Have you ever suspected that someone you’re close to is avoiding a social situation because of anxiety? Feeling anxious in social situations is common for many of us, but for some people, it can be debilitating. Your friend or loved-one may be suffering from social anxiety. People often hide their symptoms, so if you notice that a friend is anxious, it might be a good time to help. Cognitive behavioral therapy is an effective treatment for social anxiety, and knowing some basic principles can help you be supportive. Here are the basics:

Be patient

Social anxiety can be the result of physiological factors, traumatic experiences, or both. With proper support, anxiety can be overcome. Don’t criticize, blame, or minimize feelings. It’s important to listen and be supportive so that your friend will be more likely to open up.

Find out what they’re thinking

Physical feelings of anxiety usually start with thoughts. The first step is to ask your friend what he or she is worried about. Get as much detailed information as possible. Remember that no matter how unlikely or inconsequential these thoughts seem, they are real for your friend. Meet them with curiosity, not judgement.

Help reframe

Once anxiety hits, it can be very difficult for someone to get perspective on the situation. You can “widen the lens” by asking: what’s the worst thing that could happen? What’s the best thing that could happen? What is likely to happen? Have they ever felt this way before, and survived? Looking back on this situation in five years, what will they think about it?

Be a cheerleader

When helping a social anxiety sufferer, CBT therapists often ask their patients to imagine what a good friend would say to them. Here’s your chance to be that friend! Remind them of their strengths, whether it be a winning smile or a great sense of style. Remind them of the benefits of being social: reinforcing friendships, meeting new people, making connections, and having interesting experiences.

Avoid avoidance

Avoiding a social situation is what is known as “safety-seeking behavior.” Safety-seeking behaviors reduce feelings of anxiety, but they are a quick fix that actually worsens the problem. Once a certain pathway in the brain is reinforced (ie. avoid socializing = relief) it takes effort to create an alternative pathway (ie. socializing = fun). Even though avoidance is to be avoided, forcing is not the answer. If necessary, try to negotiate a compromise. It’s better to plan an exit strategy ahead of time than it is to avoid going in the first place. With any luck, once your friend is exposed to the actual
situation, it will be much better than anticipated.

Reinforce the positive

Show confidence in your friend’s ability to cope. Just because they’re worried, you shouldn’t be. In the context of the social situation, give him or her opportunities to be independent and answer questions themselves. Afterwards, offer lots of positive reinforcement for making the effort to overcome the anxiety. Get help: If your efforts are not successful, don’t take it personally. Social anxiety disorder can be crippling, but it is treatable. Recommend that your friend get help from a certified CBT therapist.

How to Get Help for Social Anxiety

The National Social Anxiety Center is a national association of regional clinics with certified cognitive therapists specializing in social anxiety and anxiety-related problems. Currently, we have regional clinics in San FranciscoDistrict of ColumbiaLos AngelesPittsburgh, New York City, ChicagoNewport Beach / Orange CountyHouston / Sugar Land, and St. Louis. Contact our national headquarters at (202) 656-8566 or visit our Regional Clinics contact page to find help in your local area or if your clinic is interested in applying for membership.



The fear of public speaking is the most common phobia ahead of death, spiders, or heights. The National Institute of Mental Health reports that public speaking anxiety, or glossophobia, affects about 73% of the population. The underlying fear is judgment or negative evaluation by others. Public speaking anxiety is considered a social anxiety disorder.

The fear of public speaking is worse than the fear of death

Evolution psychologists believe there are primordial roots. Our prehistoric ancestors were vulnerable to large animals and harsh elements. Living in a tribe was a basic survival skill. Rejection from the group led to death. Speaking to an audience makes us vulnerable to rejection, much like our ancestors’ fear.

A common fear in public speaking is the brain freeze. The prospect of having an audience’s attention while standing in silence feels like judgment and rejection.

Why the brain freezes

The pre-frontal lobes of our brain sort our memories and is sensitive to anxiety. Dr. Michael DeGeorgia of Case Western University Hospitals, says: “If your brain starts to freeze up, you get more stressed and the stress hormones go even higher. That shuts down the frontal lobe and disconnects it from the rest of the brain. It makes it even harder to retrieve those memories.”

The fight or flight response activates complex bodily changes to protect us. A threat to our safety requires immediate action. We need to respond without debating whether to jump out of the way of on oncoming car while in an intersection. Speaking to a crowd isn’t life threatening. The threat area of the brain can’t distinguish between these threats.

