Social Anxiety Disorder

Everyone feels social anxiety at some point in their lives. Whether it’s standing up and presenting in front of others, going on a date, talking in front of a group, going to a party, or being watched while completing a difficult task, social anxiety is ever-present. What’s more, it is a natural response in many situations.

However, for some people, social anxiety becomes so severe and intense that it can lead to serious difficulties living a normal life.

Individuals with social anxiety disorder (SAD) typically fear and avoid situations in which others can evaluate them, often fearing that they will act in a way that causes them to be judged negatively. People with SAD therefore aim to avoid situations where they are the focus of attention, or endure them with great distress.

Social anxiety affects millions of people around the world. Just over 12% of the population will experience it at some point in their lives (Kessler et al., 2005). This makes it the fourth most common psychiatric disorder, with only major depressive disorder, alcohol abuse, and specific phobias being more common.

Living with Social Anxiety Disorder

When social anxiety disorder was first discussed as a diagnosable mental health condition back in the 1980s, it was thought to be a relatively mild condition compared to other anxiety disorders. Research has since revealed that this is far from the truth- as anyone living with it can tell you, social anxiety disorder can be quite incapacitating. The vast majority of people living with social anxiety disorder find that it impacts every area of their lives, including work, academic, and social functioning (Acarturk, de Graaf, van Straten, ten Have, & Cuijpers, 2008).

Individuals with social anxiety disorder often find that they have fewer friends and romantic partners (Rodebaugh, 2009), and they are less likely to marry. This is true even in comparison to people living with other anxiety disorders such as phobias or panic disorder.

Social anxiety can also stop people from functioning well at work and living up to their true potential. In one research study, individuals with social anxiety disorder were more likely to work at a job below their level of ability and educational attainment- due to a lack of confidence in themselves and the belief that others saw them as not fitting in (Bruch, Fallon, & Heimberg, 2003).

More generally, symptoms of social anxiety are linked with a low level of overall life satisfaction. Individuals with SAD often have poor quality of life (Alonso et al., 2004), are more likely to attempt suicide (Wunderlich, Bronisch, & Wittchen, 1998), and are more likely to have alcohol and nicotine dependence than the general population (Wittchen et al., 1999). Living with social anxiety can be a difficult, lonely and unrewarding experience.

Despite this, and despite the suffering the condition causes, most people with social anxiety disorders do not seek treatment unless they develop an additional disorder (Schneier et al., 1992). This may be down to the nature of the condition itself causing people to want to avoid difficult social situations where they are the focus of examination.

People may also be unaware that their struggles are caused by a treatable mental health condition, instead believing they are simply shy or introverted.

Facts and Figures

SAD tends to begin in adolescence, often developing in the context of a childhood history of social inhibition or shyness. One study found that SAD had the earliest age of onset (13 years) of all anxiety disorders. Once formed, social anxiety is a condition for life which rarely disappears on its own.

Social anxiety is often experienced alongside other disorders, with about 70–80% of individuals with social anxiety disorder also having an additional diagnosis. Social anxiety disorder typically develops first (Schneier et al., 1992).

Which other disorders are most commonly experienced alongside social anxiety? The most common additional diagnoses include specific phobia, agoraphobia, major depression, and alcohol use disorders. Experiencing another disorder alongside social anxiety greatly increases the impairment and distress the person is likely to experience, and can lead to an increased risk of suicide (Schneier et al., 1992).

Women are more likely to have SAD than men- this has been consistently found around the world (for review, see Asher, Asnaani, & Aderka, 201). This gender difference is most pronounced among adolescents and gets narrower throughout the course of life.

As well as being more likely to be diagnosed with the condition, women tend to experience more severe symptoms (Asher & Aderka, 2019), higher levels of social fears, and a higher number of social fears (Xu et al., 2012). As is true for all anxiety disorders, SAD appears to be more debilitating in women, especially in white women and, to a lesser extent, hispanic women (McLean, Asnaani, Litz, & Hofmann, 2011).

Types of Social Anxiety Disorder

Individuals with social anxiety vary widely in the kinds of situations they fear, and the severity of their anxiety. Some people fear a range of situations, while for others their worries are restricted to a few specific situations.

Common kinds of situations feared include:

Social interaction fears – such as dating, joining an ongoing conversation, being assertive, speaking to a stranger
Performance fears – public speaking, playing a musical instrument in front of others
Observation fears – working in front of others, walking down a busy street

Based on current guidelines, it is possible to be diagnosed with a performance-only subtype of social anxiety if your fears are limited to performance-based situations (American Psychiatric Association, 2013).

The more situations your social anxiety causes you to fear, the greater the level of difficulty is likely to be. People with a wide-ranging social anxiety often report decreased educational attainment, higher rates of unemployment, and a lower chance of finding a marriage partner (Mannuzza et al., 1995).

Nevertheless, people who fear many social situations but who come forward for treatment using CBT improve just as much as those who only fear performance situations (Brown et al., 1995). They may, however, require a longer period of treatment.

Avoidant Personality Disorder

Social anxiety has many features in common with avoidant personality disorder (APD). APD is a separate mental health condition in which a person feels a long-standing sense of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation” (American Psychiatric Association, 2013, p. 672).

There is a lot of overlap between the symptoms for APD and social anxiety, and many people meet the criteria to be diagnosed with both. Some research shows that people diagnosed with both disorders experience more impairment and difficulty living a normal life, although this may be due to the severity of the social anxiety present in such people (Cox, Pagura, Stein, & Sareen, 2009).

You could therefore argue that APD and social anxiety disorder are the same condition, and that people living with a diagnosis of both disorders are simply the ones with the most severe social anxiety.

Diagnosis

SAD is defined by significant anxiety in relation to one or more social situations in which scrutiny from others may occur. Fear that one will act in a way that leads to negative evaluation (e.g embarrassment, humiliation, and/or rejection), or that one’s anxiety will be visible to others and negatively evaluated are also common symptoms. Symptoms of SAD usually last 6 months or more.

Having to experience their feared situations invariably produces severe anxiety in people with SAD. This fear may take the form of a panic attack. The fear is out of proportion to the actual danger or threat, though the individual with SAD may not realise this.

The fear produced by social situations causes people with SAD to either avoid them or endure them with intense anxiety and discomfort. To be diagnosed, this fear and avoidance interfere significantly with the person’s ability to live a normal life or cause them significant distress.

The final diagnostic criteria for social anxiety is that the person’s symptoms are not better accounted for by another condition, or by the effects of substance use.

A performance-only subtype of SAD exists, in which a person only experiences extreme anxiety in relation to performing in front of other people. Compared to individuals who fear other kinds of social situations, individuals with this subtype report more physiological symptoms of anxiety when confronting their feared situation. This form of SAD appears to be less influenced by genetic factors and less related to personality traits typically associated with SAD, and responds to different forms of medication more effectively.

Social Anxiety Assessment Methods

The Role of Assessment

A good assessment should achieve a number of goals:

Making an accurate diagnosis, and ruling out other conditions
Establishing the severity and frequency of symptoms and associated problems
Selecting which problems to target during treatment
Evaluating treatment outcome (at the end of the treatment course)
Detecting relapse at later review sessions

A thorough assessment is necessary in order to select the right treatment for a client. For the assessment of SAD, a multimodal approach should be taken that may include structured, semistructured, or unstructured interviews, self-report measures, and behavioural assessment. Each of these methods provides unique information for making diagnostic and treatment decisions.

Clinician Assessment Tools

During the initial stages of treatment, a clinician or therapist will normally assess the patient’s symptoms using some form of assessment tool. Often these are structured or semi-structured interviews during which the clinician asks questions about the client’s experiences, making a diagnosis once the interview is complete.

Within the field of anxiety, the two most commonly used semi-structured interviews are the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5; Brown & Barlow, 2014) and the Structured Clinical Interview for DSM-5 (SCID-5; First, Williams, Karg, & Spitzer, 2015).

The ADIS-5 and the SCID-5 each have advantages and disadvantages. The SCID-5 provides a detailed assessment of a broad range of disorders, including eating disorders and psychotic disorders. However, the ADIS-5 provides more detailed information on each of the anxiety disorders. The ADIS-5 also provides more detailed information to differentiate SAD from other overlapping disorders.

The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) is a brief, clinician-rated measure that assesses the severity of anxiety in social and performance situations. The clinician provides separate fear and avoidance ratings for 11 social interaction situations and 13 performance-based situations (e.g., speaking up at a meeting). The LSAS does not assess cognitive or physical aspects of anxiety, so it cannot measure all aspects of symptom severity.

