr &
Moscovitch, 2010; Rapee & Hayman, 1996; Rodebaugh, 2004; Rodebaugh
& Chambless, 2002; Rodebaugh & Rapee, 2005). These effects were repli-
cated with clinical populations using speeches (e.g., Rodebaugh et al., 2010)
and other tasks (e.g., McManus et al., 2009), and then extended with tailoring
of exposures to idiosyncratic social concerns (Laposa & Rector, 2014). Video
feedback led to improvements in appraisal of performance (e.g., Laposa &
Rector, 2014; McManus et al., 2009; Warnock-Parkes et al., 2017), anxiety
specific to the taping (Laposa & Rector, 2014; McManus et al., 2009;
Warnock-Parkes et al., 2017), ratings of observable anxiety and feared out-
come when comparing objective versus subjective self-ratings (Furukawa
et al., 2009), and decreased concerns about negative evaluation and observ-
able symptoms of anxiety (Laposa & Rector, 2014). Many SAD treatment
manuals now incorporate the use of video feedback (see Ahn & Kwon, 2018
for review). However, the aforementioned research is largely based on the
effects of a person viewing their own video, rather than any direct testing of
the impact of receiving group feedback about the video performance.
Although video feedback has been effectively used in group therapy set-
tings for those with SAD (Ahn & Kwon, 2018; Furukawa et al., 2009; Laposa
& Rector, 2014), these studies did not examine the specific role of audience
feedback. Some have suggested therapist and/or audience feedback may be a
helpful addition to the video feedback itself (Hirsch & Clark, 2007; Rapee &
Hayman, 1996), and this was investigated experimentally in three studies.
Smits et al. (2006) had socially anxious participants complete a speech task,
and looked at the effect of providing participants with the audience’s video-
taped reactions to their performance (e.g., the audience’s facial expression,
etc.). Surprisingly, this did not reduce anxiety. The authors suggest this may
be due to negative interpretation of ambiguous audience reactions, and that
more explicit audience feedback may be needed for positive effects. Chen
et al. (2015) randomly assigned socially anxious students to give a short
speech in one of four conditions: combined video feedback with cognitive
preparation and audience (three confederates) feedback (CP + VF + AF),
video feedback with cognitive preparation (CP + VF), audience feedback
(AF), or control condition (watched their speech with no cognitive prepara-
tion). The two conditions that included audience feedback demonstrated
576 Behavior Modification 47(3)

similar improvements on performance appraisal and state anxiety compared

to the other two conditions. However, in comparison to the control condition,
the between group effect size between the control and CP + VF + AF condi-
tions was very large, much larger than those reported in prior CP + VF or
CP + VF + cognitive restructuring studies (Harvey et al., 2000; Kim et al.,
2002; Orr & Moscovitch, 2010), suggesting that audience feedback may be
particularly impactful at producing change in self-appraisals and subsequent
anxiety.
Chen et al. (2018) followed this with another experimental study, and
examined the effects of combined audience feedback (AF) with video feed-
back (VF) plus cognitive preparation (CP) and cognitive review (CR), with
socially anxious undergraduates. Four conditions were compared,
CP + VF + AF + CR versus CP + VF + CR, versus CP + VF, versus Control.
Undergraduates did two impromptu speeches which were evaluated by con-
federates. Compared to other conditions, the CP + VF + AF + CR group
showed decreased state anxiety and perceived probability of negative evalu-
ation scores, and increased positive perception of performance before and
after feedback, and the findings generalized in a second speech.
Placing this line of research in clinical settings, Chen et al. (2010) exam-
ined video feedback in group cognitive behavior therapy (CBT) for SAD,
where participants rated performance, feared outcomes, and anticipatory
anxiety before and after video feedback that included group member peer
feedback. Video feedback combined with peer feedback was associated with
improved ratings of performance and perception of feared outcomes, as well
as decreased anticipatory anxiety. However, as the study design confounds
video feedback and peer feedback, one cannot conclude whether the positive
effects arose from the video feedback itself, the peer feedback, or the combi-
nation of the two. In addition, the feared outcomes that were assessed were
largely visible behaviors (gaze, length, body tension, facial expression, con-
centration, and flow), and did not include concerns regarding negative evalu-
ation, such as appearing weird, being rejected or ridiculed, which are core
appraisal features of SAD.
Chen et al.’s (2018) experimental study concluded “Our findings indicate
the therapeutic effects of audience feedback with video feedback plus cogni-
tive preparation and cognitive review and the possibility of disseminating
this technique in group CBT.” p.177. It is important to build on the extant
promising findings by including clinical populations in naturalistic settings,
to determine whether feedback on more personally relevant social anxiety
exposures, done in a clinical setting involving those with whom the partici-
pant has familiarity, has a beneficial impact in addition to viewing the video
feedback itself.
Laposa and Rector 577

