(p. 13) Psychoeducation: Understanding the Nature of Social Anxiety and How to Manage It
(Corresponds to chapter 2 of the Client Workbook)
■ Review homework that was assigned in the previous session
■ Discuss the tripartite model of anxiety
■ Discuss the Downward Spiral of Anxiety
■ Discuss the components of treatment and their rationale
■ Assign homework
(p. 14) Homework
■ Have the client complete Worksheet 2.4 (Monitoring the Three Components of Social Anxiety).
■ Have the client complete Worksheet 2.5 (Worksheet for Reactions to Starting This Treatment Program).
■ Instruct the client to read chapter 3 of the Client Workbook.
■ Have the client complete Worksheet 3.1 (Where Did My Social Anxiety Come From?).
Overview and Appropriate Therapist Style
Chapter 2 in the Client Workbook helps clients understand more about their own anxiety in the context of the cognitive–behavioral model. The chapter closes with a detailed discussion of the three components of treatment that will directly address social anxiety. Homework involves monitoring the three components of anxiety and an assessment of the client’s reactions to the treatment rationale and treatment components. As is true of all of the psychoeducational material, the session should be highly interactive, with both the client and you playing active roles. When you facilitate the client’s sharing of her own experience in the context of the session structure, it further builds the therapeutic alliance.
Much of the session is devoted to explaining the tripartite model of anxiety—physiological arousal, behavioral disruption and avoidance, and distorted cognition. The interaction of these three components underlies the cognitive–behavioral therapy (CBT) model for this treatment. Therefore, it is essential to spend some time developing the ideas with clients and applying them to their own experience. As clients become more sophisticated about the different aspects of their anxiety, the experience of anxiety becomes less mysterious and will be perceived as potentially more manageable. The material in this chapter begins laying the groundwork for cognition as the precipitating event in a downward spiral and for avoidance as key in maintaining the problem. These (p. 15) concepts are important for helping the client understand the rationale for the primary components of treatment (i.e., cognitive restructuring and exposure both in and out of session) presented further in the chapter.
The Tripartite Model of Anxiety
One goal of this chapter is to develop a common language to understand anxiety. We have found it helpful to spend some time on each of the three components of anxiety to ensure that the client understands each component before moving on to their interaction. Chapter 2 of the Client Workbook includes several worksheets to aid clients in identifying experiences often reported by individuals with social anxiety disorder. A recent anxiety-provoking situation can be elicited to help clients identify their physiological responses and cognitions. It is often useful to consider a broader range of situations to help the client understand the pervasive effects that overt and subtle avoidance behaviors may have on their lives. It is important to write down on an easel or whiteboard the examples generated for each of the components of social anxiety so that you and the client can view them together during the session.
The Cognitive–Behavioral Model—The Downward Spiral
Chapter 2 of the Client Workbook presents the basic CBT model in the discussion of the Downward Spiral of Anxiety. The chapter includes a vignette of Cathy, who fears asking for a promised raise. Using either this vignette or another one, it is very important to lead the client through the interaction of the three components, starting with an initial automatic thought (AT) that sets the tone. For example, Cathy starts with the following: “Something must be wrong with my work or they would have given me a raise.” The working model assumes the primacy of cognition. Although there is evidence that affect can occur prior to or without apparent cognition under certain conditions (e.g., Izard, 1992), for the purposes of this treatment, all anxiety is considered to start with an AT. In addition to the primacy of cognition, the second key concept to communicate is that avoidance has several negative consequences. Throughout the discussion, it is important to highlight the short- and (p. 16) long-term consequences of behavioral avoidance. Clients usually recognize that avoidance leads to an immediate decrement in anxiety, but initial relief is followed by negative affect, including shame, frustration, and disappointment. For socially anxious individuals to stop avoiding feared situations, they must understand that the anxiety will eventually become manageable, that it is highly unlikely that their worst fears will come true, and even if the worst were to happen, they will be able to carry on.