The Brief Social Phobia Scale (BSPS; Davidson et al., 1991) is another scale which assesses social phobia symptoms. Clinicians can use it to provide separate fear and avoidance ratings for seven different social and performance situations: public speaking, talking to people in authority, talking to strangers, being embarrassed or humiliated, being criticised, social gatherings, and doing something while being watched. Physical anxiety symptoms are also assessed.

Self‑Report Measures for SAD

Symptoms of SAD can also be assessed using a questionnaire the client fills in themselves. Often these are completed before the first session of treatment and the results are discussed during the initial session.

Two long-standing tools designed to measure social anxiety symptoms are the Fear of Negative Evaluation (FNE) scale and the Social Avoidance and Distress Scale (SADS; Watson & Friend, 1969). The FNE measures concerns about being evaluated in social situations, while the SADS assesses distress and avoidance.

Two well-tested scales that are useful when used together for the assessment of SAD are the Social Interaction Anxiety Scale (SIAS) and the Social Phobia Scale (SPS) developed by Mattick and Clarke (1998). The SPS assesses anxiety around to performance and being observed by others while the SIAS assesses fear and anxiety focused on more general social interaction.

Another frequently used measure of social anxiety symptoms is the Social Phobia Inventory (SPIN; Connor et al., 2000). The SPIN assesses fear, avoidance, and physiological arousal associated with SAD. A brief, three-item version of the SPIN (Mini-SPIN) has also been developed as a screening tool for social anxiety in adults and adolescents.

Behavioural Assessment

Assessing a client’s behaviour in social situations is useful for identifying specific fear cues and determining the intensity of an individual’s fear when exposed to the situations they fear. It can also be used to determine how impaired a client’s social skills are, which is useful since most people with SAD will have a highly negative view of how they come across which may not actually reflect reality.

The most common form of behavioural assessment is a behavioural approach test (BAT; sometimes referred to as a behavioural avoidance test). During a typical BAT, the clinician selects situations from a list or exposure hierarchy and instructs the patient to enter the situation for several minutes. This often involves role playing situations (such as job interviews or initiating conversations) with the help of assistants or others who work at the therapy practice.

The clinician observes how the client acts and assesses:

Cues that affect the intensity of fear experienced.
The intensity of the fear experienced in different social situations, which can be rated on a 0- to 100- point scale.
The physical sensations experienced (e.g., palpitations, dizziness, sweating, blushing, shakiness).
Anxiety-related cognitions experienced, including expectations, thoughts, predictions, and beliefs.
Any anxiety-related behaviours, such as avoidance, distraction, and other safety behaviours.

Practical Recommendations for SAD Assessment

When assessing the symptoms and severity of social anxiety, clinicians need to be aware of various practical considerations.

Anxiety in the Initial Evaluation

It’s important to understand that, for a patient with social anxiety, the assessment process itself constitutes a situation of intense scrutiny which will likely produce intense anxiety.

For many people with SAD, sitting in a waiting room before an appointment, filling in an initial intake form in public, and meeting a clinician for the first time are situations comparable to those that they have been avoiding for a long time.

It is important for the clinician to be aware of how significant the initial assessment is for a client, and to provide support and reassurance as needed. The clinician should explain why it is essential to gather information about the individual’s fears, as well as the therapeutic value of talking about these fears, despite the anxiety it may produce. The therapist should also aim to develop rapport with the client quickly to ease their anxiety during the assessment.

Assessing the Cognitive and Behavioural Features

It is important for the clinician to fully assess every feature of a patient’s fear, including cognitions and imagery, reliance on safety cues, and the types of avoidance strategies used, as well as the range of situations the client fears/avoids.

Cognitions include thoughts, predictions, expectations, or fear-related imagery that help to maintain their fear of social situations. Cognitions can also relate to the feeling of anxiety itself- clients may fear the experience of anxiety and how it may be noticed by others.

“Safety cues” are objects, stimuli, or behaviours that make a client feel more safe in feared situations. These may include wearing extra makeup to hide blushing or having detailed cue cards on hand when giving an informal presentation.

Avoidance can be overt, such as leaving a frightening situation or not entering it in the first place. Avoidance can also be more subtle. Subtle avoidance strategies used by individuals with SAD may include avoiding eye contact, wearing sunglasses or dark baggy clothing to appear less noticeable in public, making excuses to leave events early, or memorising what to say in advance of social events (Antony & Swinson, 2017).

Alcohol is another common avoidance strategy used by some individuals with SAD to cope with difficult social situations.

Differential Diagnosis

It is important to rule out other disorders that may have overlapping features. Feeling anxious in social situations is a feature which can be present across a range of mental health disorders, including generalised anxiety disorder (GAD), eating disorders (especially fear of eating in public), body dysmorphic disorder, panic disorder, and obsessive–compulsive disorder.

PD and agoraphobia in particular may be difficult to differentiate from SAD since individuals with these conditions are often highly anxious about the possibility of panicking in social situations. Avoiding social interaction is therefore a common behavioural symptom of these conditions. Determining whether the focus of anxiety is on having panic attacks and being unable to escape public places (as in PA or agoraphobia) or on being embarrassed or judged in a public place (in SAD) is critical to distinguishing these conditions.

It is also possible for normal levels of shyness or inhibition to be misdiagnosed as SAD. The clinician must always keep in mind whether an individual’s symptoms meet the required threshold for diagnosis. All forms of anxiety occur on a spectrum, with normal levels at one end and disorder symptoms at the other. For the criteria for SAD to be met, the individual must experience significant distress about their situation or experience clinically significant impairment to important areas of life such as work, education or in relationships.

Factors Related to Social Anxiety

Part of assessment can also involve exploring a client’s underlying beliefs, thought processes and other processes which may relate to social anxiety. Some specific factors to consider include:

Anxiety in Response to Physical Sensations

Research has shown that individuals with SAD have increased anxiety in relation to physical sensations such as shaking and breathlessness, particularly in relation to whether they will be noticed by others (Collimore & Asmundson, 2013). Two measures of anxiety in response to physical sensations are the 18-item self-report third edition Anxiety Sensitivity Index (ASI-3; Reiss, Peterson, Taylor, Schmidt, & Weems, 2008), and the 18-item self-report Body Sensations Questionnaire (BSQ; Chambless, Caputo, Bright, & Gallagher, 1984).

The extent to which a client feels If anxiety about physical sensations should determine whether this is a focus of treatment. For individuals who are highly anxious about their internal sensations, practising interoceptive exposure (deliberately inducing feared sensations to extinguish the fear response) may be a useful addition to treatment.

Other Relevant Dimensions

A thorough assessment of SAD should also include measures of factors such as:

Generalised anxiety
Depression
Perfectionism
Level of impairment to daily functioning

Using Assessment to Monitor Progress

Symptom measures are useful not only during the initial assessment phase but also to assess a client’s progress during treatment. This can be done by repeating the pre-treatment questionnaire, or a shorter equivalent, at the start of every session to measure progress in symptom reduction.

Given that exposure is a common component of treatment for SAD, patients should also complete a fear and avoidance rating for their exposure hierarchy at the beginning of each session.

A comprehensive assessment of symptoms can also be undertaken at the end of treatment to measure how successful it has been. This can be done using the same questionnaire as used at pre-treatment, and should also include a report or form to indicate how satisfied the client was with their treatment experience.

Understanding Social Anxiety Disorder

A model of how people with social anxiety process information has been created by Heimberg, Brozovich, and Rapee (2010).

The process begins when the socially anxious person is in the presence of an audience (either a single person, or a group). A person with social anxiety perceives this audience as being inherently critical and as having standards they will never be able to live up to, regardless of how friendly or understanding the audience may really be.

The socially anxious person creates a mental representation of how they think they come across to other people. This mental image of how they think they are perceived is highly negative and distorted compared to how they really appear (Hackmann, Surawy, & Clark, 1998).

This perception of how they appear to others is often based on the anxious person’s early experiences of unpleasant social events, such as bullying or abuse as a child (Hackmann, Clark, & McManus, 2000).

For example, one patient described being mercilessly teased by her peers as a young teenager for being tall and skinny. Although she was now an attractive adult, she still described her appearance as “gangly,” “awkward,” and “ugly,” as these were the words used by her bullies when she was younger.

