Tag Archives: social anxiety

A cognitive behavioral understanding of social anxiety disorder

By Brad Imhoff August 8, 2022

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“Don’t let anxiety drive the car,” I learned to tell myself.

I was standing in the hallway of the hotel’s conference center where our state counseling association was hosting its annual conference. I had co-presented with my professors at the conference a handful of times before, but I viewed them as experts who could handle anything that came up during our presentation. There was comfort in that. 

Now here I was as a doctoral student about to present a 60-minute session as lead presenter for the first time. The anxiety I had tried fending off for the past several hours (and, let’s be honest, past several days) rushed over me like a tidal wave as I looked at my watch and saw the presentation was scheduled to start in 15 minutes.

My stomach was in knots, my hands were ice cold (yet sweaty), and my thought process went something like this: “They all know so much more than I do; what am I doing here? They’ll see I’m a fraud and don’t belong. What if I run out of things to talk about? What if they ask questions and I have no answers? Great, now I’m sweating. They’re going to see I’m sweating and know I’m nervous. The sweat is fogging up my glasses and now I can barely read my notes. Do I have enough notes? What if I run out of material and have nothing to say after 20 minutes? How embarrassing. They’re going to judge me. Why am I doing this?”

Anxiety was absolutely driving the car.

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Social anxiety disorder

As its name implies, social anxiety disorder can be understood as an intense fear of, and overwhelming distress in, social situations. Situations that involve scrutiny, being observed, and real or perceived evaluation create extreme discomfort and dread for individuals with social anxiety. Common examples that trigger social anxiety for these individuals include speaking or performing in front of others, interacting with unfamiliar people, dating, being interviewed, initiating conversation and being at the center of attention. The underlying concerns are largely centered on judgment, negative evaluation and the potential for embarrassment. There is a persistent worry about appearing inadequate, humiliating oneself or being evaluated as awkward, boring, weird or any number of other negative descriptors.

As if the discomfort associated with social situations were not enough, social anxiety disorder also involves a fear of exhibiting anxiety symptoms. There is anxiety about being anxious. People who are overly anxious often sweat, blush, tremble or stumble over their words and fear that others will notice this and judge them for it. They may have racing thoughts, a quickened heartbeat, muscle tension or a dry throat, all of which can impede functioning at their best. When this happens, they become hyperaware of their internal experience and focus less on the task at hand and what is going on externally.

Take, for example, someone who is on a first date or someone interviewing for a job. They might have sweaty palms from feeling anxious and then be consumed by worry about having to shake hands. Rather than mentally preparing for a positive greeting or being excited about an introduction, the person might ruminate on the thought, “If I shake hands, they’ll feel the sweat and think I’m gross, but if I don’t shake hands, they’ll think I’m awkward.” This creates the sense of a no-win situation that might lead a person to avoid such situations altogether. 

Another example is a young student who raises her hand to participate in class and feels her face getting warm as she begins blushing. She is rehearsing in her mind what she wants to say but now turns her attention to the anxiety symptoms she is experiencing — worried that others might notice them too. Her embarrassment intensifies and her fears are actualized as her peers giggle and comment on how red she is turning. Not only does she feel anxious about speaking up, but it is confirmed to her that her anxiety symptoms are on full display for others to see and judge. She decides it is safer to just not raise her hand in the future.

Many readers can relate to these scenarios because most people experience anxiety in some social situations. It would be rare to go on a first date, present in front of an audience or go into a job interview without feeling some level of anxiety. With social anxiety disorder, however, the anxiety is excessive and out of proportion to the situation. Furthermore, the anxiety creates extreme distress or impairment. That is, it gets in the way of typical functioning. 

Individuals are very likely to use avoidance behavior to not have to engage in social situations or they may tend to escape situations once in them (e.g., leaving a social gathering shortly after arriving). Social situations feel as if they are being endured and survived as opposed to enjoyed. This can create various challenges related to employment, educational opportunities and relationships. When anxiety gets in the way of life in this way, treatment with a professional is warranted.

When considering the treatment of social anxiety disorder, I tend to conceptualize it as a three-pronged approach that involves understanding the disorder, learning to accept and value oneself, and reconstructing the reality clients have built for themselves. The latter two processes are very much intertwined, and all three are fluid and ongoing as clients learn about their anxiety, discover new ways of thinking about themselves and begin to engage the word differently. As they do all of this, they are practicing new skills with an aim toward interacting and functioning more effectively in their daily lives.

Understanding the disorder

Understanding social anxiety disorder begins with psychoeducation. This process is very reciprocal, however, because counselors learn from clients too. Clients who struggle with social anxiety are well aware of the discomfort associated with it, having experienced it daily for much of their lives. Still, counselors can work through the features, symptoms and diagnostic criteria with them to help put a name and label to their experiences. 

While this is being done, clients are asked to share how the various features of the disorder have played a role in their lives. This becomes a parallel process of educating clients on the ins and outs of social anxiety disorder while they educate counselors on their individualized experience with it. This joint effort builds rapport and trust and sets the tone for a collaborative partnership throughout treatment. It also helps normalize the challenges clients have encountered due to their anxiety, puts a name to what they have experienced and may help them feel less alone in the struggle.

According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the onset of social anxiety disorder occurs most often between the ages of 8 and 15, and people go an average of 15-20 years experiencing symptoms before receiving treatment. This means clients have likely avoided and missed out on many opportunities going back well into childhood. 

The counselor should explore these opportunities. Doing so can be beneficial for several reasons. First, it gives a clearer understanding of the disorder’s role throughout clients’ lives and how it has affected their quality of life. Second, it offers insight into the areas each individual client may struggle with most — at work, in school, initiating friendships, building intimate relationships and so on. Finally, the historical challenges and missed opportunities can provide motivation for truly engaging the therapeutic process now. Building this motivation can be especially important when it comes to the gold standard for anxiety treatment — exposure (discussed later in the article). 