Lastly, believability of feedback is key; if the feedback is not perceived as

believable, it may be dismissed. Chen et al. (2015, 2018) included this exper-
imental control check, and reported audience feedback belief ratings in the
low-mid 60s/100%. Given the interpretation bias common in SAD (Amir
et al., 2005), it would also be important to assess whether participants felt the
feedback was honest, as someone with SAD might think the feedback was
honest, but then not believe it.
The current study uses video feedback during CBT for SAD in group for-
mat, to examine whether receiving group feedback on the same video affects
ratings of anxiety, performance, and appraisal of social concerns, with further
benefit from the individual just watching the video itself. Following early
experimental findings, we hypothesized that (1) across the time points used
in this study, the video feedback procedure would be effective on these
dimensions and (2) the addition of receiving group feedback would lead to
further decreased perceptions of anxiety, increased perceptions of perfor-
mance, and decreased perceptions of social concerns in comparison to par-
ticipants’ ratings after they viewed their video.

Method
Participants
Sixty-seven treatment seeking individuals with SAD participated in this
study. After completing a psychiatric consultation with a psychiatrist who
then referred for SAD CBT, a primary SAD diagnosis was confirmed with
the SAD module of the Structured Clinical Interview for Axis I Disorders
fifth edition (SCID 5; First et al., 2015; 94%) or the full SCID 5 (6%). The
SCID 5 assessment was conducted by psychologists, psychometrist, and PhD
level graduate students. Graduates students completed rigorous training on
the SCID 5, including watching training videos, observing at least two SCID
5 assessments by a senior psychologist or psychometrist, then being observed
doing at least two SCID 5 assessments by the same. They then received
weekly supervision from a psychologist, where each assessment was reviewed
to ensure diagnostic accuracy, and the psychologist cosigned their assessment
report, attesting to the diagnosis in the participant’s medical record.
Participants’ average age was 33.80 (SD = 10.80), and they were largely
Caucasian (74%) and single (71%). About 49% identified as female, 49%
male, and 2% transgender. The sample is from a naturalistic clinic data col-
lection, in a government funded academic hospital tertiary care setting.
Inclusion in the study was determined by being referred by a psychiatrist for
CBT for SAD, in our specialty mood and anxiety disorder clinic. Exclusion
578 Behavior Modification 47(3)

criterion were: substance use at a level that would interfere with engagement
in treatment, psychosis or mania symptoms in the last 6 months, current
active suicidality or recent suicide attempt, and recent completion of a course
of CBT for SAD (more than eight sessions in the last 1–2 years) with a thera-
pist with known expertise in CBT for SAD.

Measures
Anxiety. Anxiety was assessed using a scale of 0 to 100. Before the exposure,
participants predicted how anxious they would feel, after the exposure they
rated their maximum anxiety during the exposure, and after viewing the vid-
eotape and after receiving group feedback they rated how anxious they
looked during the exposure.

Performance. Performance was assessed with a composite measure of two

items that were summed together, each rated on a Likert-type scale where
0 = not well/adequate and 7 = extremely well/adequate. Before taping their
exposure, participants predicted how well they thought they would come
across in this exposure (cf., Harvey et al., 2000, Laposa & Rector, 2014) and
how confident they were that they would be able to perform the exposure
adequately (cf., Laposa & Rector, 2014, Rodebaugh & Chambless, 2002;
αpre = .78). After the taping, viewing the tape and getting group feedback,
participants rated how well they thought they came across, and to what extent
they performed the exposure adequately.

Appraisal of social concerns. Appraisal of social concerns was assessed with the
ASC (Telch et al., 2004) a 20-item measure of various social concerns (e.g.,
appearing stupid, trembling, etc.). Participants rate each item on a scale of zero
(not at all concerned) to 100 (extremely concerned), with respect to how much
they felt this outcome happened during the exposure (taping) and actually
occurred during the exposure (after viewing and after group feedback). There
is a total score, αtaping = .92, as well as three subscales: 1. Negative evaluation
(nine items; example item “Appearing incompetent”), αtaping = .88. 2. Observ-
able symptoms (eight items; example item “Poor voice quality (cracking, stut-
tering, squeaking, etc.)”), αtaping = .82. 3. Social helplessness (three items;
example item “Losing control (screaming, running out, etc.)”), αtaping = .69.

