Once again, I’m deferring the first case example; one of the issues it will include is Social Anxiety which, despite being a common issue, is not well-known to many practitioners. I'm therefore giving a description of it here, along with some of the standard CBT approach to it, so as to lay the ground for next week’s Integrative CBT perspective on dealing with the complexities of a client presentation.
The DSM-IV criteria for Social Anxiety Disorder/Social Phobia (in summary) are:
A. A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.
The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
B. Exposure to the feared situation almost invariably provokes anxiety, which may take the form of a Panic Attack.
C. The person recognizes that this fear is unreasonable or excessive.
D. The feared situations are avoided or else are endured with intense anxiety and distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
This is a useful description, though I’m not convinced that it necessarily has to involve unfamiliar people (point A above).
A simpler summary would be that Social Anxiety refers to symptoms such as:
• acute self-consciousness, awkwardness and self-focus
• over-focus on anxiety symptoms such as blushing, shaking and sweating
• frequent embarrassment, feeling different, unwanted and negatively judged.
While we all experience some social anxiety when we are in social situations outside of our comfort zones (e.g. attending a wedding where we know nobody), the extremeness of the above symptoms in some cases, and the huge extent to which they negatively affect some people's lives, are what leads us to diagnose Social Anxiety. For the Socially Anxious person there is a constant fear of being negatively judged – social life is like one long nightmare job interview. They can never fully relax when there are others around, and so often tend to avoid social situations. In some cases there are particular worries and self-consciousness about anxiety symptoms such as blushing, sweating, shaking etc. These may of course be real, but are rarely as bad as the sufferer imagines.
Social Anxiety is not the same as shyness (a shy person may not be very confident in social situations, but they don’t necessarily experience a high level of anxiety around them) or introversion (a personality characteristic – some people just like a lot of time alone). Nor or the Socially Anxious person’s social skills necessarily poor, though they generally fear they are (and they may well be out of practice).
For some people these symptoms are experienced in all social situations, for others just in specific but important ones (e.g. meetings, presentations, speeches). Many sufferers manage to mask and cope with the problem to a certain extent, but only at the cost of quite a lot of damage to their life and happiness: they experience constant high levels of anxiety, and/or impose serious limitations on their social life, relationships, work, education etc).
Unfortunately, some also try to manage their anxiety using alcohol or other drugs, which can eventually lead to an addiction problem.
The loneliness and isolation that is the result of some people’s Social Anxiety problem can lead them to depression and even ultimately to suicide.
CBT for Social Anxiety helps the client explore their tendencies
• To worry and mentally rehearse for hours before social events
• To practice a range of “Safety Behaviours” in social settings (e.g. staying on your own, leaving early, drinking before going out, trying too hard to be “interesting”)
• To carry out a thorough, self-critical, “post mortem” after social events.
Such habits of thinking and behaving are understandable, given the anxiety the sufferer feels, but unfortunately they all tend to further exacerbate and perpetuate the problem. The Cognitive Behavioural Therapist and client work together to change these ingrained habits by identifying habitual thoughts (e.g. 'what if somebody sees me blushing'), beliefs (e.g. “people will think I am weak”), and patterns of thinking (e.g. common cognitive distortions/thought filters such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising), which can be questioned and tested. Even getting a clear picture of these can take some of their power away. The next step is to reality-test some of these in an experiential way, through planned behavioural experiments (e.g. going to a cafe and observing that not everyone is looking at you). People who believe that they blush “as red as a fire engine” may need to take the step of seeing themselves on video when they are blushing (e.g. when describing an embarrassing moment to the therapist), so that they can see that the reality does not match their fears.
One crucial step is that the socially anxious person must, at some point, begin to drop some of their safety behaviours, and see what happens. This may mean, for example, not preparing what to say in advance, not trying to agree with everyone, not bringing a huge present to a dinner party, etc. They gradually begin to see that not only are people not judging them all the time (only sometimes, and maybe they can survive this!), but that they are not even in other people’s minds most of the time.