Anxiety disorders are common among the population. When the various types of anxiety disorders are taken all together, they represent one of the largest reasons that people enter therapy. For those counselors who work in a private practice or agency setting, they will most likely deal with clients who experience various types of anxiety disorders, better described as phobias.
Although there are a variety of strategies for treating anxiety disorders, the primary way in which phobias are treated in counseling situations is through what is called exposure treatments. Individuals are directly exposed to, that is must encounter, the phobic situation that leads to their severe anxious responses, responses that can and often do entail panic attacks. For example, if a person has a severe phobia regarding dogs, then therapy will involve helping the individual be in the close proximity of a dog, even to the point of developing the ability to pet a dog. The best way for individuals to conquer severe phobias of elevators is simply to get on an elevator and ride it up and down over and over again.
Because therapy entails supporting individuals to physically engage that which causes their phobic reactions, such treatments are called exposure. Individuals expose themselves to that which they fear the most. The basic premise of exposure treatment is that once people are in the presence of the feared phobic object or situation, they can learn to stay in its presence, seeing that what they fear the most will not occur. While being exposed to phobic stimuli, individuals who experience anxiety disorders will be asked not to utilize compensatory and avoidance strategies that they normally use to curb their anxiety. The longer they can stay in the presence of the object or contexts that lead to their phobic reactions, they will see that their anxiety will begin to dissipate because what they catastrophize about the phobic situation does not come true.
Research results indicate that exposure treatments for phobias are highly effective. In fact, in most cases, unless people engage such exposure treatments, they rarely will overcome their phobias to the point that they can better function in the presence of what leads to their fears. It is not that some people cannot overcome their anxieties apart from exposure treatment. It is just highly doubtful that they can. Even if they do, it takes a much longer time to overcome such fears, and the relapses tend to be quicker and more numerous where exposure treatment is not used.
Social anxiety, also called social phobia, has at its roots the fear of negative evaluation by others. To some extent, most of us have experienced the fear of negative evaluation in social settings, but for individuals who struggle with social anxiety, the fear of negative evaluation reaches the extent that their functioning becomes severely impaired. For example, individuals will avoid and cease attending situations that involve social gatherings, especially social situations in which they do not know most of the people present. They may enter a social situation but stay close to a friend or friends whom they know, and then hang out on the perimeters of the social context so as to avoid interacting with people whom they don’t know. Such avoidance strategies are called compensatory strategies because they allow individuals to find ways to curtail their anxieties. While curtailing anxiety is not necessarily a bad thing, compensatory strategies prevent individuals from engaging experiences that they would prefer to engage. The ultimate compensatory strategy for social anxiety is when individuals consistently turn down social invitations, thereby avoiding social interaction all together.
The problem with such strategies is that many people do not feel good about turning down social invitations. It is something that they would actually prefer to do if they weren’t so anxious about the social contexts they must engage. The aim of therapy for social anxiety is not to turn people into party animals where they are the life of the party. The goal of such work is simply to help clients reach their own comfort levels, deciding to what degree they want to become more relaxed in social outings.
Many times social anxiety is cast in the discussion of introversion and extraversion. Nothing could be further from the truth. Introversion and extraversion have nothing to do with social anxiety. There is nothing wrong with being an introvert, irrespective of how our society highly regards extraversion. The aim of therapy is not to help one evolve from being an introvert to and extravert. Introverts as well as extraverts can function comfortably in social situations. The aim of therapy is to help individuals become more comfortable in social gatherings where their anxiety and compensatory strategies have become pronounced. Socially anxious people simply want to develop the ability to walk into social gatherings without being hampered by anxiety. They want to experience the comfort of meeting people they don’t know in social contexts. They may want to introduce themselves to people, network at parties and other social contexts, or carry on simple conversations at social gatherings.
Fear of Negative Evaluation
As stated above, the root fear of those who experience social anxiety is the fear of negative evaluation. From a cognitive behavioral perspective, people hold beliefs about what they fear will occur in social contexts. Socially anxious people state their fears in several ways, which help therapists get at their thinking related to social contexts. One client may say, people will think I’m weird somehow. Another client might say, people will think I’m unattractive. Still others believe such things as people will think I look funny – sound funny – dress funny – etc. Therapists hear clients say things like I will feel like a fool trying to carry on a conversation, especially with someone I don’t know. Others might say: I don’t like meeting people; I don’t like parties; I don’t enjoy introducing myself to people I don’t know. Again, there is nothing wrong with these statements and actions in-and-of-themselves. If people prefer not to meet others, if they don’t like parties, and if they don’t care about turning down invitations to social events, then that’s fine. Individuals, however, come to therapy because they believe their anxiety regarding social situations is over the top. Due to their fears, they can’t do the things they would prefer to engage. They may desire to make new friends, date different people, and talk more to individuals they don’t know that well at social gatherings. Hence, they want to make some changes that can help them become more comfortable in social contexts.
Researchers have developed several Fear of Negative Evaluation (FNE) scales that therapists can use with clients who experience social anxiety. Most of these scales contain statements that clients can rate on a Likert-like measurement. For example, clients can rate from 1 to 5 with one meaning not at all and 5 meaning highly true, the statement I am extremely sensitive to what people think about me. Rather than creating some major quantitative data, these scales can be used qualitatively to generate conversations between therapists and clients. Through these conversations, therapists can obtain a good grasp of how their clients function in social settings. Additionally therapists can learn how their clients utilize avoidance and compensatory strategies when it comes to social engagements.