I like for clients to consider this question: “In light of all the missed opportunities you have described, I wonder what life will be like moving forward if anxiety continues to lead the way?” With an eye toward collaboration, motivation and building hope, the counselor may follow up with, “I want to help you take back control from this anxiety.”

When anxiety leads the way and controls our behavior, it becomes problematic. It creates impairment. Anxiety itself, however, is actually healthy and helpful. Being anxious about an important exam motivates us to study for it. Having anxiety about an upcoming business presentation focuses our preparation and encourages us to give it due attention. Feeling anxious about an upcoming networking opportunity might indicate that we value relationships and view social connection as important. 

Part of educating clients is helping them understand the benefits of anxiety and learning to distinguish helpful anxiety from the excessive anxiety they experience. The former motivates us and helps us prepare, whereas the latter paralyzes us into inaction.

Don’t let anxiety drive the car

Back to the opening story. The anxiety had stopped being helpful long before my presentation began. It was excessive and paralyzing at times. When I was anxiously preparing to begin a conference presentation, I would start implementing a handful of interventions to try to get rid of the anxiety. I would quickly run through them, expecting one to be the magic pill that would make me feel better. It was not a helpful way to view anxiety, and when none of the interventions made it disappear altogether, I was left feeling even more anxious. I had a combative relationship with the anxiety; it was overwhelming me, and I was fighting as hard as I could to make it go away. Only when I accepted that it was going to be there did I experience some level of freedom from it.

“Don’t let anxiety drive the car” was the phrase and visual that came to my mind. It became my imagery for managing anxiety. Anxiety was coming along for the ride — there was no doubt about that — but it did not have to be all-consuming and control where we went, whether we went at all or how we got there. 

Instead of creating an inner conflict that I was battling and trying to overcome, I began to externalize the anxiety and invite it along. I had a mental image of me sitting in the driver’s seat and opening the passenger door to welcome it. Essentially, I was saying, “I know you’re going to be there, so get in and let’s go.”

Externalizing the anxiety and inviting it along meant that I was no longer fighting against it and consistently losing. Rather than fearing the symptoms and engaging the racing thoughts, I could simply acknowledge them, accept that they would be there and make the decision to continue forward anyway. To keep things light and in perspective, I might even say to the anxiety, “It sure would be nice to just put you in the trunk.” For some anxiety-inducing situations, that can be a good way to monitor its severity. Is it tucked away in the trunk and mostly out of mind? Is it in the back seat just riding along? Or is it sitting in the passenger’s seat trying to grab the wheel and take control? 

Once we understand that anxiety is not something that is going to disappear, we can turn our attention to navigating our lives despite its presence. We can learn how to lessen its impact and manage it when it becomes excessive and unhelpful.

Acceptance of oneself

If I think poorly of myself, it naturally follows that I will expect others to think poorly of me too. How could I expect others to view me in high regard if I do not see myself that way in the first place? This is important because social anxiety is largely focused on how we think others perceive us, which leads to the presence of anxiety when around others.

Therefore, the second prong to the treatment approach is to help clients better accept and value themselves. Counselors can explore with clients their natural dispositions and work with them to understand and value their individual strengths and personalities. People with social anxiety may long to be extroverts or overvalue outgoing personalities, despite themselves being quiet observers who are rejuvenated by alone time and drained by social interaction. It is important to recognize these tendencies, not only to manage client expectations but also to highlight the value of these tendencies and reframe them. A client who puts herself down for being too reserved may learn to recognize how this plays a role in her being such a good listener with her friends. A client who longs to be more outgoing may learn to recognize how his quieter demeanor has made him more observant and intuitive.

It is also possible that social skill development is necessary for some clients. Areas may exist in which clients can improve their role in social interactions. Those who have social anxiety have spent years avoiding social situations and have not practiced and honed their skills in the way that others who are more socially comfortable have. Take, for example, a child who plays a sport or musical instrument. If this child shows up to practice two days each week while all the other children practice five days per week, those who have practiced more will have developed better skills. Similarly, an individual who has not had much practice in social situations may need to develop and practice skills that have not regularly been used. The counseling relationship is an opportunity for clients to become more competent with initiating conversation, recognizing social cues, speaking clearly, making eye contact, practicing how to show interest in others through prompts and questions, and any number of other social skills. With improvement of skills and competency comes more confidence.

Self-esteem activities are another useful tool in the process of helping clients accept and value themselves. One that I particularly like is having clients consider five different aspects of themselves: physical, spiritual, emotional, intellectual and social. Clients are asked to identify personal characteristics within each area that they value and appreciate in addition to identifying some areas for growth. Using this approach makes the abstract concept of self-esteem more concrete and can help clients create a more balanced and holistic view of themselves. As counselors observe this process, they can also keep an ear out for particularly negative language or self-talk.

Reconstruction of reality

Throughout the steps noted in the previous sections, clients are beginning to understand themselves better and view themselves differently. The third prong to treatment — helping clients reconstruct their reality — continues this effort. Here, clients really begin to explore their self-talk and maladaptive behaviors. 

This process is easier said than done. Clients often come to us with low self-esteem, and there is no switch to flip to instantly have them think better about themselves. To emphasize it as an ongoing process, counselors can present it as “chipping away” at old ways of thinking and starting to entertain new ones.

Negative self-talk: One of the first steps in this process is exploring our clients’ negative self-talk and inner critic. This is that voice in our mind that continually criticizes us for not being good enough. It is hard to develop a healthy sense of self with such a critic living within. 

