Dr. Richard Heimberg Addresses NJ-ACT
On Treating Social Anxiety
By Lynn Mollick
The Cognitive-Behavioral Model
On September 25, Dr. Heimberg asserted that the core problem for socially anxious patients is their belief that other people view them negatively. These patients have highly unrealistic and perfectionistic standards for themselves and believe that others have the same standards. As a result, socially anxious patients misperceive positive and neutral interactions as failure. “Their heads are full of nonsensical ideas about themselves and how everyone views them,” Dr. Heimberg commented casually.
Over time, repeated, imagined failures add up and create anxiety with severe cognitive, behavioral, and physiological symptoms. Eventually the anxiety causes social, educational, and occupational impairment as well as increased vulnerability to depression, suicide, and substance abuse.
Avoidance. Socially anxious individuals use multiple avoidance strategies to cope with anxiety. Many avoidance behaviors are easy to identify – refusing party invitations, not taking classes that require oral presentations – but others are more subtle – going to a party and spending the entire time helping in the kitchen instead of interacting with other guests.
Safety behaviors are another kind of avoidance. For example, during conversations, socially anxious patients focus on asking specific questions instead of listening, or when they speak in public, they prepare excessively.
Assessment requires understanding precisely what socially anxious patients are doing in social interactions and exactly what they fear. Socially anxious patients often report that they lack conversational skills, but Dr. Heimberg asserted that this is seldom so. More often, they believe that their social behavior is inadequate but actually their expectations and self-evaluations are unrealistic. “If you take these patients at their word, you will seriously underestimate what they are capable of,” he said.
Ask questions to assess exactly what socially anxious patients fear:
What if the thing you feared turned out to be true?
Why would that be bad?
Help patients to identify their irrational beliefs. Here are some examples:
Any silence would be awful.
I am totally responsible for the flow of conversation.
I can’t talk about that, it’s too superficial.
I won’t know what to say.
I don’t have anything interesting to talk about.
I’m not good at making conversation.
People will think I’m boring.
People won’t like me when they hear what I say.
I’ll freeze, my mind will go blank.
They’ll ask questions I can’t answer.
I shouldn’t be nervous.
People will see that I’m nervous.
If I prepare more, I won’t be nervous.
Psychoeducation. Teach patients how physical symptoms, irrational thoughts and avoidance behaviors interact.
Externalize the social anxiety. Dr. Heimberg tells his patients about SAM, the Socially Anxious Monster who sits on their shoulder and encourages them to think and behave dysfunctionally.
Have patients make a card listing the following questions to ask themselves:
Am I 100% certain that ______?
What evidence do I have that _____ is true?
What is the worst thing that can happen?
How bad is that? How would I cope with that?
Do I have a crystal ball?
Is there another possible explanation for _____?
What does _____ mean?
Does it really mean that I am a(n) _____?
Simulated social interactions. Invite confederates into therapy sessions to simulate social interactions. Set up simulations by describing the situation, identifying the irrational thoughts patients expect, rating the strength of these thoughts on a suds scale, naming the specific thinking errors, and finally correcting those errors. Then ask patients to identify an important rational thought to tell themselves during the simulation.
Setting an appropriate goal for simulated social interactions is essential. Ask patients to work on improving a specific observable behavior instead of trying to perform perfectly, feel completely relaxed, or make a good impression. Incremental improvement is the only way to overcome social anxiety. When the simulation is over, ask patients if they met the goal for observable behavior.
During simulations, stop patients every minute for a suds rating and to identify current irrational thoughts. When the simulation is over, discuss the relationship between suds ratings and rational and irrational thoughts. Anxiety usually rises with irrational thinking and drops with rational thinking. However, anxiety sometimes rises and remains high throughout. This demonstrates that patients can function in spite of anxiety. It is not necessary for anxiety to diminish in every simulated social interaction.
Three people (therapist, confederate and the patient) simultaneously rate the patient’s anxiety. Observers seldom rate patients as harshly as patients rate themselves.
Dr. Heimberg strongly advised allowing patients to be anxious during in-session exposure so that they learn to cope. “Do not rescue them,” he asserted. “These patients are not fragile, and they are often able to function far better than they report.”
Increasing the effectiveness of simulations. To be effective, simulations must always evoke anxiety. Find out what patients fear will go wrong and make sure it happens. Instruct patients to speak haltingly instead of smoothly, or ask patients to stutter or stumble over words. Ask the confederate(s) to be attentive, respectful, bored, questioning, or disparaging. Plant difficult questions and have patients practice saying “I don’t know.”
Group therapy is very helpful for public speaking anxiety since audience ratings are usually superior to patients’. Video feedback is helpful when there is a big discrepancy between patients’ performance and their perception of themselves.
Generalization. To facilitate generalization to the real world, end simulations with patients describing what they learned in their own words. Ask questions to help them reach conclusions: Was the simulation as difficult as you anticipated? Did what you feared actually occur? If it did, how did you cope? Did you use your rational thought and was it helpful? What evidence did you discover that your irrational thought is true? What evidence did you discover that it was untrue?
Interventions for Specific Types of Social Anxiety
Fears of eating, drinking, or writing in public. Use behavioral and cognitive interventions to restructure irrational thoughts such as: My hand will shake; I won’t be able to swallow; I’ll make a mistake; Someone will see that I’m anxious; People will think there is something wrong with me; Everyone will think I’m incompetent.
Writing fears. Do simulations and assign homework such as: taking minutes at a meeting; going inside the bank instead of using the ATM; using a check or credit card instead of cash whenever possible; writing out your check at the cash register, especially when there is a line behind you.
Drinking in front of others. Give homework such as: carry a beverage with you and take sips frequently in front of people; drink without a straw; at a fast food restaurant, go inside to have your beverage instead of staying in your car; pick beverages that are difficult to swallow; order extra beverages at restaurants and invite friends and co-workers to join you.
Eating in public. Advise patients to eat something whenever food is offered; create opportunities to eat with others by bringing food to work or social events and offering it to others; eat at restaurants when they are more or less crowded, whichever is more difficult for patients.
When patients’ fears actually occur. Ask patients to evaluate consequences. Maybe half of the observers will notice (50%), half of those who notice will remember (25%), and only half of those who notice will care (12.5%). The patients may be willing to tolerate this level of criticism.
All rights reserved.