Social Anxiety Treatment
Social Anxiety and 3 Dysfunctional Beliefs
Social anxiety, also known as social phobia, is defined as a continuous fear of social situations that might embarrass or expose one to scrutiny (APA, 2000). It is the most common anxiety disorder and one of the world’s largest mental health concerns (Bener, Gholoum, & Dafeeah, 2011). If affected individuals do not receive treatment for social anxiety, they can experience chronic anxiety as well as significant social and occupational disadvantages (Wong, Sarver, & Beidel, 2012).
Cognitive-behavioral therapy (CBT) holds a dominant role in social anxiety research and treatment. CBT has established a strong foundation of evidence for cognitive factors in social anxiety as well as articulated the key role that beliefs play in the disorder.
Three dysfunctional beliefs have been identified as the primary cause of social anxiety: high-standard beliefs, conditional beliefs, and unconditional beliefs (Clark & Wells, 1995). High-standard beliefs involve holding oneself to unrealistic standards such as “I must be liked by everyone I meet” or “I always need to appear confident”. Even though these high-standard beliefs are not inherently anxiety-causing, when one fails to meet these high standards, one can experience a lot of anxiety. When an individual clings to these impossible standards, they feel constant dissatisfaction as a result of failing to live up to this ideal picture of themselves (Van Yperen & Hagedoorn, 2008).
Conditional beliefs predict that when an individual exhibits a particular behavior, it will result in social consequences. Some examples are, “if I make mistakes, others will hate me and never forgive me” or “’if I try to talk in public, I will be laughed at” (Clark & Wells, 1995). Conditional beliefs often act as a self-fulfilling prophecy, by causing the very outcome the individual is most afraid of (Hadji-christidis et al., 2007).
Unconditional beliefs are constant negative assessment of oneself such as, “I am a loser” or “I am a bad public speaker”. Interestingly, individuals with social phobia hold positive ideas about themselves in situations outside of their feared social situations. However, in social situations, these individuals view themselves through negative unconditional beliefs (Clark & Wells, 1995).
CBT for Social Anxiety
The success of CBT can be measured by changes in individuals’ irrational/unrealistic beliefs. CBT therapists help clients form new patterns of thinking and behaving by cultivating positive and realistic thoughts to replace unrealistic, negative thinking (Arch & Craske, 2008). CBT can be done either individually or in groups. Some therapists prefer groups as it allows clients to practice exposure within a safe group (Hope et al., 2010).
Cognitive restructuring is especially important for individuals with social anxiety, as they learn to challenge and question the truth of their beliefs (Hope et al., 2010). This can be done by providing evidence against the problematic beliefs in a Socratic dialogue (Frojan-Parga, Calero-Elvira, & Montano-Fidalgo, 2011). Behavioral experiments are also useful in showing individuals that the disastrous events predicted by their irrational beliefs do not end up happening during exposure exercises. This shows clients the falseness of their beliefs (Arch & Craske, 2008).
Although CBT has been shown to be very effective in the treatment of social anxiety in numerous studies, it does not necessarily appeal to all therapists and clients. Next are some other theoretical orientations that sometimes also incorporate the three core beliefs into their treatment approaches.
Acceptance and Commitment Therapy (ACT)
ACT is based on relational frame theory and believes that not only the content but also the context, in which learning occurs, is important (Blonna, 2010). In other words, individuals can be experiencing problematic cognitions and beliefs in the present, even though they are related to old situations or events. Problems arise when individuals use old frames of reference to deal with current experiences. As a result of using past relational frames, clients are living through their past instead of being in their current experience, and this causes stress, worry and anxiety (Hayes, 2008). For instance, if a child was told he was worthless by his parents, as an adult he might hold the unconditional belief that he is worthless, therefore everything he has to say is worthless, which then causes social anxiety. The goal of ACT is to help clients create awareness in the present moment and accept their thoughts, feelings and behaviors. Clients are encouraged to view themselves as “self-as-context” and experience their lives through their current context while abandoning old relational frames (Hayes, 2008). ACT also utilizes pychoeducation, creative hopelessness, clarifying values, values-based exposures and committed action (Eifert & Forsyth, 2005).