To emphasize the importance of healthier self-talk, counselors might pose the following scenario to a client: “I want you to think about the person you love most in this world. It could be your child, your partner, your niece or nephew, or any person you just absolutely love. Now, tell me how that person would develop mentally and emotionally if you talked to them the same way you talk to yourself.” 

Often, this becomes a rhetorical question that, in my experience, generates tears for many people. They recognize that they would never talk so harshly and critically to someone they love, and they recognize their loved one would not develop into a healthy, confident, high-functioning person if they did. This helps make clear the connection between our self-talk and our self-esteem. If we want to be healthy and confident, it is helpful to talk to ourselves in a way that promotes that. 

Again, this does not mean our clients will flip a switch and miraculously begin thinking only in helpful and healthy ways, but it does lay a foundation for monitoring their thought processes; identifying negative, unhelpful self-talk; and beginning to choose kinder ways of speaking to themselves.

Monitoring negative self-talk becomes another collaborative process. Counselors can prompt discussion by simply asking about it (“What were you telling yourself in that moment?”) and by pointing it out in the present (“I am hearing a lot of negative self-talk as you discuss this. Can we pause to look at that?”). This process teaches clients how to train their own ears to catch it as well. They can begin to monitor their self-talk outside of the counseling office and use interventions such as thought records that they write down and bring back to session. When reviewing such records, counselors can help clients brainstorm new thoughts to interject as healthier ways of thinking. Over time, this practice can give rise to clients monitoring and replacing negative self-talk in real time on their own.

Core beliefs: To further enhance the treatment process, counselors would do well to connect their clients’ thoughts to the idea of core beliefs. Core beliefs are those that develop early in life and become deeply held, foundational views of ourselves, others and the world in general. These tend to take the shape of absolute statements such as “I am _____” or “The world is _____.” Everyone has both positive and negative core beliefs, but the negative beliefs tend to be more prominent, especially for people experiencing enough distress in life to seek counseling.

Early childhood interactions, especially with caregivers, play a significant role in the development of these beliefs. Take, for example, a client who as a child was told by her parents that she was always in the way, she was a “mistake baby,” and they wished they had never had a kid. A profoundly negative message such as this is repeated in various ways throughout the client’s life, so she develops the belief that “I am worthless and unlovable.” One can imagine the implication of this belief on her thoughts and how it interferes with developing healthy relationships throughout life. A second example might be a client who experienced significant traumas early in life and develops a belief that “the world is unsafe and dangerous” or “people are manipulative and untrustworthy.”

Clients are generally not going to walk into the counseling office and tell us their core beliefs. They are usually unaware of this concept, and their beliefs operate more implicitly. Clients’ thought processes and self-talk very much lend insight into what their beliefs may be, however. As we listen to clients share stories about their day-to-day lives, recall memories from their past and especially make “I” statements, we can hear how their language is shaped by core beliefs about being unlovable, incapable, inadequate and so on.

I like to think of core beliefs as root systems. Any flowering plant needs a healthy root system to produce healthy flowers or fruits. An unhealthy root system will lead to unhealthy plants. Similarly, a client’s negative core beliefs will naturally result in negative thought processes. So I want to help my clients reevaluate their root systems, or core beliefs, to establish a healthier foundation that can give life to healthier thoughts about themselves and the world around them.

When working with clients on restructuring how they perceive themselves and others, we cannot expect an immediate switch from negativity to positivity. They have spent their entire lives with these negative core beliefs as a foundation and, once made aware of them, can often provide significant evidence as to why they think their beliefs are true. Our job is to help clients chip away at those unhelpful core beliefs and begin to find a healthier balance. 

We can do so by helping them discover alternative ways of thinking about themselves and then intentionally looking for evidence to support those newer, healthier ways of thinking. This evidence might come from a reinterpretation of past experiences or be found by intentionally looking for it moving forward. For example, a compliment from one’s boss may no longer be shrugged off as obligatory and undeserved, but instead lead to ownership of a job well done — thinking to oneself, “I did do good work on that project. I’m glad it was recognized.” The new evidence and ways of thinking begin to plant the seed of a new core belief of “I am capable” or “I am enough.”

Exposure: The previously discussed interventions for helping clients view themselves differently build motivation and courage for what comes next — exposure. Exposure is generally considered the gold standard for anxiety treatment, which often comes as bad news for those who experience anxiety. It can be hard to hear that engaging in the very situations that create anxiety is ultimately the best way to reduce that anxiety. Avoidance feels safer in the short term, but it impedes us in the long term. 

The inconvenience of this reality is why I like to start treatment with understanding the disorder and developing a better acceptance and valuing of oneself. As we do these things and establish a strong counselor-client relationship, clients grow more willing to expose themselves to situations that require a lot of bravery.

Exposure therapy does not mean identifying what causes our clients the most anxiety and having them jump right in. On the contrary, it is a process of identifying situations that cause varying levels of anxiety and working through them systematically. We can help our clients create a list of situations that create anxiety for them and rate them on a 1-to-10 scale. At the bottom of the list (1) is something that evokes mild anxiety symptoms; at the top (10) is a situation that causes significant anxiety. 

These lists are extremely individualized, but examples may include waving to and saying hello to a neighbor across the road as a lower anxiety situation and attending a networking event where the client doesn’t know anyone as a higher anxiety situation. Between the two are many situations that induce increasing levels of anxiety that can be worked through one at a time, from least frightening to most frightening.

Clients work through the list systematically with the support of the counselor. It may begin with simply visualizing the scenario together in the counseling session and thinking through how it might go, discussing what clients feel as they think about it, and talking about how to best approach the real scenario outside of the counseling office. This imaginal exposure can introduce clients to the process, allowing them to first navigate it from a distance and deal with some of the feelings associated with it prior to engaging the real scenario. 