Help for public speaking anxiety

We want our brains to be alert to danger. The worry of having a brain freeze increases our anxiety. Ironically, it increases the likelihood of our mind’s going blank as Dr. DeGeorgia described. We need to recognize that the fear of brain freezing isn’t a life-or-death threat like a car barreling towards us while in a crosswalk.

Change how we think about our mind going blank.

De-catastrophize brain freezes. It might feel horrible if it happens in the moment. The audience will usually forget about it quickly. Most people are focused on themselves. We’ve handled more difficult and challenging situations before. The long-term consequence of this incident is minimal.

Leave it there. Don’t dwell on the negative aspects of the incidents. Focus on what we can learn from it. Worry that it will happen again will become self-fulfilling. Don’t avoid opportunities to create a more positive memory.

Perfectionism won’t help. Setting unachievable standards of delivering an unblemished speech increases anxiety. A perfect speech isn’t possible. We should aim to do our best instead of perfect.

Silence is gold. Get comfortable with silence by practicing it in conversations. What feels like an eternity to us may not feel that way to the audience. Silence is not bad. Let’s practice tolerating the discomfort that comes with elongated pauses.

Avoidance reinforces. Avoiding what frightens us makes it bigger in our mind. We miss out on the opportunity to obtain disconfirming information about the trigger.

Rehearse to increase confidence

Practice but don’t memorize. There’s no disputing that preparation will build confidence. Memorizing speeches will mislead us into thinking there is only one way to deliver an idea. Forgetting a phrase or sentence throw us off and hastens the brain freeze. Memorizing provides a false sense of security.

Practice with written notes. Writing out the speech may help formulate ideas. Practice speaking extemporaneously using bullet points to keep us on track.

Practice the flow of the presentation. Practice focusing on the message that’s delivered instead of the precise words to use. We want to internalize the flow of the speech and remember the key points.

Practice recovering from a brain freeze. Practice recovery strategies by purposely stopping the talk and shifting attention to elsewhere. Then, refer to notes to find where we left off. Look ahead to the next point and decide what we’d like to say next. Finally, we’ll find someone in the audience to start talking to and begin speaking.

Be prepared for the worst. If we know what to do in the worst-case scenario (and practice it), we’ll have confidence in our ability to handle it. We do that by preparing what to say to the audience if our mind goes blank. Visualizing successful recovery of the worst will help us figure out what needs to be done to get back on track.

Learn to relax

Remember to breathe. We can reduce anxiety by breathing differently. Take slow inhalations and even slower exhalations with brief pauses in between. We’ll be more likely to use this technique if practiced in times of low stress.

Speak slowly. It’s natural to speed up our speech when we are anxious. Practice slowing speech while rehearsing. When we talk quickly, our brain sees it is a threat. Speaking slowly and calmly gives the opposite message to our brain.

Make eye contact with the audience. Our nerves might tell us to avoid eye contact. Making deliberate eye contact with a friendly face will build confidence and slow our speaking.

Join a group. Practice builds confident in public speaking. Groups like Toastmasters International provide peer support to hone our public speaking skill. Repeated exposure allows us to develop new beliefs about our fear and ability to speak in public.

The fear of our mind going blank during a speech is common. Job advancement or college degree completion may be hampered by not addressing this fear.

By John R. Montopoli, LMFT, LPCC

Cofounder, National Social Anxiety Center; Director, NSAC San Francisco ; (415) 689-4131

How to Get Help for Social Anxiety

The National Social Anxiety Center is a national association of regional clinics with certified cognitive therapists specializing in social anxiety and anxiety-related problems. Currently, we have regional clinics in San FranciscoDistrict of ColumbiaLos AngelesPittsburgh, New York City, ChicagoNewport Beach / Orange CountyHouston / Sugar Land, and St. Louis. Contact our national headquarters at (202) 656-8566 or visit our Regional Clinics contact page to find help in your local area or if your clinic is interested in applying for membership.


“Performance” anxiety, indeed! That’s precisely the problem: thinking of sex as a performance, as something we are doing that is being scrutinized and evaluated by an audience. This performance mindset leads many men to be self-conscious, self-critical, worried, tense and anxious while being sexual. This in turns often results in bringing about the very problem they were worrying about in the first place: erectile dysfunction, premature ejaculation or difficultly experiencing orgasm.