Research has also shown that people with social anxiety rate their own social behaviour and social skills more negatively than objective observers, believing that they come across as awkward, boring or uncomfortable (Rapee & Lim, 1992). They also overestimate how obvious their anxiety is to observers, believing themselves to be open books in this regard (Norton & Hope, 2001).

Reduced Processing Ability

Believing that they are unacceptable to other people, that other people are inherently critical, and that the evaluation of others is extremely important causes individuals with social anxiety disorder to be extremely alert and vigilant for any indications of disapproval from others, such as frowns, yawns. They also become very aware of any possible parts of their own appearance or behaviour which might be judged negatively by others.

Paying attention to all these different things- their own appearance, possible signs of judgement from others and their own distorted view of themselves- means that the socially anxious person has a lot of different things to keep in their head during social situations. This increased mental work means that they are likely to have difficulty following conversations and meeting the demands of the particular social task they are engaged in. This can then lead to negative appraisal from others.

In other words, people with social anxiety are so preoccupied with how they come across that they end up coming across badly.

Meeting Standards

People with social anxiety disorder will often try to predict or guess the standards that the audience holds for them. They do this based on the characteristics of the audience (e.g. Position of authority, attractiveness) and features of the situation (e.g. whether it is formal or informal setting).

They then attempt to judge the extent to which their current mental representation of their appearance and behaviour meets these predicted standards. Given how negatively people with social anxiety view their own social abilities, they are likely to conclude that they have failed to meet the standards other people place upon them. They then imagine unpleasant consequences to this failure, such as rejection, ridicule or loss of social status.

These negative predictions result in cognitive, behavioural, and physiological symptoms of anxiety. Over time these symptoms feed into the person’s view of themselves in the eyes of others, further reducing their estimation of their own social ability and perpetuating the cycle of anxiety.

Fear of Positive Evaluation

A recent change to this model suggests that people with social anxiety fear not only negative evaluation, but evaluation of any kind from others (e.g., Weeks, Heimberg, Rodebaugh, & Norton, 2008).

Fear of positive evaluation (FPE) occurs when someone with social anxiety receives good feedback from others about their social performance, but then fears that this standard will be expected of them in the future.

For a person with social anxiety, this creates an expectation they feel they will be unable to meet. In their view, it is better to be seen as socially incompetent so as not to draw attention to themselves and risk losing further status by failing to meet higher expectations.

Treatment for Social Anxiety

There are a variety of treatment types available for SAD. Researchers have examined the efficacy of many forms of treatment, including cognitive and behavioural treatments, acceptance and commitment therapy (ACT), interpersonal psychotherapy (IPT), mindfulness training, attention bias modification, interpretation training, psychodynamic therapy, and social skills training.

Many different formats of treatment are also available, including individual therapy, group therapy, virtual reality exposure treatment, and Internet/computer-delivered treatment.

Cognitive Behavioural Therapy

CBT is the most widely researched treatment for SAD and has been shown to be highly effective. Importantly, CBT for SAD has been found to be effective under less-controlled, real-world conditions (Stewart & Chambless, 2009), not just in clinical trials. CBT is also considered effective across a range of formats, including individual therapy (Aderka, 2009), group therapy (e.g., Wersebe, Sijbrandij, & Cuijpers, 2013), in virtual reality exposure treatment (e.g., Carl et al., 2019) and in internet-delivered treatments (e.g., Kampmann, Emmelkamp, & Morina, 2016).

The following section will go into further detail on how CBT for social anxiety works and outline how treatment typically plays out.

Acceptance and Commitment Therapy (ACT)

ACT is a form of treatment focussed on learning to accept, rather than change or worry about, negative thoughts and experiences. It teaches mindful acceptance and staying focussed on the present, while encouraging commitment to positive life changes.

ACT has also been found to be effective in treating SAD. In a review of research examining ACT as a treatment for social anxiety, medium to large effect sizes were found in 10 separate studies (Swain, Hancock, Hainsworth, & Bowman, 2013). Its effectiveness is considered comparable to that of CBT (Craske et al., 2014), and was likewise found to be effective in reducing symptoms in group formats (Kocovski, Fleming, Hawley, Huta, & Antony, 2013), as an internet-delivered treatment (Ivanova et al., 2016), and in naturalistic settings (Dalrymple & Herbert, 2007).

Interpersonal Therapy (IPT)

Interpersonal therapy specifically focussed on teaching clients skills and strategies to solve problems in their relationships and improve the quality of their social relationships overall. As such it stands to reason that IPT can be used effectively to treat social anxiety.

A number of studies have examined IPT for the treatment of SAD. Most studies find IPT to be an effective treatment for SAD, but in most studies CBT results in superior outcomes.

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness is an ancient practice of focusing your mind on the present and accepting any thoughts that come without judgement or critique. In recent times it has been used effectively to improve mental wellbeing since it is proven to help with stress relief and reducing the distress caused by negative thoughts.

MBSR is a form of treatment focussed on meditation and using mindfulness to reduce the distress caused by negative thoughts and emotions. MBSR has been shown to be effective in treating and reducing the distress caused by various conditions, including depression, generalised anxiety and SAD. In one study Goldin et al. (2016) compared the effects of MBSR and CBT to a wait-list. It was found that CBT and MBSR led to comparable improvements in social anxiety symptoms.

In contrast, Koszycki, Benger, Shlik, and Bradwejn (2007), found that while both treatments improved social anxiety to some degree, CBT resulted in better outcomes overall.

CBT Group Therapy

A study by Heimberg, Dodge, and colleagues in 1990 was the first to test the effect of group-based CBT for social anxiety disorder. Their treatment consisted of exposure, cognitive restructuring, and homework assignments.

They found that participants in the group therapy reported less anxiety during a behavioural test and showed improvements in their level of anxiety when assessed by a therapist. These improvements were still in effect five years later, suggesting that group CBT for social anxiety produces long-term effects.

Since in SAD the focus of client’s anxiety is on social situations, running a group treatment may be more anxiety-provoking, while at the same time offering more opportunity to practise social skills and overcome anxious thoughts.

CBT as Self-help

Because of its focus on learning coping skills and practical exercises, CBT can be completed individually on a self-help basis. This form of CBT has also been studied and found to be effective.

For example, a study of the individually administered version of this treatment was recently completed, with half the patients assigned to self-help CBT while the other half were on a wait list (Ledley et al., 2009). CBT consistently improved symptoms more significantly than the waiting list condition and very few of the patients dropped out of the course.

Cognitive Therapy

Cognitive therapy (CT) for social anxiety disorder has been shown to be another promising form of therapy. CT includes exposure and cognitive restructuring, with emphasis on identifying and eliminating safety behaviours (actions taken to try and reduce distress in social situations which can interfere with exposure treatment).

In CT, the therapist and patient work together to create a personalised understanding of the factors maintaining the patient’s fear around social situations, including the patient’s unique thoughts, images, and specific safety behaviours. The patients views of themself as being incompetent and awkward during social situations are challenged by recording the patient in these situations and comparing their predicted performance to how they actually look.

Another feature of CT is that the therapist encourages the patient to direct their attention away from their internal experiences (feelings of anxiety and unpleasant physical sensations caused by worry) and to focus on the task at hand instead.

CT has been proven to be effective in treating social anxiety (Clark et al., 2003), and is superior to other forms of therapy such as interpersonal therapy (Stangier, Schramm, Heidenreich, Berger, & Clark, 2011). Like CBT, CT allows patients to continue managing their symptoms effectively once treatment has ended, and so reductions in symptoms caused by this treatment are normally maintained when assessed five years later (Mörtberg, Clark, & Bejerot, 2011).

In summary, it appears that a combined package of exposure and cognitive restructuring is the most effective form of treatment for social anxiety disorder, with three out of four people with social anxiety showing significant change after treatment. Whether it is more effective than exposure alone is a little bit more tricky to ascertain and more research is needed.

Cognitive Bias Modification

Attention or cognitive bias modification is a new form of treatment for anxiety. People with high levels of anxiety (not just those with SAD) are particularly attentive to possible threats in the environment around them- their focus is automatically drawn to any stimuli which could be perceived as threatening. In the context of SAD, this could be the one frowning face in a room of people while you are giving a talk, or any nonverbal cue that a person is uninterested in what you are saying. By focusing exclusively on these stimuli, anxiety is maintained.

Attention bias modification aims to modify this tendency for individuals with SAD to attend toward cues of social threat and away from cues associated with safety. Attention bias modification uses computerised attention tasks, such as the dot-probe detection task, to train individuals to attend away from social threatening cues (e.g., angry faces) and toward neutral cues such as neutral faces (Carlbring et al., 2012).

