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SOCIAL ANXIETY

By Milton Spett, Ph.D.

Cognitive Therapy 

            Clark and Wells begin treatment by explaining the cognitive errors made by social phobics: Social phobics believe:

              1. Their social behavior is much more inept or inappropriate than it actually is.

              2. Their physical anxiety symptoms (blushing, rapid heartbeat) are much more apparent to observers than they actually are.

              3. Others evaluate them much more poorly than others actually evaluate them.

              4. The negative consequences of their allegedly inept behavior are much more dire than they actually are.

            In these ways, patients with social phobia systematically misinterpret their behavior and its consequences, and they conclude that their worst fears have in fact been realized.

 Interventions:

            1. Focus on listening to others. Fear of having nothing to say often causes social phobics to plan their next comment instead of carefully listening to other speakers. This attempt to avoid negative social judgments causes social phobics to respond less effectively, leading to the very situation they are desperately trying to avoid. In addition, by not paying attention to other speakers, they miss cues that others are not judging them as negatively as they imagine.

            2. Respond with whatever you are thinking, without censoring yourself or worrying about what others will think.

            3. Do not pay attention to your real or imagined social deficits or your anxiety symptoms.

            4. Use role playing to practice these skills.

            5. Ask social phobics to do what they fear in order to demonstrate that others do not have the negative reaction they expect. For example, have the social phobic stammer, intentionally spill a drink, or speak very slowly. (Social phobics often speak quickly because they fear boring the listener.)

            6. Reduce the perfectionistic standards social phobics use to negatively evaluate their social behavior.

            7. Stop ruminating on negative social interactions and overlooking positive interactions.

            8. Eliminate safety behaviors. Social phobics use safety behaviors to reduce anxiety or hide their anxiety from others. Two common safety behaviors are avoiding eye contact and gripping a glass tightly to avoid spilling liquid. But focusing their attention on safety behaviors causes these patients to miss social cues and thereby impairs their social behavior.

CT Beats BT for Social Phobia 

            Clark et al. (J. of Consulting and Clinical Psychology, June, 2006) report that seventeen 90-minute sessions of cognitive therapy was significantly superior to behavior therapy for social phobia. CT alleviated social phobia in 84% of the patients, compared to only 42% for the BT group. Both treatment groups were significantly superior to the waiting list control group. The improvements and the advantage of CT over BT were maintained at the 3-month and one-year follow-ups.

            Patients in the CT group were not encouraged to practice repeated, prolonged exposure to anxiety-provoking situations, but some exposure probably occurred in the CT group.

            Although cognitive therapy was significantly superior to behavior therapy, this study did not investigate the possibility that CT plus repeated, prolonged exposure might be superior to cognitive therapy alone.

            Note that Clark developed the cognitive therapy used in this study. The behavioral and cognitive interventions are described elsewhere on this page.

Behavior Therapy 

            The BT included two components: relaxation training and repeated exposure to progressively more anxiety-provoking situations. Patients did not use relaxation in phobic situations until they had completely mastered the relaxation techniques -- usually around the 10th session. Exposure and relaxation were practiced in sessions and also given as homework assignments. BT patients were told to remain in social situations for a planned time period no matter how anxious they felt.

              BT patients were warned that leaving a social situation when they feel anxious prevents them from overcoming their social anxiety. But if they remain in anxiety-provoking social situations, they will begin to feel better after a while. Therapists carefully monitored avoidance of feared social situations, and encouraged BT patients to confront situations they normally avoided.

Why BT is Less Effective for Social Phobia 

            According to David M. Clark and Adrian Wells (in Heimberg et al., eds., 1995, Social Phobia: Diagnosis, Assessment, and Treatment), cognitive therapy, rather than exposure and response prevention (ERP), is the treatment of choice for social phobia.

            These authors point out that ERP is effective for patients with other anxiety disorders because ERP teaches these patients that the consequences they fear do not occur. If panic patients simply experience their panic attacks while doing nothing to avoid or escape these attacks, they learn that they do not die or have a heart attack.

            But social interactions provide little objective feedback to contradict the fears and negative misperceptions of patients with social phobia.

Group Therapy for Social Phobia

            Turk et al. (in “Clinical Handbook of Psychological Disorders,” Barlow, ed., 2001) recommend their Cognitive-Behavioral Group Therapy (CBGT) for social phobia. This approach can be used in a group with as few as two or three patients. The authors assert that CBGT:

            1. Prevents avoidance and provides a structured exposure experience that assures patients will remain in the situation long enough for anxiety reduction (habituation) to occur.

            2. Enables patients to practice social skills and receive constructive feedback.

            3. Positive feedback is more credible when it comes from group members rather than from the therapist. This positive feedback can change patients’ unduly negative views of their social behavior.

            4. Vicarious learning -- patients can learn from the experiences of others -- for example seeing how other social phobics overestimate their anxiety and underestimate their social skills. Also, they can learn about the techniques other patients used to alleviate their social phobia.

            5. Other group members and the therapist are available for role playing.

A Clinical Intervention

            Wells and Papageorgiou (Behavior Therapy, Summer, 1998) recommend giving the following instructions to socially phobic patients:

              “When you enter a feared social situation, you tend to focus your attention on yourself. For example, your anxiety symptoms become the center of your attention, and because they feel bad, you think that you must look bad. Focusing on yourself prevents you from getting a realistic sense of the social situation.

              “In order to overcome your anxiety, you have to go into the situation and allow yourself to discover that your fears are not true. To do this, you should observe other people closely in order to gain clues about their reactions to you. For example, when you are self-conscious and it feels as if everyone is looking at you, you should look around and check this out. By focusing attention on what is happening around you, you will become more confident and discover that your fears are not true.”

Cognitive Errors in Social Phobia

            Two cognitive errors in social phobia are overestimating the probability of negative evaluations and overestimating the consequences of negative evaluations. Smits et al. (Journal of Consulting and Clinical Psychology, Dec. 2006) found that in treating social phobics, reductions in the estimated probability of negative evaluations preceded and probably caused improvements in social phobia. But reductions in the estimated consequences of negative evaluations followed and probably did not cause improvements in social phobia.

            The authors suggest that therapy with social phobics could be improved by finding ways to reduce these patients’ expectations of the negative consequences of negative evaluations. However, this study could also be interpreted as suggesting that treatment should focus on reducing overestimates of the probability of negative evaluations rather than on reducing overestimates of the consequences of negative evaluations. 

Two More Clinical Interventions

Focus on Others

            It has been said that there are two kinds of people in the world: those who enter a social situation wondering “Will they like me?” and those who enter a social situation wondering “Will I like them?” In social interactions, patients should focus on what they think of the people they are talking to. This focus will help patients decide if they want to continue talking to the person or see the person again. But more importantly, this focus helps to counteract patients’ tendencies to focus negatively on themselves.

            Point out that trying to figure out what another person thinks of you is very difficult and a waste of time. As B.F. Skinner would advise, just note how they treat you.

Reveal Your Fears 

            I recommend that patients with social phobia tell others about their fears. (This is helpful with all patients who are too concerned with others’ opinions of them.) Admitting fears to others has the following benefits:

             1. Patients  no longer need to worry about or waste energy hiding their fears.

             2.  Patients feel less ashamed of their fears.

             3. Patients almost always receive support and acceptance from others, counteracting their negative views of themselves.

             4. Others usually tell them that they have similar fears, reducing the patient’s feelings of inferiority.

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