Social anxiety disorder left untreated may have profound implications for an individual’s life. I became interested in treating social anxiety at the beginning of my career when I encountered a young adult with schizophrenia who was unemployed, socially isolated and living at home with their parents. His previous case manager had assumed that all the problems were due to his schizophrenia. However, having got acquainted with this person, I realised that his schizophrenia was being well managed with medication and it was actually social anxiety that was ruining his life.
People with social anxiety disorder (SAD) struggle with social situations including in the context of meeting new people, public speaking or even eating or drinking in public. Underlying this anxiety is a fear of negative judgement and rejection by others. Around eight per cent of the Australian population will experience social anxiety disorder at some point in their life (Andrews et al., 2018).
Research shows that people with social anxiety are more likely to be single, unemployed and attain a lower level of education. They may drop-out of school and or tertiary education because of their anxiety – be it fear of entering a classroom or lecture hall, participating in tutorials, giving a presentation, or being unable to make new friends. Their career path, courses and subjects in study may be chosen to minimise or avoid social interaction altogether (National Collaborating Centre for Mental Health).
Fortunately my client was a highly motivated person and following our work together went on to further education, got employment, moved out of home, lived independently and made some friends. This experience showed me the importance of correct diagnosis and treatment, and how helping someone overcome social anxiety can be very enjoyable and rewarding.
“Research has found that safety behaviours make the person who performs them more anxious, which is the opposite of what the client needs”
Assessment of social anxiety
As is best practice in assessment generally, obtaining a good history from the client is important including the severity and duration of their symptoms. Other critical themes to explore include:
- Are other family members anxious?
- Do their parent/s have social anxiety?
- Did the client have selective mutism as a child?
- Were they bullied at school?
- How were they treated within their family of origin in terms of criticism and praise?
I routinely give clients the Leibowitz Social Anxiety Scale which lists common social scenarios and they are rated for anxiety and avoidance. This questionnaire can be re-administered at regular intervals to track progress. Psychologists should also look for comorbid disorders including in particular other anxiety disorders and depression (Andrews et al., 2018). For example, do they have obsessive compulsive personality disorder, avoidant personality disorder, complex PTSD, and/or body dysmorphic disorder? Are they depressed? Obviously depression may need to be addressed first as they are going to need motivation to successfully engage in treatment.
I consider it important to know the client’s current living situation. Are they living alone or with family members? In a share house? The other people the client lives with can be enabling the client to avoid social interaction. Ideally the socially anxious person, depending on their goals and fears, should be encouraged to answer the door, do the grocery shopping, order the takeaway and interact with tradespeople. This can be facilitated by those around the person or conversely they can impede social behaviour so knowing what is happening in the household is important. Furthermore, if the person lives alone they may be terribly lonely.
Having family members join at least one session can be helpful in terms of them understanding that it is not helpful to enable their loved one to avoid exposure. People with social anxiety can be highly avoidant and entering into treatment doesn’t mean that avoidance magically disappears. Doing the homework exercises can be very challenging and anxiety provoking so it is very tempting for people to avoid engaging in exposure to their feared social and performance scenarios.
Supportive strategies
If you only have 10 sessions with the client under a Mental Health Treatment Plan, clients need to be motivated and to do their homework between sessions. I believe in giving clients access to suitable resources from the first session referring them to commercial and free manuals and suitable articles available online. I routinely request clients read a social anxiety self-help manual as part of their homework. Some people dislike reading, are time-poor or have reading difficulties, so the availability of audiobooks allows them access to information.
I encourage people to be open about the fact that they are socially anxious rather than trying to hide it as a shameful secret. Some people with social anxiety may appear tense or unhappy when in social gatherings which may be misinterpreted as being rude or disinterested. Therefore I encourage people to be open with others that they are a ‘bit shy’ when meeting new people.