The idea behind exposure is that clients learn to engage situations that make them uncomfortable as opposed to continuing patterns of avoidance behavior. As they do so, they build a tolerance for discomfort and learn to take control of the anxiety, moving forward even with it present. Successfully engaging situations will help develop a sense of accomplishment and self-efficacy that motivates them to continue working toward more challenging situations. 

Clients will also notice a reduction in anxiety symptoms if they engage situations many times before moving on to a more challenging one. Clients do not need to feel 100% comfortable and confident before engaging the scenarios or moving on to the next one, however. They may need to learn that the anxiety will sometimes come along for the ride. Clients just need to make sure it isn’t driving the car.

 

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Brad Imhoff earned his doctorate in counselor education from Ohio University and currently serves as the director of the online Master of Arts in addiction counseling program at Liberty University. His scholarly interests include the understanding and treatment of social anxiety disorder, substance and behavioral addictions, and counselor well-being and self-care. Contact him at bimhoff@liberty.edu.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Online role-playing games as group therapy during the COVID-19 pandemic

By Per Eisenman and Ally Bernstein February 18, 2021

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During the challenging era of COVID-19, many young people are experiencing the sort of isolation that can interfere with healthy social development. This may be particularly true for young people who were already wrestling with significant mental health challenges before the pandemic. Telehealth group therapy that utilizes role-playing games offers a hopeful modality for facilitating individual growth in a group context.

Setting the stage

When one of us logs in to the Zoom session 10 minutes early, a picture of a cat immediately pops up. Martin has been waiting all morning for the group to start. He appears briefly and shows us his cat, Betty, sitting on his lap, before turning the video off so that only the photo of Betty is visible.

Gradually, everyone else joins and our game begins. Martin is committed to the group; he has never missed a session and is always early. In Dungeons and Dragons and other role-playing games, group members play fantastic adventurers, working together to overcome obstacles and gain rewards. The facilitator narrates a story, and the group members describe how their characters respond.

Martin plays an elf wizard named Sylvan who has a cat (also named Betty) as his magical animal companion. Martin was initially a bit shy but has integrated into the group and participates in collaborative decisions; he also loves to talk about Sylvan’s cat and backstory. Martin joined the group after the COVID-19 stay-at-home order in the spring of 2020, once we moved to a virtual environment. As is the case with some others in the group, this is Martin’s only social contact outside his family.

The therapeutic group allows for a structured social interaction — a place where people can connect, practice social skills, and modulate their inner and outer worlds. Many of the young people we work with experience social anxiety, depression or social skill deficits. The experience of a safe social setting where they can experiment with becoming someone else allows them to develop connections that can be both an antidote to loneliness and an opportunity for growth.

The COVID-19 pandemic has been a time of isolation. Young people especially are having fewer opportunities to develop socially, and schools are not able to provide as many opportunities for social contact. Telehealth group therapy using role-playing games creates opportunities for social connection and resiliency-building that may not be possible in person during the pandemic.

Collaborative creativity

Role-playing games hold a place in the pop-culture imagination as a niche interest, but their popularity has increased in recent years, and therapists have started implementing the games more widely as a group therapy modality for older children and adolescents. In role-playing games, one facilitator describes an imaginary world, and the participants (playing characters) describe their actions in that world. Sometimes success and failure are based on dice rolls, but players’ creativity and collaboration are also key in helping a group achieve its goals within the world. The game has many decision points, and each player can change the course of the story.

Martin’s character, Sylvan, has blasted open treasure chests with fireballs, duped goblins by pretending to be their grandmother, and hatched a dragon egg. Martin’s creativity influenced the world for himself and the other players, creating a new set of circumstances and changing the direction of the story.

During the game, the facilitator sets the stage: “You enter the pirate’s cavern. As you go in, you see a couple of pirates standing guard.”

The group members discuss how they would like to respond. Should they fight the pirates or try to sneak past them?

“Let’s trick them,” Maya suggests enthusiastically. Maya is shy in real life, but in the game, she plays a tough brute who likes smashing down doors. Martin’s character is cunning and enjoys deception. He likes the idea, and they work together to come up with a ruse.

Martin’s character says, “We are poor pirates who have lost our way in the tunnels. Could you tell us the way to the ship?” He rolls the dice to see whether he can convince the pirate guards to let them pass.

Traditionally, role-playing games are played in person, sitting around a table with maps of the adventure setting, rolling dice, and telling the story together. However, it is possible to play the games remotely through videoconferencing and the use of online platforms. In recent years, remote role-playing game use has increased dramatically. The virtual medium confers new benefits during the COVID-19 pandemic and in an era of physical distancing. It translates surprisingly well to a telehealth group therapy experience. Martin, who struggles with social anxiety, told facilitators, “I like playing online better. I can turn off my video.”

Emergence of change

In the many groups we have run with colleagues, we have observed the emergence of group dynamics and group member interactions that have influenced the choices members make and their participation in the group. Some group dynamics become apparent through the group members’ interactions with one another or from the progress of the group over the course of many sessions. Other patterns emerge in the development of individual group members and the impact they have on the group.

We were particularly struck by the memory of Kendra, who had a very clear vision of how she wanted the game to proceed. She wanted to control the narrative so badly that she soon began frustrating the other players.

“Can I roll the dice to persuade Maya that she should give me her gold?” Kendra asked. She prioritized stealing gold or impressing pirates controlled by the game master over helping the other characters.

This led to frustration among the other group members. Some members began to go silent. One spoke out angrily against Kendra, suggesting the group members’ characters fight Kendra’s character. The frustration of the group turned into a discussion, and Kendra ended up changing her character’s behavior entirely, deciding that her character needed to work with the group and eventually save them, sacrificing herself for the greater good.