Therapists often find the graph in Figure 2.A helpful in the discussion of the reinforcing nature of avoidance. We draw the graph on our whiteboard, walking the client through step by step, typically using a recent experience that she has shared. We start by explaining how the graph works, drawing the x and y axes and labeling them. Then we draw the line indicating what individuals with social anxiety expect their anxiety to do if they do not avoid: continually increase, as indicated by the line ending in the upward arrow. We draw then the second example that depicts escape or avoidance, with the vertical line indicating when avoidance occurs. Clients easily identify with the idea that their anxiety would decrease rapidly at that point. Finally, we draw the third line on the graph, indicating that anxiety increases and then decreases, and present this as the normal course of anxiety as the body regulates itself (p. 17) to not experience excessive fear in the absence of actual physical threat. One of the biggest problems with avoidance is that clients never find out that their anxiety will eventually decrease. Many clients find this visual depiction compelling, and it can serve as a useful cue to avoid avoidance later in treatment. For many clients, it is a turning point in treatment once they have the personal experience that their anxiety increases then decreases in a predictable fashion.
Some clients, of course, do not show the expected decrease in anxiety within a situation over time or, at this early point in treatment, find it hard to believe that they ever will. It is often useful to present another graph for discussion, focusing on the idea that anxiety may not decrease within a single exposure to a feared situation, but it may decrease across successive and repeated exposures to that same situation. A graph demonstrating this idea is presented in Figure 2.B. The discussion of this figure provides an opportunity to emphasize the idea that even if anxiety does not decline or subside within a situation, it is important to remain in the situation because doing so may both facilitate eventual anxiety reduction and increase the chances that the client can behave in a way consistent with her values and goals.
(p. 18) Presenting the Components of Treatment
Once the client understands how the three components of anxiety interact to create a downward spiral of anxiety, it is important to carefully describe how the components of treatment (systematic graduated exposure, cognitive restructuring, and homework) interrupt this cycle. This discussion requires a careful balance of informing the client about the nature of exposures, yet not making her so anxious that avoidance of treatment becomes a problem. We usually share our slogan “Invest anxiety in a calmer future” to emphasize the fact that facing one’s fears may create anxiety, but there is a positive long-term payoff. The notion that one must face her fears to overcome them is familiar to most people and part of our folk wisdom. You can draw on the client’s likely agreement with this principle while emphasizing that exposures are done very systematically. It is essential to make these three points:
1. Exposures will not start right away. There are at least four other sessions (and typically more) that must happen first.
2. Exposures are graduated, starting with easier ones and working up to the harder situations as the client builds her confidence with success.
3. Exposures occur only after the client develops some skills to cope with anxiety (e.g., cognitive restructuring skills).
The Client Workbook includes an analogy of learning to swim that we have often used for presenting the rationale for graduated exposure. A person can learn to swim by repeatedly jumping into the deep end of the pool and struggling to the side. After swallowing a lot of water and being repeatedly frightened, the person will likely learn to swim. On the other hand, one can learn to swim by starting gradually in the shallow end of the pool. First, the person gets used to being in the water and then may practice putting her face in the water. As the person gets more comfortable, she can begin to float and later paddle around. Although the person is likely to be somewhat anxious jumping into the deep end of the pool the first time, she will be able to depend on the skills already learned and jump in with greater confidence. Both methods result in learning to swim. The graduated method may be a little slower, but it is definitely less painful.
(p. 19) The description of cognitive restructuring need not be very elaborate or cover all of Beckian theory. If you have pointed out the thoughts the client has in anxiety-provoking situations and fully developed the model, then the client should readily accept that thoughts are an important part of her anxiety. Cognitive restructuring can then be described as learning a series of steps to look at those thoughts and see how helpful or realistic they truly are.
As with cognitive restructuring, the description of homework can be fairly succinct. Clients appreciate that they must learn to overcome their fears in their daily lives, not just within the therapy session. In fact, some are relieved that there is specific attention to transferring therapeutic gains to their lives outside of therapy. As with the discussion of exposure, it is important to emphasize that they will not be asked to face highly feared situations immediately.