To complement the work I do with them I often suggest clients participate in anxiety support groups. For example, in Victoria we have ADAVIC (Anxiety Disorders Association of Victoria) and ARCVic (Anxiety Recovery Centre of Victoria) which pre-COVID-19 offered face-to-face support groups and now offer online support groups. Attending these groups has been a positive experience for many of my clients, and provides a safe place for people to practice dropping their safety behaviours and allows them to engage in social interaction.
Treatment of social anxiety
Cognitive behaviour therapy (CBT) is considered first-line treatment for social anxiety (Andrews, 2018). Cognitive therapy for social anxiety disorder is based on Clarks and Wells (1995) cognitive model of social anxiety disorder (SAD) and involves six components.
1. Developing a personalised cognitive model using a flowchart which shows the client’s negative thoughts, focus of attention, safety behaviours and anxiety symptoms and undertake an exercise to demonstrate that self-focused attention and safety behaviours make social anxiety worse.
2. Attention training to make the client more externally focused.
3. Behavioural experiments requiring clients to drop their safety behaviours and be externally focused in social situations and deliberately make mistakes/display feared behaviours or show signs of anxiety.
4. Video feedback to correct negative self-perceptions.
5. Surveys to discover how the public views feared outcomes such as blushing sweating or shaking.
6. Memory work to decrease the impact of early social trauma experiences.
The following is an overview of how I implement the Clarks and Wells (1995) model in my practice. David Clark has a social attitudes questionnaire, a social cognitions questionnaire and a social behaviours questionnaire. The client’s responses to these inventories are used to help develop the personalised cognitive model of the clients social anxiety in the first or second session.
Attention training
David Clark has his clients do attention training and they listen to a recording of six to eight sounds for 10 minutes twice a day for several months. There are instructions on the soundtrack as to what noise to selectively focus on while ignoring the others and during the 10 minutes practice, they switch their attention from one noise to another.
Attention training helps clients improve their ability to switch their attention from themselves (e.g., their intrusive thoughts or images) to their external environment (e.g., the person they are having a conversation with) and this enables them to respond more appropriately to their audience.
“The aims of the attention training technique are to reduce perseverative thinking, increase flexibility over processing, reduce threat monitoring and self-focused attention and increase attention to disconfirmatory information” (Veale & Neziroglu, 2010, p. 265).
Safety behaviours
It is very important that people with social anxiety understand that not only do they have to stop avoiding feared social scenarios, they have to drop their safety behaviours. Safety behaviours can be overt or covert acts intended to prevent feared social catastrophes such as public embarrassment or humiliation or minimise its consequences. Safety behaviours prevent the client from disconfirming some of their erroneous beliefs about the feared social encounter (Gray et al., 2019).
Safety behaviours can be categorised as avoiding aspects of social interaction (which tend to be overt) or impression management (which tends to be covert).
If people with social anxiety use avoidance strategies their performance is judged as poorer by conversational partners but impression management safety behaviours (e.g., mentally rehearsing sentences, picturing how one is coming across) are covert and therefore not detected by conversational partners (Gray et al., 2019).
Research has found that safety behaviours make the person who performs them more anxious, which is the opposite of what the client needs (Wells et al., 1995). Safety behaviours backfire on their social anxiety as they make the person appear more awkward and less likeable. Clients may not be able to cope with dropping all their safety behaviours at once, but over time they need to reduce their safety behaviours and the goal is to eventually abandon all safety behaviours.
Safety behaviours are things that people do before or during anxiety provoking social situations to make themselves feel more comfortable, that is, less anxious. However the use of safety behaviours is the major factor maintaining social anxiety and the reason people don’t feel relief during exposures.
CBT for social anxiety disorder can include a behavioural experiment where a client holds two conversations – one with safety behaviours and one without safety behaviours and they compare how they have felt in the two conditions.
The therapist can set up a role-play situation where they act socially anxious and use avoidance behaviours during a conversation or can use video feedback. This helps the client see that avoidance safety behaviours give the opposite impression to the one that they want to convey (e.g., poor eye contact, short answers, not asking questions can give the impression the client is not interested in talking to other people and perhaps does not like them).
