What is Cognitive Behavioural Therapy for Social Anxiety?

Overview

Clark and Wells formulated a behavioural model of social phobia (a condition contemporarily referred to as social anxiety disorder). According to the researchers’ model, entering a feared situation leads to the automatic activation of beliefs and assumptions. Individuals with social anxiety disorder are apprehensive in their approach to social situations, interpreting them as threatening or dangerous.

Individuals fear they will not fulfil the expectations they perceive others will place upon them or their expectations of themselves. This leads to automatic affective, attentional, behavioural and somatic processing, a state that contributes toward a maladaptive cycle, a part thereof that functions to maintain social anxiety.

Clark and Wells Model

Clark and Well theorize that entry into social situations leads to the activation of unhelpful beliefs, leading an individual to perceive the social situation as threatening. This subsequently leads to a detailed, attentional shift inwards, coupled with heightened self-focused attention. These individuals demonstrate an automatic tendency to compare themselves to what they believe others expect of them. This facilitates three specific, maladaptive, dysfunctional assumptions regarding social situations that surround:

Excessively high standards for one’s social performance

Any perceived deviations away from “perfection” may be internalized and interpreted as a personal failure. For instance, an individual with a social anxiety disorder may hold the belief that others may perceive them as “fun”, “competent”, “good looking”, and “smart”.

Conditional beliefs

Demonstrating “unstable self schemata”, individuals with social anxiety disorder hold negative beliefs about themselves. These beliefs are conditional and readily activated based on marked social situations. This leads individuals to adopt different maladaptive beliefs. For instance, those with social anxiety disorder may believe “if I present myself as boring or make mistakes, others will dislike me”.

Unconditional beliefs

Individuals with social anxiety disorder process the self as a social object. Their negative view of themself is perceived to be an accurate depiction of how others in their environment perceive them. They tend to believe “what others think of me is unequivocally, objectively true” (e.g. People believe I am unlikeable and inferior, and therefore I am). These stringent beliefs further provoke and perpetuate symptoms of anxiety.

Somatic and cognitive symptoms

• This self-focused attention promotes both cognitive and physiological symptoms of anxiety (such as sweating, blushing, a racing heart, and an unsteady voice) and the subsequent activation of more dysfunctional beliefs. Important to note is that individuals with social anxiety disorder tend to be hypervigilant of these symptoms, increasing their overestimation of their intensity.
• Furthermore, individuals with social anxiety disorder believe these symptoms will be noticed by others, leading others to evaluate them more negatively. For instance, they may hold the belief that “others will notice my fast-paced breathing” or “others will notice my shaking hands” and “others will consequently evaluate me negatively”.
• This consequently leads to a further escalation of social anxiety’s psychological and somatic symptoms.

Behavioural symptoms

In order to reduce the risk of negative evaluation, individuals engage in safety behaviours: coping behaviours that reduce the anxiety endured by the perception of social threat. These may take overt behaviours (such as avoidance) or internal mental behaviours (such as rehearsing what one should say next or mentally rehearsing one’s actions before performing them).

Safety behaviours maintain social anxiety disorder in four distinct ways:

1. The individual is likely to attribute social success to safety behaviour, believing their rehearsal or precautions are “working”. This is exceptionally consequential as it prevents the individual’s ability to disconfirm their incorrect assumptions. Specifically, it prevents them from noticing that the catastrophe they fear will not occur if they behave as they usually would.
2. The situation the individual aims to avoid is further exacerbated. Specifically, an individual who fears others may notice their shaking hands may begin worrying even more, which leads to further shaking they can no longer conceal.
3. Safety behaviours lead individuals to direct attention to themselves. This consumes much of their cognitive capacity and reduces their ability to process new, objective information from their surroundings.
4. Safety behaviours may ironically lead to social evaluations. Specifically, some of the individual’s actions may cause feared consequences. For instance, covering one’s face to conceal one’s unpleasant emotions may lead others to perceive the act as peculiar, inadvertently inviting other people’s attention back to oneself.

Other strategies that maintain anxiety

1. Pre-event anxiety: Prior to the event taking place, individuals may focus on memories and failures, leading them to fall down a rabbit hole as they experience anticipatory anxiety by focusing on all the things that could go wrong.
2. Post-event processing: Also described as ‘postmortem’ processing, post-event processing describes the process by which people with social anxiety replay their behaviours in their mind. Post-event processing is a negatively valenced review of certain social situations that emphasize their inadequacies, imperfections and mistakes. The individual may integrate this perceived ‘failure’ into their more repertoire of memories of poor social performance. Their access to these memories further undermines their future social interactions and maintains their negative self-impression.