She said, “I want my character to help the group, but the shift has to make sense for her character arc. She can’t just change overnight.” We had numerous discussions about what it might mean for her character to develop.

We asked the other group members what they valued about the game, and another member said, “Working together as a team.” The emotional message felt palpable. We were thrilled that the adolescent participants were able to lead this discussion themselves and process as a group with only minimal prompting from the adult facilitators.

Role-playing games involve the players describing the actions of their characters, while the game master describes the rest of the world and the people who inhabit it. The world is imaginary, and visual aids are optional. In a therapeutic group, this system allows for group members to explore identity construction and navigate group dynamics. Therapy groups for teens support the essential task of identity development in the context of relationships with peers and adults.

Much like with any good therapeutic group, what happens within the context of the game often reflects the members’ lives out-of-game. When the game master is also a therapist, questions such as “How are you similar or different from your character?” and “Why did your character make that decision?” make the game a clinical experience. The avatar of the character allows each group member a safe distance through which to explore, process, experiment, fail and succeed.

Group process as an adventure

Role-playing games have long been an effective group therapeutic modality, but creating a shared imaginary world presents unique opportunities during the COVID-19 pandemic, when we are unable to safely convene in person.

Every age has different developmental tasks to achieve, and during the pandemic, these tasks have either been interrupted or have required us to make notable changes in how we carry them out. With schools shifting the way education is delivered because of the pandemic, the amount of social interaction has been significantly reduced. On the whole, we are spending more time isolated from others, and young people are having fewer opportunities to develop socially. Role-playing games, a high-interest activity, allow for social experiences to happen through telehealth in a way that might currently be impossible in person.

Role-playing games feature goals, conflict, choices and relationships. Young people can do something together by completing tasks that require creativity and teamwork. Playing every week creates routine and ritual. Having a group means that young people have regular contact with adults and peers outside their immediate family.

Games can be adapted for different age groups and needs. Children and adolescents can develop executive function and practice resiliency. The technology necessary to play the game online can malfunction and lead to frustration, allowing participants to practice patience and engage in troubleshooting. Also, because the games are fun and silly and joyful, the fantasy setting can provide everyone with a much-needed break from the stress and grief of the current world (or a way to process grief and loss, because characters can die too).

This innovative form of group telecounseling provides an opportunity to engage young people who might not otherwise actively participate in a group process. It also provides an opportunity to support the cultivation of interpersonal relationships with group members in serious need of social skill development. Right now, during the pandemic, if we want to offer something that simulates living and striving in close proximity to others, we can. These challenging times call for innovation. Therapy can become exactly what kids need: a safe but exciting place to be challenged to grow. In other words, an adventure.

 

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Related reading, from the CT archives: “The power of virtual group therapy during a time of quarantine”

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Per Eisenman (peisenman@csac-vt.org) and Ally Bernstein (abernstein@csac-vt.org) are community mental health counselors in the Youth and Family Services Program at the Counseling Services of Addison County in Middlebury, Vermont. They have been leading therapeutic groups for teenagers using role-playing games since 2015 and 2018, respectively. At the beginning of the COVID-19 pandemic, they transitioned these groups to telehealth.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Heading to college with social anxiety

By Bethany Bray July 31, 2019

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The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety.

The key is preparation, says Holly Scott, a licensed professional counselor whose Dallas private practice is a regional clinic of the National Social Anxiety Center. Counselors who are working with college-aged clients with social anxiety should talk through and create a plan for the client to navigate the many anxiety-provoking situations that may arise as they begin (or return to) school.

Try and anticipate daily challenges with the client, such as eating in the cafeteria with peers instead of taking food to go and eating it alone in their dorm room. Talk through healthy ways to negotiate shared space with a roommate who has a different lifestyle or sleeping schedule, Scott suggests. Help the client identify places on campus where they can study quietly as well as plan for ways to meet new friends, such as joining clubs on campus or finding volunteer or extracurricular activities.

“If I’m working with a client who is getting ready for college, we focus a lot on getting rid of avoidance behavior. People with social anxiety might rush back to their dorm room [after class] because it’s scary for them, which can lead to isolation … Their strongest coping skill is often avoidance,” Scott says.

Help the client identify what might be the most fearful experiences for them, and build a plan with healthy coping mechanisms and small goals they can work toward. Perhaps they’re anxious about the thought of having to share a bathroom and walk down the hall to take a shower. Talk that through with the client and get creative, Scott suggests. For someone with social anxiety, the best plan might be to schedule a daily shower in between classes during the day, when the dorms will be quieter.

“The first step is educating the client on what to expect at college. Some have a good idea but others don’t,” Scott says. “The more they can see what it will be like – what will their dorm room look like, where they will eat, what the classrooms look like – the better. Lower their level of uncertainty as best you can. Establish a daily plan. [Unmanaged] social anxiety can lead to depression so it’s good to equip clients with a routine.”

Scott recalls a college-aged client whose social anxiety would spike on weekends, when he didn’t have scheduled classes. She worked with him to set small goals and establish a plan for weekends, such as inviting someone to lunch or going to a sporting event on campus.

More than being shy, introverted or socially awkward, social anxiety is a diagnosable form of anxiety that is accompanied by a constant feeling of apprehension regarding social or performance situations and a fear of judgement from others.

Roughly 12% of U.S. adults will experience social anxiety disorder in their lifetime, according to the National Institute of Mental Health. In adolescents (ages 13-18), the lifetime prevalence is 9.1%.

In cases of severe social anxiety, a counselor can work with a college for special accommodations for the client, such as finding a single (unshared) dorm room, Scott notes.

While planning ahead for the college transition is important, it’s equally vital to ensure that clients with social anxiety continue to check in with a counselor throughout the semester, Scott says. It’s helpful for clients to debrief – and readjust, if needed – on the ways they’re managing their anxiety, as well as the goals they’ve set with a counselor.