Believability of group feedback. Two items assessed the extent of the believ-
ability of the group feedback. Both were rated on a 7-point scale, where
1 = not at all and 7 = very much: “To what extent did you believe the feedback
given to you after you watched your taped exposure?” and “To what extent
were the group members/leaders being honest in their feedback to you?”
Laposa and Rector 579

Social Interaction Anxiety Scale (SIAS). The SIAS (Mattick & Clarke, 1998)
assessed social anxiety symptom severity in relation to interaction with oth-
ers. About 20 items are rated on a 5-point Likert-type scale, where 0 = not at
all and 4 = extremely. Research shows the SIAS to have good reliability and
validity (Heimberg et al., 1992; Mattick & Clarke, 1998). In the current study,
internal reliability was α = .89.

Procedure
Prior to the start of treatment, participants completed the SIAS. The CBT for
SAD groups were typically 8 to 10 participants, with two co-leaders. At ses-
sion 5 of the CBT for SAD group, participants taped their exposure in ses-
sion. Exposures were approximately 3 minutes long, selected by the
participant from their exposure hierarchy for an exposure that would be about
50/100 for anxiety. Exposures could be done individually (e.g., giving a
monologue about a personal interest, playing an instrument), or with other
group members (e.g., maintaining a conversation, roleplaying being asser-
tive). When setting up their exposure, participants outlined their behavioral
goals for the exposure (e.g., maintain eye contact, speak for 50% of the con-
versation, etc.). Before taping and after taping, participants rated anxiety, per-
formance, and the ASC. The following week, before watching their video
participants a) did cognitive preparation, which makes viewing video more
effective (Harvey et al., 2000; Kim et al., 2002; Rodebaugh, 2004), “(1) look
over their ratings to remind themselves of what happened last week; (2) visu-
alize in their mind what they did for the exposure last week, how they felt,
how they came across and how it went; (3) once they indicated that they had
this image in mind, they were instructed to watch the video as if they were
watching a stranger; and (4) to pay attention to how they appeared on screen
rather than how they felt during the exposure” (Laposa & Rector, 2014, p.
365), (a) reminded the group what their behavioral goals were for the expo-
sure, (b) viewed their tape, and (c) repeated the anxiety, performance, and
ASC ratings. Participants then shared with the group their perceptions of how
they did, following which group members gave them feedback, and this was
then followed by the group leaders giving feedback. The taping, viewing, and
feedback portions were all done in the presence of the full group and thera-
pists. Feedback given by group members typically included positive com-
ments as well as areas for improvement. After receiving group feedback, the
participant re-rated anxiety, performance, and the ASC. The procedure was
the same as Laposa and Rector (2014) with the new addition of assessing
anxiety, performance, and appraisal of social concerns again after receiving
group feedback. The participants are an independent sample from those who
participated in the Laposa and Rector (2014) study.
580 Behavior Modification 47(3)

Table 1. Means and Standard Deviations of Study Measures.

M(SD)
SIAS pre-treatment 55.27 (12.15)
Anxiety
Predicted 65.78 (14.53)
After taping 60.05 (19.97)
After viewing 45.83 (22.53)
After group feedback 27.42 (23.04)
Performance
Predicted 7.74 (2.03)
After taping 8.23 (2.65)
After viewing 9.12 (2.78)
After group feedback 10.94 (2.26)
ASC total score
After taping 710.01 (371.62)
After viewing 462.80 (367.74)
After group feedback 255.21 (301.14)
ASC negative evaluation
After taping 315.65 (186.73)
After viewing 220.06 (184.15)
After group feedback 115.93 (144.80)
ASC observable symptoms
After taping 322.00 (153.64)
After viewing 197.33 (154.77)
After group feedback 115.66 (137.45)
ASC social helplessness
After taping 72.37 (67.31)
After viewing 45.40 (52.33)
After group feedback 23.62 (34.33)
Believe group feedback 5.46 (1.27)
Group members’ feedback was honest 6.12 (0.93)

Note. ASC = appraisal of social concerns.

Results
Means and standard deviations for study measures can be found in Table 1.
The average score at the start of treatment on the SIAS was more than 20
points above the clinical cut off on this measure (34), indicating a highly
symptomatic participant sample. Believability and honesty ratings on
the feedback received were high. There were two outliers on the social
Laposa and Rector 581

helplessness after group feedback subscale, which did not affect the sig-
nificance pattern of results, thus were left in. The following had missing
data; SIAS (1), anxiety rating after taping (6) and after viewing (1), and
performance after taping (1). Due to administrative error, 21 participants
were not given the ASC after viewing, and 4 after group feedback. Further,
two had missing data after viewing for negative evaluation, and one for
after viewing for the social helplessness subscales. The repeated measures
ANOVA sphericity assumption was not met; application of the Lower-
bound correction, the most conservative correction, did not impact the sig-
nificance pattern of the results, they all remained p < .001.

