How social anxiety is treated in my office.

First, let's quickly cover what social anxiety is. Social anxiety is a pattern of relationships with distressing thoughts and sensations rooted in a fear of being judged. The fear of being judged sounds specific, yet we can see later in the blog how we can get even more specific to see our capabilities are beyond what we think they are.

Social anxiety commonly leads to a lower quality of life and worsens as time goes on. A deep sense of doubt often makes it challenging to feel close to friends and family who are there for you. Academic or occupational adventures feel overwhelmingly daunting, leading to academic underachievement and underemployment in the career.

As time goes on, isolation grows, often leading to co-occurring challenges like depression. Since we know a strong connection exists for social trauma, post-traumatic stress disorder (PTSD) is commonly co-occurring as well. Each of these challenges is addressed in a personal, unique combination of skills and insights to help people discover how awesome they truly are.

For more help, check out the social anxiety survival kit by clicking here.

Step 1: Build Saftey in the Office

I remember the first time I was going to get therapy for my social anxiety. I found the therapist I wanted to see and felt like they could help me, and then I sat on that for 18 months at least. I tried to email or call so many times I can't remember. I've always had such a strong empathy for people taking the brave step to contact me. I try to really slow things down in the strategy call/email and the first few sessions.

I find it interesting that social anxiety is the only disorder that you must directly confront the core issue when going to pursue therapy. For addiction, you don't need to be sober to get help. For depression, you don't need to make any behavioral changes (other than attending) to get help. Yet, for social anxiety, you risk being judged when you reach out. I want to assure you that I hold unconditional positive regard for you. I will not judge you. I ask that you trust yourself here, not me. You don't know me. Trust yourself to be brave and give me a chance to prove my trustworthiness.

First Session: In the first session, we discuss your history and try to understand when these fears first occurred. We also find time to discuss your other interests. We will also learn one specific skill that helps immediately. For example, we may discuss that you see challenges with overthinking. We can teach the skill of defusion.

1. "I notice a thought of doubt."

2. Expand "The doubt is trying to keep me safe."

3. Present-moment connection: "Right now, I am safe. In this moment, everything is okay."

4. Pair with relaxing muscles.

In the first session and future sessions, I teach specific skills to help with what you bring up. At this point in my career, giving you any random skill is challenging because many excellent and particular skills can help you reach your unique first goal. At the end of the first session, we will confirm our first few goals. Some people like to have this written down, and others like a verbal agreement. It's up to you what we do.

Step 2: Notice Patterns & Educate on Acceptance and Commitment Therapy

I use a few modalities in my office. The primary one for social anxiety is acceptance and commitment therapy (ACT). ACT has six foundational elements and skills within each element: acceptance, committed action, contact with the present moment, defusion, self-as-context, and values. As each element presents itself in therapy, I educate, and then we apply it to your context.

For example, maybe you share a childhood friend throwing a party, and you want to go but fear they'll think negatively of you (we would get more specific with what your brain is anticipating). We could use this to practice any of the six. Let's use values as an example. Values are abstract concepts that are never ticked off a to-do list. The value that is possibly being communicated here is "long-term friendships." We would know if that's the value if there's a relaxation response, and we then combine other skills to pursue this value in the party. We can think of a few questions or memories to share with your friend.

Notice Patterns: as the sessions progress, we can notice more specific patterns of social anxiety in your life. For example, one core fear is being wrong and being made fun of. As we see this in multiple scenarios over time, we can start to target those fears with historical context using timelines or memories and process the trauma likely driving that fear.

Step 3: Process Unhelpful Shame

The challenge with shame is the paradox our brain holds with it. Shame is shaming. So, when we process shame, we leave ACT and shift into relational psychotherapy and compassion-focused therapy. The central theme of shame is feeling like we are a mistake. We are broken and unworthy of connection or love. This pattern can be seen in the harsh inner critic, even when you spill milk or cringe after socializing.

For example, we can discuss patterns of "should" or "have to" statements that often indicate shame. Dr. Karen Horney called this the "tyranny of the shoulds," which compares us with an ideal-worthy version of you. We learn to have compassion for the present and reword our statements into things we can control and want to do. "I should write more blogs." Breathe, relax. "I want to be consistent with my weekly blogs."

Step 4: Process Trauma

There is a robust relationship between trauma and social anxiety. Over 80% of people with social anxiety have a social trauma around age 10-14. The social trauma can be bullying (siblings and school), psychologically controlling parents, or natural events. Any trauma can lead to social anxiety, as we see 1/3 of people with PTSD have co-occurring social anxiety, and 1/3 of people with social anxiety develop PTSD.

For information on how trauma affects the brain, check out this helpful blog: lanierlawfirm.com/how-trauma-affects-the-brain

I have many tools in my toolbox to help process trauma, from Eye Movement Desensitization and Reprocessing (EMDR) to timelines, narrative approaches, or Cognitive Processing Therapy. Sometimes, a relational approach of listening, attunement, and resharing in a third person is helpful, too. Either way, we will agree on the strategy before exploring it and know we can switch anytime.

Last Step: Facing Our Fears Carefully and Bravely

It is commonly called "exposure and response prevention" in the field. This is when people can drop out, so it's our last step. We also benefit from the previous steps that prepare us to do hard things. The good news is that despite what you might feel or think of this now, you'll have seen your strength and believe you can do hard things by this point in therapy.

We can use "subjective units of distress" and rank fears on a 1-10 scale where 10 is our biggest fear, and 1 is still anxiety-provoking, yet easily tackled. We can use this scale in a specific sense or broad approach. For example, 1-10 steps for facing the fear of snakes or 1-10 for facing the fear of conflict with friends. We can use the scales to face these fears systematically in the office, practicing the "rule of 3" as we process, then bravely facing outside the office, applying all the skills we have while we do.

Hope and Encouragement

I genuinely know how intimidating it can be to consider going to therapy for social anxiety. I want to try to reinforce and remove an all-or-nothing approach. We can talk and think about things without having to change. You can talk about more 'surface level" topics before facing fears. We can even talk about depression or school or careers first if that's easier to get working. Whatever your choice is, I'll meet you wherever you're at with unconditional positive regard and will not judge your process. I'll never criticize the "what" you do and will curiously and compassionately explore the "why" you chose that option. I believe in you. Take care.