Exposure therapy for social anxiety disorder (SAD) can help you overcome fears of specific social and performance situations. Although exposure training is normally conducted with the assistance of a therapist as part of a cognitive-behavioral treatment program, it can also be incorporated into your daily life.
If you have social anxiety, you most likely face these types of situations with fear and dread or avoid them completely. This strategy can sustain your anxiety in the long term.
While avoiding situations you fear might alleviate your distress in the short term, you are teaching yourself that you can’t handle those triggers.
Leaving situations in a state of panic also teaches you that they are to be feared. Ideally, you need to gradually introduce yourself to increasingly more difficult situations and stay in those situations until your fear subsides. This type of exposure training can be done in real life (in vivo) or in your imagination.
Below is a list of articles with specific tips for carrying out exposure training for a variety of different fears.
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Most of us experience a level of social anxiety at some point in our lives. We worry about what people think of us, about being excluded, about being judged or humiliated.
Social anxiety is characterised by an excessive fear of negative evaluation or judgement, triggered by social or performance situations. For social anxiety to be considered a disorder, the person must also be distressed by their social concerns or report a disruption in their life. They may find it difficult to interact with work colleagues, to make friends, or even to have brief conversations with others.
Excessive social anxiety makes us feel lonely and reduces our quality of life. Social anxiety disorder is the most common anxiety disorder and begins as early as 11 years of age.
Exposure therapy – where people face their feared social situations, with the guidance of a therapist – is one form of treatment that can be used to reduce excessive social anxiety symptoms. So how does it work?
Avoidance and safety behaviours
Although it’s normal to want to avoid social situations that make us uncomfortable, social fears almost always become worse when we avoid those situations.
Avoidance can mean a conscious decision to avoid a dreaded social situation, such as deciding not to go to a party, or it can mean using “safety behaviours” to cope with or avoid a perceived threat.
Overt safety behaviours might include wearing a hat to cover your face, away from scrutiny. Covert acts involve mental actions, such as excessive effort in memorising a speech before giving it.
People with excessive social anxiety often attribute feeling safer or averting a distressing social situation to the fact they carried out these safety behaviours. For example, “no one looked at me in a weird way because I wore a hat”, or “the speech went OK because I made the effort to memorise it all”.
The problem is, when safety rules becomes established, actions become conditional on them. For example, “the only way I can be safe from scrutiny is to keep my face hidden”. Safety behaviours need to be addressed, or they can undermine treatment and end up maintaining the person’s anxiety levels.
What is exposure therapy?
Exposure therapy is where people face a feared social situation until their anxiety decreases or the anxiety-related expectancies are disrupted.
It’s a well-researched treatment for anxiety disorders and is usually done within cognitive behaviour therapy, which also addresses the underlying unhelpful thoughts.
Exposure to the source of social anxiety is confronting, but it’s possible to achieve your goals with professional guidance. A trained therapist is able to identify the source of these social concerns, how severe they are and whether this has stopped you from doing what you would like to do.
More importantly, a trained therapist can identify and address any unhelpful thoughts and beliefs you may carry.
There are different variations of exposure strategies and the choice of which type to use is dependent on the situation. Real world confrontation, such as speaking in front of a large audience, is one possibility, but it may not always be possible.
Vividly imagining the feared situation, role-playing with the therapist and using technology such as virtual reality can also deliver exposure. Other modes of delivery include flooding (tackling the most difficult task straight away) or systematic desensitisation (often combined with relaxation exercises).
Therapists often grade the level of exposure to social situations that make the person distressed, from easiest to hardest, to ensure the process is safe and tolerable. There is, however, a risk that therapists deliver these treatments too quickly and too much, which can cause distress and a reluctance to try again. Treatment may also be approached in an overly cautious way, which slows down its effectiveness.
How does it work?
Say your feared social situation is going to a party. Here’s an example of how graded exposure therapy might play out:
1) Rank how anxious you feel about going to different types of parties. You can use a 0 to 100 scale (0 refers to no anxiety at all or 100 very anxious) or rank it from lowest to very high anxiety (as below).
2) Select a task lower down on the list. This is a task that you find difficult but feel you can succeed in. If you are unable to stay engaged with this task, go back and select an easier task.
3) Stay in the situation until your anxiety reduces.