Anxiety
To examine whether anxiety changed across the four time points, a repeated
measures ANOVA was completed. Anxiety decreased significantly, F (1,
57) = 65.46, p < .001. To determine more specifically whether anxiety
changed following group feedback, a repeated measures ANOVA was run
with only the two time points of after viewing the tape and after receiving
group feedback, and again, anxiety decreased significantly, F (1, 65) = 93.53,
p < .001, Cohen’s d = 0.80.

Performance
To examine whether performance changed across the four time points, a
repeated measures ANOVA was completed. Performance improved signifi-
cantly, F (1, 63) = 45.29, p < .001. To determine whether performance ratings
changed following receipt of group feedback, a repeated measures ANOVA
was run with only the two time points of after viewing the tape and after
receiving group feedback, and again, performance increased significantly, F
(1, 66) = 66.77, p < .001, Cohen’s d = 0.73.

Appraisal of Social Concerns

To examine whether appraisal of social concerns changed across the four
time points, a repeated measures MANOVA was completed, for ASC total
score and the three subscales. The multivariate effect was significant, F (6,
156) = 15.55, p < .001. At the univariate level, all ASC scores improved sig-
nificantly across the board, for the total score, F (1, 40) = 51.64, p < .001,
negative evaluation F (1, 40) = 33.70, p < .001, observable symptoms F (1,
40) = 57.27, p < .001, and social helplessness F (1, 40) = 18.67, p < .001 sub-
scales. To determine whether ASC ratings changed following receiving group
582 Behavior Modification 47(3)

feedback, a repeated measures MANOVA was run with only the after view-
ing and after receiving group feedback time points. Similarly, the multivari-
ate effect was significant, F (3,38) = 18.75, p < .001 and then all ASC scores
improved significantly, for the total score, F (1, 40) = 54.82, p < .001, Cohen’s
d = 0.62, negative evaluation F (1, 40) = 41.31, p < .001, Cohen’s d = 0.63,
observable symptoms F (1, 40) = 52.77, p < .001, Cohen’s d = 0.56, and social
helplessness F (1, 40) = 12.25, p = .001 subscales, Cohen’s d = 0.49.

Discussion
The current study aimed to investigate whether the use of video feedback in
group based CBT for SAD would be effective in decreasing perceptions of
anxiety and appraisal of social concerns, and increasing perceptions of per-
formance, overall, and more particularly, whether the receipt of feedback
from the group about the video would lead to improved perceptions beyond
ones’ initial ratings after viewing the video. On all measures, the study
hypotheses were confirmed. The addition of receiving group feedback led to
further decreased perceptions of anxiety and appraisal of social concerns, and
increased perceptions of performance, in comparison to participants’ ratings
after they viewed their video. The group feedback led to ratings that exceeded
one’s own initial evaluation of their video.
The largest effect size in the study after receiving group feedback was for
anxiety. It is well established in clinical samples that video feedback decreases
one’s ratings of anxiety related to the video (e.g., Laposa & Rector, 2014;
McManus et al., 2009; Warnock-Parkes et al., 2017), and this study furthers
the research base by demonstrating an additional large effect size anxiety
decrease after participants receive group based feedback. The mean differ-
ence between anxiety ratings after taping versus after group feedback was
more than double in comparison to the difference between the anxiety ratings
after taping versus after self-viewing.
Many non-clinical (e.g., Orr & Moscovitch, 2010; Rapee & Hayman,
1996; Rodebaugh, 2004; Rodebaugh & Chambless, 2002; Rodebaugh &
Rapee, 2005) and clinical (Laposa & Rector, 2014; McManus et al., 2009;
Rodebaugh et al., 2010; Warnock-Parkes et al., 2017) studies reported that
video feedback improves self-ratings of performance, with studies employ-
ing a variety of types of anxiety provoking situations. In the current study,
performance ratings increased following the addition of group feedback on
the video, and this was the second largest effect size improvement in the
study, with a medium-large effect size. In Chen et al.’s (2018) experiment,
they found increased performance perception with video and audience feed-
back following speeches, therefore that finding is now replicated with a
Laposa and Rector 583