A similar intervention known as interpretation bias modification aims to modify the tendency of individuals with SAD to automatically make negative interpretations of ambiguous stimuli (for example assuming a person is angry if their facial expression is unclear). These types of interventions use sentence-completion tasks to train individuals to make neutral interpretations.

These treatments are computer-based and they can therefore be completed online, requiring less intensive therapist support.

Though some studies have found these interventions to be effective, (Carlbring et al., 2012), others have not (e.g.,Nowakowski, Antony, & Koerner, 2015). Recent study shows that even when effective, gains made through this treatment are modest and often disappear by the time a follow-up session is conducted.

So while attention bias presents an interesting and potentially valuable treatment intervention, it cannot yet be considered an effective substitute for established forms of therapy.

How Does CBT for Social Anxiety Compare to Other Forms of Treatment?

CBT vs Medication

Research shows that medication can be used to treat social anxiety with some success, but that CBT is overall a stronger option in terms of maintaining an anxiety-free life in the long run.

For example, in one study 133 clients were randomly assigned to receive CBT, a drug used to treat anxiety called phenelzine, or a placebo pill. Both the patients who received CBT and phenelzine showed reduced symptoms, but 6 months later 50% of the patients who had received medication had relapsed, compared to only 17% of patients who received CBT (Liebowitz et al., 1999). CBT teaches people the skills to continue managing their symptoms for life, so they are better equipped to manage if their symptoms return.

CBT vs Mindfulness and Acceptance

Koszyski, Benger, Shilk, and Bradwejn (2007) compared CBGT to mindfulness-based stress reduction. Both treatments were shown to create improvements in mood, functioning, and quality of life. However, CBT led to much greater reductions in social anxiety.

In a similar study, Piet, Hougaard, Hecksher, and Rosenberg (2010) compared CBT to mindfulness-based cognitive therapy in socially anxious young adults. Again, both forms of treatment improved symptoms and reduced distress, although CBT produced slightly bigger effects.

Treatment Principles Using CBT

The heart of the approach to treating social anxiety using CBT is the combination of exposure and cognitive restructuring (Heimberg, & Turk, 2002).

Exposure, while a daunting prospect for many, is beneficial for several reasons that the client needs to understand. One of the main reasons it is so vital is that it allows the client to test and correct dysfunctional beliefs which might be causing them to feel excessively anxious in social situations, and to generate more realistic views of themself and their capabilities.

Exposure also allows clients to experience the natural anxiety reduction that occurs when you simply remain in a feared situation for long enough that you get used to it- a process called habituation.

Finally, exposure allows clients to practice social skills which they may have been avoiding using for a long time. Initiating conversation, speaking in groups, small talk and similar skills get better with practice, and so the more a client practices them, the better they get and the better reaction they get from others.

Cognitive restructuring is also important for various reasons. Firstly, clients learn to treat thoughts and beliefs which trigger anxiety as suggestions- hypotheses to test, rather than as concrete facts or foolproof depictions of reality. This opens them up to the possibility of finding better, more helpful ways of viewing themselves and situations they encounter.

As clients come to view social situations as less frightening, they grow in confidence and become more inclined to face them.

As mentioned in the model of social anxiety above, dysfunctional cognitions about the self and expectations you are required to meet can take up a lot of your attention, making it hard to actually follow what is happening around you. Correcting these dysfunctional beliefs frees up your attention resources and should therefore help improve how you perform in social situations.

Additionally, cognitive restructuring may help clients to take credit for successes- rather than dismissing or getting anxious over them- and cope with disappointments after exposure sessions.

Finally, as clients develop a more realistic view of the threat level posed by social situations, their level of physical anxiety decreases during them. This means that they no longer have to be concerned by unwanted symptoms of anxiety such as blushing, sweating or stammering.

In Practice

When using CBT as part of in-person therapy for social anxiety, the most common and effective format is to undertake in-session exposure training, with cognitive restructuring occurring before, during, and after each exposure session.

With the emotional support of the therapist, clients are often willing to explore situations and attempt behaviours they have been avoiding for years. Successfully facing these situations in-session can therefore give clients the confidence to face them on their own.

In-session exposure can also be a lot less daunting than performing in the real world, and therefore be used as a ‘stepping stone’ to build up the client’s confidence before attempting real-world exposure.

For example, a client who is afraid of public speaking could begin by reading an excerpt from a book in front of the therapist, while sitting down. In the next session, they could read it while standing, and then read it in front of a small audience, and so on.

Practising exposure with the therapist during sessions also allows for the client to learn important principles about exposure from the therapist as they go along.

There are several principles which are necessary for exposure to produce a reduction in anxiety, such as staying in the feared situation for a reasonable length of time until anxiety subsides. In-person exposure allows the therapist to see how the patient is performing and make suggestions in the moment.

Safety Behaviours

Performing exposure with the therapist also lets the therapist see if the client is using any strategies or actions to try and reduce the worry they feel. Examples include a person who fears public speaking keeping their eyes fixed on their notes to avoid making eye contact.

These behaviours may be designed to reduce the fear you feel in difficult situations, but are actually counterproductive to the exposure process. First, they can make you appear socially awkward or distracted, making it more likely you get a negative reaction from others.

Moreover, clients who only engage in their feared situations while using safety behaviours maintain some level of fear around the situation- they believe there must be some level of threat present or they wouldn’t need to use safety behaviours.

In this way safety behaviours stop clients with social anxiety learning that they are able to cope with social situations perfectly well without them.

Group Versus Individual Treatment

Conducting social anxiety treatment in groups has numerous advantages. Clients are able to learn vicariously through watching others take part in exposure, receive support from other group members, and also practice their social skills in a low-key setting with others who share their anxieties. Having a group of people available also allows for multiple points of view to be put forward, which can be invaluable in helping clients to challenge distorted thinking (Heimberg & Becker, 2002).

There are also some disadvantages to running social anxiety treatment in groups. First and most obviously, receiving treatment for a condition involving fear of social situations as part of a group may be anxiety-inducing in and of itself. Treatment usually cannot begin until a group of six patients has been established, meaning some clients may end up stuck on a waiting list until the right number of people have signed up for treatment.

It’s possible that, like in most forms of group therapy, each individual client receives less attention. It is also always possible that interpersonal difficulties will arise, especially if one client is aggressive, domineering in group discussions, or otherwise difficult for the therapist to handle.

As to whether group therapy or in person is more effective, Powers and colleagues (2008) reported similar levels of effectiveness for both, but another meta-analysis (Aderka, 2009) suggested that individual treatment may be somewhat more effective.

Key Components of CBT for Social Anxiety

Cognitive Reappraisal

Cognitive reappraisal (or cognitive restructuring) is the process of changing the meaning a situation holds, in order to change how you feel about it (Gross, 1998). This process includes helping clients to adopt new perspectives and consider multiple viewpoints.

Cognitive reappraisal is typically divided into three stages: identifying, evaluating, and modifying maladaptive thinking (Wenzel, 2018). Identifying maladaptive thinking typically begins by discussing a context or situation in which clients recently experienced high levels of anxiety.

During the conversation, the aim is to uncover the thoughts which are triggering anxiety for the client. Clinicians can ask questions such as “What was going through your mind at that moment?” or “What were you thinking about when that happened?”

Some clients find it difficult to put their thoughts into words. If this is the case, therapists can ask them to guess at what their thoughts could have been, or to imagine what someone else may have been thinking if they were in the same situation.

Identifying maladaptive thinking forms the basis for later stages of cognitive reappraisal, but it can also have therapeutic value in and of itself. The process of reflecting on your own inner thoughts and identifying maladaptive thoughts increases a client’s awareness of their internal world, creating a deeper connection with their own experiences. This helps reduce client’s need to try and avoid their own experiences and gets them used to being fully in the present moment.

Once the thoughts responsible for generating anxiety are identified, the next step is to begin evaluating them. In evaluating maladaptive thoughts, it is important for therapists to avoid being overly challenging or critical. Rather, they should adopt a position of curiosity; attempting to help the client discover additional information by themselves.

The idea is to evaluate thoughts together and learn more about them. Questions that facilitate this evaluation (known as disputing questions) may include

“What is the evidence for and against this thought?”
“What alternative explanations exist?”
“What is the best, the worst, and the most realistic things that can happen in this situation?”
“What would you tell a friend or family member if they were in a similar situation?”;
“What are the consequences of focusing on this thought versus thinking differently or focusing on something else?”

