CBT for Social Anxiety Disorder

Do you need treatment for social anxiety disorder? Although social anxiety disorder is very serious, people around you may dismiss it as you being shy, introverted, or difficult. If it has impacted your ability to function in an area of your life, it is a true disorder.  It can affect your ability to be successful in romantic relationships, family relationships, friendships, and at work. In its most severe form, when agoraphobia is involved, it can cause you to stop leaving your house!

Depending on where you are in your experiences, you may want to seek cognitive behavioral therapy (CBT) for social anxiety disorder rather than tackle it yourself.


CBT for Social Anxiety Disorder

  • CBT is more effective than social skills training
  • CBT is more effective than medications alone
  • CBT is more effective than support groups
  • CBT is more effective than exposure therapy alone ( which can be a part of CBT)
  • CBT is more effective than mindfulness mediation which is less effective for social anxiety than placebo

Do I Need Treatment for Social Anxiety?

Social anxiety might be the most difficult anxiety disorder to help yourself with. In social anxiety what you fear is WHAT YOU THINK OTHER PEOPLE ARE THINKING ABOUT YOU. This is a hard thing to prove or disprove. It's easy to continue to tell yourself people are thinking negative things even when you have no evidence to this effect. Without the help of a professional who is skilled in treating this, it may be difficult to decrease social anxiety. Additionally, some of the ways in which you are maintaining your anxiety through avoidance can actually be disguised. It is likely you are engaging in safety behaviors. Safety behaviors are behaviors you engage in to reduce your anxiety in the short term that maintain and increase your social anxiety in the long term.

Confidence is a big issue in social anxiety. When you are using safety behaviors in social anxiety, you put your confidence in the safety behavior, instead of in yourself.

Safety behaviors  can be specific behaviors such as avoiding eye contact or internal behaviors such as rehearsing sentences. They can be hard to detect without the help of a skilled therapist. Finding a good therapist who can help you using CBT for social anxiety disorder might be an important step for you.




Anxiety Treatment. A Formula.

Intensity of Anxiety =   

How Likely We Think the Threat is

x How Severe We Think the Threat is

+ Some Physiological Elements( coffee, drug with anxiety side effects,genetic predisposition)

_____________________

 Our Belief in Ability to Cope  

What Does Does Social Anxiety Treatment Look Like

As with most forms of anxiety, therapy for social anxiety disorder is usually delivered in the form of cognitive behavioral therapy(CBT). This kind of therapy teaches you to change how you think, believe and behave before, during, and after the situations that cause you anxiety. Ultimately, this results in a change in your anxiety. Recent research indicates the use of so-called third wave therapy of acceptance and commitment therapy (ACT) techniques in the treatment of social anxiety disorder in combination with traditional CBT techniques are highly effective.

What can I expect from CBT therapy for social anxiety disorder?

You might be wondering what treatment for social anxiety looks like. Here are some examples of CBT for social anxiety, it's components, and examples.

People with social anxiety often have a dialog in their heads about their inferiority, inadequacy, and the fact that they think other people are constantly judging them as unacceptable. This interferes with their ability to interact with others. Rather than being able to focus on having interactions  with others, or in front of others, they are paying attention to their internal dialogue, sensations, and fears. This reinforces the anxiety cycle. 


Shame and Social Anxiety

People with social anxiety feel a tremendous amount of shame, inadequacy and often, the need to be perfect for others. Good social anxiety disorder treatment must also address the shame. In my office, I use self-compassion work with my clients with a social anxiety disorder as a way to address shame


ACT strategies that are helpful for social anxiety treatment

External Mindfulness, Cognitive Diffusion, and Curiosity Training

External Mindfulness.

External mindfulness teaches people to focus on situations, people, and conversations in their environment rather than what is happening in their head. Attention training strategies help build this skill. These strategies can be taught in various and interesting ways in session and through homework,  the use of audio recordings, apps, and logs. External mindfulness is the opposite of mindfulness meditation which shows you how to pay attention to your own internal cues. Mindfulness meditation is not useful for helping someone with social anxiety, as they already pay too much attention to their own internal cues. If you have social anxiety, you want to increase your attention to conversations, your external environment, and the people you are interacting with.