clinical treatment seeking population. Furukawa et al. (2009) reported that

after participants viewing their own video, their performance ratings were
still not in line with objective ratings by others on the participant’s perfor-
mance. A future research area would be to examine whether the further
increased performance ratings achieved after receiving group feedback, are
more in line with observer performance ratings.
This study assessed appraisal of social concerns beyond just observable
symptoms, including negative evaluation and social helplessness. Laposa and
Rector (2014) reported that the former two dimensions improved following
participants watching their own tape in a group setting. The current study
extends that finding to show consistent improvements across all three sub-
scales, following receipt of group feedback. The effect sizes for improve-
ments in appraisal of social concerns were smaller than those for anxiety and
performance, yet still ranged from medium to medium-large effects. Of the
three subscales, the improvements were greatest for negative evaluation
appraisals, which is important given the hallmark negative evaluation fear
central to SAD. The finding is consistent with Chen et al. (2018)’s experi-
mental finding of decreased perceived probability of negative evaluation
with video and audience feedback.
Decreases were also noteworthy for observable symptoms, which have
been more typically examined in video feedback studies. Individuals with
SAD tend to overestimate visible signs of anxiety (McEwan & Devins, 1983),
which is one reason why video feedback can be so helpful. The study find-
ings are in line with reported improved ratings on face and body tension
(Chen et al., 2010) and bodily sensation cognitions (Chen et al., 2015), and
further the extant work on video feedback by demonstrating improvements
following group feedback in appraisals of social helplessness also.
The current study builds on significant findings from the experimental
work of Chen et al. (2015) and Chen et al. (2018), who employed under-
graduates doing speeches to examine the possible benefit of audience feed-
back. In contrast to Chen et al.’s (2015, 2018) audience confederates, group
members and therapists were not instructed to avoid giving critical or nega-
tive feedback. In practice, positive feedback occurred more frequently than
constructive feedback, but both could be included, and were at times. The
study findings highlight the impact of peer feedback, and raises the ques-
tion of whether peer feedback may be more powerful than therapist or self-
observation. Although the design of the current study precludes examination
of this hypothesis, it may be a fruitful area for future study. A recent meta-
analysis of educational studies found that peer assessment improves aca-
demic performance when compared to teacher and no assessment, but not
compared to self-assessment, however the effectiveness of peer assessment
584 Behavior Modification 47(3)

was demonstrated across a variety of contexts (Double et al., 2020). In the

context of SAD, additional peer support can increase benefits of internet
based SAD treatment (see Schulz et al., 2014 for review).
Studies on videotape feedback have participants view the taped exposure
in the same session (e.g., Chen et al., 2010), or a week later (e.g., Furukawa
et al., 2009; Laposa & Rector, 2014), and report similar improvements on key
variables. In the current study, having group participants all tape their expo-
sures in one session and then view them in the next session, was convenient
in our setting. We have shown previously that participants engage in post
event processing (PEP) about the taped exposure over the week between tap-
ing and viewing (Laposa & Rector, 2011). As PEP can amplify memory of
negative aspects of a social situation (see Brozovich & Heimberg, 2008),
having participants watch their taped exposure a week later may have led to
an increased discrepancy between their recollection and what they saw on the
tape. However, the main aim of the current study was the difference between
self-rating after watching the tape versus the rating after receiving group
feedback, and these two phases occurred directly after each other. Watching
the taped exposure along with their group members (vs. alone) may have
increased feelings of self-consciousness, or alternatively, decreased them,
due to the sentiment that we are all in this together, as all group members
were doing the same procedure. It is possible there are order effects, for
example of viewing the tape first then feedback (vs. feedback first then view-
ing the video), or receiving peer feedback before therapist feedback, and vice
versa. It is unlikely that there are effects of repeated assessment, as dependent
variables were assessed twice only on one day, which would be consistent
with studies that examined the effects of video feedback within a single ses-
sion, although the design of this study cannot rule out this possibility. Further
research is needed to determine the optimal conditions for receipt of group
feedback.
Strengths of the current study include a large diagnosed SAD naturalistic
clinical treatment-seeking sample, examining for the first time the specific
effect of incorporating group based feedback for videotaped exposures that
were personally relevant, with assessment of impact on several key indica-
tors. There are also limitations to the study. As the data was collected natural-
istically as part of a routine clinical setting using a within-subjects design,
there was no control condition with random assignment. An alternative
explanation for the results is that the effects are not related to the group feed-
back content per se, and instead are related to the fact that another interven-
tion was given. For example, perhaps having a participant review their video
a second time could have led to similar improvements. The study design can-
not rule out this possibility. However, given the replication of experimental
Laposa and Rector 585

