Cognitive Behavioural Therapy for Social Anxiety

As we saw in the model earlier, when we find ourselves in a situation in which our social anxiety is activated, our behaviours and focus of attention change.  We typically find that we become much more self-focused – so much so, that we notice every little change in our movements, our speech and our body.  And, as our model suggests, noticing these small changes through this enhanced self-focus leads us to become more anxious, leading to more self-focus – the problem gets worse.

Likewise, because we don’t want people to notice how anxious we feel, we also use lots of safety behaviours to get through the situation.  Again these behaviours (e.g., avoiding eye contact, saying little, holding onto something to keep our hands still) also keep the problem going. This stage in the treatment is all about understanding the role that self-focused attention and safety behaviours play in the maintenance of our social anxiety symptoms.

Firstly, your therapist will talk you through the role that attention and safety behaviours play in the problem maintenance, just like we have done here.  Then they will create two situations for you to experiment with what happens when you both use your safety behaviours and self-focus and then when you drop them.

So for instance, we may agree on you having two conversations with one of my colleagues.  In the first conversation, you would use every one of your safety behaviours, really use them.  You would also deliberately focus upon yourself – How you’re coming across, how anxious you feel, etc.  We then take a rating and have a discussion about how anxious you felt, how anxious you think you looked and any other factors relevant to your particular formulation.

In the second role play we would drop all of these safety behaviours.  Maintaining appropriate eye contact, keeping hands relaxed and speaking less quickly for example.  You would also be aiming to shift self-focus by focusing more on what the other person is saying, doing and wearing.  And again, just like in the first role play, we would take a rating on how anxious you felt, how anxious you think you looked etc.

People tend to find that they feel more anxious in the first role play, whilst using self-focused attention and their safety behaviours, than they do in the second.  They realise that the self-focus and behaviours actually keep the problem going and are unhelpful for them in their social anxiety. The client is then encouraged, over the following week, to experiment with dropping and using their safety behaviours in any social situations that they come across over the next week and see the effects that this has upon their social anxiety.

So, we talked earlier about how we create an inaccurate internal image of how we think we look – what the model calls, “processing of self as a social object.”  How do we challenge this?

What we need to do is create an opportunity for you to compare the image of you that you have in your mind and how you actually look.  Using Video feedback is  fantastic way to do this.

This is what we do…

1. Create a firm picture of how you think you look.  For instance, we might use a “redness” colour chart to predict how much you think you blush.  We will also get a firm idea of how much you believe you will shake, your voice wobble or get hot and sweaty.  It’s important for us to as closely define each of these areas as possible.
2. Create a trigger situation for your social anxiety.  For instance we might get you to give a presentation in front of a group of people.
3. Record the situation using a video recorder.
4. Watch the video and compare what you predicted you would look like in a social anxiety situation with what you actually did look like.
5. Reflect – Was your blushing as noticeable as you though it would be?  How much did your hands really shake?  What did you learn from all of this?  What does this mean for the future?

People tend to find that how they expect to see themselves doesn’t match what they actually look like in the social situation.  In fact, they’re often shocked to find out just how different they actually look compared to how they think they look.  This leads to a significant reduction in anxiety for them.

Behavioural experiments are used a lot in Social Anxiety Disorder and in CBT in general.  A behavioural experiment is a way of us testing out old, unhelpful beliefs or new more balanced beliefs in a “real-world” context.  It’s often much better for us to learn new perspectives and beliefs by actually putting them into action.  As you may have experienced, it’s one thing to “know” something in your head, but when a situation arises it can often be forgotten. There are lots of different ways to create behavioural experiments in social anxiety so we’ll give you just one example here:

Kevin had the belief that if he didn’t pay close attention to the words coming out of his mouth when he was in a social interaction, then he would say something stupid and be laughed at.  He and the therapist agreed to create an experiment to test this belief out. First of all they defined the negative thought as: “I must pay close attention to saying intelligent words otherwise I will say something stupid and get laughed at.”  Kevin rated his belief in this thought at 90%, a belief so strong that it meant that he always put a lot of effort into finding the right words to say in a conversation so that he didn’t appear stupid or incompetent.  The problem with this was that he then often stumbled in getting his words out which contributed to him appearing to be more anxious and less comfortable in social situations. What would happens when Kevin stops trying to choose the right words and lets them come out naturally?

Alternative Thought:  Paying close attention to my thoughts makes it more difficult to find the right words and leads me to stumble in getting my words out: Belief in alternative thought:  40%

Experiment:  I’m (Kevin) going to have 3 conversations this week with different people at work.  In each conversation, I’m not going to focus upon the words that come out and instead listen to what the other person says and then respond spontaneously with whatever comes into my mind.

Safety behaviours to drop:  Trying to find “intelligent” words, self-focused attention, trying to hold my hands still, avoiding eye contact, avoidance, speaking quickly.  Pre and post event processing.

What happened?:  I spoke to 5 people over the week.  At first I found it difficult to speak spontaneously but this passed quickly once I had been speaking for a while.  I found that I was able to hold a reasonable conversation and make a point without obsessing over saying the “right” thing.  The words seemed to come out a little easier too.

What does this mean?:  I can probably stop trying so hard!  The words will come out anyway and thinking about saying the right thing stops the flow – it’s counterproductive. Re-rate your belief in the initial thought:  50%  Re-rate your belief in the alternative thought:  80%

A key theme in social anxiety disorder and social phobia is the idea that other people create some degree of social threat – If we do something wrong, then we will be ridiculed, shamed, rejected or criticised by others, this may have even happened in the past and be contributing to these feelings now. However, whilst these events may have occurred in the past, this doesn’t necessarily mean that they are going to happen today.  We are “hard-wired” with a tendency to over-estimate threat, to expect to find threat more often than we will actually find it.  From the perspective of evolution this makes sense.  Our ancestors that paid more attention to potential threat were generally more likely to survive than ones who didn’t.

This is where bandwidth experiments come into play.  The idea of a bandwidth experiment is to reduce our tendency to over-estimate social threat, by broadening the range (bandwidth) of socially acceptable behaviours. Here is an example:

Kevin and the therapist agreed to engage in a bandwidth experiment to challenge his belief that he would be ridiculed for making a mistake.  They agreed to go to the local supermarket and fill up a basket with small, unbreakable, goods such as toilet rolls and a few tin cans.  Kevin then found a place in the supermarket where he could observe the therapist “model” the experiment.

The therapist walked with the basket of goods down a fairly busy aisle.  He then pretended to fall to the floor, sending contents of the basket spinning down the aisles.  What do you think Kevin got to observe?

He saw that people came quickly to his aid and helped him to his feet and gathered his groceries before everyone continued to go about their business. Kevin and the therapist discussed their findings.  Kevin was unsure whether people would react in the same way to him, so they agreed to find out.

Kevin filled his basket of groceries and repeated the experiment after a few nervous false starts. What happened?

Exactly the same thing as happened previously, people came to his aid, showed concern that he was OK and helped to gather his groceries, and then went about their business.

The therapist and Kevin again reflected upon the experience.  What had Kevin learned?  “No one’s really bothered about the fact that I fell – they seemed to be more interested in making sure I was OK.”  What does this mean for the future? “I probably can be a bit less concerned about making mistakes in front of people, in some situations at least.”