Clients’ beliefs about social contexts and the compensatory strategies they use to avoid such settings are the very things that must be challenged via exposure treatment. The question becomes: how is exposure treatment best done for those who experience social anxiety?
Group Therapy for Social Anxiety
Group Design for Working with Clients Who Experience Social Anxiety
There are several pathways to help clients face their anxieties about social situations. As part of their therapy counselors can ask them to attend meet-up groups, social gatherings, office parties, and any social context where there will be people clients do not know. Therapists and clients can agree on homework assignments in which clients take on the tasks of introducing themselves to people they don’t know. If clients are in classroom situations, they can agree to speak up in class a specified number of times. Such social arrangements are useful but can be difficult to control, monitor, and structure so that the client gets optimal benefit from taking on the task.
One of the major tools used in working with individuals who experience social anxiety is group therapy. The group setting itself creates a built-in form of exposure for clients. Groups can be structured along several lines. They can be non-specific encounter groups that comprise some members who experience social anxiety and other members who do not have such concerns. Such a group is representative of most social settings clients will enter.
Group settings where all members experience social anxiety is another form of group therapy. I believe that for those clients who have never experienced group work, these specified groups are a good entrance point into this kind of work. Group meetings should be weekly for a specified period of time, for example six weeks. Groups should be limited to no more than eight members. Groups comprise people that each member does not know. Hence, each week members must enter the group room where people exist with whom they have not made contact. This act alone exposes clients to one form of fear they experience about social situations. Additionally, group activities will provide each client with opportunities to act and speak in front of the other group members. Such activities expose group members to some of their worse fears: speaking in front of people, being observed by others, and then getting feedback from all the participants. Moreover, the very act of giving feedback provides exposure for group members who can learn that feedback is neither negative evaluation nor being overtly judgmental.
Role of the Group Therapist(s)
Therapists know that socially anxious individuals excessively fear such social engagements where they must talk, interact, and in some way be observed by others. Therapists must hold a space for each participant so that all group members can feel safe, respected, attended to, and not judged. Therapists should prevent personal attacks among members, which is a cardinal rule for all group therapy, but it is especially important for social anxiety groups because such personal attacks come across as judgmental, which is the very thing group members fear. Personal attacks, however, are not the same as personal disagreements. Group members can learn that disagreements among members are neither negative evaluations nor judgmental acts on the part of others. Therapists should guide and channel any disagreements that arise in constructive ways, perhaps teaching people how to voice disagreements in ways that do not sound or look like personal attacks. Group process will allow group members to give honest but non-judgmental feedback to other members in the group. Group participants will hopefully emulate the therapists’ ways of holding a safe space for clients, and begin doing the same for each other as they interact during group activities.
Therapists should take on the role of screening group members. Although not all group dynamics include screening, I think for a specified type of group, such as one designed for social anxiety, therapists should screen clients with a one-on-one interview before admitting them into the group. The primary focus of the group, and the primary concern of each group member should be social anxiety. Therapists should also administer a short FNE scale for each group member. Therapists should also create some type of qualitative feedback form for group members to complete so as to ascertain how clients believe the group therapy setting worked for them.
Individuals in a therapeutic group eventually get to know one another and thereby become more comfortable with one another. Although for most process groups, such comfort is a good thing that can lead to group cohesion, this presents a problem for groups designed to treat social anxiety. As members become comfortable with one another, the group setting begins to lose its exposure power. Once a social anxiety group loses its exposure edge, then how does therapy proceed so that clients can continue to work on their socially anxious concerns?
Social Gatherings of Various Groups
If therapists are working with more than one group designed to treat social anxiety, then they have a built-in mechanism for creating social gatherings. Following the six-week group therapy session, clients can be asked to attend social gatherings comprising members of other groups who have sought to deal with their social anxiety. In these social gatherings, members can introduce themselves to people they don’t know, and then talk to, and interact with individuals they don’t know. The caution for designing and setting up these social gatherings entails the logistics that must be navigated so that members will feel safe in the social gatherings. Informed consents should be developed, and therapists should work with their specific groups, discussing expectations for the social gatherings. Should they be totally voluntary or required? As therapists work with numerous groups, past group members can attend the social gatherings to provide a good mix of individuals present at the gatherings. Perhaps past members can take a couple of minutes to speak in front of the attendees at the social gathering, demonstrating how they have come to manage their social anxiety. As social gatherings continue, they will grow in number, and clients can continue to follow up by attending the gatherings as long as they feel it necessary to attend. Such social gatherings can be treated as booster sessions for past group members.
Existential concerns exist with social anxiety just as they exist with practically any struggle through which human beings undergo. As stated above, those who experience social anxiety have as their greatest fear that other people will somehow negatively evaluate them. The simple fact is the world comprises people who do negatively evaluate others, whether or not those who are doing the evaluating know anything at all about the people on whom they are dumping. Given that negative evaluators do exist in the world, the question becomes is how much power does one want to grant such evaluators. This is an existential question. Another existential concern revolves around the question why should individuals care if people negatively evaluate them. Therapy for those who experience social anxiety does not include a promise that they will not experience negative evaluation from someone. Helping clients manage their social anxiety and become more realistic about their catastrophic beliefs and ensuing fears can have the added benefit of helping clients adjust to a world where there are some ugly things that happen out there.
At Contemplations, I hope to begin a series of group counseling experiences for those struggling with social anxiety. Be sure to check out this website for more information regarding my practice.
John V. Jones, Jr., Ph.D., LPC-S/February 14th, 2020