results of the two aforementioned well designed studies that included a con-
trol group with random assignment, this suggests that the positive findings of
this study are likely to have been from the addition of the group feedback
itself. The participants in the current study were largely Caucasian, and find-
ings may not generalize. The research team has overseen SCID training and
delivery in research for the past 25 years and although inter-rater reliability
was not directly tested for participants in this study, the team has published
previous studies with reliability estimates obtained in the same research con-
text. Lastly, the study design precludes conclusions about the enduring impact
of group feedback over time. Post event processing could diminish the effects
over the following days or weeks. Our prior work using video feedback twice
during a course of group CBT found that accommodating corrective informa-
tion from the first taping lead to increased performance ratings for the second
taping which occurred four weeks later (Laposa & Rector, 2014), suggesting
some maintenance of gains. Future research could examine the longstanding
impact of the effects of group feedback, and could also examine whether giv-
ing feedback to others in the group about their videos enhances, or does not
impact, the effect of receiving such feedback themselves.
In conclusion, feedback from others about a taped exposure during group
SAD CBT led to marked benefits over and above those apparent from self-
viewing the video. Inclusion of group feedback after self-viewing of a taped
exposure was easily translated into clinical practice, took minimal extra time
during the CBT group therapy session, and had a large positive impact. As
such, it may be something to consider adding routinely to the delivery of
SAD CBT groups. It is possible that the extent of the positive impact of the
group feedback may have been in part due to the participants already having
a therapeutic relationship with the other group members (vs. confederate
audience), which could have increased incorporation of the feedback. It was
noteworthy that participants highly endorsed that the group feedback was
honest, and that they believed the feedback received (vs. feeling the feed-
back was honest, but still not believing it). Honesty and belief ratings were
both high, and in the current study the feedback belief ratings (78%) were
higher than those reported in the Chen et al. (2015) (62%) and Chen et al.
(2018) (66%) experimental studies. Group feedback in this study was con-
versation based. There may be further benefit from eliciting formal ratings
by the group and incorporating technology into the discussion to make the
information more salient, by graphically showing on a screen the patient’s
ratings before and after viewing, as well as the overall ratings by the group
(Chen et al., 2010, 2015; Hirsch & Clark, 2007). In addition, although not
done in this study, there may be utility in having clients write down the feed-
back for future reference, as individuals high in social anxiety have biased
586 Behavior Modification 47(3)

memory of feedback that others provide (Edwards et al., 2003). The possible
incremental benefit of such modifications could be explored in future
studies.

Acknowledgments
We thank the participants for their involvement, as well as the following for their
assistance with data management: Jane Yating Ding, Alex Tran, Amanda Marshall,
Ailya Salman, Argie Gingoyon, and Robyn Wong-Lee.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research,
authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research,
authorship, and/ or publication of this article: The author(s) received financial support
for the research from CAMH.

ORCID iD
Judith M. Laposa https://orcid.org/0000-0002-2749-9783

References
Ahn, J., & Kwon, J. (2018). Modifying negative self-imagery increases the effective-
ness of cognitive behavior therapy for social anxiety disorder: A benchmarking
study. Cognitive Therapy and Research, 42(5), 598–611.
American Psychiatric Association [APA]. (2013). Diagnostic and statistical manual
of mental disorders (5th ed.). American Psychiatric Publishing.
Amir, N., Beard, C., & Bower, E. (2005). Interpretation bias and social anxiety.
Cognitive Therapy and Research, 29(4), 433–443.
Brozovich, F., & Heimberg, R. G. (2008). An analysis of post-event processing in
social anxiety disorder. Clinical Psychology Review, 28(6), 891–903.
Chen, J. W., Furukawa, T. A., Nakano, Y., Ietsugu, T., Ogawa, S., Funayama, T.,
Watanabe, N., Noda, Y., & Rapee, R. M. (2010). Video feedback with peer
ratings in naturalistic anxiety-provoking situations for social anxiety disorder:
Preliminary report. Journal of Behavior Therapy and Experimental Psychiatry,
41(1), 6–10.
Chen, J. W., Mak, R., & Fujita, S. (2015). The effect of combination of video feed-
back and audience feedback on social anxiety: Preliminary findings. Behavior
Modification, 39(5), 721–739.
Chen, J. W., McLean, J. E., & Kemps, E. (2018). Combined audience and video
feedback with cognitive review improves state anxiety and self-perceptions
Laposa and Rector 587

