CBT helps social anxiety by identifying and adjusting negative thought patterns and behaviors that contribute to anxiety in social situations, using techniques like cognitive restructuring and social skills training. As a result, people learn how to manage their anxiety, build confidence, and improve their ability to engage in social interactions.
Social anxiety disorder (SAD), also known as social phobia, is characterized by experiences of intense fear and avoidance of social situations due to worries of being judged, embarrassed, and/or humiliated.
It can vary in severity, from a fear of specific situations, like public speaking, to a more generalized fear of all social interaction. This fear can interfere with daily activities, work, and relationships, significantly impacting someone’s life.
Cognitive-behavioral therapy (CBT) is a widely used psychotherapy treatment for SAD that focuses on identifying and modifying negative thought patterns to change emotional responses and behaviors.
By working with a trained therapist, people learn coping strategies to manage their anxiety and improve their social interactions.
In this article, we will explore how CBT can help those struggling with social anxiety and highlight some of the key techniques used in this therapeutic approach.
Why is CBT recommended for social anxiety?
CBT is highly recommended by various institutes, such as the National Insitute for Mental Health (NIMH), the American Psychiatric Association (APA), etc., for treating social anxiety because it targets the root causes of the disorder, which are negative thought patterns and avoidance behaviors.
Research has consistently shown that CBT is effective in reducing the symptoms of social anxiety and helping individuals develop more positive social interactions.
The structured nature of CBT, with its focus on specific goals and measurable outcomes, makes it particularly well-suited for addressing the specific fears and behaviors associated with social anxiety.
Specifically, it can support with:
- Identifying and challenging negative thoughts: Helping individuals recognize and reframe unhelpful thoughts that contribute to anxiety.
- Gradual exposure to feared situations: Encouraging individuals to face social situations in a controlled and gradual manner.
- Developing coping strategies: Equipping individuals with tools to manage anxiety in real time.
- Building confidence: Enhancing self-esteem and self-efficacy through skill-building exercises.
- Improving social skills: Teaching effective communication and social interaction techniques.
Getting started
A crucial step in addressing social anxiety through CBT is creating a personalized Fear and Avoidance Hierarchy. This tool helps you identify and rank your specific anxiety triggers, providing a roadmap for your treatment journey.
How to Create Your Hierarchy:
- List Your Fears: Write down all the social situations that cause you anxiety. Be specific and include a wide range, from mildly uncomfortable to extremely frightening.
- Rate Your Fear: For each situation, rate your level of fear on a scale from 0 to 100, where 0 is no fear and 100 is the most intense fear imaginable.
- Rate Your Avoidance: Similarly, rate how often you avoid each situation on a scale from 0 to 100, where 0 is never avoid and 100 is always avoid.
- Rank Your List: Arrange the situations from least to most anxiety-provoking based on your fear ratings.
Example Hierarchy:
- Saying hello to a neighbor (Fear: 20, Avoidance: 10)
- Making small talk with a cashier (Fear: 35, Avoidance: 30)
- Eating in public alone (Fear: 50, Avoidance: 60)
- Asking a question in a meeting (Fear: 70, Avoidance: 80)
- Giving a presentation at work (Fear: 90, Avoidance: 95)
Using Your Hierarchy:
- Start with lower-ranked items and gradually work your way up.
- Use this as a guide for setting exposure exercise goals.
- Track your progress by regularly reassessing your fear and avoidance ratings.
Creating this hierarchy allows you to visualize your anxiety triggers and plan a step-by-step approach to facing your fears. It’s an invaluable tool for setting realistic goals and measuring your progress throughout your CBT journey.
Exposure Hierarchy PDFCBT techniques for social anxiety
There are many techniques used in CBT, some of which will be discussed below:
Cognitive restructuring
Cognitive restructuring involves identifying and challenging negative thought patterns that contribute to social anxiety.
Often, people with social anxiety have distorted thoughts (also referred to as “hot thoughts”), like believing they will be humiliated or judged in social situations.
These often manifest as core beliefs, rooting themselves deep inside someone’s brain like alarm bells that go off when those hot thoughts occur.
In CBT, a therapist will help the individual recognize these irrational thoughts and replace them with more realistic and positive ones. This process involves examining the evidence for and against these thoughts and developing alternative, balanced perspectives.
For example, the thought:
“I will embarrass myself if I try to speak up during a meeting, and everyone will think I’m stupid” can be altered to
“While it may be possible that I might make a mistake, it is unlikely that everyone will think I am incompetent. Most people understand that mistakes happen. Therefore, if I prepare well, I can share my ideas confidently”.
Over time, cognitive restructuring can reduce the intensity of anxiety and help individuals approach social situations with greater confidence.
Challenging Unhelpful Thoughts PDFBehavioral experiments
Behavioral experiments are a key component of CBT for social anxiety. These experiments involve testing the accuracy of negative beliefs through real-life experiences.
For example, someone who fears public speaking might believe they will embarrass themselves and be judged harshly. A behavioral experiment could involve gradually exposing the individual to speaking in front of small, supportive groups and monitoring the outcomes.