One way a therapist might work on attention training and external mindfulness is to have you listen to a recording with a variety of sounds and have you pick out one of the sounds ( for example a bird chirping) and focus on just that one sound.

Eventually, you will be shown in therapy through these strategies how to  improve your ability to focus on social interactions, thus decreasing your anxiety.

Cognitive Diffusion.

Cognitive diffusion strategies help socially anxious people to learn how to disengage from thoughts and emotions related to their social anxiety and reengage with life. They can be taught through role-plays, practice in session, apps homework and logs. Cognitive diffusion is essentially diffusing from the stories, images or sensations that our minds and bodies produce, rather than becoming overwhelmed and identified with them. Saying " I am not believing this story you are telling me" to your mind, is a simple diffusion technique. We know that anxious people are less likely to be able to disengage from their thoughts, and more likely to become overwhelmed and overcome by images and sensations that accompany anxiety. These techniques are very powerful for socially anxious people.

Curiosity Training.

Curiosity training is paying attention to conversations and situations you are anxious about with curious interest instead of using judgment. Cultivating this attitude is a mindfulness strategy that takes the focus off of your own anxious signals.

Hot Thought Identification, Challenging and Reframing

There are many different strategies to learn cognitive reframing or restructuring. Cognitive restructuring is done in the therapy session to help you identify and explore your disturbing thoughts and images that help maintain social anxiety. After you have done so, you begin to challenge them against real-world evidence.

Common disturbing thoughts people with social anxiety have

  • I will look or sound anxious or they will see me blush, stutter etc. 
  • I’ll say something stupid/foolish/wrong.
  • I'll forget what to say
  • They won't like me
  • They will think I'm boring
  • They won't want to be friends
  • I'll embarrass myself 
  • Thoughts or images about performance related to a specific thing: sex, urination etc

Your therapist will also help you to come up with a more constructive and helpful attitude.

People who have anxiety have cognitions that are not accurate about how other people are judging them and perceiving them that prevent them from having a fulfilling and happy life. Because of their beliefs, they limit their life in many ways. These exercises help you to adopt a more helpful and truer perspective.

Cognitive restructuring changes the perception or likelihood of threat, and the severity of the threat and thus decreases our anxiety. This addresses the anxiety formula in the call out box above. Typically, worksheets, role plays, logs, surveys, imagery, and real-world assignments are used in cognitive restructuring.

For example, a therapist may ask you to do a role play where you imagine entering a group of people with your "unhelpful thoughts", and then that therapist would facilitate another role play with you imagine entering the group of people with new and more helpful thoughts that you have worked out together in therapy.

Core Belief Identification

People with social anxiety have core beliefs that are the root of some of what they struggle with. Similar to the cognitive restructuring of thoughts, core belief work looks at the thoughts that are maintaining your social anxiety. Social anxiety is more than a phobia, as it is based on negative beliefs about self, and perfectionist beliefs about others’ expectations, and shame. Core belief work is important.

Here are some examples of core beliefs people with social anxiety have. Do you recognize them?

  • I am bad at being social
  • I am boring
  • I am ugly
  • I am not good enough
  • I always have to please others
  • If people know who I really am they will judge me
  • People will always hurt me

A therapist will help you uncover these beliefs and challenge them through experiments.

Experiments are what we do to learn whether what we believe is true in CBT. Generally, your therapist should encourage you to come up with experiments to help you learn to modify your cognition and beliefs so they become more helpful for you, so you can live a life more consistent with your values. Experiments are also known as exposures.

An example of an experiment you might do is to have a conversation with a person to see if all of the things you predict might happen will happen. This is a step in the direction of creating a new set of cognition and beliefs. You may be considering this gathering evidence.

If for example, you believe you are poor conversationalist and no one will want to talk with you, they will turn away from you, or laugh at you, the experiment might help show you whether this is or isn't true. Your therapist will help you use the strategies of external mindfulness, thought diffusion, and curiosity to pay attention to the person in the conversation to help the experience go well.

You may have done worksheets and role-plays prior to this experiment to help you generate the confidence to decide this would be a good experiment to do.

References

I rely heavily on the work of Larry Cohen and workshops I've attended done by him. A great resource for social anxiety disorder is The National Social Anxiety Disorder Center

Leave cbt for social anxiety disorder for types of social anxiety disorder

Other pages

Love the picture? Connect with the artist.