during speech tasks in socially anxious individuals. Behavior Therapy, 49(2),

165–179.
Clark, D. M. (2001). A cognitive perspective on social phobia. In W. R. Crozier &
L. E. Alden (Eds.), International handbook of social anxiety: Concepts, research
and interventions relating to the self and shyness (pp. 405–430). John Wiley.
Clark, D. M. (2005). A cognitive perspective on social phobia. In W. R. Crozier &
L. E. Alden (Eds.), The essential handbook of social anxiety for clinicians; the
essential handbook of social anxiety for clinicians (pp. 193–218). John Wiley.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G.
Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia:
Diagnosis, assessment, and treatment (pp. 69–93). Guilford Press.
Double, K. S., McGrane, J. A., & Hopfenbeck, T. N. (2020). The impact of peer
assessment on academic performance: A meta-analysis of control group studies.
Educational Psychology Review, 32(2), 481–509.
Edwards, S. L., Rapee, R. M., & Franklin, J. (2003). Postevent rumination and recall
bias for a social performance event in high and low socially anxious individuals.
Cognitive Therapy and Research, 27(6), 603–617.
First, M. B., Williams, J. B. W., Karg, R. S., & Spitzer, R. L. (2015). Structured
clinical interview for DSM-5—Research version (SCID-5 for DSM-5, Research
version; SCID-5-RV). American Psychiatric Association.
Furukawa, T. A., Chen, J., Watanabe, N., Nakano, Y., Ietsugu, T., Ogawa, S.,
Funayama, T., & Noda, Y. (2009). Videotaped experiments to drop safety behav-
iors and self-focused attention for patients with social anxiety disorder: Do they
change subjective and objective evaluations of anxiety and performance? Journal
of Behavior Therapy and Experimental Psychiatry, 40(2), 202–210.
Hackmann, A., Clark, D. M., & McManus, F. (2000). Recurrent images and early
memories in social phobia. Behaviour Research and Therapy, 38(6), 601–610.
Hackmann, A., Surawy, C., & Clark, D. M. (1998). Seeing yourself through others’
eyes: A study of spontaneously occurring images in social phobia. Behavioural
and Cognitive Psychotherapy, 26(1), 3–12.
Harvey, A. G., Clark, D. M., Ehlers, A., & Rapee, R. M. (2000). Social anxiety and
self-impression: Cognitive preparation enhances the beneficial effects of video
feedback following a stressful social task. Behaviour Research and Therapy,
38(12), 1183–1192.
Heimberg, R. G., Mueller, G. P., Holt, C. S., Hope, D. A., & Liebowitz, M. R. (1992).
Assessment of anxiety in social interaction and being observed by others: The
social interaction anxiety scale and the social phobia scale. Behavior Therapy,
23(1), 53–73.
Hirsch, C. R., & Clark, D. M. (2007). Imagery special issue: Underestimation of
auditory performance in social phobia and the use of audio feedback. Journal of
Behavior Therapy and Experimental Psychiatry, 38(4), 447–458.
Hirsch, C. R., Clark, D. M., Mathews, A., & Williams, R. (2003). Self-images
play a causal role in social phobia. Behaviour Research and Therapy, 41(8),
909–921.
588 Behavior Modification 47(3)