Various sub-techniques can be used based on individual needs, end goals, and fear thresholds. These include the general go-to of “gradual exposure” and at the end of the spectrum a technique called “flooding” (presenting someone with their fear at its maximum capacity without allowing them to flee).
These experiments help people gather evidence that specifically challenges their negative beliefs and demonstrates that their fears are often unfounded. This process can reduce anxiety, build tolerance to it, and gradually increase confidence in social situations.
Imaginal Exposure
This method is particularly useful when real-life exposure is not feasible or when an individual is too anxious to confront the feared situation directly. It focuses on vividly imagining and mentally rehearsing situations that provoke anxiety.
Here is a step-by-step guide on how to practice this:
- Identify the Fear: Choose a specific situation that triggers social anxiety.
- Create a Script: Develop a detailed and vivid narrative of the feared situation, including thoughts, feelings, and sensory details.
- Relaxation: Before starting the exposure, engage in relaxation techniques such as deep breathing or progressive muscle relaxation to reduce baseline anxiety.
- Visualize the Scenario: Close your eyes and imagine the scenario in as much detail as possible. Try to engage all senses to make the visualization as realistic as possible.
- Stay with the Anxiety: Allow yourself to feel the anxiety without trying to avoid it. The goal is to experience the anxiety until it naturally decreases.
- Repeat and Review: Repeat the imaginal exposure regularly, gradually increasing the intensity of the scenario. After each session, review the experience and note any changes in anxiety levels.
Through using imaginal exposure you will begin to desensitize the feared scenario, reduce anxiety, and overall build confidence over time.
Behavioral Activation
This technique is based on the principle that engaging in positive activities can improve mood, reduce anxiety, and enhance overall well-being. It is used to help individuals engage in activities that are enjoyable or meaningful, which can counteract the tendency to withdraw and avoid situations due to social anxiety.
Here is an example scenario of behavioral activation to feeling isolated due to social anxiety. This has been broken down into steps for you to use and adapt:
- Identify Avoidance Behaviors: For example, avoiding social gatherings, rarely going out with friends, and spending most weekends alone at home.
- List Enjoyable or Meaningful Activities: For example, meeting a friend for coffee, attending a local book club, or taking a walk in the park.
- Set Specific Goals: For example, this week I will meet one friend for coffee, next week I will attend the book club meeting, and I will take a walk in the park twice this week.
- Plan Activities: For example, schedule coffee with a friend on Wednesday afternoon, mark the book club meeting on the calendar for next Thursday evening, and plan to take a walk in the park on Saturday and Sunday mornings.
- Gradual Exposure: Start with a less anxiety-provoking activity, like taking a walk in the park alone. Progress to meeting a friend for coffee, which involves social interaction but with a trusted person. Finally, attend the book club meeting, which involves interacting with a group of people.
- Monitor Progress: Keep a journal to record the activities completed, how they felt before, during, and after the activity, and any positive outcomes or challenges faced. Example entry: “Met Sarah for coffee on Wednesday. Felt anxious before going but enjoyed the conversation. Felt more relaxed and happy afterward.”
- Reward Success: Practice self-praise for example, “I did a great job meeting Sarah for coffee today. I felt anxious but went through with it and had a good time.”
Relaxation techniques
Relaxation techniques are used in CBT to help individuals manage the physical symptoms of anxiety. Techniques such as deep breathing, progressive muscle relaxation, grounding, and mindfulness meditation can reduce physiological arousal and promote a sense of calm.
Deep Breathing
To practice deep breathing, sit comfortably and inhale slowly through your nose for a count of four, letting your abdomen rise. Hold your breath for four counts, then exhale through your mouth for a count of six. Repeat this cycle for five to ten minutes to achieve a state of relaxation.
Progressive Muscle Relaxation
Start by sitting or lying down in a quiet place. Begin with your toes, tensing the muscles for five seconds, then relax for 15-20 seconds. Move up through the body, tensing and relaxing each muscle group to release overall tension.
Grounding
5-4-3-2-1 technique: identify five things you can see, four things you can touch, three things you can hear, two things you can smell, and one thing you can taste. This sensory awareness exercise helps divert attention from anxious thoughts and anchors you in the here and now.
Mindfulness
To practice mindfulness, sit comfortably in a quiet place and focus on your breath, noticing the sensation as it enters and leaves your nostrils.
When thoughts arise, acknowledge them without judgment and gently bring your focus back to your breath. Start with five to ten minutes daily to build this calming practice.
By practicing these techniques regularly, individuals can learn to control their anxiety responses in social situations.
Relaxation techniques can also work as a coping mechanism during exposure exercises, making it easier for individuals to confront and manage their fears.
Social skills training
Social skills training is an important aspect of CBT for social anxiety. Many people with social anxiety struggle with some basic social interactions and may lack confidence in their communication abilities.
Therefore, social skills training involves teaching specific skills, such as making eye contact, starting and maintaining conversations, and assertiveness. Exercises such as role-playing are often used to practice these skills in a safe and supportive environment.
