Acceptance and Commitment Therapy for Social Anxiety

What is Social Anxiety?

Social Anxiety, referred to as Social Anxiety Disorder (or Social Phobia) in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-V), is an anxiety disorder marked by fear of social situations in which the individual could possibly be negatively evaluated by others. While most people have some level of anxiety about what others think of them, for individuals with Social Anxiety Disorder, this anxiety causes significant distress and impairment in their lives.

For individuals to be diagnosed with Social Anxiety Disorder, the social situation of which they are anxious must almost always cause anxiety and is either avoided or fraught with “intense fear or anxiety.” In order for a diagnosis to be made, these symptoms must be persistent (usually present for longer than six months). However, individuals whose social anxiety is limited to situations which involve performing or speaking in public may be diagnosed with Social Anxiety Disorder, Performance Only (American Psychiatric Association, 2013). 

Can Social Anxiety be cured or treated?

While social anxiety disorder cannot be “cured,” research has found a variety of treatments to be effective. Research has found various medications to be effective at treating social anxiety. Medications traditionally thought of as antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Monoamine Oxidase Inhibitors (MAOIs) were found to be effective in reducing social anxiety disorder symptoms. Benzodiazepines, such as Clonazepam were also proven effective (Blanco et al., 2003).

However, studies have found that psychotherapy is just as effective as medication at treating social anxiety – sometimes even more effective. Most research points to Cognitive Behavioral Therapy (CBT) as being the most effective type of psychotherapy for individuals struggling with Social Anxiety Disorder (Mayo-Wilson et al., 2014). However, more recent research has suggested that Acceptance and Commitment Therapy leads to similar outcomes for individuals with Social Anxiety Disorder (Herbert et al., 2018).

What is ACT?

ACT, which is said as one word rather than three separate letters, stands for Acceptance and Commitment Therapy. ACT is a type of behavioral therapy centered around the concept of psychological flexibility. Psychological flexibility is the ability to live and act in a way that is mindful and guided by our values (Harris, 2019). ACT consists of 6 core processes that, together, make up psychological flexibility:

  1. Acceptance
  2. Contact with the present moment
  3. Cognitive Defusion
  4. Self-as-context
  5. Values
  6. Committed action

These six processes are not numbered steps in treatment, but rather six interrelated techniques that are utilized throughout the process of Acceptance and Commitment Therapy. A core aspect of ACT is acceptance, and ACT aims to help clients to identify and acknowledge their thoughts and feelings without judgment. Another goal of ACT is to help clients increase their level of connectedness with the present moment.

When individuals are connected to both their internal and external environments in a more direct way, they are better able to change their behavior to be more in line with their values. Another key part of ACT is cognitive defusion. The goal of cognitive defusion is to help individuals change the way in which they relate to their thoughts. ACT also aims to help clients view the self as context.

This is the idea that each human being has a “noticing self” that is separate from the self which thinks, feels and acts. ACT also aims to help clients identify and name the core values which are important to them. Finally, ACT is designed to help clients take specific actions that are in alignment with these values (Harris, 2019).

Is ACT an effective treatment for Social Anxiety?

Many studies have found ACT to be incredibly effective at treating social anxiety disorder (Herbert et al., 2018). One study found that acceptance based behavioral treatment (such as ACT) was more effective than traditional Cognitive Behavioral Therapy at reducing symptoms of performance anxiety (Glassman et al., 2016).

Another study found that acceptance based behavioral treatments such as ACT were effective at reducing symptoms of Social Anxiety Disorder and improving quality of life even when conducted via video conferencing telehealth sessions (Yuen et al., 2013). Research also found that group acceptance based behavioral treatment, such as ACT, was just as effective as group CBT treatment in reducing social anxiety symptoms (Kocovski et al., 2013). Data also suggests that ACT is especially effective at improving behavioral symptoms of Social Anxiety Disorder (Herbert et al., 2018).

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How long does it take for ACT to be effective in treating Social Anxiety?

Length of ACT treatment for social anxiety disorder varies on a case-by-case basis. Clinical trials testing the efficacy of ACT treatment for social anxiety disorder found that individuals experienced significant results in as few as twelve sessions (Yuen et al., 2013; Herbert et al., 2018; Kocovski et al., 2013).

However, research suggests that as many as ninety percent of individuals diagnosed with Social Anxiety Disorder also meet the criteria for another psychological disorder (Koyuncu et al., 2019). In these cases, treatment may be longer so that all of the client’s needs can be addressed. Your therapist will conduct an assessment and determine the length of treatment that is best for you. 

How can I find an ACT therapist in NYC?