These sexual problems can be caused by various medical conditions, or may even result from—or be made worse by—various medications you may taking. If you experience these problems frequently while being sexual with someone else, but seldom experience them while being sexual by yourself, then it is unlikely that a medical problem or medication is the principle cause. But if you are unsure, consult with your physician first for an assessment. In addition, there are medications available that can help with these sexual problems, although sometimes with side effects. In addition, these medications sometimes have the effect of reinforcing the tendency to focus on “performance” rather than pleasure, which keeps the problem alive.

Stage fright: vicious cycles & self-fulfilling prophecies

15394-Loving-CoupleEvaluating our “performance” while we are performing typically results in hurting our performance. This vicious cycle occurs in all sorts of social anxiety: making social conversation, speaking in groups, performing on stage…or having sex.

Let’s take an example of a true performance in front of an audience: an actor (or other stage performer, public speaker or athlete). Certainly it makes sense that the actor wants to please the audience. But if the actor is monitoring and critiquing her performance while she is performingand worrying about what the audience is thinking while she is actingshe is likely to perform less well due to distraction and self-consciousness.

The same is true for people making conversation…or making love: monitoring and evaluating how we think we are doing, and worrying about the other person is reacting to us, tends to have a negative impact on how well the conversation or the sex goes, and how much we and our partners enjoy it. Ironic, isn’t it?! We’re doing all this self-monitoring and self-evaluation in an effort to make things go better, but that strategy backfires badly on us!

Mindful focus: being in the moment, not in your head

The constructive alternative to self-monitoring is focusing our attention on the experience in the moment, and to to treat any self-evaluative and worrying thoughts as unimportant background noise. This is called mindfulness. For the actor, mindful focus means throwing herself utterly into the role, and saving evaluation until the performance is over. For the conversationalist, mindful focus means focusing with curiosity what is being said in the moment, and saying whatever comes to mind naturally, without scripting.

For the man being sexual, mindfulness means focusing our attention on any or all of the pleasurable sensations we are experiencing in the moment–touch, sight, sound, smell, tasteas well as focusing on any pleasant emotions we may be experiencingexcitement, affection, enjoyment. Mindfulness when being sexual also means distancingdefusingfrom any evaluative or worrying thoughts and feelings we may be having, treating them like unimportant background noise.

Well, this takes a lot of practice! Some of us have become so used to self-evaluating and worrying while being sexualand often before and after being sexual, toothat it’s unrealistic to expect us to suddenly be in the moment the next time we have sex. And if you wait until having sex to try to be mindfully focused, there’s a chance that you will start evaluating how well you are being in the momentwhich will only worsen self-consciousness and self-criticism.

Cognitive-behavioral therapy (CBT) homework practice

1. Cognitive restructuring (attitude change): Identify your belief about the sexual problem you are having. Typically, it’s something like “My partner and I won’t enjoy sex if I don’t perform really well (don’t get erect or lose an erection, ejaculate too soon, or never have orgasm).” Then write down a constructive alternative attitude that you believe, at least intellectually, such as: “My partner and I can greatly enjoy being sexual together if I focus on the pleasant sensations, feelings and experiences we are having, regardless of what my penis is doing!” Creating a new attitude that is both helpful and believable may take some discussion first, with your sexual partner, with a trusted friend, or with a cognitive-behavioral therapist (CBT).

2. Practice mindful focus while masturbating: Read your constructive attitude (from #1) before masturbating. Breathe slowly and deeply. Mentally scan your entire body for areas of muscle tension, and loosen up one area at a time. Then bring up a vivid image in your mind of you being sexual, and perhaps romantic, with a partner. Focus on this image while slowly masturbating, as well as touching other areas of your body that please you. Leave yourself plenty of time; don’t rush it. Most importantly, focus on the pleasurable sensationstouch, sight, sound, smell and tasteand the pleasurable emotionsexcitement, affection, enjoyment—that you are experiencing in your image or in your body.

Practice mindful focus on imagery while masturbating regularly, and vary the imagery when you do. Don’t limit your imagery to sex going the way you most prefer. It is important that some of the time you do imagery of enjoying the sexual experience even when you are not erect in your image, or when you ejaculate soon or not at all in your image (regardless of what your body is actually doing). Don’t stop because you imagine losing an erection or ejaculating. Instead, keep the imagery going, and focus on continuing to give and receive pleasure with no shame, embarrassment or sense of apology. While doing so, practice setting aside any self-critical or worrying thoughts and feelings you may be experiencing as background noise, and return your attention to the pleasurable sensations and emotions you are experiencing in your imagery and in your body.