Exposure work
I encourage clients to do some exposure work as part of their session. For example, we go out to the local shops and they can practise ordering a coffee. While in the cafe, they can use this time to observe how many people are there by themselves and what these individuals are doing (e.g., reading the paper, using a laptop or playing on their phone). Many socially anxious people would not go to a cafe alone as they believe they would be judged as weird, or as having no friends.
I encourage clients to go to shops and request items (e.g., ask the assistant for clothes in different sizes or colours), visit the local butcher or baker and request a specific item, thereby risking being asked a question, and use the cashier at the supermarket rather than the self-serve checkout. All these activities are exposure exercises that can be done in session time.
COVID-19 has been a challenging time for social anxiety treatment as masks mean that people’s faces are obscured and therefore masks can be a safety behaviour. Social interaction has been drastically reduced with people working and studying from home so people have fewer social demands let alone opportunities to engage in social interaction.
Telehealth has meant that people can make phone calls rather than video sessions and I have found some severely socially anxious clients are opting for phone calls as their preferred option, however if that is their first step towards seeking help maybe telehealth has helped people who normally would have avoided therapy altogether take their first step.
Quite often people with social anxiety have perfectionistic traits and they need to understand that it is ok to be imperfect. Working with them on behavioural experiments that allow them to be imperfect can help them challenge their anxiety about this by seeing if anyone notices and if they do notice if they care or if anything terrible happens. Can the audience’s response be tolerated by the client? Clients can be very resistant to being seen to be imperfect.
Video as a treatment tool
Video feedback can be a helpful tool in treatment provided it is used correctly. It can be highly effective in changing client’s distorted negative self-perceptions and has been associated with a significant reduction in social anxiety (Warnock-Parkes et al., 2017). By watching a video of their behaviour, a client can see that they performed better in a social interaction than they originally predicted. And now that virtually everyone has a smartphone, clients can video themselves. The client needs to give their permission to be videoed and that should be obtained early in treatment. Videoing can start early in therapy so it is part of the treatment routine. For video feedback to be helpful, a few points need to be addressed.
1. The camera should be placed out of the client’s field of view but so that both people in the interaction are visible and the client can see the context of the interaction rather than overly focusing on themselves.
2. The client should predict what they think they will see and their perceptions of what will happen e.g., “I blushed and my hands shook prior to watching the video”. We need a clear description of how they think they will appear on the video. For example, if they think they will shake on the video, they need to demonstrate how severely they think they will be shaking. If they think they will blush, they need to identify the shade of red. If they were sweating under their arms they need to indicate the size of the sweat patch they expect to see.
3. Clients need to be prepped to try to watch their video as if they are watching a stranger, that is, they need to have an unbiased mode of viewing. Clients can feel very anxious watching themselves on video and this can negatively affect how they appraise their performance.
4. Clients need to watch their video with compassion, treating themselves as they would treat a friend in order to counteract critical thoughts about their performance.
5. Compare and contrast the client’s predictions from what they see. Clients need to compare their predictions and ratings before and after watching the video. Clients will often find they performed better than they predicted.
Surveying public views
Surveys can be helpful for clients to gain an understanding of how other people perceive behaviours that are of concern to the client like blushing, sweating of shaking in certain situations. Ideally the client should hand surveys out, but getting them to agree to do this can be problematic. Often I can get the client to write me a list of the questions they would like to get the public’s responses to, but I end up being the one who distributes the questionnaires. Sometimes the client needs a very specific audience (e.g., fellow lawyers) but others times the general public will suffice. The results can be enlightening for the client when they realise that the public has an accepting view of such difficulties.
Easing the burden
Social anxiety is a relatively common anxiety disorder and while not easy to treat, clients who persevere and actively take part in treatment can have good outcomes. Various psychological strategies and practice activities can be used with clients to boost opportunities for clients to gain insights and challenge the maladaptive thoughts and behaviours that maintain their social difficulties.
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