Using questions such as these, the client gradually opens up to the possibility that their maladaptive thoughts are not the only way of viewing a situation, and their belief in them starts to diminish.

Modifying maladaptive thinking, the third and final stage of cognitive reappraisal, refers to the process in which clients (with guidance from the therapist) develop alternative, more balanced views of the original situation.

The goal of this stage is not to replace maladaptive thoughts, or discard thoughts that are “wrong.” The goal is to incorporate new information into existing thoughts to create a more balanced and helpful way of thinking.

As an example, imagine a male client who was anxious about an upcoming date. He identified a number of maladaptive thoughts which made him feel anxious. One in particular was “I’ll mess it up. She’ll hate me and won’t want to see me anymore.”

During the evaluation stage, the therapist asked the client whether this outcome was absolutely set in stone and represented 100% of all possible scenarios. The client responded that it was not. This sparked a discussion of possible alternative outcomes. Based on this, the client was able to develop the following perspective: “It is absolutely possible that I will mess it up, that she’ll hate me and never want to see me again. However, it is also possible that things won’t be that bad. We could get along, she may like me, and we could see each other again. Or maybe I won’t want to see her again- there are lots of different ways it could go.”

This type of flexible and multifaceted thinking retains aspects of the original thought, but views it as a single outcome among many, while accepting the inherent uncertainty in a situation such as a first date.

Exposure and Behavioural Experiments

Exposure is a process whereby the client chooses to systematically enter situations that provoke fear. This is a collaborative process in which choosing the exact situations to face and planning how to do so is a joint effort between client and psychologist.

In exposure, clients make a conscious choice to engage with the situations they fear- they must not be forced or coerced. Effective exposure should be systematic and includes planning, and gradual progression through a hierarchy of feared situations, from least frightening to most.

Exposure for social anxiety treatment can be divided into four stages: establishing the rationale, choosing and planning exposure scenarios, completing each exposure exercise, and processing each one after completion.

Since facing feared situations is a daunting task many clients wouldn’t voluntarily choose, establishing a clear rationale is vital. The first possible rationale is centred on habituation.

Repeated exposure to anxiety-provoking situations results in habituation, meaning that fear and other negative emotions naturally decline the more you experience them.

The second rationale is cognitive, the idea being that exposure to situations about which the client holds maladaptive beliefs grants the opportunity to test these thoughts and beliefs.

Exposure exercises conducted under this rationale are sometimes referred to as behavioural experiments, since a hypothesis (the maladaptive belief) is tested through the gathering of evidence (the exposure exercise).

The third rationale for exposure focuses on fully experiencing and accepting all the emotions the feared situations trigger. Engaging with the emotions a client usually tries to avoid reduces the fear of experiencing them and increases their ability to tolerate unpleasant experiences.

Choosing and planning exposures is the second stage of this intervention. This is typically done by constructing a hierarchy of feared situations. Exposure typically starts with situations that elicit 30–40% of a client’s maximum possible anxiety, a level that is challenging but still seen as possible.

Once the list of target exposure exercises has been developed, the next stage is to practically plan how the client will go about facing them. Establishing clear, specific goals for what the client wants to achieve in each situation is important. These goals need to be fully under the client’s control: having a 10-minute conversation with someone is a poor goal since it is dependent on the actions of the other person in the conversation. Initiating a conversation and asking two questions about the other person would be a more appropriate example.

It is also helpful when planning exposure to elicit predictions from the client, such as ‘it will be unbearable’ or ‘everyone will laugh at me’. These can be tested using the behavioural experiment principle and compared to actual outcomes as part of cognitive restructuring.

Once the actual exposure exercise has been carried out, the final stage is to process the experience. If the goals for the exposure are met, therapists should praise clients and highlight clients’ accomplishments. The simple act of praising the client’s efforts can be surprisingly impactful. In fact, recognizing and praising the effort a client puts into their exposure, facing situations they may have been avoiding for years, has been shown to be a strong predictor of therapy success (Ewbank et al., 2019).

If, on the other hand, exposure goals are not met, the therapist and client should try to gain an understanding of what might have gone wrong and decide on alterations to be made for future exposure practice. This may include reducing the difficulty level of the next exposure, changing goals, or trying exposure in a completely different context.

Another important part of this discussion is determining the meaning of the exposure, and what was learned in the exposure. Important questions to ask include “What have you learned from completing this exposure?” and “What do you know now that you didn’t know before?” This is an essential part of changing the thoughts and beliefs which contribute to a client’s anxiety.

Enhancing Emotional Processes

Individuals with SAD often experience a reduced capacity to differentiate between negative emotions. This makes negative emotions such as anxiety, anger, disgust very difficult to regulate and accept. Work on distinguishing between different emotions is often therefore an important precursor to other aspects of treatment.

Learning to differentiate emotions can involve various techniques. First, psychoeducation on emotions is extremely important- clients should aim to get a better understanding of their function, definition, and differences. Understanding the difference between shame and guilt, for example, or loneliness and sadness, or anger and frustration, and the different situations which may bring about these emotions- as well as the different thoughts they may trigger- provides a solid foundation for the rest of treatment.

One tool that can be useful in this is an Emotion Log. This is a journal clients keep for a week and use to record the different emotions they experience, along with the context it occurred and any thoughts it triggered. This log can help clients start to recognise different emotions, and can also be referred to during discussions with the therapist.

A third tool for helping clients recognise emotions is reading vignettes and asking clients to guess others’ emotions. Identifying emotions in other people is often easier than identifying them in oneself, making this a gentler way in for many clients.

Once clients become better at identifying their emotions and the differences between them, the next task is to begin work on emotional acceptance or emotional regulation. Emotional regulation comes from working on cognitive reappraisal in many different contexts and for many different emotions. Helping clients adjust the cognitions which make them feel afraid, or angry, or upset in as many contexts as possible helps reduce the impact of these strong emotions.

Emotional acceptance is a complementary skill to that of emotional regulation. Acceptance is about letting emotions exist as they are, rather than trying to change or shut them out, and developing an open and non judgemental attitude towards them (Hayes, Strosahl, & Wilson, 2012). This reduces the distress caused by negative emotions and leads to a client’s thoughts and behaviour being less driven by them.

Mindfulness meditation is one of the main ways clients can develop emotional acceptance. In mindfulness exercises, clients practise observing their emotions and any physical sensations that accompany them, in a nonjudgmental fashion. Various meditations exist which can help facilitate this new stance towards emotions with regular practice.

Another kind of exercise that facilitates emotional acceptance is defusion. In defusion exercises, the focus is on creating distance between internal stimuli, such as thoughts and emotions, and the self. The idea is that while we see our thoughts and emotions as a part of us, we act on them without thinking. Creating some sense of distance between us and our inner experiences allows us to act based on other criteria, such as our values or more rational thinking.

When viewed in this way, emotions are merely information- one piece of the puzzle used in determining how to act but not the complete picture.

Factors Affecting Treatment Success

So what makes social anxiety treatment successful, aside from the therapist and client using the right evidence-based treatment approach?

Client Motivation

Treatment for social anxiety requires willingness to do a lot of emotional and cognitive work. Facing difficult situations through exposure can also be daunting. As such clients need to understand and commit to the level of work involved and be motivated to see it through.

Clients who are not motivated to change, or who experience high levels of ambivalence toward change, are at higher risk for treatment failure. This is true of all treatments, not merely CBT for social anxiety (Miller & Rollnick, 2012). Understanding and maintaining a client’s motivation is therefore critical.

Before treatment can be a success, some clients need to resolve any apprehension or mixed feelings they have about committing to change. Motivation-focused strategies (e.g., motivational interviewing; Miller & Rollnick, 2012) can be utilised in such cases.

Client Preferences

The client’s preferences for the type of treatment chosen, and the individual goals and steps therein, should also be taken into consideration. The therapist should aim to get a good understanding of the client’s preferences before starting treatment, as interventions that are perceived by clients as inappropriate, insufficient, irrelevant, or inferior to other options are unlikely to be successful. Motivation in such cases is also likely to be low.

Ensuring that the client understands and accepts the rationale for treatment is vital. In cases where clients do not “buy-in,” use of alternative interventions may be necessary. Typically, multiple interventions can be used to achieve any particular outcome or goal within therapy, so therapists have some level of flexibility in working with a client’s preferences.

CBT for Social Anxiety: Treatment Outline

Is the Client Right for Treatment?