Let us look at an example:
Jo experiences very strong anxiety when attending social gatherings. She often feels awkward and struggles to start conversations. Using SST, Jo’s therapist first helps her identify specific skills she wants to improve, such as starting conversations and maintaining eye contact.
Jo practices these skills through role-playing in various scenarios and receiving constructive feedback and positive reinforcement. She also learns assertiveness techniques, such as politely expressing her opinions and setting boundaries.
Over time, she becomes more confident in her social interactions, reducing her anxiety and enhancing her ability to connect with others.
This is an example of how social skills can help people enhance their social interactions and reduce anxiety over time.
Goal setting
Goal setting is a crucial part of the CBT process. Setting realistic and achievable goals can help individuals track their progress and stay motivated. Goals in CBT for social anxiety might include attending a social event, speaking up in a meeting, or initiating a conversation with a stranger.
Let us look at an example:
Ahmad experiences social anxiety in professional settings. His long-term goal is to feel comfortable and confident during work meetings. Therefore, his therapist began by helping him set SMART goals, starting with smaller, attainable steps.
Initially, Ahmad aims to contribute at least one comment or question during each meeting over the next month. He breaks this down into smaller steps, like preparing comments in advance, practicing speaking in front of a mirror, and role-playing with a friend.
They create an action plan together, detailing these steps and scheduling regular practice sessions. Ahmad tracks his progress, making notes on his experiences and any anxiety levels. With time and as he gains confidence, his goals are adjusted to include more challenging objectives, like leading parts of the meeting or presenting updates.
Therefore, by breaking down these goals into smaller, manageable steps, individuals can gradually build confidence and reduce their anxiety. Goal setting also provides a sense of accomplishment and reinforces the progress made in therapy!
SMART Goals PDFHow effective is CBT for social anxiety?
CBT has been extensively researched and is widely recognized as one of the most effective treatments for social anxiety disorder.
Numerous studies have shown that CBT can significantly reduce symptoms of social anxiety and improve overall functioning, with long-term effects.
For example, a meta-analysis of randomized controlled trials found that CBT was more effective than placebo and other forms of therapy in reducing social anxiety symptoms.
The effectiveness of CBT is attributed to its structured and goal-oriented approach, which targets the specific thoughts and behaviors that contribute to anxiety.
By addressing these underlying issues, CBT helps individuals develop long-term strategies for managing their anxiety and improving their quality of life.
Additionally, CBT can be tailored to each individual’s needs, making it a versatile and adaptable treatment option.
Lastly, there is evidence to suggest that other forms of therapy can be equally as effective as CBT, such as psychodynamic therapy.
My Story
As someone who struggled with SAD for most of my life, CBT techniques have truly been transformative in my journey. For example, we made a list with the top 10 social phobias with a therapist (1 being the least frightening, 10 being the most), and we slowly started working down that list.
There were struggles in the beginning, such as overwhelming negative thoughts that I would never get better and feeling a loss of safety. SAD can exist to protect you from things your brain perceives as threats.
When you are actively trying to fight SAD tendencies, your body can react negatively at first as it feels it is in danger. Having a good support network and being open with your therapist is key to getting through this hurdle.
Once I started seeing results such as speaking on the phone without severely stuttering, I gained more confidence and began with flooding techniques such as signing up for seminars and conferences.
It was a long journey that took a few years to get me to the social functioning level that I am now. However, my life was forever changed for the better.
I have met so many incredible people and made happy memories that would have never happened had I stayed trapped in my head. I still get flare-ups from time to time, but slow and steady is key. So join me, and let us start living life, one small interaction at a time!
Considerations
While CBT is highly effective for many people with social anxiety, it may not work for everyone.
The success of CBT depends on various factors, including the individual’s commitment to the therapy process, the severity of their anxiety, and the quality of the therapeutic relationship.
As individuals confront their fears through exposure therapy, it is not uncommon for their symptoms to temporarily worsen before improving.
This initial increase in anxiety can be discouraging, and high dropout rates are possible, which can impact the overall effectiveness and progress of the therapy.
To combat this, additional support and reassurance from the therapist may be required. It is important to highlight that recovery and getting better is not linear, so it is completely normal to feel overwhelmed or out of your depth at times.
Additionally, CBT for social anxiety is not an overnight treatment but requires at minimum between 6-12 sessions. The standard course for SAD usually lies between the 12-20 session range.
There is flexibility in the delivery of SAD CBT as well which includes online and group sessions. These can benefit those with:
- Busy schedules
- Those whose SAD is too intense that prevents them from leaving the house to attend therapy
- Those who want to begin exploring social interactions in a structured, controlled group environment
Some individuals may benefit from a combination of CBT and medication or may require additional support to address other underlying issues. Therefore, it is important to work with a qualified mental health professional to determine the best treatment approach for your specific needs.
Lastly, it may not be applicable to a few people such as those with:
- Severe mental health issues, e.g., psychosis
- Personality disorders that will require a combination of therapeutic support
- Cognitive impairment struggles will make it challenging for them to engage in the sessions
- Those not ready or willing to engage in how active CBT is as it has components of homework and active participation outside of therapy
References
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