Solution-Focused Brief Therapy (SFBT)
SFBT views the client as the expert in solving his/her own problems. Therapists help to identify clients’ strengths and resources so that clients can clarify goals and find solutions to problems. This is achieved by using solution-focused questioning that motivates clients to utilize effective past and present problem-solving skills to find new solutions to their problems (Mishima, 2009).
The three main types of questions utilized are coping questions, miracle questions, and exception questions.
Coping questions draw on past coping skills to address current challenges and remind clients of the ways they used to be effective in the past. Therapists can ask clients about how they have coped with fear in the past and what strategies have worked in dealing with anxiety.
Miracle questions ask clients to imagine their future without their problem by looking beyond the narrow confinements of their problem, imagining a different reality and clarifying goals (Stith et al., 2012). This can inspire clients to come up with new ways of approaching the problem and work towards realistic and effective solution building.
Exception questions ask clients to describe times in the past when the problem was not present and thus realize that the problem is not always interfering with their lives. For instance, if a client’s belief dictates that he will be too afraid to speak in a group, the exception question can reveal that often the client is able to speak to groups despite his fear. Clients can also see that even though sometimes they may not be able to live up to their high standards, they can still have a good time and be proud of their efforts.
Social Anxiety Treatment References
Macarthur, J. (2013). An integrative approach to addressing core beliefs in social anxiety. Journal of Psychotherapy Integration, 23, 386-396.
Bener, A., Ghuloum, S., & Dafeeah, E. E. (2011). Prevalence of common phobias and their socio- demographic correlates in children and adolescents in a traditional developing society. African Journal of Psychiatry, 14, 140 –145.
Wong, N., Sarver, D. E., & Beidel, D. C. (2012). Quality of life impairments among adults with social phobia: The impact of subtype. Journal of Anxiety Disorders, 26, 50 –57.
Van Yperen, N. W., & Hagedoorn, M. (2008). Living up to high standards and psychological distress. European Journal of Personality, 22, 337–346.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg M. Liebowitz D. A. Hope F. R. & Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69 – 93). New York, NY: Guilford Press.
Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science and Practice, 15, 263–279.
Hadjichristidis, C., Handley, S. J., Sloman, S. A., Evans, J. S. B. T., Over, D. E., & Stevenson, R. J. (2007). Iffy beliefs: Conditional thinking and belief change. Memory & Cognition, 35, 2052–2059.
Froján-Parga, M. X., Calero-Elvira, A., & Montaño- Fidalgo, M. (2011). Study of the Socratic method during cognitive restructuring. Clinical Psychology & Psychotherapy, 18.
Hope, D. A., Burns, J. A., Hayes, S. A., Herbert, J. D., & Warner, M. D. (2010). Automatic thoughts and cognitive restructuring in cognitive behavioral group therapy for social anxiety disorder. Cognitive Therapy and Research, 34, 1–12.
Blonna, R. (2010). Stress less, live more: How acceptance and commitment therapy can help you live a busy yet balanced life. Oakland, CA: New Harbinger Publications.
Hayes, S. C. (2008). Climbing our hills: A beginning conversation on the comparison of acceptance and commitment therapy and traditional cognitive behavioral therapy. Clinical Psychology: Science and Practice, 15, 286 –295.
Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and commitment therapy for anxiety disorders: A practitioner’s treatment guide to using mindfulness, acceptance, and values-based behavior change strategies. New York, NY: Guilford Press.
Mishima, N. (2009). Imagery in solution-focused therapy. Japanese Journal of Autogenic Therapy, 29, 1–9.
Stith, S. M., Miller, M. S., Boyle, J., Swinton, J., Ratcliffe, G., & McCollum, E. (2012). Making a difference in making miracles: Common road- blocks to miracle question effectiveness. Journal of Marital and Family Therapy, 38, 380–393.