Cognitive-behavioral therapy (CBT) has been identified as an effective and evidence-based treatment for social anxiety disorder (SAD). Studies have consistently reported that most patients with SAD benefit from cognitive-behavioral therapy. However, a substantial proportion of patients respond poorly or incompletely (Clark et al., 2006; Springer, Levy an, 2018). Many patients who improve with treatment continue to have residual symptoms and impaired functioning (Aderka, 2009; Hoffmann and Bogels, 2006). There is a need to address the factors that operate to diminish treatment efficacy and impede resolution of symptoms. In this symposium, the speakers will address factors that can hinder progress in therapy with SAD patients and the strategies that have been found helpful in addressing them.

NOTE: This is a 90-minute symposium comprised of four presentations. The description of each presentation, along with its video and PowerPoint slides, are included separately, below. The question-answer period for all four presenters at the end of the symposium are included at the end of the last of these four videos.

(This symposium was presented on March 30, 2019 at the Anxiety and Depression Association of America conference in Chicago, IL.)

Reducing the Detrimental Impact of Maladaptive Perfectionism in Treating Social Anxiety Disorder

Maladaptive perfectionism (MP) has been described as a multi-dimensional phenomenon with pressure to meet perceived expectations of others and negative self-evaluation being the main negative facet (Stoeber et al., 2008, 2010). Shafran, Cooper and Fairburn (2002) have used the term clinical perfectionism and defined it as an over dependence on self-evaluation in the determined pursuit of personally demanding, self-imposed standards in at least one highly salient domain, despite significant adverse consequences (cognitive, emotional, behavioral, physical and social). They have outlined a model that specifies the processes that contribute to the maintenance of clinical perfectionism and developed a focused cognitive-behavioral treatment intervention based on this conceptualization. Maladaptive perfectionism has been identified as a contributing and maintaining factor in Social Anxiety Disorder (SAD) (Clark and Wells, 1995). Maladaptive perfectionism interferes with the process of treating the primary disorder and significantly high levels of MP in SAD clients has been found to result in poorer treatment outcomes as compared to the clients who do not have high levels of MP (Lundh & Ost, 2001). It is important for clinicians to have an understanding about the role MP can play in reducing treatment efficacy and what can be done to help reduce or eliminate the detrimental impact.

This presentation aims to achieve the following learning objectives: (i) Attendees will be able differentiate maladaptive perfectionism from adaptive perfectionism. (ii) Attendees will be able to develop a comprehensive conceptualization of their SAD clients which incorporates the role of MP in maintaining SAD symptomatology in those clients with high levels of MP. (iii) Attendees will be able to apply strategies to diminish or eliminate the impact of MP to help patient with SAD have better treatment outcome. Case examples will be used to illustrate the model of clinical perfectionism in the context of SAD, and to demonstrate the application of intervention strategies.

Suma Chand, PhD: St Louis University; board representative, director and psychotherapist, NSAC St. Louis (SLUCare Adult Psychiatry Services, Cognitive Behavior Therapy Program).


Managing Challenges to Engaging and Retaining Socially Anxious Clients in Treatment

Evidence-based therapies are efficacious in improving the lives of those with social anxiety disorder (SAD). However, 80–95% of people with SAD report receiving no treatment and those who seek treatment do so only after many years of suffering from the disorder (Grant et al., 2005). A multi-country study found that only 21% of those who satisfied the criteria for SAD had sought professional help (Ormel et al., 2008). The average time from onset of SAD to seeking help is as high as 16 years (Wang et al., 2005). Some of the factors contributing to low rates of seeking treatment include lack of knowledge about social anxiety, barriers to accessing care, and stigma associated with mental illness. The underutilization of treatment for all mental health disorders is a universal challenge. Given the nature of social anxiety, engaging and retaining patients in treatment is particularly challenging. Despite significant functional impairment, those with SAD symptoms reported that a central reason for not seeking treatment was concern regarding what others might think or say if they did seek treatment (Olfson et al., 2000), a fear consistent with their elevated fear of negative evaluation. CBT is an effective and durable treatment available to individuals with SAD. Unfortunately, many either do not seek services or drop out of treatment prior to completion. The proportion of patients with SAD who withdraw before treatment completion is high (10–20%) (Rodebaugh et al., 2004).

This presentation aims to achieve the following learning objectives: (i) Recognize outreach strategies to increase social anxiety clients’ engagement with mental health services for those in the pre-contemplative and contemplative stages for readiness to change. (ii) Plan strategies to help family members and friends who may be the first point of contact with mental health professionals on behalf of the sufferer. Techniques to help family and friends to motivate the treatment refuser will be discussed using a case example. (iii) Apply techniques to decrease pretreatment attrition and dropout of social anxiety sufferers who have initiated treatment with mental health services.

