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Tuesday 13 November 2012

Social Anxiety: Find the Landmine!

Especially during exposure exercises.

Almost everyone has social anxiety. Take us to a formal reception where we don’t know anyone, and watch the heart rate rise. Put us on a stage with a set of notes and a hostile audience and see what happens.

Like most fears, social anxiety exists on a continuum. Beyond a certain point the fear becomes disabling – preventing the person from reaching his or her deeply-held goals and wishes.

The treatment for just about any unhelpful fear is the same: approach the feared situation, tolerate the anxiety, and stay there long enough for the anxiety to fade (in a process we officiously call habituation), replaced (usually) by boredom.

To this we usually add an examination of the belief system. This can be complicated, but usually boils down to “What is it that you imagine happening, how likely is that, really, and how bad would it be if it did?” From there the thing can become enormously complicated, but that’s the nub.

Effective treatment depends on our ability to identify the real fear. If we believe that our agoraphobic client who avoids shopping malls fears shopping, then we might create an exposure task involving a browse through the Amazon website. And we would almost certainly get nowhere, because agoraphobia is not at all a phobia of the agora, nor is it a fear of shopping. It is usually a fear of specific internal bodily sensations developing in situations from which it might be difficult to escape.

One problem is that the person himself or herself often isn’t too clear about what they fear. Ask a socially anxious client what they are afraid of, and you will often hear “job interviews, public speaking, social events.” If you ask what it is about these situations that seems fearful, you can hit a wall. “I just don’t like them; never have.”

Left unexplored, this would pull therapists to suggest exposure tasks like attending small social events and working upward. And this might be helpful. But often we will get no improvement, and clients will report a feeling of relief when the tasks are over that does not translate into a reduced anticipatory fear. They feel like they have traversed a minefield without being blown up, but this does not reduce the fear of minefields in the least.

Why not? Because the client was never afraid of minefields. They were afraid of mines.

We have to figure out the nature of the landmines that the client fears within social situations. And they often have difficulty telling us.

That’s an awfully long leadup to a tiresomely obvious tip, I’m realizing. My own anxiety about appearing foolish in this forum is waking up and looking furtively around. Which, of course, makes posting it a perfect exposure exercise.

See enough people with serious social anxiety, and you know darned well what they’re afraid of. But things go better if you get it from them, and every so often you are surprised. A simple question will usually crack open the cognitive shell:

“Imagine we were to make you utterly invisible, then send you to a party – exactly the type that you say you are most afraid of. No one can see you. How would you feel?”

The usual answer is that the person would feel much better, plagued only by a residual anxiety that the invisibility spell might wear off. This tells the therapist – and the self-surprised client – that they aren’t afraid of parties after all. They are afraid of something that might happen at parties – something that depends on them being visible to others.

“I’m afraid of doing something stupid – like dropping food on the floor or having my fly down, or not being able to think of anything to say.”

But none of this is true either.

“Have any of those things ever happened when you were alone? How did you feel?”

“Oh, fine.”

“So it depends on you doing something that seems foolish to you, and them seeing it. What would happen if they did?”

And here we get the reality. Our socially anxious person isn’t afraid of social situations at all, nor of being awkward. They’re afraid of other people seeing and possibly negatively evaluating their performance. Consequently, simply exposing the client to a social situation is unlikely to produce impressive results – unless we expose them to what they really fear: making errors visibly in front of others and risking – or, even better – receiving negative evaluations.

The further down the anxiety chain that we can structure our exposure exercises, the better. Not just going to the party, but doing something awkward. Not just doing something awkward, but doing it so someone notices. Not just having them notice, but letting them develop a negative evaluation of us. And surviving that.

It’s not always possible to go all the way. Most of us are unwilling to do things that will make our bosses even more convinced that we are idiots, no matter how therapeutic the task might be. But usually we can come up with something that gets us far enough to dissolve some of the irrational fear. Look as though you are about to hand the boss a report, then confess an error – “Oh, I haven’t included the appendix at the end – I’ll add that and get this to you later.”

Most effective social anxiety exposure work involves making at least some deliberate errors while entering moderately feared situations. Deliberateness, of course, is critical. “I seem to make errors constantly and the fear never gets any better.” It is the voluntary performance of social errors that helps. Stumble on the way into the cinema. Spill your coffee at Starbucks. Mis-button your coat before going into a store. Make your hand shake as you hand over money. Confess your anxiety before commencing your talk.

Know the true nature of the landmine you fear. Then jump on it.

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