Social anxiety disorder is often comorbid with other disorders (Schneier et al., 1992). In these situations, the client and therapist need to agree whether social anxiety is the main disorder they want to focus on. Typically a therapist may suggest focussing on one disorder for a set period of time, such as 16 weeks.

It’s important for clients to understand how long they are going to focus on social anxiety- particularly as some clients may express the desire to switch to a new area of focus once the daunting prospect of exposure practice is suggested.

The Right Therapist

Social anxiety treatment also requires the right kind of therapist to be successful. The ideal therapist has a strong background in CBT for anxiety disorders, experience conducting exposures, good therapeutic skills in general, and specific experience with social anxiety.

CBT for social anxiety can also be manualised, meaning it is possible to be delivered from a treatment manual by a more novice therapist or in a community setting. Treatment manuals are designed with sufficient detail to allow therapists from a wide variety of backgrounds to conduct treatment, although supervision for nocive therapists and those unfamiliar with CBT principles would be advantageous (Hope et al., 2010a)

How does medication affect CBT for social anxiety?

Lots of clients are already using medication to manage their symptoms when they start therapy. This could be for either symptoms of social anxiety or another comorbid disorder. While it isn’t a requirement of treatment for clients to stop taking medication, therapists normally recommend stabilising their dosage and refraining from changing or trying new medication during therapy.

The reasons clients are discouraged from changing medications during therapy is that it’s helpful for clients to be certain that any positive changes they experience are due to their work in therapy, and not due to medication. For the same reason, clients are advised not to take as-and-when medications or self-medication such as alcohol to control their anxiety during therapy- so that they can be sure that any reduction in anxiety they experience is due to their hard work in therapy.

Treatment Contract

Following the therapist’s initial assessment, at the next session their role is to explain their conclusions, offer a diagnosis and explain the recommended course of treatment to the patient.

In the event that a client is diagnosed with more than one condition, the therapist will recommend which disorder to address first, and why. Clients should also be kept aware of the review process- their symptoms will be reassessed following the first course of treatment and a new plan will be made from there.

Principles and Logistics

Treatment for social anxiety using CBT typically comprises 16 weekly 1-hour sessions over a period of 16–20 weeks. One session per week is ideal, but typically this is not feasible due to illness, other commitments, vacations etc. Taking longer than 20 weeks to complete 16 sessions may compromise the momentum of therapy, and therefore its effectiveness.

The assessment sessions and post-treatment feedback session(s) are not counted towards this 16.

Treatment is divided into five segments, described below. Typically clients are given a workbook to complete during their treatment, and this contains reading materials they are expected to read in preparation for each session. Writing things down during a session helps clients better to track and process the information they are being taught, and is generally very helpful.

The Therapeutic Relationship

As in all forms of therapy, the relationship between the therapist and client is a key component of treatment success (Hayes, Hope, Van Dyke, & Heimberg, 2007). The therapist and client need to establish trust, rapport and common goals for treatment in order for it to proceed effectively.

To help foster this relationship, the therapist should engage in active listening, respond to the client’s verbal and nonverbal cues and help the client invest in treatment, while supporting and guiding them through the difficult aspects of treatment.

Additionally, it is important for therapists to help clients to experience the full depth of the different emotions which come up during treatment. A therapist should, for example, encourage their client to feel the full force of anxiety during an exposure practice, rather than trying to shut it out, and to feel sadness when considering things they have lost. A therapist should be able to guide clients through experiencing these difficult emotions and using them as information to help with treatment.

Clients’ ratings of the therapeutic alliance are positively related to how helpful they find the sessions. Interestingly, the relationship between the therapeutic alliance and anxiety symptom reduction has been found to be curvilinear. When ratings of the relationship were very high or low, clients showed less anxiety reduction than when the ratings were moderate.

A low level of therapeutic trust leading to poor treatment outcomes is unsurprising, but a relationship that is too good leading to less symptom reduction seems odd. It is possible that if a client feels very at ease in the presence of their therapist, this may reduce the anxiety they feel during exposure, meaning that exposure practice is actually less effective at helping the client to cope without the therapist present. Maintaining an appropriate level of trust and closeness is therefore important for successful treatment.

Treatment Part 1: Psychoeducation

The first phase of treatment is to educate the client about their condition and the treatment process. Typically this segment lasts for three to four sessions, although with an especially bright and motivated client it can take as little as two.

Therapists will often assign some of this psychoeducation as homework for the client to read on their own time and then review their understanding at the beginning of each session.

Key topics covered at this stage include:

Understanding Normal vs Problematic Levels of Social Anxiety

Everyone experiences social anxiety to some extent, but most people do not find it disruptive or unmanageable. One of the first things a client should come to understand is that some degree of social anxiety is normal and expected.

By discussing what types of situations most people find frightening, and what function this anxiety serves (encouraging you to act in an appropriate way) the client can come to appreciate that anxiety is meant to serve a useful function.

Treatment Outcomes

Once a client understands that anxiety is a normal and potentially useful part of human experience, this naturally affects the goals they have for treatment. By appreciating these facts, clients can accept the idea that living a life totally free from social anxiety is neither realistic nor beneficial.

Moving down the spectrum of anxiety from problematic to normal levels of social anxiety is a much more realistic goal for treatment.

Some clients may struggle with the idea that social anxiety could ever be useful given how much their anxiety has caused them to suffer. At this stage of treatment, the goal is merely to introduce this idea to the client. Rather than trying to persuade a resistant client of the truth of this idea, it is normally more productive to show understanding of their experience and position, and move on to a new topic.

Required Investment

The therapist needs to make the client aware of the level of commitment required for treatment in terms of time and energy. Effective treatment requires not only attending the sessions but completing all reading assignments and exposure practice outside of weekly sessions.

Since positive expectations of treatment are correlated to treatment success, this is a good opportunity to instil hope in the client- helping them believe that by putting in the effort, they will be able to make lasting changes to their life. Quoting figures about the success rates of treatment- for example 75–80% of patients who receive CBT experienced meaningful reductions in their social anxiety (e.g., Heimberg et al., 1998). Attending sessions, completing homework, facing your fears fully during exposure and being open to trying new ways of viewing themselves and the world are key variables which can determine how successful treatment is for the client.

Goal Setting

Clients are typically asked to discuss their concerns about engaging with treatment and pinpoint the goals for a better life they wish to work towards. Clients often complete an exercise in which they list pros and cons for both completing treatment and not completing it as a way to solidify their motivation and commitment.

Components of Anxiety

The therapist reviews with the client the three main components of anxiety (Hope et al., 2010a). These are:

The physiological component- bodily reactions, such as a shaking, sweating and a racing heart
The cognitive component- what a person thinks, such as “I will look like an idiot”
The behavioural component- what a person does when anxious, such as avoiding eye contact.

While discussing the behavioural component, the therapist explains how avoiding social situations and using avoidance strategies to minimise fear during them may offer short-term relief, but in the long run leads to feelings of guilt and shame, not to mention a difficult, unsatisfying life.

Exploring these three components using a hypothetical example can help the client see how they operate without them having to experience the fear and shame of talking about their own experiences at this early stage of treatment. Furthermore, many clients are not used to describing their own thoughts and may reply with responses such as ‘I wasn’t thinking anything’ when asked about their experiences.

A suitable example could be something along the lines of a person sat waiting for a job interview. The client is asked to consider what thoughts this person might be experiencing, what physical feelings and symptoms they might have, and how they would act.

This exercise is useful in helping clients to see how each of the three components interact. The therapist may prompt this using questions (‘what might he/she think about the fact his/her palms are sweaty?’ ‘How might this cause him/her to act?).

Once the client is able to analyse the interplay between the three components of anxiety in a hypothetical example, the next step is to repeat the process with a recent memory of their own. The goal here is not to challenge or correct unhelpful thoughts around anxiety, but merely to identify them and see how they interact. A client may complete more exercises of this kind as homework to get used to the process of analysing their experiences.

The therapist concludes this section of treatment by explaining that treatment involves learning to disrupt this spiral of anxiety.

Constructing a Fear Hierarchy

The therapist and client next turn their attention to creating an ordered list of the situations and experiences the client fears from least uncomfortable to most. Scales used to measure anxiety and discomfort such as the Subjective Units of Discomfort Scale (SUDS; Wolpe & Lazarus, 1966) may be used here to put a number to the level of fear and discomfort a client experiences. A scale from 0 to 100 is often used.

Factors Contributing to Social Anxiety

Next, the therapist describes the factors related to the development of problematic social anxiety.

