Social Anxiety: Causes & Cures
Copyright ©Donald Robertson, 2011. All rights reserved.
This short article will outline some key features of cognitive-behavioural therapy (CBT) for social anxiety by distinguishing between anxious feelings, actions, and thoughts which can contribute in different ways to maintaining the problem.
A. Feelings (A = Affect)
If you ask people who are highly anxious what they expect will happen if they repeatedly face their fears for prolonged periods they’ll typically hesitate and feel slightly unsure about the answer. Repeated, prolonged, exposure to feared events very reliably tends to reduce anxiety in both experimental and clinical research studies on anxiety. In fact the anxiety-reducing effect of proper exposure to anxiety-provoking situations, which is technically termed “habituation”, is arguably one of the most robust findings in the whole field of psychotherapy research. Animals may be anxious and avoidant of strangers, until they get used to them. Children have many fears that they simply “grow out of” over time and many people are anxious about facing new experiences as adults, such as dangerous sports or demanding jobs, which they “get used to” with experience.
It’s a truism: People don’t like doing, or thinking about, things they don’t like doing or thinking about. The first paradox of exposure therapy is that the client needs to reverse their avoidance and do things they normally avoid doing, facing their fears, and exposing themselves to things that provoke anxiety. However, this is normally done in a “graduated” manner, in steps and stages that make it more manageable. When people are anxious they automatically exhibit more “all-or-nothing” thinking, which makes it hard for them to envisage how they could face their fears systematically and gradually. Sometimes, however, exposure may begin simply by talking about things, imagining them repeatedly, or rehearsing (role-enacting) social situations with the therapist during a session, before facing real situations in gradual steps and stages.
B. Actions (B = Behaviour)
The central “paradox” of social anxiety is that although we all tend to have quite a lot of exposure to social situations but certain people remain anxious and don’t get used to the experience. However, there are a number of potential reasons for this, which have emerged from clinical practice and experimental research.
- Avoidance. People who are socially anxious often avoid anxiety-provoking social situations and may become generally withdrawn from social encounters. Avoidance is the main thing that prevents habituation from occurring, though.
- Escape. Fleeing a situation (the urge to “run away”) is the quickest way to reduce anxiety, although it’s a very temporary solution. Habituation takes time and people usually need to remain in an anxiety-provoking situation until their level of anxiety has reduced substantially (e.g., halved) in order to experience a permanent reduction in anxiety in future situations. However, people who are socially anxious tend to feel a powerful urge to “escape” to safety by breaking off conversations, hurrying to leave, etc., before their anxiety has actually reduced. If only they remained a little longer, they would probably achieve a permanent rather than temporary reduction in their anxiety.
- Focus of attention. It’s very well-established that when people are anxious they tend to focus more attention automatically upon their own thoughts, actions, and feelings, as a source of further anxiety. When anxious people say they feel “the centre of attention” or “in the spotlight”, that also implies that they are exceptionally focused on themselves, i.e., they are also the centre of their own attention. Self-focused attention increases during social anxiety but when people are socially confident they tend to naturally focus more on other people, their audience, and on the task-at-hand, i.e., the topic of conversation, etc. Focusing on yourself tends to magnify sensations of anxiety (such as heart racing, or body trembling), making them seem much more problematic than they actually are, and leading people to over-estimate how noticeable they are to others. It also tends to interfere with performance, e.g., distracting you and making it harder to think of what to say and do.
- Subtle avoidance. People avoid social experiences in many subtle ways. One of the most common strategies, often used automatically, is avoidance of eye-contact. Other people might avoid things like asking questions, speaking about certain subjects, expressing disagreement, talking to “important” people, speaking about emotional subjects, talking at length about a subject, etc.
- Safety-seeking behaviour. People also tend to do things, sometimes deliberately but sometimes very “automatically” and perhaps not consciously, to “protect” themselves or feel safer in social situations. For example, they might automatically tense their muscles, become aggressive, become submissive, try to please people, apologise compulsively, grip objects or wring their hands, repeat themselves unnecessarily, etc.
The basic principle of therapy is to reverse avoidance, even subtle avoidance, and to endure anxiety for slightly longer than normal in order to permanently overcome it. In doing so, people tend to also develop more social skills, such as assertiveness strategies and communication skills, etc. These can be studied and rehearsed during therapy sessions but they also tend to develop with real-world practice. Increasing social skills and assertiveness tends to also reduce social anxiety and raise confidence and self-esteem, as well as potentially helping to solve social problems such as bullying, etc.
