Cognitive Behavioural Therapy for Social Anxiety Disorder - Indonesian Psychological Healthcare Center

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Cognitive Behavioural Therapy for Social Anxiety Disorder

Cognitive Behavioural Therapy for Social Anxiety Disorder

Authored by: Christiana Louisa Ticoalu, M.A., Psychology & Management
Language Editor: Alda Belinda, S. Psi.
Clinical Editor: Dr. phil. Edo S. Jaya, M.Psi., Psikolog

A Quick Refresher

What is Social Anxiety Disorder?

Most individuals are affected by how others perceive various aspects of themselves, including their physical appearance, accolades and achievements. It is not uncommon for individuals to be nervous, even fearful, when placed in certain social situations (for instance, being tasked to give a speech in public) for fear of embarrassing themselves. Whilst it is not uncommon to contemplate what others think of us and how they perceive us, individuals with social anxiety disorder possess an extreme fear of situations that may lead to social scrutiny and possible negative external appraisal. Situations that may initiate anxiety may include

  • Social interactions (such as holding a conversation with authority figures, e.g. one’s boss)
  • Completing an activity whilst others observe oneself (for instance, eating food in one’s school cafeteria or office space)
  • Performing in front of other people (for instance, giving a toast at a wedding).

Moreover, individuals with social anxiety disorder present behaviours that are disproportionate to what is considered normal, or expected, within a given social situation or cultural context. Collectively, the symptoms of the condition last several months. Further, they are detrimental to one’s day-to-day life and may lead to considerable distress and impairment across important life domains, interfering with functioning (social, occupational or otherwise). Normal functioning is typically only maintained through conscious exertion of additional effort.

Importantly, the symptoms of social anxiety disorder are not better explained by another mental health condition.

Symptoms of Social Anxiety Disorder

For a comprehensive list of social anxiety disorder symptomatology, we recommend you visit the ICD-11 webpage.

Clark and Wells Model

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.

Tailored Treatment Plans

Dear Reader,

At IndoPsyCare, we formulate treatment plans on a case-by-case basis. Contingent upon your condition and situation, your therapeutic journey may or may not include a variation of the following components:

Assessments

Your therapist may administer assessments at various points throughout your therapeutic journey. This is done as a way of assessing your improvements and, by extension, the effectiveness of the treatment plan. When treating social anxiety disorder, our clinicians typically administer the Social Phobia Inventory (SPIN) and the Liebowitz Social Anxiety Scale (LSAS). Nevertheless, we ask that you please keep in mind that assessments may vary depending upon your specific condition.

Psychoeducation

During this stage, your therapist will likely provide you with pertinent information surrounding your disorder including its prevalence, common symptoms, and other in-depth information. Demystifying and increasing your understanding of social anxiety disorder will inadvertently address the stigma that is often associated with it.

Furthermore, psychoeducation seeks to enhance your understanding of the rationale behind Clark and Wells’ model, including its various components. Your therapist may aim to help you feel more at ease by increasing your awareness regarding different treatment strategies, why they are undertaken, and how they are important aspects of your roadmap to recovery.

Behavioural experiments

Behavioural experiments allow therapists to examine behaviours and cognitions that are situationally activated. This will allow patients to test pessimistic predictions and incorrect assumptions regarding themselves and others’ reactions to themselves.

Initial experiments may allow you to see how safety behaviours further perpetuate social anxiety by inadvertently interfering with your social interactions.

Other experiments are usually focused on abstaining from safety behaviours; later experiments focus on the process of de-catastrophizing, specifically, intentionally inducing a feared situation.

This may involve deliberately sharing a boring or unpopular view and testing others’ reactions to oneself. Between-session “homework” may also be assigned based on a collaborative agreement between you and your therapist.

Integration of multimedia

This therapy usually includes video recordings of social interactions with both inward-directed and out-ward-directed attention. Video feedback may be used to highlight and help you identify your distorted self-imagery.

Following watching each video, you may be asked to rate your attention, anxiety, and self-consciousness.

Training in external focusing and attention shifting

Through integrating both psychoeducation and behavioural experiments, your therapist can aid you in engaging in external, non-self evaluative attention.

Addressing anticipatory worry and post-encounters rumination

Your therapist might help you identify the way you behave prior to, and following social interactions. This can help you identify the advantages and disadvantages of your anticipatory and post-encounters worries. Your clinician will provide you with the skills to sidestep these “post-modem” worries.

Managing assumptions and negative beliefs

Throughout different therapy components, your therapist can aid your ability to reappraise your social behaviours and how you are perceived in the social sphere.

