The following is a narrative of a fictitious character, Ms. Anonymous (Ms. A), and her treatment for social anxiety. This case illustrates how evidence-based methods can be applied in therapy to help alleviate symptoms and recover from social anxiety. Again, Ms. A is a fictitious character, and any resemblance to a real person is purely coincidental.
Ms. A came to therapy in January after experiencing several panic attacks during the November/December holiday season. She was missing a lot of work because she experienced overwhelming anxiety when she thought about her panic attacks. Any time she felt a pang of nerves, she would spiral into a place of intense, debilitating fear. The assessment interviews revealed Ms. A had Social Anxiety Disorder. Her specific symptoms included:
- A persistent fear of being judged negatively in social interactions, especially by her family members.
- A belief that she would be embarrassed during & after any conversations with family members.
- Feelings of extreme anxiety when she thought about past and future interactions with her family.
- Avoidance of any situations where family members may be present.
After some psychoeducation on the symptoms and treatments of Social Anxiety, we identified the following specific challenges to tackle first:
- Lessen her intense fear of feeling anxious by learning to treat thoughts and feelings as background noise.
- Learn to initiate and sustain conversations with family members or co-workers.
- Learn to reveal personal information about herself, especially to her grandparents.
- Become comfortable when she blushes or starts sweating in the presence of others.
- Change her beliefs about herself regarding how others view her and her abilities to develop and maintain relationships.
We discussed evidence-based treatment for Social Anxiety and agreed on the following plan:
- Mindfulness Training
- Exploration and Restructuring of Cognitive Distortions
- Assertiveness Training
- Behavioral Experiments
- Identifying and Restructuring Core Beliefs
Therapeutic Technique #1: Mindfulness Training
To help Ms. A become less fearful of her anxious feelings, we discussed several mindfulness approaches. Ms. A found the technique defined with the acronym RAIN to be a particularly useful way for her to lower her fear of anxiety. RAIN is:
- Recognize what is going on
- Allow the experience to be there, just as it is
- Investigate with kindness
- Not identifying with the experience
Therapeutic Technique #2: Exploration and Restructuring of Cognitive Distortions
Ms. A first learned to use a worksheet to record her Thoughts, Feelings, Behaviors, and Cognitive Distortions related to initiating and maintaining a conversation with her family members. Here is an example of one of her worksheets:
Situation: She is going to meet her Grandparents for dinner.
Thoughts: “I will not know what to say.” “They will think I am stupid.” “They don’t want to have dinner with me.” “I must find a way out of this.”
Feelings: Nervous, Anxious, Embarrassed, Afraid.
Behaviors: Try to memorize a script, Say as little as possible, Don’t initiate conversation, Don’t ask any questions.
Cognitive Distortions: Perfectionist thinking, Magnifying and Minimizing, Fortune Telling.
Ms. A then learned to challenge and reframe her thoughts by asking these questions: What is the objective evidence? Could there be an alternative explanation? How likely is it that these things will happen? Can I handle it if they do happen?
After challenging and reframing, she was able to change her thoughts to:
“I know how to talk to people.” “I will have some things to say.” “They will understand.” “They asked me to dinner, and I do not have any reason to think they don’t want to be here.” “I do not wish to cancel, and I can do this.”
These new thoughts and beliefs helped lower her anxiousness and feelings of fear. For a more detailed description of cognitive distortions and restructuring, consult Managing Social Anxiety: A Cognitive-Behavioral Approach – Workbook, by D. Hope, R Heimberg, and C. Turk, 2019.
Therapeutic Technique #3: Assertiveness Training
Ms. A’s biggest fears about spending time with her family are a result of these thoughts/beliefs: “My grandmother will ask if I am dating anyone. When I say no, she will think I am a loser.” “My grandfather will make me so nervous that I will go blank in the middle of a sentence. He will think I am stupid.” We worked together to help Ms. A see she could assert herself in these situations by responding assertively without being defensive or overly apologetic. She was able to stand up for herself by acknowledging any truth but dismissing insults. Here are her new responses: “No, grandma, I am not dating anyone right now, but I am happy and have a full life with my work, volunteering, and friends.” “Oh, grandpa, I just lost track of what I was saying. I know that happens to most everyone at some point. Let me start over.” After some in-session and at-home practice, Ms. A was able to have a comfortable conversation with her grandparents without the intense fear that they would judge her negatively. For a more detailed description of assertiveness training, consult Padesky, C.A. (Filmed appearance, 2008.) Center for Cognitive Therapy (Producer). Social Anxiety: Assertive Defense of the Self. [DVD; Code: VSA]. Huntington Beach, CA: Center for CognitiveTherapy.
Therapeutic Technique #4: Behavioral Experiments
Ms. A wanted to learn how not to be bothered by the fact that she blushes and sweats when she is in a social situation. Her fear that others would notice her blushing and judge her negatively lead her to isolate and avoid others. We developed some behavioral experiments to help her test her hypothesis about blushing and sweating.
Before the Experiment:
Situation: Going to an after-work happy hour.
Predictions: As soon as I start to talk, I will begin to blush and sweat. People will think I am weird and stop talking to me. I will be standing alone for the rest of the evening because I started blushing and sweating. I believe 100% this will happen. I will be so embarrassed by my sweating that I will never go to another happy hour.
Experiment: Go to a happy hour and stay for at least an hour. Initiate a conversation with a group of co-workers. Continue the conversation even if I start to sweat and blush. If anyone comments on either, respond calmly & rationally and continue the conversation.
After the Experiment:
Outcome: Ms. A was able to initiate and maintain a conversation. Once she started blushing and sweating, she was able to resist the urge to leave the happy hour. No one noticed her physical reactions to anxiety.
What Ms. A Learned: Ms. A. learned she does have the ability to initiate conversations. She was able to maintain them if she kept her focus on the present and kept her interest in the other person speaking. She learned that she could tolerate the awkwardness of openly sweating and blushing.
This example is just one of the behavioral experiments we performed during Ms. A’s therapy. For a more detailed description of this technique, consult Clark and Beck’s 2012 The Anxiety Workbook.
Therapeutic Technique # 5: Restructuring Core Beliefs
During the early stages of our therapy, Ms. A identified the following Old Unhealthy Core Beliefs:
- I am socially inept, awkward, and cannot maintain friendships.
- My family spends time with me because they have to. They also think I am boring and tedious.
- I was born this way and cannot change. I will always be a social burden to others.
We used a combination of techniques to help her restructure these beliefs. For a more detailed description of restructuring core beliefs, consult Greenberger and Padesky’s 2015 Mind Over Mood.
Ms. A. learned to believe these new Healthier New Core Beliefs:
- Some people are better than I am at socializing, but I have some abilities and am pretty good at it if I try.
- My family tells me they love me, so I believe them. Even if I am sometimes awkward around them, they still want to spend time with me.
- I have made some significant changes in my ability to socialize and make friends. I can continue to improve.
Ms. A was encouraged to build on her successes by continuing to practice her new skills regularly. She was able to return to work and significantly improve her quality of life. The above fictional account is meant to introduce some evidenced-based approaches to treating social anxiety.
Holly Scott, MBA, MS. LPC
National Social Anxiety Center, Dallas Regional Clinic