C. Thoughts (C = Cognition)
The basic cognitive formula for anxiety is summed up in the phrase: “Something bad is going to happen and I won’t be able to handle it.” Cognitive therapy helps clients to modify their underlying beliefs and attitudes to reduce unnecessary anxiety by reducing over-estimates of the severity or awfulness of social threat, and improving under-estimates of coping ability.
1. Primary Appraisal of Social Threat versus Safety
People who are anxious in social situations typically fear some kind of “social threat”, such as humiliation, embarrassment, criticism, rejection, etc. This tends to involve something people tend to call the error of “mind-reading” in cognitive therapy, meaning jumping to anxious conclusions about what other people are actually thinking. In social anxiety, people often fear that their own voluntary behaviour (speech or actions) or involuntary responses (such as blushing or sweating) will be visible to others and perceived as signs of weakness or incompetence, etc. This is sometimes an unfounded or exaggerated fear. However, social fears often become “self-fulfilling prophecies” because if someone fears blushing, e.g., they make themselves anxious and cause themselves to blush, if they fear making mistakes, their anxiety may cause them to become confused and lose concentration, leading to mistakes, causing the very problems that they fear. However, the same person may not fear blushing or losing concentration when alone, highlighting the fact that their underlying “fear of negative evaluation” from other people and they may also be mistaken either concerning the visibility of their problems to other people, or the importance that others place on these things. For example, many great speakers, such as politicians, or performers, such as comedians, can be seen, on closer inspection, to sweat, shake, stammer, or make speech errors, but audiences do tend to overlook these things and focus more upon what they’re saying. By reviewing videos closely, it often becomes striking how many imperfections we overlook in others. For example, how much importance did people really place on the frequent stammers and speech errors made by Prime Minister Tony Blair?
People with social anxiety are also known to often exhibit “high social standards”, and to place unreasonable demands on themselves in terms of their performance in social situations. This is often expressed in terms of personal rules or “must” and “should” statements, e.g., “I must not show any fear”, “I must never make mistakes”, etc. This includes the concept of “perfectionism”, which is a common trait among people who fear making gaffes in public or mistakes in their performance. A more forgiving or accepting attitude toward trivial errors is often important in overcoming social anxiety. If you believe that you must “never” show any fear or make mistakes then you’re bound to make yourself anxious because you’re only human, and imperfect, and everyone else experiences anxiety and makes mistakes sometimes. We refer to the process of coming to accept anxiety as being more common and harmless than you might initially have assumed as “normalising” anxiety. Remember another truism: people who are socially anxious tend to try to keep it a secret and don’t like to broadcast the fact. That’s bound to lead you to under-estimate how common the problem is. Everyone experiences some degree of social anxiety, at some point, if they have a pulse. Up to 15% of people will at some time experience full-blown social anxiety disorder (“social phobia”), the most extreme form of social anxiety. So if you have social phobia and are in room with at least twelve people, statistically, there should be at least one other person present who has experienced the same extreme form of the problem and most of the others will have had social anxiety to a lesser degree.
2. Secondary Appraisal of Vulnerability versus Self-Confidence
On the other hand, people who are socially anxious also tend to complain of a sense of vulnerability and helplessness in social situations or an “inability to cope”, often expressed by saying “I don’t know what to do”, “I don’t know what to say”, “I can’t do this”, etc. Learning different strategies and social skills, and rehearsing them until they’re ready-to-hand and familiar can help people to increase their appraisal of their coping ability and to feel more self-confidence. Many people who feel they lack social skills or assertiveness merely lack confidence in their ability to use their existing communication skills. Rehearsal of social behaviour in imagination, in role-play, and in gradually more challenging real-world situations, can lead to a progressive increase in self-confidence.
Some research from the stress field also suggests that people who have a flexible repertoire of different coping strategies tend to experience less anxiety and stress in challenging situations. Sometimes feeling that you’re confident about responding in a number of different ways can reduce anxiety further than simply learning a single coping skill. People sometimes try to cope with anxiety by reducing or avoiding it (emotion-focused coping), however, there’s some reason to believe that it’s generally better to endure anxiety and focus your coping attempts on the situation itself (problem-focused coping). Research also shows that when people are anxious they find it easier to recall times in the past when things have gone wrong and they’ve struggled to cope. Knowing this and making an effort instead to remember and focus upon times when you’ve coped well with similar situations, or at least “survived” them, will tend to enhance your sense of confidence and reduce your anxiety.