Treating Social Anxiety with Talk Therapy

Social anxiety disorder (social phobia) is more common than you may think. Furthermore, you do not have to have a “disorder” to get talk therapy for social anxiety. The DSM, used by mental health professionals, says about 7% of Americans have social anxiety disorder. An additional 10% experience “subclinical” social anxiety.

Let’s break that 7% number down a bit. There are approximately 335.8 million people in the US, of which 7% is about 23.5 million. That’s 23,500,000, which is quite a few more 0’s than I expected when I first learned the prevalence.

I'm a social anxiety therapist in Allen, Texas, so to give an idea of size, the Dallas Cowboys stadium can hold between 80,000 and 105,000 people. Let’s call that 100,000. You would fill 23 stadiums and still have some people waiting in the parking lot. That means that every person attending a Dallas Cowboys game over an entire season would still fall short of representing the number of people in the US living with a treatable condition.

Helping people see through the stigma that prevents them from getting started is the most challenging part of treating social anxiety. The DSM mentions people with a social anxiety disorder will wait 15-20 years before they seek treatment. No judgment, but oof, that’s a long time. Also, less than 1/2 of the 7% (not to mention that additional 10%) will not seek treatment and continue suffering.

We also know that access to counseling is more significant than it has been in history. So, it’s not access that prevents people from getting social anxiety therapy; it’s stigma. Let’s look at the different talk therapy available. 

Acceptance and commitment therapy social anxiety

What is acceptance and commitment therapy (act)? A branch of cognitive behavioral therapy (CBT) that incorporates mindfulness, acceptance, values, and recognizing thought patterns. There are 6 pillars to ACT: acceptance, values, present moment awareness, committed action, self as context, and cognitive defusion. The premise of ACT for social anxiety treatment is the use of the six pillars to teach and train a new focus that the symptoms of social anxiety are not the problem; instead, it's our relationship to those symptoms that we seek to change. 

For example, suppose you notice your blood pressure increasing (and you don’t usually have high blood pressure or beta blockers lowering your blood pressure), your heart beating faster, it’s becoming difficult to make eye contact, you start sweating, and your thoughts focus on something specific.

Are you feeling fear, anxiety, or excitement? Notice that I did not mention being in social situations.

Suppose we learn to use feelings as feedback. In this situation, we can identify two primary emotions: excitement or fear. Rather than a conscious decision, we react based on the context of the situation and our relationship with those feelings.

Your symptoms of social distress can develop whether you are around people or not. Unfortunately, when we have a “relational frame” to avoid unpleasant experiences, these symptoms grow over time, and we become more isolated. In the above description, you may assume that was a description of fear or anxiety, yet it’s not. That outlines how our nervous system is activated, which can be for excitement or nervousness.

As we learn, we develop “relational frames.” Someone with a relational frame (I’ll explain that in a moment) of approach seeks connection, sharing, etc., and will experience the same symptoms yet want to talk to people instead of interpreting them as something wrong or to be avoided. Most people with social anxiety, however, have a relational frame to avoid unpleasant experiences and analyze the activation as anxiety.

Thus, feelings are feedback, and our values are the compass for choosing a direction in life instead of feelings that give you half the picture of reality. Values are like a compass. If your compass points to college, but you don't feel like going, you still go because that's what the compass says.

We use talk therapy for social anxiety. This helps people see that the feelings can be seen as excitement to learn something new, which is better than fear, which can lead to avoiding college because the feelings are overwhelming. We then develop skills and tools to regulate the symptoms as we follow exposure to social anxiety and response prevention techniques to overcome our fears over time. 

However, don’t give up if getting over social anxiety takes time. Remember, it may be over a decade of habit formation to rewire. This also means that the theory of why social anxiety is growing and how it is maintained in your life is through avoiding things because there is a negative or unpleasant connection to what you are experiencing.

Your social anxiety will continue to get worse as you try to control the unpleasant emotional and physical sensations. AKA, if we wait to “want to,” “feel motivated,” or “not be anxious,” we may be strengthening our avoidance instead of overcoming social anxiety.

What are relational frames?

ACT is based on relational frame theory, which, in an oversimplification, is how we develop our language abilities as humans. As we learn words representing objects, how those objects relate to our safety, how we are told to experience the world, and how we experience the world (known as combinatorial and mutual entailment, respectively) builds a relational frame of reference.

These relational frames are how our brains, wired for efficient survival, work together to keep us safe. Unfortunately, the “safe” in our brain can be a relational frame with pleasantness, which means unpleasant is unsafe, and thus, how people with social anxiety find themselves isolated overtime, even such that the DSM mentions females in particular without a job is a significant indicator of social anxiety disorder. 

ACT has six pillars I draw from in social anxiety talk therapy: acceptance, mindfulness, cognitive defusion, self as context (remember we can change the context and see ourselves as more than our behaviors), committed action, and values. Acceptance and commitment therapy is an evidence-based treatment for social anxiety disorder. 

Cognitive behavioral therapy social anxiety

Within the cognitive theory of social anxiety, there are inaccurate, faulty, and unhelpful assumptions about the perception of social experiences that increase stress. Thus, treatment for social anxiety with a cognitive behavior therapist is growing recognition of unhelpful thinking styles and using thought experiments first, then behavioral experiments, to test new assumptions and change our behavior. 

My explanation is, admittedly rooted still in ACT, that the core fear of social anxiety is negative evaluation, and anxiety is worse when we feel judged. However, there are many kinds of “judgment” in the world. Two polar ends of the spectrum of judgment are criticism (shame, guilt, the meaning is being broken or wrong) and evaluation (observation, noticing complexity, the meaning is finding areas of growth). 

Often, we seek to understand our inner dialogue first. If we criticize ourselves, how are we going to grow? This is where teaching skills and practicing self-compassion come into play in therapy.

Let’s say, for example, you are working on talking to your family during the next holiday. We discuss how you see the holiday and what concerns you may have. We also talk about whether we are concentrating on criticism rather than acknowledging the physical symptoms of social anxiety. Additionally, we explore ways to shift negative thoughts to a more positive mindset. Thus, over time, we transform your relationship with social anxiety to become a tool for growth instead of the bane of your existence. 

How long does it take for therapy to work for anxiety?

This question is challenging to answer. Your specific goals and barriers provide nuance to your answer.

In a nutshell, if “working” means you begin to learn new skills and gain new insights, well, ideally, therapy is working from the moment you talk with a therapist. However, if “work” means “cure” or no more panic attacks, alas, I’m not sure we have a working definition for that. Instead, I encourage the adoption of a recovery mindset.

A recovery mindset is similar to a growth mindset. In a growth mindset, the focus is not on the outcomes of events but on the process of effort. An essential compliment to give yourself is “I’m getting better.” This emphasizes the continued progression of improvement rather than the destination of a cure. It’s unfair to expect yourself to stop working out and stay in the same physical shame, just like it’s unfair to expect yourself to stop growing your toolbox of coping skills and working toward recovery.

Here’s another example: waiting until I “feel motivated” is waiting for an outcome. Instead, I can focus on the amount of effort I can put toward “feeling motivated.” Is there a step I’m willing to take today despite not feeling motivated? 

Ask yourself, “What’s the purpose of these thoughts?” What’s the purpose of this question? Is there a length of time that would make it feel worthwhile? Is there a specific skill or insight you’re after?

In treating social anxiety, the goal is to develop more awareness of our relationship with ourselves, how we go about our lives, and eliminate barriers to recovery. I believe in you without knowing you. Begin counseling today and have an experiment on how long therapy takes to work.