John Montopoli, LMFT, LPCC: cofounder of the National Social Anxiety Center; board representative, director and psychotherapist, NSAC San Francisco (Pacific CBT).


Excessive Internet Use as a Safety Behavior in Social Anxiety

Fear of negative evaluations by others is a core feature of social anxiety disorder (Hirsch and Clark, 2004). Socially anxious individuals worry about behaving in a visibly anxious manner and acting in a manner that results in others thinking less of them, leading, they think, to devastating social consequences. Thus, persons with social anxiety disorder (SAD) typically use a number of maladaptive safety-seeking behaviors to hide their insecurities and physical manifestations of anxiety. These often include going to great lengths to avoid face-to-face encounters they perceive as risky for embarrassment or out-right rejection. The internet has become an integral and widely accepted platform for communication. Individuals with social anxiety may be tempted to overuse it as a safety behavior, perceiving that online communication minimizes opportunities for negative evaluation by others. Indeed, a number of studies, (Lee and Stapinski, 2012; Caplan, 2007; Erwin, et al., 2004), have demonstrated a positive relationship between social anxiety and problematic internet use (PIU), (also referred to as internet addiction), which will be defined in this presentation. The problem for individuals with SAD is that, while internet communication may decrease anxiety in the short run, in the long run it erodes confidence to interact with others face-to-face, (Campbell et al. 2006; Shepherd & Edelmann, 2005). The avoidance of in-person communication undermines opportunities to disprove negative assumptions, thereby maintaining the exaggerated, negative beliefs.

This presentation aims to achieve the following learning objectives: (i) The attendees will recognize the key features of PIU. (ii) Participants will be able to predict which socially anxious clients are most vulnerable to this safety behavior of PIU and thus elicit relevant information regarding their internet use to help inform treatment treatment. (iii) Clinicians will acquire a cogent rationale for educating their socially anxious clients about the long-term detrimental aspects of over-utilizing online communication while avoiding face-to-face interaction with others. A case example will be used to illustrate how the therapist can introduce a behavioral experiment to facilitate the client’s learning, through face-to-face communication, that their fear of being negatively judged is overestimated.

Randy Weiss, LCSW: board representative and psychotherapist, NSAC Phoenix (Randy Weiss Therapy).


Cannabis Use:
A Treatment-Interfering Behavior in Social Anxiety Disorder in a Time of Increasing Legalization and Normalization

Individuals with Social Anxiety Disorder (SAD) experience high rates of substance-related problems. Those with high levels of social anxiety are especially vulnerable to cannabis dependence (Buckner et al., 2012). Nearly one fourth to one third of people with cannabis dependence have SAD (Agosti et al., 2002). Particular attention and caution should be paid to the function and use of cannabis in treating social anxiety. A model of substance abuse within SAD has conceptualized various functions of the behavior, including decreasing physiological arousal, social avoidance, avoiding potential negative evaluation by others, managing affect, and striving to overcome perceived social deficits (Buckner et al., 2013). It is important for clinicians to collaboratively identify the function of cannabis use with their clients, and to conceptualize its potential to interfere with learning needed for treatment progress. As a growing number of states are legalizing cannabis, availability and normalization of use has increased cannabis being seen as a positive coping behavior for anxiety. In addition, initial research has shown cannabidiol (CBD) to produce an anxiolytic effect and decrease physiological arousal (Crippa et a., 2011). With such shifting norms, balancing potential adaptive benefits of cannabis with the risks of over-generalizing use as a coping behavior is a current challenge for clinicians. Individuals with social anxiety may be even more prone to use cannabis as a maladaptive coping response, interfering with necessary learning required for treatment progress.

Learning objectives: (i) Attendees will be able to describe shifting social norms, including research into proposed benefits of cannabis use for anxiety, which can serve as barriers to problem recognition. (ii) Attendees will be able to identify various functions of clients’ cannabis use in SAD, and be able to conceptualize their potential maladaptive nature as a treatment interfering behavior with clients. (iii) Attendees will be able to identify and apply strategies to reduce and alter treatment interfering cannabis use within the context of legal recreational use. Case examples will be used to demonstrate strategies to alter function of use as a means of removing a barrier to treatment progress.

Robert Yeilding, PsyD: board representative and psychotherapist, NSAC Newport Beach / Orange County (Anxiety and Depression Center).


Our workshops and webinars are offered as an educational resource for
mental health professionals who are already familiar with cognitive and behavioral therapies.
These resources alone do not suffice as adequate training
to conduct cognitive and behavioral therapies
for those with social anxiety and related problems.