4) Repeat it until the task becomes easy. Only move to a more difficult task when you feel comfortable with your current task.
5) Reflect on what happened and what you can take away from the exercise. Some of your predictions of social disasters, for instance, may not have occurred.
Always target something you can succeed in. In this example, option two or three may be too difficult for you to work on. But you may be able to manage option four (having lunch with colleagues).
Don’t rely on your safety behaviours. For example, you may find that you spend a lot of time fiddling with your mobile or drinking too much alcohol to feel more comfortable. If you feel a need to use any of your safety behaviours, first select a task you feel more comfortable with.
Don’t feel like you have to get rid of all your anxiety. It is normal to feel socially anxious. And don’t expect your social anxiety to go away immediately.
Finally, practise again until you feel more comfortable. You can move to a more difficult task only after you feel comfortable with the previous task.
Keep in mind that individual cognitive-behaviour therapy is the single most effective treatment for those with social anxiety disorder, more so than exposure therapy alone. So while exposure therapy may help, it’s best if it forms part of an individual cognitive-behaviour therapy plan.
A Brief Commentary on the COVID-19 Pandemic
Around the world we are all witnessing an event that most people have never experienced before. The COVID-19 pandemic has tested humanity’s resolve and resiliency by having to change and alter how we live our lives each day. Whether it is a stay-at-home order, wearing a mask, or school being cancelled, this has had an impact on nearly everyone. For us at NSAC it has forced us to be creative with how we do our treatments to continue to help the individuals that struggle with social anxiety. Please note that different orders are in place for different states, cities and countries regarding what is recommended and allowed to do, so please follow those specific orders and guidelines.
Exposure Therapy
Treatments for social anxiety typically involve situational exposures along with other combinations of treatments (e.g. Abramowitz, Deacon, & Whiteside, 2019). A situational exposure in regards to social anxiety involves a situation that someone might avoid due to a fear of being judged, embarrassed, or the like. The goal of entering into such a social situation is to assist them in acquiring new information or safety learning that disconfirms their fear based beliefs (e.g. Abramowitz, Deacon, & Whiteside, 2019). Exposure therapy falls under the umbrella of cognitive-behavioral therapy (CBT) and is an evidence based practice. For an overview of the evidence I recommend reading Exposure Therapy for Anxiety Principles and Practice second edition by Abramowitz, Deacon, and Whiteside p 23-31.
With current restrictions being in place around the world, we are faced with the unique challenge of having limited opportunities for many situational exposures. One could say this is unfortunate, another perspective is that it “allows” us to be creative and novel in how we work. I thought this would be perfect timing to create a list of possible exposures that can still be done while we are adapting to this change. I also believe these will continue to be helpful once this pandemic ends.
List of Common Situations that elicit Social Anxiety
Rather than simply compile a list I thought it would be helpful to organize it in a specific way. In Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach 3rd Ed. Workbook By Hope, Heimberg, and Turk (2019), the authors provide a common list (below) of situations that people with social anxiety identify with:
Speaking in front of a group, casual conversations, sharing an opinion, sharing personal information during a conversation, meeting someone new, sending text or email, talking on the phone, posting to social media, eating or drinking in front of others, writing or typing while being observed, being assertive, talking with an authority figure, talking with a very attractive person, job interviews, unexpectedly seeing an acquaintance, giving or receiving a compliment, saying “no” to someone, attending meetings. (p. 66-68 Hope, Heimberg & Turk, 2019).
Some Examples of how to do Exposure Without Being “Exposed”
Some of these practices still can be done the same way even during this time: send a text or email, talking on the phone, and posting to social media. Most will require some augmentation or adjustments during COVID-19. The following list comes from many different sources: myself, clients, colleagues and the like.
Speaking in front of a group:
- Record yourself giving a prepared short talk; watch the recording.
- Post the recording on a social media platform (eg. create a YouTube video and post).
Casual Conversations:
- Facetime, Zoom, Skype, etc. to have a casual conversation. Variables to change to make it easier or more difficult would be whom you have the conversation with (friend/family, acquaintance, stranger).
- Using social distancing, introduce yourself to as many neighbors as you don’t know. Note: it’s possible they are bored and would appreciate it.
- Comment with a question about a post on social media to spark a conversation (friend/family, acquaintance, stranger).