Firstly, the therapist explains the role of genetics. People may inherit a tendency to be very sensitive and emotionally reactive, rather than a specific gene which results in social anxiety (Barlow, 2002). This inherited sensitivity is not necessarily a bad thing- it can help people be more empathic towards others and even allow them a greater capacity to feel joy.

However, if a person with this genetic sensitivity experiences challenging or unpleasant social circumstances such as bullying or public embarrassment, they may learn that other people pose a threat. This experience, combined with their genetic sensitivity, leads to the development of problematic social anxiety.

At this stage the therapist could inquire whether any of the client’s family members seem to have problems with social anxiety or other types of anxiety, which could indicate a genetic predisposition.

Experiences within the family are then discussed as another potential factor contributing to social anxiety. This is a distinct factor to genetics in that it is to do with learned and shared behaviours between family members. For example, a socially anxious mother might teach her child -directly or simply through the child observing how she acts- that the opinions of others are extremely important and appearing inadequate in the eyes of otters is to be avoided at all costs.

Direct adverse experiences can also play a part in this. For example, living with a verbally abusive father might teach a child that other people are dangerous, and that avoiding being in the spotlight is safer.

The therapist also highlights that experiences outside the family, such as teasing or bullying at school, can also contribute to a fear of social situations in later life.

Once they are aware of the main possible contributing factors to social anxiety, the client can examine their own history to identify which of them may have played a role in their own condition.

One of the key messages to take from this exercise is that social anxiety is learned through experience. This means it can be changed through experience too.

Dysfunctional Thoughts

Discussing the learned nature of social anxiety leads naturally into how these experiences can contribute to dysfunctional ways of thinking.

The therapist asks the client what lessons they may have learned through their experiences, and how this may impact their view of themselves and their automatic thoughts and beliefs. Bullying and teasing, for example, may teach a child that they don’t fit in, or that attention from other people is dangerous.

Since many individuals with social anxiety view these negative thoughts as a sign of personal weakness or as character flaws, learning that they are in fact a result of experience can be quite a revelation.

Once they understand how these dysfunctional thoughts may have arisen, clients are asked to consider how they may cause someone to act. The belief that you don’t fit in, for example, may lead to avoiding large gatherings such as parties, or avoiding talking to new people if forced to attend.

At this stage clients are introduced to the idea that if these dysfunctional thoughts were changed, their experiences in social situations may be very different.

Treatment Part 2: Cognitive Restructuring

Training the client in cognitive restructuring typically requires two to three sessions. If, after this time, a client is still struggling to grasp the concepts around cognitions, it is often best to simply move on to the exposure component rather than trying to force the issue.

Clients are at this stage taught the basic principles of CBT- that emotional responses occur due to cognitive interpretations, rather than as a direct result of situations. They are introduced to the concept of ‘automatic thoughts’- negative thoughts about oneself, the world or the future driven by distorted or inaccurate logic. These automatic thoughts are explained to be the cause of problematic social anxiety.

This concept can first be illustrated using hypothetical examples, such as two men meeting a woman, and their different automatic thoughts leading them to act very differently. One man’s anxious, self-conscious thoughts lead him to give up any attempt to talk to the woman and cause him to feel shame and embarrassment. The other experiences more neutral automatic thoughts, leading him to have a better experience in talking to her.

Once clients are comfortable following this process in hypothetical examples, they can turn their attention to analysing examples from their own recent history, using examples written down as part of their homework.

Common Thinking Errors

“Thinking errors” are defined as common forms of automatic thoughts often present in various forms of mental illness. Clients are introduced to common forms of thinking error as defined by Judith Beck (1995) in the first edition of her book Cognitive Therapy: Basics and Beyond.

Understanding these common biases in thinking allows the client to review their homework examples and see if they themselves were falling prone to any in their recent experiences. Often certain individuals are more prone to certain kinds of thinking errors, such as mind-reading bias or catastrophizing.

As homework at this stage in treatment, clients monitor their automatic thoughts and rate their belief in each one as it arises (on a 0- to 100-point scale). They also practise identifying the thinking errors their automatic thoughts contain and the emotions they cause.

Challenging Automatic Thoughts

The next steps in cognitive restructuring are to challenge the automatic thoughts leading to anxiety and work on formulating more rational ways of reacting to difficult situations.

This process is often begun using what are called disputing questions – questions designed to challenge automatic thoughts. Examples include ‘Do I know for certain that X?’ or ‘what evidence is there to support X?’ and ‘what is the worst that could happen if X? Would that really be as bad as I’m anticipating?’

As with other aspects of the process, clients can begin by applying these questions to hypothetical examples before looking at their own recently recorded examples. The automatic thoughts identified are questioned and challenged using disrupting questions and more realistic thoughts are devised.

Often when the client attempts to use disrupting questions on their automatic thoughts, the answers themselves include some level of negative automatic thinking, which must be further disputed, creating a chain of thoughts and challenging questions sometimes referred to as the Anxious Self/Coping Self Dialogue.

Eventually through this dialogue the client arrives at a more rational response to the original situation. This is typically more positive than the negative automatic thoughts the client would normally use.

Homework then builds on this by encouraging clients to apply the process at home. This involves:

Recording their automatic thoughts in anxiety-provoking situations during the coming week
Rating their level of belief in the thought (from 0 to 100)
Identifying any thinking errors contained within the automatic thoughts
Disputing the thought using disrupting questions
Developing a new, more objective thought
Rate their belief in this new, rational way of viewing the situation (from 0 to 100)

Treatment Part 3: Exposure

As previously discussed, exposure is the core of social anxiety treatment. Exposure practice should be undertaken during at least four sessions, and the client should be instructed on a specific exposure task to complete as homework after each session.

The first in-session exposure exercise is normally a role play with the therapist of a situation which the client assigned a SUDS rating of at least 50. This ensures the exposure is challenging for the client but not overwhelming in the anxiety it creates.

The therapist should make these exposure practices as realistic as possible, using props or rearranging the furniture, and utilising other staff members to act in certain ways. Failure to make the exposure seem real may lead it to be too artificial to have any effect on the client’s anxiety in the real world.

Exposure exercises should be developed based on careful attention to what the client finds anxiety-provoking. Careful attention should be paid to aspects that make the situation more or less anxiety-provoking. For example, a client who fears eating in front of others may be more anxious when eating something that is easy to spill, such as soup, than when eating a sandwich.

Exposure Preparation

The therapist begins by briefly describing the exposure situation they are about to attempt. The client may suggest modifications or alternatives, but the therapist should not be too accommodating of these requests as they may alleviate too much of the client’s fear and therefore be counterproductive. Such requests can also be a delaying tactic anxious clients use to avoid actually starting exposure.

The therapist and client then discuss the automatic thoughts the client has in regard to the proposed exposure situation. One or two are chosen to be the focus of examination during the exposure practice. The client rates their level of belief in this automatic thought (typically on a scale from 0 to 100) and attempts to identify any of the thinking errors they have previously learned about. A new, rational response is then developed, and is often written out somewhere (such as on a whiteboard or flipchart) so that the client can refer back to it during the practice.

Next, the client decides on the goals they want to achieve during this exposure session. The therapist should help them set specific and realistic goals, rather than aiming too high (eg ‘I want to feel no anxiety’ or ‘I will talk perfectly the whole time’). Two or three measurable behavioural goals are set, such as asking three questions during a conversation, stating your belief on a topic, or initiating a conversation.

Exposure Practice

The therapist and client then begin the exposure exercise. During the exposure, the therapist requests SUDS ratings from the client every minute and whenever anxiety appears to increase or decrease, to track how they are feeling as the exposure progresses. After giving their rating, the client also reads his/her rational response aloud as a way of reinforcing it in their mind.

Exposure should continue until anxiety has begun to decrease or plateau and the agreed goals have been met. Often this takes around 10 minutes. The therapist should be the one to end the practice.

Exposure Review

After completing exposure, the therapist and client process the experience together. Goals are reviewed and the client indicates how often their automatic thoughts appeared and whether any new or unexpected thoughts arose. They also discuss how useful the new rational thought was in reducing anxiety.

To prevent the client focusing too much on the perceived negative aspects of the exercise, the therapist should keep the discussion focussed on goals that were achieved, sharing their own observations of goals they the client successfully reached. Assistants or other staff members who were involved in the role play can also share their observations at this point. This feedback should aim to counter the negative thoughts the client has demonstrated, and to show that the client’s feared expectations did not come true.