If a client goes to college far from home, teletherapy or phone conversations with their existing counselor may be an option. But ideally, a client who needs regular sessions should find a local counselor to see while on campus, either at a college counseling center or in the community, Scott says. If granted permission by the client, a counselor can work in tandem with the client’s college counselor, sharing treatment plans and keeping in contact.

 

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Read more on living with social anxiety in Counseling Today’s August 2019 cover story, “More than simply shy.”

 

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Transitioning to college life: Tips for success

“Should I change my major?” “What should I do this weekend?” “Should I drop this class?” It’s easy to feel paralyzed by all the potential and possibilities that come with starting college. Decisions — even minor ones — often feel as if they will have an unchangeable and lasting impact on the direction your life will take.

If you’re feeling overwhelmed, know that you’re not alone. University counseling centers across the country are seeing an increase of students looking for support as they face the academic and social challenges college can bring, says Richard Tyler-Walker, president of the American College Counseling Association. Social anxiety, social isolation, interpersonal and self-esteem issues are some of the most common issues that bring students to college counseling centers, according to the Center for Collegiate Mental Health.

Setting small goals – and reaching out to your college counseling center for extra support – can help you find balance and manage anxiety as you start college, says Tyler-Walker, a licensed professional counselor supervisor and associate director of the College Counseling Center at North Carolina State University in Raleigh. He suggests the following:

  • Set realistic goals. A student who may not have had the social life they wished for in high school may view college as a fresh start or a “do-over.” College is a time to build new friendships and deepen existing ones. A person can set themselves up for success by setting goals that reflect who they are, not who they wish they were. It is unlikely that someone who is most comfortable with quiet conversation will feel content becoming the life of the party.
  • Build a network. Many students report feeling socially isolated at college. As you walk across crowded lawns and through noisy hallways on campus, it can feel like everyone else has all the friends they need. Reach out to acquaintances who are going to the same college. Start a conversation with your roommate before you arrive on campus. Get to know your resident advisor (RA), teaching assistants, academic advisor and other helpful personnel. Join a group for people with similar interests. Identify a cultural center on campus that interests you. Most colleges have centers for groups that include women, African American, LGBTQ and multicultural students.
  • Practice being friendly. Introduce yourself to a new person each day. Join clubs that focus on things of interest. Student involvement can help with getting a sense of the college or university and starting to build connections with others. Challenge yourself to go to meetings at least three times before deciding if it’s right for you. This will allow you to see the core group of people that attend and allows the members to become more familiar with you at the same time.
  • Embrace orientation. Orientation is staffed by student affairs professionals and trained students who focus on creating a welcoming environment for all new students. It’s a time to learn about the ins and outs of the system and make connections with others. Everyone is new to the college, so orientation is a great level playing field.
  • Pick a residence hall that suits you. “Where will I live?” It’s one of the first decisions a college student makes. Residence halls may be massive dormitories where there are shared rooms and bathrooms. In other cases, they’re set up with suite-style rooms or learning villages. Some students may enjoy the anonymity of a larger space while others may benefit from a smaller environment – especially where there might be common thread that connects. Learning villages at universities put students with common interests such as the arts, international studies, women in science, technology or other subjects together.
  • Find a space to breathe. Colleges and universities range from massive to virtually pocket-sized. Whatever the size of your school, look for a quiet corner where you can get away when you need to have some quality alone time. You might have done this by your choice of residence, such as a single room. For those whose living quarters are not a solitary refuge, every library, student union, green space and building on a college campus can have a nice spot for sanctuary if you keep your eyes open.
  • Reduce avoidance. No one likes the feeling of anxiety and we tend to avoid those situations that make us anxious. The more we do that, the more we create an endless loop of anxiety and avoidance. Your anxiety is trying to tell you that it is keeping you safe by not putting you into situations that will be scary. Once you put a name on fear it has much less power over you.
  • Practice, practice, practice. No one is a virtuoso the first time they pick up an instrument. It takes practice and skill. Don’t get caught up in whether [social skills] seem easier for others than for yourself. This is a challenge that you can welcome with the right attitude. Practicing these skills isn’t a matter of standing in front of a mirror, it’s about incorporating small moments of opportunity throughout the day. Practice smiling at others, saying hello, accepting a compliment, telling a joke or even flirting.
  • Ask for help if you need it. College counseling centers have trained staff that can help through counseling, either in group or individual formats. Counselors can build on the skills you’ve identified and help create harmony between your public and private selves.

Source: Richard Tyler-Walker, LPC-S, president of the American College Counseling Association, a division of the American Counseling Association.

 

 

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Bethany Bray is a senior writer for Counseling Today. Contact her at bbray@counseling.org

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

More than simply shy

By Bethany Bray July 29, 2019

4 Comments

Social anxiety is different from — and much more than — simply being shy or introverted or having poor social skills. Even so, people who live with social anxiety often find the disorder trivialized or minimized by others, including some mental health professionals, according to Robin Miller, a licensed professional counselor (LPC) and a member of the American Counseling Association.

“Shyness doesn’t necessarily have a negative impact on someone’s life. That’s an important thing to remember from a clinical point of view,” explains Miller, who specializes in working with adults with anxiety disorders at an outpatient practice just outside of Milwaukee. “Many of my clients get a pat on the head from people and [comments such as], ‘You’re just shy. You have nothing to worry about.’ But you wouldn’t get that for [symptoms of] posttraumatic stress disorder or other mental health issues. You wouldn’t say there’s nothing to worry about.”