Finding a therapist can be a daunting task, especially in New York City. An easy place to start your search is online. There are many therapist directories online where you can search for therapists based on the primary issue you are seeking support for, type of therapy, location and cost. When searching these websites, look for therapists who specialize in treating anxiety disorders such as social anxiety, and who utilize Acceptance and Commitment Therapy as part of their practice.

Another resource to utilize when looking for a therapist is your primary care physician. Many doctors have relationships with local therapists and may be able to refer you to a clinician in your area who utilizes ACT. It is important to remember that finding a therapist can take time, and it is important that you find a provider who is right for you. Many therapists offer free phone consultations where you can speak about your goals for treatment and determine whether or not you are a good fit to work together.

How is ACT used at NYBH?

Therapists at NYBH use a variety of therapeutic modalities, including ACT, in a compassionate and understanding manner. Clinicians will present clients with many treatment options and educate them about the therapeutic process before collaboratively creating a customized treatment plan for each client. Therapists at NYBH focus on treating the whole person, not just their disorder (such as social anxiety) and focus on developing strong professional relationships with clients by demonstrating expertise and empathy. 

Many therapists at NYBH will utilize techniques from ACT when working with clients struggling with social anxiety. These techniques include cognitive defusion, acceptance and values clarification exercises. One way in which your therapist at NYBH may help you understand the concept of acceptance is through metaphors. For example, your therapist may ask you to engage in what is called the “pushing away paper” exercise. The purpose of this activity is to help clients understand the way in which pushing away negative thoughts and feelings is not only helpful, but can actually be harmful (Harris, 2019).

Your NYBH therapist also may utilize the ACT technique of value clarification. A large aspect of ACT is helping clients live a life that is more in-line with their values, but in order to achieve that goal, clients first must identify the values important to them. Your NYBH therapist may help you identify your values by asking you to describe a person’s life whom you admire or to write your own obituary (Harris, 2019). Individuals with social anxiety often suffer from frequent anxious thoughts about what others are thinking about them.

Therapists at NYBH may use cognitive defusion techniques to help you learn to give these thoughts less weight. For example, your therapist may ask you to write down your anxious thoughts, and then say them out loud very slowly or “sing” them. The goal of these exercises is to help clients identify and neutralize these anxious thoughts (Harris, 2019). 

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) https://doi-org.ezproxy.cul.columbia.edu/10.1176/appi.books.9780890425596.dsm01

Blanco, C., Schneier, F. R., Schmidt, A., Blanco-Jerez, C.-R., Marshall, R. D., Sánchez-Lacay, A., & Liebowitz, M. R. (2003). Pharmacological treatment of Social Anxiety Disorder: A meta-analysis. Depression and Anxiety, 18(1), 29–40. https://doi.org/10.1002/da.10096 

Glassman, L. H., Forman, E. M., Herbert, J. D., Bradley, L. E., Foster, E. E., Izzetoglu, M., & Ruocco, A. C. (2016). The Effects of a Brief Acceptance-Based Behavioral Treatment Versus Traditional Cognitive-Behavioral Treatment for Public Speaking Anxiety: An Exploratory Trial Examining Differential Effects on Performance and Neurophysiology. Behavior Modification, 40(5), 748–776. https://doi.org/10.1177/0145445516629939

Harris, R. (2019). Act Made Simple: An easy-to-read primer on acceptance and commitment therapy . New Harbinger Publications, Inc.

Herbert, J. D., Forman, E. M., Kaye, J. L., Gershkovich, M., Goetter, E., Yuen, E. K., Glassman, L., Goldstein, S., Hitchcock, P., Tronieri, J. S., Berkowitz, S., & Marando-Blanck, S. (2018). Randomized controlled trial of acceptance and commitment therapy versus traditional cognitive behavior therapy for Social Anxiety Disorder: Symptomatic and behavioral outcomes. Journal of Contextual Behavioral Science, 9, 88–96. https://doi.org/10.1016/j.jcbs.2018.07.008 

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for Social Anxiety Disorder: A randomized controlled trial. Behaviour Research and Therapy, 51(12), 889–898. https://doi.org/10.1016/j.brat.2013.10.007 

Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8, 212573. https://doi.org/10.7573/dic.212573

Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368–376. https://doi.org/10.1016/s2215-0366(14)70329-3 

Yuen, E. K., Herbert, J. D., Forman, E. M., Goetter, E. M., Juarascio, A. S., Rabin, S., Goodwin, C., & Bouchard, S. (2013). Acceptance based behavior therapy for Social Anxiety Disorder through videoconferencing. Journal of Anxiety Disorders, 27(4), 389–397. https://doi.org/10.1016/j.janxdis.2013.03.002 

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