It is very rare for clients to look as anxious as they think they do, so it is often quite appropriate to acknowledge that the client showed some symptoms of anxiety, but to emphasise that the levels of visible anxiety were much less than the client’s discomfort ratings would suggest.

For a therapist, telling a client that they saw no signs of anxiety in them risks the client not believing them. However, pointing out too many symptoms of anxiety or anxious behaviours may be unhelpful too, as clients will focus on this negative feedback and discount the positive. A better strategy is to take note of these anxious behaviours/symptoms and incorporate them as goals for future exposure.

When clients become self-critical due to exhibiting unhelpful or anxious behaviours during exposure, the therapist should use this as a learning opportunity. They can help the client see that the behaviour in question is not due to some fault or defect in the client, but is rather a response to anxiety they are feeling. They may help the client identify any negative thoughts leading them to act in this way, which can then be challenged.

Next, the pattern of SUDS ratings is presented to the client as a graph. Typically, SUDS ratings are highest at the start of the exposure session, and then begin to decline over time. If this is the case, the therapist can highlight to the client how getting started is often the hardest part, and can carry this mentality with them into future situations knowing that once they start a difficult task, it gets easier.

Sometimes SUDS ratings remain consistently high throughout the entire exposure session. If the client was still able to meet their goals, the therapist can congratulate them on being able to achieve everything they set out to despite their anxiety. They can also attempt to identify any negative thoughts which arose and stopped them relaxing into the session.

It is also common to see consistent or dropping SUDS scores interrupted by occasional spikes in anxiety during a part of the session which the client found harder. Sometimes these are noticeable to the therapist (such as a gap in the conversation where the client could not think what to say), but not always. Identifying these situations which caused increased anxiety may lead to new goals (such as becoming comfortable pausing in situations rather than seeing it as a bad sign).

Clients are then asked again to rate their degree of belief in their automatic thoughts and rational responses, based on how the exposure session went. Finally, the therapist and client discuss what the client has learned during this exposure session, and how they can apply this to their real life.

Homework

As homework, the client is asked to practice exposure to situations similar to the one that was practised in the session. This real-world or in-vivo exposure is just as important as the practice that occurs in therapy sessions, and follows the same process of identifying automatic thoughts, challenging them, SUDS ratings and so on. Clients are often provided worksheets or other materials to take them through the steps of challenging negative thoughts before exposure and analysing their behaviour afterwards.

Treatment Part 4: Advanced Cognitive Restructuring

As exposure continues, the client and therapist should start to observe common themes in the client’s automatic thoughts. When this happens, more advanced cognitive structuring work can begin.

At this stage of treatment, the therapist helps the client move beyond identifying situation-specific automatic thoughts and towards finding the deeper beliefs which underpin all of them. For example, a client may show fears relating to looking foolish which present differently in different situations. These may all be driven by the belief ‘I need to be accepted by others’.

Using a technique called the downward arrow (J. S. Beck, 1995), the therapist and client review examples of automatic thoughts which have arisen throughout the treatment process, attempting to peel off each layer of belief until the core belief is identified.

Exposure continues during this process, and once the core belief has been identified, exposure can be tailored to challenge it as would be done with the surface-level automatic thoughts. If the client discovers a core belief around needing to be perfect in order to be accepted, for example, they may undertake an exposure exercise in which they deliberately make a mistake in front of others to challenge this notion.

Treatment Part 5: Termination

As treatment continues the issue of ending the course of sessions and reevaluating the client’s situation is brought up several times. Towards the end of the allotted sessions, the therapist and client formally review the client’s progress and start to discuss strategies for relapse prevention.

As part of the assessment, clients are encouraged to think about what they have learned during treatment, and rate their current level of fear around all of the items from their fear hierarchy. Based on this, areas for future work are identified. They may also be assessed using the same measures of anxiety and distress which they completed at the beginning of treatment.

Many clients still show some level of social anxiety at the end of treatment. Clients should therefore be reminded that the total elimination of social anxiety was never the goal. Rather, if the client has experienced a significant reduction in anxiety, has stopped avoiding key situations and feels comfortable continuing to use the principles of treatment by themselves, they would be considered ready to end treatment.

Possible areas of relapse are also highlighted, such as when the client encounters new situations or when other people place social pressure on them to act in a certain way. Strategies for dealing with these situations are discussed.

At this stage it is also important to discuss the termination of treatment itself, and acknowledge any mixed emotions the client has about the idea of treatment ending (pride, sadness, fear etc). Follow-up appointments at 1 and 6 months to monitor the client’s situation are usually recommended.

Most clients who are able and willing to continue using the principles of exposure and cognitive restructuring on their own maintain their reduced anxiety and improved functioning after treatment. However, in some clients, their levels of anxiety and avoidance may still be too high for them to continue alone. Clients with severe social anxiety, or other comorbid conditions, are most at risk of this.

In these situations, a new course of treatment is recommended, working on exposure and cognitive restructuring in new areas so as to improve the client’s confidence and coping ability across a wider spectrum of situations.

Process Based Treatment for Social Anxiety

An alternative to structuring social anxiety treatment with specific goals and aims for each session has been developed, known as process-based treatment (PBT). Rather than having a predetermined structure to treatment, with certain sessions including specific components, the process-based approach aims to provide therapists and clients with more flexibility.

PBT involves a wide range of possible strategies that can be applied flexibly based on what is best for a particular client and context. For example, some individuals with SAD have very negative self-perceptions and believe that they possess very poor social skills. These may be treated by cognitive restructuring and modifying core beliefs.

Another individual’s social anxiety, by contrast, may have a strong emotional component, with the main issues being difficulty differentiating between negative emotions and an intolerance of anxiety-related emotions. Such an individual would be better treated by psychoeducation on emotions, working on defining and differentiating their emotions, and developing their acceptance of different emotional experiences.

Even for the same individual, the important factors may vary depending on the context. For example, socially anxious individuals may be extremely concerned with the physiological symptoms of anxiety (blushing, sweating etc) and the possibility that others will notice and judge them negatively while giving a presentation during a work meeting, but be much more concerned with how their nervous speech causes them to come across when on a date.

Carefully considering the individual, their specific fears, and the ways these appear across different contexts, is therefore an important part of treatment.

Given the wide range of individuals and possible symptoms, many different treatment approaches may be utilised. These include:

Contingency management
Stimulus control
Self-management
Arousal reduction
Emotion regulation
Problem solving
Exposure
Behavioural activation
Interpersonal skills
Cognitive restructuring
Identifying and modifying core beliefs
Cognitive defusion
Acceptance
Values clarification
Mindfulness practice
Enhancing motivation
Crisis management

Stages of PBT of Social Anxiety

PBT for social anxiety disorder includes a three-stage process that is repeated throughout treatment: contextual assessment, intervention, and processing and feedback.

Contextual Assessment

This process starts by identifying a specific target for intervention. This is done through a collaborative process where both the client and therapist examine a particular context or situation, using both the client’s unique knowledge of themself and their situation and the therapist’s in-depth psychological knowledge. In combination, the therapist and client are able to develop a shared understanding of what is happening in that particular context and to identify targets for intervention.

What sort of situations and contexts are used? One example would be if a client shared that they have a stressful or anxiety-inducing situation coming up in their immediate future, such as a party, a presentation, or a date. Other times, the therapist might suggest a possible context to examine based on their familiarity with the client.

Often, the process of examination includes drawing a schematic or flow diagram of the relevant processes that occur to cause anxiety in the given situation. This allows the client and therapist to come to a shared understanding or model of what is happening in the situation.

Intervention

An appropriate intervention strategy is then chosen based on what has been discussed. For instance, if the model identified a situation the client feels anxious in and where they regularly use an important safety behaviour (e.g., rehearsing topics for conversation before a date), then planning an exposure exercise while dropping the safety behaviour could be a good strategy to attempt.

Cognitive restructuring focusing on the reasons and beliefs behind rehearsing topics could also be an option, as well as strategies cultivating acceptance of the anxiety experienced due to the uncertainty of not knowing the topics of conversation beforehand.

Choosing which intervention to pursue is also a collaborative process that takes into account context, client preferences and values, and the therapist’s experience and knowledge.

Processing and Feedback

After the chosen intervention is carried out, the final step is to process how the intervention went and provide feedback. This includes discussing the client’s experiences during the intervention, evaluating what the client learned if the experience was positive, and identifying what may have gone wrong or could be improved.

The client and therapist also feedback on the intervention and decide whether to use it again in similar contexts in the future. If the chosen strategy was not fully successful they may decide to change some aspect of what was decided, or try a totally new intervention.

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