If you have problems with premature ejaculation, pay close attention to the physical sensations as you very slowly masturbate, and learn to distinguish the building sensations that immediately precede the point of ejaculation. Learn to occasionally change your touch to less sensitive areas of your penis and testicles to gain greater control over the way your body is responding. (This is more effective than stopping touch all together so as not to reinforce all-or-nothing thinking about genital pleasure.) Don’t distract yourself in an effort to delay ejaculation. Instead, keep your attention on your sensations, and set aside any self-critical thoughts and feelings as background noise.

One last point: physical relaxation is important when being sexual. Tension and anxiety often lead to sexual functioning problems (erectile dysfunction, premature ejaculation, and lack of orgasm). So, right before doing the sexual imagery exercises, practice muscle relaxation and slow, deep breathing to relax your body. Then, during the imagery and masturbation, continue to relax whenever you notice tension, but keep returning your focus to the pleasurable sensations and emotions.

6361088922824314301648346557_tumblr_nvzlzvTIAY1uivxxlo1_12803. Practice mindful focus while being sensual with a partner: Have you practiced the imagery exercises enough that you have become quite adept at physical relaxation, mindful focus on pleasurable sensations and emotions, and setting aside unpleasant thoughts and feelings? It is now time to begin practicing with a partner. If it is possible, it is best to talk to your partner first about your working on overcoming this problem. Explain to her or him that it is important to go very slowly; to be mutually supportive and not pressure each other; and to focus on the whole experience of pleasure, not just intercourse. And silently recite your constructive attitude before each sexual practice session together.

Ideally, the initial few practice sessions would involve focusing on taking turns pleasuring each other with sensual, but non-genital touch all over one’s body, so that there is no pressure to get or maintain an erection. Each of you might take turns giving and receiving pleasure for 15 minutes or so. The receiver may give gentle, non-critical, non-pressuring directions as to what he or she likes and doesn’t like. While giving or receiving, focus your attention mindfully on the pleasurable sensations and emotions you are experiencing, and set aside self-critical or worrying thoughts as background noise. It doesn’t matter what your penis is or isn’t doing! Just keep returning your attention to the pleasure, and treat any distressing thoughts and emotions as background noise. And remember to relax: proceed slowly, breathe slowly and deeply, and loosen any muscle tension in your body.

Continue these practice sessions as you become gradually more sexual with your partner in later sessions. As always: relax, and focus on the pleasurable sensations and feelings, not on evaluating your poor penis’ performance! If it turns out you do not get or maintain an erection, or you ejaculate earlier than you want or not at all, then set aside any self-critical thoughts and feelings as background noise, and return to focusing on giving and receiving pleasure.

Ideally, talk openly with your partner between practice sessions about feelings you both are having in your sexual experiences together. Hopefully such conversations will help to reinforce your constructive attitude that being sexual can be enjoyable even when it doesn’t go perfectly, so long as you focus on the pleasure and not on self-evaluation and worry.

Self-help resources:

Here are two very useful self-help cognitive-behavioral therapy (CBT) books for sexual anxiety and sexual dysfunction. (Unfortunately, these otherwise excellent books ignore LGBT people. Still, the content is highly helpful regardless of sexual orientation or gender identity.)

Coping with Erectile Dysfunction, by Michael Metz, PhD and Barry McCarthy, PhD.

Coping with Premature Ejaculation, by Michael Metz, PhD and Barry McCarthy, PhD.

by Larry Cohen, LICSW
Cofounder and Chair, National Social Anxiety Center; Director, NSAC District of Columbia; 202-244-0903

How to Get Help for Social Anxiety

The National Social Anxiety Center is a national association of regional clinics with certified cognitive therapists specializing in social anxiety and anxiety-related problems. Currently, we have regional clinics in San FranciscoDistrict of ColumbiaLos AngelesPittsburgh, New York City, ChicagoNewport Beach / Orange CountyHouston / Sugar Land, and St. Louis. Contact our national headquarters at (202) 656-8566 or visit our Regional Clinics contact page to find help in your local area or if your clinic is interested in applying for membership.

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