Updating incorrect, negative self-images and impressions

You may have the opportunity to identify the links between your memories of previous social interactions, early social trauma, and your current self-image and behaviour in social situations. Through therapy, you can gather corrective information that will allow you to update these dysfunctional core views of yourself and others.

Relapse prevention

During this phase, your therapist will seek to reinforce your understanding of the strategies you have learned, including when and how they should be implemented. Furthermore, you will likely be taught to recognize your own personal warning signs. It is essential that you understand these warnings so you can seek timely assistance from your therapist who will re-address your recovery treatment plan.

Treatment Duration

How many sessions will I need?

The UK’s National Institute of Health and Care Excellence (NICE) recommends up to 14 sessions, each of which lasts 90 minutes, over the course of 4 months. Nevertheless, every patient is unique, thus it depends upon your personal situation.

The number of sessions you require is typically influenced by:

  • The severity of your symptoms
  • Existing comorbidities (co-existing conditions)
  • The length of time you have been experiencing your condition
  • Your personal motivation and progress
  • Your social support network

Making the Most of Therapy

Asking for help is commendable

Asking for help is understandably difficult, thus reaching out is a testament to the strength of each individual who does so. A call for help should never be seen as a sign of weakness, as it is the first step in your journey to recovery. Although sometimes uncomfortable, sharing your vulnerabilities with the right people may provide an appropriate, timely, and forthright avenue through which your problems can be assessed and addressed.

Be open and honest

Think of therapy as a journey in which you are steering the ship; your therapist is your guide, navigating the journey based on your account of what you see and experience. Reaching your desired destination and goals will be acquired with more proficiency when you share your feelings and fears. As your therapist acquires a clearer understanding of the intricacies of your situation, he or she will be in a better position to guide you in the right direction.

Be consistent

You will not see change overnight. True, lasting, cognitive and behavioural change takes time. Therapy is not a “quick fix”, rather it requires patience, consistency and tenacity on your part. Allow yourself time, communicate with your therapist, and share your feelings if you feel you are losing sight of your destination.

Trust the process

More often than not, improving your condition requires you to go beyond your comfort zone, letting go of your maladaptive coping strategies. Trust that, whilst this process may inevitably become uncomfortable or difficult at times, temporary discomfort may bring long-term and lasting benefits.

A Gentle Reminder

Dear Reader,

We sincerely appreciate your dedication; you have made it through this page of our Psychlopedia. We trust that you have gleaned valuable information from this page. Before we part ways we would like to reiterate that each treatment plan will be uniquely tailored to you, your situation and your requirements. Your personal treatment plan may or may not include the elements on this page.

If you feel as though you require professional assistance, please refrain from self-diagnosis. IndoPsyCare has professionals who are here to help.

Resources and Recommended Readings

Disclaimer

We would like to emphasize that the information presented herein was derived from external sources. IndoPsyCare does not claim ownership of any information or research within these pages. For your convenience, our team has constructed a list of the sources utilized and included further research and reading.

National Institute for Health and Care Excellence. (2022). Social anxiety disorder: recognition, assessment and treatment. Retrieved 1 July 2022, from https://www.nice.org.uk/guidance/cg159

World Health Organization. (2019). ICD-11: International Classification of Diseases (11th revision). Retrieved from https://icd.who.int/
Code for Social Anxiety Disorder: 6B04

Bufferd, S. J., Dougherty, L. R., Olino, T. M., Dyson, M. W., Carlson, G. A., & Klein, D. N. (2018). Temperament Distinguishes Persistent/Recurrent from Remitting Anxiety Disorders Across Early Childhood. Journal of Clinical Child and Adolescent Psychology: The Official Journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 47(6), 1004–1013. https://doi.org/10.1080/15374416.2016.1212362

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). The Guilford Press.

Garcia, K., Carlton, C., & Richey, J. (2021). Parenting Characteristics among Adults With Social Anxiety and their Influence on Social Anxiety Development in Children: A Brief Integrative Review. Frontiers In Psychiatry, 12. doi: 10.3389/fpsyt.2021.614318

Hur, J., DeYoung, K. A., Islam, S., Anderson, A. S., Barstead, M. G., & Shackman, A. J. (2020). Social context and the real-world consequences of social anxiety. Psychological Medicine, 50(12), 1989–2000. https://doi.org/10.1017/S0033291719002022

Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLOS ONE, 15(9), e0239133. doi: 10.1371/journal.pone.0239133

Kraus, Christoph; Lanzenberger, Rupert; Windischberger, Christian (2017). Task-dependent modulation of amygdala connectivity in social anxiety disorder. Psychiatry Research: Neuroimaging, 262, 39–46. doi:10.1016/j.pscychresns.2016.12.016

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