Hulme, N., Hirsch, C., & Stopa, L. (2012). Images of the self and self-esteem: Do
positive self-images improve self-esteem in social anxiety? Cognitive Behaviour
Therapy, 41(2), 163–173.
Kim, H., Lundh, L., & Harvey, A. (2002). The enhancement of video feedback by
cognitive preparation in the treatment of social anxiety: A single-session experi-
ment. Journal of Behavior Therapy and Experimental Psychiatry, 33(1), 19–37.
Laposa, J. M., & Rector, N. A. (2011). A prospective examination of predictors of
post-event processing following videotaped exposures in group cognitive behav-
ioural therapy for individuals with social phobia. Journal of Anxiety Disorders,
25(4), 568–573.
Laposa, J. M., & Rector, N. A. (2014). Effects of videotaped feedback in group cog-
nitive behavioral therapy for social anxiety disorder. International Journal of
Cognitive Therapy, 7(4), 360–372.
Mattick, R. P., & Clarke, J. C. (1998). Development and validation of measures of
social phobia scrutiny fear and social interaction anxiety. Behaviour Research
and Therapy, 36(4), 455–470.
McEwan, K. L., & Devins, G. M. (1983). Is increased arousal in social anxiety noticed
by others? Journal of Abnormal Psychology, 92(4), 417–421.
McManus, F., Clark, D. M., Grey, N., Wild, J., Hirsch, C., Fennell, M., Hackmann,
A., Waddington, L., Liness, S., & Manley, J. (2009). A demonstration of the effi-
cacy of two of the components of cognitive therapy for social phobia. Journal of
Anxiety Disorders, 23(4), 496–503.
Orr, E. M. J., & Moscovitch, D. A. (2010). Learning to re-appraise the self during
video feedback for social anxiety: Does depth of processing matter? Behaviour
Research and Therapy, 48(8), 728–737.
Rapee, R. M., & Hayman, K. (1996). The effects of video feedback on the self-
evaluation of performance in socially anxious subjects. Behaviour Research and
Therapy, 34(4), 315–322.
Rapee, R. M., & Heimberg, R. G. (1997). A cognitive-behavioral model of anxiety in
social phobia. Behaviour Research and Therapy, 35(8), 741–756.
Rapee, R. M., & Lim, L. (1992). Discrepancy between self-and observer ratings
of performance in social phobics. Journal of Abnormal Psychology, 101(4),
728–731.
Rodebaugh, T. L. (2004). I might look ok, but I’m still doubtful, anxious, and avoid-
ant: The mixed effects of enhanced video feedback on social anxiety symptoms.
Behaviour Research and Therapy, 42(12), 1435–1451.
Rodebaugh, T. L., & Chambless, D. L. (2002). The effects of video feedback on self-
perception of performance: A replication and extension. Cognitive Therapy and
Research, 26(5), 629–644.
Rodebaugh, T. L., Heimberg, R. G., Schultz, L. T., & Blackmore, M. (2010). The
moderated effects of video feedback for social anxiety disorder. Journal of
Anxiety Disorders, 24(7), 663–671.
Rodebaugh, T. L., & Rapee, R. M. (2005). Those who think they look worst respond
best: Self-observer discrepancy predicts response to video feedback following a
speech task. Cognitive Therapy and Research, 29(6), 705–715.
Laposa and Rector 589

Schulz, A., Stolz, T., & Berger, T. (2014). Internet-based individually versus group
guided self-help treatment for social anxiety disorder: Protocol of a randomized
controlled trial. BMC Psychiatry, 14, 115.
Smits, J. A. J., Powers, M. B., Buxkamper, R., & Telch, M. J. (2006). The efficacy
of videotape feedback for enhancing the effects of exposure-based treatment
for social anxiety disorder: A controlled investigation. Behaviour Research and
Therapy, 44(12), 1773–1785.
Stopa, L., & Jenkins, A. (2007). Images of the self in social anxiety: Effects on
the retrieval of autobiographical memories. Journal of Behavior Therapy and
Experimental Psychiatry, 38(4), 459–473.
Telch, M. J., Lucas, R. A., Smits, J. A. J., Powers, M. B., Heimberg, R., & Hart,
T. (2004). Appraisal of social concerns: A cognitive assessment instrument for
social phobia. Depression and Anxiety, 19(4), 217–224.
Voncken, M. J., Alden, L. E., & Bögels, S. M. (2006). Hiding anxiety versus
acknowledgment of anxiety in social interaction: Relationship with social anxi-
ety. Behaviour Research and Therapy, 44(11), 1673–1679.
Voncken, M. J., Dijk, C., de Jong, P. J., & Roelofs, J. (2010). Not self-focused atten-
tion but negative beliefs affect poor social performance in social anxiety: An
investigation of pathways in the social anxiety–social rejection relationship.
Behaviour Research and Therapy, 48(10), 984–991.
Warnock-Parkes, E., Wild, J., Stott, R., Grey, N., Ehlers, A., & Clark, D. M. (2017).
Seeing is believing: Using video feedback in cognitive therapy for social anxiety
disorder. Cognitive and Behavioral Practice, 24(2), 245–255.
Wild, J., & Clark, D. M. (2011). Imagery rescripting of early traumatic memories in
social phobia. Cognitive and Behavioral Practice, 18(4), 433–443.
Wild, J., Clark, D. M., Ehlers, A., & McManus, F. (2008). Perception of arousal in
social anxiety: Effects of false feedback during a social interaction. Journal of
Behavior Therapy and Experimental Psychiatry, 39(2), 102–116.

Author Biographies
Dr. Judith M. Laposa is a Psychologist and Clinician Scientist at the Centre for
Addiction and Mental Health, and an Associate Professor in the Department of
Psychiatry at the University of Toronto.
Dr. Neil A. Rector is a Psychologist and Senior Scientist at the Sunnybrook Health
Sciences Centre, and a Professor in the Department of Psychiatry at the University of
Toronto.