Sharing an Opinion:
- Post an opinion on social media. This might be sharing a simple preference of yours, sharing something intentionally “different,” or offering an opinion you are passionate about.
- Post in the comments section of an article about what you thought of the story.
Sharing personal information during a conversation:
- Post an update of how you are surviving during COVID-19. Use a video for greater difficulty.
- Follow up a conversation with those neighbors you introduced yourself to 😊.
- Type up your favorite memory as a kid; email it to ten people. Post it on social media and tag others with encouraging them to do the same.
Meeting someone new:
- Look for friends of friends on social media and introduce yourself to one of them.
- Host a virtual meet-up, ask a friend to “bring” one person you don’t know.
- See casual conversations section.
Drinking or eating in front of others
- Record yourself making food and eating it; post online.
- Attend virtual happy hour and “accidentally” spill your drink.
- Using social distancing, eat food in a public space where you can be observed by others.
Writing or typing while being observed:
- Record yourself writing your signature multiple times.
- Ask a friend to “observe” you typing or writing virtually.
Being assertive:
- Attempt to host a virtual meet up (can use something like Zoom, or GoToMeeting).
- Order something over the phone, then change your mind and decide not to order it.
- Disagree with someone respectfully on a post or comment.
Talking with an authority figure:
- Call the mayor’s office of your city or town and ask for guidance regarding current social distancing practices.
- Call a state or federal congressperson or senator and ask the same question.
- Call a store and ask to speak to the manager. Ask them a question that they probably won’t know such as “when will you be serve food again?”
Talking with an attractive person:
- Message, text, or arrange virtual meet up with someone you already know who you think is attractive (think of it as practice).
- Use a dating app to message someone who you think is attractive. Repeat many times.
- Have a virtual date
Job interviews:
- Write a list of common questions, record yourself answering them.
- Have a friend ask these questions to you and record yourself.
Giving a compliment:
- Compliment someone online.
- Text a compliment to a friend or acquaintance.
- During phone or video call offer a compliment to someone.
Saying “no” to someone:
- Call a business that does sales (cars, insurance, etc.) and ask some questions. Say no thanks after they give you information or their sales pitch.
- Decline someone’s request for help when you feel it is beyond your comfort level.
Attending meetings:
- Join an online support group.
- Join a webinar – ask a question during presentation.
- Attend a meet-up group that has already been established.
This is not an exhaustive list but it will be a good start for people wanting to continue their work during this difficult time. Hopefully this gives helpful tips or ideas of what exposures you can do during the pandemic. Before doing an exposure there are several things to consider to make it successful. One helpful tool is using cognitive restructuring to come up with a thought that is more helpful and believable that helps you to enter the situation. Also be sure to be on the look-out for any safety behaviors you may use to ease the anxiety. These will impede you from gaining maximum benefit of the exposure. Afterwards reflect on what you have learned from this, acknowledge your hard work and accomplishments. Doing exposure is hard work normally, but doing it during a pandemic now that’s something to brag about!
How to Get Help for Social Anxiety
The National Social Anxiety Center is a national association of Regional Clinics and Associates with certified cognitive therapists specializing in social anxiety and anxiety-related problems. We have compassionate therapists who can help you to reduce social anxiety. Currently, we have Regional clinics and Associates in San Francisco, District of Columbia, Los Angeles, Pittsburgh, New York City, Chicago, Newport Beach / Orange County, Houston / Sugar Land, St. Louis, Phoenix, South Florida, Silicon Valley / San Jose, Dallas, Des Moines, San Diego, Baltimore, Louisville, Philadelphia, Montgomery County, Maryland / Northern Virginia, Long Beach, Staten Island, North Jersey, Brooklyn, Santa Barbara, Bixby Knolls, CA, Denver, Kalamazoo, MI, and Massachusetts (Children & Teens). Call our national headquarters at (202) 656-8566 or visit our contact page to find help in your local area.
Written by
Zach Pacha, LISW
NSAC, Des Moines
References
Abramowitz, J.S, Deacon, B.J., & Whiteside, S. P. H. (2019) Exposure therapy for anxiety: Principles and practice second edition. Guilford Press.
Hope, D. A., Heimburg, R.G., & Turk, C. L. (2019). Managing social anxiety: A cognitive-behavioral therapy approach third edition workbook. Oxford University Press.
