A cognitive behavioral therapy approach
In a previous post I indicated the nature and prevalence of social anxiety. If you find yourself inhibited and anxious in a variety of social situations (speaking in front of a group, meeting new people, using public lockers or rest rooms, eating in public) and you fear that people will see your anxiety and that you will feel humiliated, then you may suffer from Social Anxiety Disorder. Many people with this problem will choose to avoid situations where they anticipate being anxious or they may use alcohol or drugs to self-medicate before entering these situations. Social anxiety is associated with increased risk for alcohol abuse, depression, loneliness, decreased occupational advancement and the increased likelihood of remaining single. You can take the Leibowitz Social Anxiety Scale and find out if you have symptoms that might indicate social anxiety.
The good news is that you can do something about it.
Cognitive behavioral therapists have made great advances for a drug-free approach to dealing with these problems. There is now considerable evidence that CBT (cognitive behavioral therapy) is an effective treatment for social anxiety. The therapy focuses on your behavior and what you are thinking—“cognitive behavioral therapy”. So let’s take a closer look at how this approach can help you overcome your social anxiety.
What are you avoiding?
The behavioral problem for people with social anxiety is the tendency to avoid anxiety-provoking situations. When the socially anxious individual anticipates going to a party, she becomes quite anxious—but, then, decides not to go and the anxiety immediately decreases. This reduction of anxiety with the decision to avoid the party (or to leave a party) reinforces avoidance (or escape). This simple “reward for avoidance” maintains the fear of negative social evaluation even when the person does not experience humiliation. For example, if I feel anxious thinking about approaching someone and then I decide to avoid talking with them my anxiety immediately drops. This immediate decrease in anxiety teaches me, “In order to feel less anxious just avoid interacting with strangers.”
A key element of CBT is to help the individual practice approaching social situations and stay in them in order to learn that nothing really bad is going to happen and that their anxiety will subside. You also learn that you can do it and the willingness simply to confront your fears is empowering. You begin to realize “I am the kind of person who can actually do this kind of thing”. The first step in helping people with social anxiety is to identify the situations that you are avoiding. You can make a list of the kinds of situations that you feel anxious in or avoid. For example, one person identified using a public rest room (where he was worried that people would observe him), meeting people at a party, speaking up at a meeting, and talking with a woman for the first time. What are the situations that provoke your anxiety? What are you likely to avoid? Make a list.
Set up a hierarchy of fear
For each situation you can identify how the situation could be rated in terms of levels of anxiety that you would experience. You can rate each anticipated behavior from 0 to 10 in terms of the level of anxiety that you might expect. 0 would correspond to no anxiety and 10 would be a panic attack. For example, the young man with the fear of meeting people at a party had the following hierarchy of fear, from least to highest: Thinking of going to the party (3), going to the party (5), walking into the room (6), seeing people in the room (6), deciding to start a conversation (8), talking with an attractive woman (9). It’s important to write down your predictions so that you can find out how anxious you really are when you go. Sometimes people find that they are not as anxious as they anticipated they would be.
Test your predictions
We often forget the fact that we cope better than we thought we would. This is a great opportunity to test out your specific predictions. As I mentioned above, you can write out how anxious you think you will be for each thing that you do? What is the level of the anxiety that you predict? How long will you remain that anxious? Specifically, what do you predict will happen. This is how you can test out your catastrophic fortune-telling. For example, a young man who was socially anxious predicted that he would have a level of anxiety at 9 for the entire duration of speaking with a woman at a party. He predicted that his mind would go blank and that he would be so anxious that he would have to leave. As it turned out, he was very anxious when he initiated a conversation, but once he was into the discussion his anxiety subsided to 3. He did not leave and, in fact, he had the impression that the woman he was talking to actually liked him. So be clear about what you are predicting so that you can find out if you are anticipating more than what actually happens. Keep an on-going record of your predictions.
Identify your safety behaviors and eliminate them
Many people who are anxious engage in superstitious behaviors that they think make them safer or less likely to humiliate themselves. These safety behaviors include self-medicating with alcohol or drugs, holding yourself very stiffly, avoiding eye contact, holding a glass tightly saw that people won’t see your hands shake, wiping your hands so that people won’t notice you are sweating, rehearsing verbatim exactly what you will say, and talking very fast. The problem with safety behaviors is that they are like the training wheels on a bicycle—they make you think that the only way you can get through these experiences is by using the training wheels. The more you can give up these behaviors the more powerful your experiences will be—“I did it without a drink” or “I did it without rehearsing everything”.
Challenge your anxious thoughts
You are often thinking about how badly things will go. For example, you predict that you will fall apart and make a fool of yourself. You predict that everyone will notice that you are sweating–and that they will all talk about it. You think it is a catastrophe that your mind will go blank. You can challenge these thoughts by asking yourself the following: “Have you really made a fool of yourself or are you just predicting the same thing over and over?” Is it possible that people don’t notice your sweating, because they are thinking about what they are going to say?” “What is the evidence that people talk about your anxiety? How do you know?” “Why would anyone really care if you are feeling anxious? How is it relevant to them?” “Have you ever noticed that someone else said, ‘I forgot what I was going to say’? Did anything terrible happen?” Argue back at these negative thoughts.
Practice doing what makes you anxious
Once you have identified the situations that make you anxious and you have rated the hierarchy from least to most anxious then you are ready to confront your fears. We find it helpful to start with “imagining” each step in the hierarchy. So, imagine that you are thinking of going to the party and stay with that image until your anxiety drops. Then move on to imagining the next step in the hierarchy. You can also remind yourself of your rational responses to your negative thoughts. For example, when you imagine walking into the party and the thought pops up, “Everyone can see I am anxious”, you can remind yourself that people have a very hard time noticing your internal feelings and that they are focusing on their own concerns (perhaps their own anxiety). Keep imagining and let the anxiety flow out and away.
Then, you can start with the “exposure”—or practicing what you fear. Don’t take that extra drink—instead, go to the party, walk in, notice that your anxiety might be there, acknowledge it and then say, “I am going to do this even if I am anxious”. It’s OK to be anxious when you do the exposure—that is the point to exposure. You can learn that you can actually do things when you are anxious and there is no catastrophe.
I know that I have been saying these things to people for years— but people often say, “Yeah, but what if my mind goes blank?” So, a number of years ago I decided to fake my mind going blank. I was giving a workshop on anxiety and I decided to make-believe my mind went blank and I announced, “My mind just went blank. What was I saying?” As you can imagine, no one seemed to care. Why should they? What is so bad for them if your mind goes blank?
In fact, it might be helpful to even exaggerate your anxious symptoms. For example, if you are afraid that people will notice that you are sweating then you can douse your shirt with water and go right in. So, people will notice you are sweating. Big deal. I’ll bet that almost every day when it is warm we notice people who are sweating. Why do we forget it? Because it is irrelevant.
Rather than practice the post-mortem practice self-reward
As I mentioned in my previous post, socially anxious people often review their “performance” and criticize everything that they do. This “post-mortem” only adds to more anxiety about the next time. You can replace this post-mortem with a self-rewarding congratulation for facing your fears, doing what is difficult to do, and taking your life back one step at a time. Who deserves more congratulation than you for trying hard to confront what is difficult? Just trying, just going, just staying in, and just tolerating the discomfort are reasons for reward. Each time you face your fear you win and your fear loses.
Robert L. Leahy, Ph.D., is the author of Anxiety Free, The Worry Cure and Beat the Blues. He is a clinical professor of psychology at Weill-Cornell Medical School.