Most of all, clients with social anxiety need support and reassurance as they try to discontinue old patterns and behaviors that they have adopted to cope with the paralyzing fear that often accompanies the disorder, says Brad Imhoff, an LPC who was diagnosed with social anxiety disorder in 2012 as he was working on his doctorate.

One characteristic of social anxiety is a constant feeling of apprehension regarding social situations. It is difficult to express just how oppressive and pervasive that feeling can be, says Imhoff, an assistant professor of counseling at Liberty University who lives in central Ohio and teaches in the university’s online program. “You carry this feeling of ‘I just can’t do this’ all the time,” he says. “As human beings, we’re social. And apprehension in every one of [those social situations] can be overwhelming.”

Imhoff, a member of ACA, says he recognizes the irony of his career choice: a person with social anxiety who speaks regularly to rooms full of people, both as a counselor educator and as a frequent presenter at conferences, including giving a session on social anxiety at the ACA 2019 Conference & Expo in New Orleans.

Imhoff has learned to navigate the challenges of social anxiety since his diagnosis, but he acknowledges still feeling anxious before speaking engagements. “The question is, how do I manage it and not let it get in the way of life?” he says. “I will have to manage this, to some extent, for my entire life and not let it get to the extremes it has in the past.”

Navigating life through avoidance

Social anxiety is one of a number of related issues — including specific phobia, panic disorder, separation anxiety disorder, generalized anxiety disorder and others — that fall under the anxiety heading in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

Called social phobia in decades past, social anxiety disorder is characterized by persistent fear over social or performance-related situations, according to the National Institute of Mental Health, which cites diagnostic interview data to estimate that 12.1% of U.S. adults will experience social anxiety disorder during their lifetime. Among adolescents ages 13-18, the lifetime prevalence is 9.1%. For all ages, social anxiety disorder is more prevalent in females than in males.

Researchers have not singled out a specific cause for social anxiety disorder, pointing instead to a combination of biological and environmental factors as contributors. Genetics appears to play a large role in many cases, as can negative childhood experiences such as family conflict or being bullied, teased or rejected by peers. It is also believed that individuals who have an overactive amygdala may experience more anxiety in social situations.

According to the Center for the Treatment and Study of Anxiety at the University of Pennsylvania, “Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience, and the severity varies by individual. … There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment and biology all play a role in the development of the disorder.”

People often experience symptoms of social anxiety disorder to varying degrees across the life span, according to the center. Symptoms may lessen for stretches of time and then worsen during periods of change or stress, such as a job transition or when dealing with feelings of grief and loss.

What sets social anxiety apart from general anxiety is not only the social component but also an intense fear of judgment by others, explains Holly Scott, an LPC whose Dallas private practice is a regional clinic of the National Social Anxiety Center. People with social anxiety often harbor strong and pervasive feelings that others will notice their anxiety and judge them, which triggers avoidance behaviors, she says.

At the same time, there are nuances to the diagnosis, and social anxiety can look different in each client, Scott adds. For example, someone may be fine with public speaking and yet not be able to walk into a room in which they don’t know anyone.

“People think it’s not treatable,” Scott says. “Clients label it as ‘this is just the way I am, and I can’t change the way I am.’ It can be difficult to treat or to find a qualified practitioner, but it is treatable.”

Imhoff says he has read that on average, people go 15 years before seeking treatment for social anxiety. Counseling itself is a social interaction, he notes, and people with social anxiety may avoid treatment out of a fear of the close interaction or of being scrutinized by a practitioner.

Because people with social anxiety typically adopt avoidance as one of their coping mechanisms, and perhaps because of the way that social anxiety tends to get minimized or passed off as simply being introverted or shy, these clients often live life without seeking treatment until they reach a breaking point. As Imhoff points out, people can self-manage their social anxiety for an extended period of time by maintaining the same small circle of friends and following certain behavioral patterns such as always using the self-service checkout line at the grocery store.

Living with social anxiety is their reality, Imhoff explains, and they “forge ahead until something causes [them] to realize it’s more significant.” For Imhoff, that “something” was the impending scrutiny involved in defending his doctoral thesis.

“For social anxiety, it’s possible to navigate life with avoidance and survive for a long time. Then something comes up — a life change, such as entering the workforce — that causes them to need help,” he says. “A lot of these safety behaviors aren’t being done consciously. They are things we’ve done throughout our lives to find safety.”

Assessment and core beliefs

Avoidance behaviors are one of the biggest red flags that a client might be dealing with social anxiety, Miller says. These behaviors can extend to staying in situations in which the person is unhappy yet comfortable, such as a bad romantic relationship, a toxic friendship or a job that the person doesn’t enjoy or isn’t advancing in.

Other indicators include rumination and overthinking social experiences. This can include asking oneself over and over again, “What did that person think of me?” Miller explains, whether it’s an interaction with a neighbor while walking the dog or a yearly performance evaluation with one’s supervisor.

Counselors should be aware that social anxiety often co-occurs with other mental health issues such as depression and substance abuse (which often becomes a coping mechanism) that may need to be treated first or in tandem with the disorder, Miller adds. In addition, other issues such as grief may be complicating a client’s social anxiety. “They’re not always struggling with one thing. Make sure you’re working on what they’re struggling with the most,” Miller says.

Scott suggests asking clients at intake about how they deal with social situations and how often they go to gatherings or parties. Are they uncomfortable introducing themselves to new people, making a phone call or using the restroom in public places? If Scott hears symptoms that might indicate the presence of social anxiety, she uses a questionnaire (she recommends the Liebowitz Social Anxiety Scale, available at nationalsocialanxietycenter.com) to pinpoint the client’s fear level and to identify goals to focus on in therapy.