Linking the three components—graduated exposure, cognitive restructuring, and homework—to the symptoms the client experiences via the CBT model is the final point in building the rationale for therapy. For example, as the therapist, you will make sure that the client understands that cognitive restructuring targets anxiety-provoking thoughts directly, targets physiological arousal by decreasing perceptions of danger, and targets the behavioral component by freeing up more attention for the social task at hand and decreasing avoidance. It is also important that the client understands that exposures help her to practice the behaviors needed in feared social situations and allow for a test of negative predictions about the feared social situation so that faulty beliefs may be corrected, and that, as she repeatedly enters anxiety-evoking situations and stays in a situation for longer periods of time, anxiety should become more manageable.
Frank and Frank (1991) listed a shared rationale as one of the fundamental components of psychotherapy. The client and the therapist now have a common language to discuss social anxiety. As with all good rationales, this one points to a set of procedures or treatment techniques that are required to overcome the problem. These techniques, or the ritual in the Franks’ language, are another fundamental component of psychotherapy. Because of the importance of agreement on the rationale and ritual, chapter 2 in the Client Workbook ends with an assessment of (p. 20) the client’s agreement (see Worksheet 2.5) based on Borkovec and Nau’s (1972) measure of treatment credibility. This is typically done at home and then reviewed in the subsequent session. Processing of the responses is described in chapter 3 of this Therapist Guide.
Worksheets and Homework
Throughout chapter 2 of the Client Workbook, there are worksheets that allow the client to record her symptoms. If the client is reading the chapter before the session, this recording can initially be done at home and then reviewed and expanded in the session. If the client is reading after the session, then the discussion can orient around filling in the worksheets after initial presentation of the concepts. In either event, the client should complete Worksheet 2.4 (Monitoring the Three Components of Social Anxiety) and Worksheet 2.5 (Worksheet for Reactions to Starting This Treatment Program) outside of session. This approach allows an extra opportunity for the client to think about and apply the concepts discussed in session without the therapist’s guidance. This homework is then reviewed during the subsequent session as a check of the client’s understanding of the material.
Common Issues That Arise
Physiological symptoms are the defining experience of anxiety for many socially anxious individuals. Symptoms often occur in anticipation of an anxiety-provoking event, during the event, or, less commonly, after the event is over. Many clients focus on only one or two symptoms. Occasionally, a client’s entire presentation of social anxiety revolves around the belief that a specific symptom, such as blushing or sweating, is visible to others, with disastrous consequences.
In contrast to the physiological symptoms, some socially anxious individuals are often much less aware of their anxious cognitions. Often it seems that the thoughts are so ingrained that they are experienced as facts. For example, “I made a fool of myself” is not considered a thought by the client (e.g., “I was thinking that I had made a fool of myself”). Rather, it is reported as an aspect of the event (e.g., “That was the time (p. 21) I made a fool out of myself”). The best strategy is not to argue at this point whether a statement is accurate or not. Rather, you can just identify potential thoughts in the client’s narrative of a situation and record those on the board.
It is very helpful if you begin to shape the client’s reporting of ATs by recording the thoughts in a format that will be useful later for cognitive restructuring. In the preceding example, the therapist would write “I made a fool out of myself” on the board and verbally note that this is what the client was thinking about the situation. Similarly, questions should be rephrased in statement form. Statements better represent what it is that the client is afraid of and are easier to work with than questions in cognitive restructuring. For example, the client might report saying to herself, “What does she think of me?” The therapist should encourage the client to talk about the answers to that question that would be anxiety provoking by asking, “What are you afraid she might be thinking of you?” “For this situation to be anxiety-provoking, you probably aren’t focusing on all of the good things she might be thinking of you. What are some negative things you are concerned that she might be thinking?”
Occasionally, socially anxious individuals will have very little awareness of their thoughts. Sometimes they can describe images of feared outcomes that can be translated into thoughts. Most of these individuals can become more aware of their thoughts through repeated self-monitoring in feared situations. At this point, just encourage continued effort. We will discuss further what to do if the cognitive aspects of the anxiety continue to be vague during cognitive restructuring.
Behavioral avoidance of feared situations is a hallmark of social anxiety disorder, but occasionally individuals will endure even the most anxiety-provoking situation without avoiding or escaping. Sometimes, these clients have little behavioral disruption as well. It can be acknowledged that the behavioral component does not play a major role in their presentation of social anxiety. If they are still anxious despite continually facing their feared situations, then it is likely that they are engaging in significant discounting of success. It is worth noting that clients who initially claim that they do not avoid anxiety-provoking situations do, in fact, avoid aspects of the situation. For example, if someone does not avoid parties, she may talk only with certain people, wear certain clothing that is unlikely to reveal anxiety symptoms (e.g., avoid sheer (p. 22) blouses that may reveal perspiration), or discuss only certain “safe” topics.
Such avoidance within social situations can also include “safety behaviors,” which have been discussed at length by David M. Clark and Adrian Wells (e.g., Clark, 2001; Clark & Wells, 1995; see review by Piccirillo, Dryman, & Heimberg, 2016). When confronting feared social situations, clients may adopt certain strategies intended to decrease the likelihood of showing anxiety symptoms or behaving in an unappealing way. The client hopes that these strategies, the safety behaviors, will help her avoid disastrous social consequences. For example, the client who is afraid of her legs trembling during a speech may attempt to tense and lock her leg muscles to keep this feared event from happening. A client who is afraid of inadvertently asking a question that is too personal might never ask other people about themselves during conversations. Safety behaviors have a number of unfortunate consequences. Like any avoidance behaviors, they interfere with effective exposure in that what is feared is not fully confronted, interfering with new learning. Safety behaviors also tend to increase the likelihood that what is feared will, in fact, happen. Tensing and locking one’s leg muscles may result in muscles straining and shaking. Never asking people about themselves during conversations may result in appearing socially unskilled. Therefore, especially for individuals who deny overt avoidance, careful questioning regarding safety behaviors is warranted.
During the explanation of the treatment rationale, sometimes clients will respond to the exposure aspect of treatment by protesting that they have tried to face their fears in the past, and it has only made them more anxious. It is important to inquire about and listen carefully to what clients have tried before responding. Typically your response will be that the exposures must be done in a certain way to be helpful. Usually the client’s “exposures” were too infrequent or too difficult or the person escaped when the anxiety became intolerable. In some cases, very reasonable self-paced exposures have been undermined by cognitive distortions, such as finding reasons to disqualify successful outcomes. Although clients may not fully appreciate how treatment exposures will be different from their own bad experiences, they only need to agree to withhold judgment until they have tried them. There are very strong data that exposure is an effective treatment for social anxiety (p. 23) (Feske & Chambless, 1995; Gould, Buckminster, Pollack, Otto, & Yap, 1997; Powers, Sigmarsson, & Emmelkamp, 2008). Regardless of what the person has tried before on her own, you can state with confidence that these procedures are worth pursuing as they are very likely to be helpful.
When to Use Generic Examples Versus the Client’s Actual Experience
Over the years of group and individual CBT for social anxiety, we have developed a rule of thumb that it is usually best to first cover concepts with a generic example and then apply it to the client’s own experience. This strategy has two advantages. First, anxiety interferes with processing information. Socially anxious individuals are more likely to understand concepts as applied to others because discussing themselves evokes greater anxiety. Second, given socially anxious individuals’ fear of negative evaluation, they may be quite ashamed when sharing their anxiety experiences or ATs. Starting with more impersonal examples facilitates learning and makes the process less threatening.
There are examples in the Client Workbook to use for the generic cases so you can present the three-component model and the downward spiral. Therapists occasionally draw from their own experience as well. In the original group manual for cognitive–behavioral group therapy (CBGT), one therapist shared about anxiety (which included physiological, behavioral, and cognitive symptoms) in anticipation of a conference presentation. By having the therapist describe how her own anxiety began to spiral out of control, the client can see the therapist as a coping model. This can proceed without excessive self-disclosure and provides another example of how social anxiety is part of normal experience. Alternatively, a hypothetical example may be used. For example, in CBGT (Heimberg & Becker, 2002), clients work through an example in which they are asked to imagine a situation in which a person is in the lobby waiting to interview for a very desirable job. They are also asked to imagine that the person is feeling anxious and to consider what may be happening with that person in terms of physiological arousal (e.g., sweaty palms); thoughts (e.g., “She’s going to know how anxious I am when she shakes my hand”); and behaviors (e.g., wiping one’s palms on one’s suit). (p. 24)