It can also be helpful to identify a client’s core beliefs and values and how those are affecting the person’s choices and behaviors, Imhoff says. People with social anxiety often carry a core belief that they’re inadequate or inferior, which spurs a fear of being judged, he explains. These clients frequently place weight and focus on situations that seemingly confirm their core belief and discount those that might disprove it. They might ruminate over a conversation with a colleague that didn’t go well, for example, without giving any consideration to all of the past conversations that did go well, Imhoff notes.

“They move through life paying very close attention to and taking to heart scenarios that confirm their core belief,” he says. “It’s important to help the client take off the blinders. Talk through ways they are competent, and get to the root of their concerns. Be aware of the multitude of their experiences and not just those they struggle with.”

To identify core beliefs, counselors can listen for themes in the way that clients talk about themselves, other people and the world. These themes can suggest deeply held beliefs to challenge or to explore further in therapy. Having clients work on thought journals can also be helpful in finding patterns, Imhoff says. He also suggests using a prediction log, in which clients name upcoming social scenarios that make them anxious and describe what they assume will happen. After the scenario occurs, clients can look back at their predictions with the counselor to talk through how accurate these foresights were.

After core beliefs and values have been identified, the counselor can work with clients to reframe their perspective around new core beliefs. For example, clients who place value on providing for their family could focus on that value to help them overcome their anxiety and discomfort over applying for a new job.

“Look for evidence that supports their new core belief,” Imhoff says. “If their belief is ‘I am capable,’ have them write down even the most minor piece of evidence [in a journal]. It makes it concrete and documented so they can refer back to it and talk it through with a counselor.”

From there, the counselor can work with clients on challenging cognitive distortions and black-and-white thinking, Imhoff suggests. Acceptance and commitment therapy (ACT) can be helpful, as can guiding clients to adopt a growth-focused orientation. With that mindset, every social interaction becomes an opportunity to learn rather than a pass-fail situation, Imhoff explains.

Clients with social anxiety may also feel that they’re failing because they can’t assume an extroverted, life-of-the-party façade. Counselors can help these clients learn that there is a continuum of social skills, Imhoff says. For example, perhaps they got through a work meeting and contributed their thoughts despite having a shaky voice and sweaty palms. “Work on [helping them realize] that it’s not black and white, it’s not all success or failure. There’s an in between for almost all scenarios,” he says. “Help them to recognize that in all social interaction, there is ebb and flow. It’s not a pass-fail exercise but an opportunity to connect with someone and learn moving forward.”

Additionally, ACT techniques can help clients learn to accept their anxiety rather than trying to get rid of it or avoiding triggering situations. Imhoff uses the imagery of “keeping anxiety in the passenger seat because I know it’s coming along but not letting it take control of the wheel.” Clients can learn to say, “There you are anxiety; I knew you were coming,” even as they move on with life and navigate situations they previously would have avoided.

Scott regularly uses cognitive restructuring and cognitive behavior therapy (CBT) with her clients who have social anxiety. She also uses a mindfulness technique called curiosity training that helps clients label their anxious thoughts as “background noise.” With this technique, users try to adopt an approach of curiosity about and interest in what is being said by others rather than assuming that others are judging them.

“In any situation,” Scott says, “whether they’re having a conversation, public speaking or sitting somewhere having lunch, they’ve usually got a constant dialogue going in their head. [It’s] self-criticism about how people must be thinking of them: ‘They don’t like my clothes’ or ‘I just stuttered while speaking.’ Curiosity training helps keep your mind on the present and learn how to pull your mind back when it starts wandering.”

Elizabeth Shuler, an LPC who has been working as an international school counselor in Amman, Jordan, for four years, recommends mindfulness techniques. She has often used Kristin Neff’s self-compassion practices in addition to dialectical behavior therapy, meditation and yoga for clients with social anxiety, both when she was in private practice in Colorado and Wyoming and currently in her work with adolescents and adults at her school.

“When we dig into their fears, most clients with social anxiety are really afraid that other people will agree with their own negative judgments of themselves. They’re worried that they will be proved right,” says Shuler, an ACA member. “I had a client who walked through the office the same way every day to avoid the people he was afraid of interacting with and had panic attacks when his route had to change or people he was avoiding crossed his path. These types of behaviors are meant to stave off panic but end up reinforcing it. My role as a counselor is to help clients see how these behaviors are actually making their panic worse and help them to slowly replace them with more helpful behaviors.”

Exposure

Exposure techniques are often central to treating social anxiety because they gradually reintroduce clients to anxiety-provoking situations in a healthy way.

Miller is trained in exposure and response prevention and finds it a powerful tool for working with clients with social anxiety. The behavioral technique requires clients to put in a lot of work themselves outside of sessions. The counselor collaborates with the client to develop a hierarchy of exposure based on the client’s needs and treatment goals and supports the client throughout the process.

As Miller explains, exposure assignments start small and build over time as clients become comfortable with each homework task. She describes this as a “Goldilocks situation” — not too much challenge and not too little, but just the right amount, tailored to each individual client. Miller says she emphasizes to clients that the treatment is in their hands — they have to do their part to experience a successful outcome.

“A lot of people have anticipatory anxiety, but once they do it [complete the exposure assignment], they’re OK,” Miller says. “A lot of people get over that hill of worry. They do it for a week or two and realize they can do it. Trust between a client and clinician is huge because we’re asking them to do really scary things.”

Miller often gives clients who are early in treatment the assignment of calling multiple businesses to ask what their hours are. Clients might have to overcome feeling a little foolish because that information is readily available on the internet, she notes. However, the goal is for clients to complete the task without falling back on habits they formed to avoid social situations, such as relying on technology in lieu of having personal interactions. Clients repeat the task over and over until they no longer feel anxious about picking up the phone and making a call, she explains.

Once they’ve mastered that task, clients might move on to going inside a store and asking a question in person. Or they might switch to walking their dog in their neighborhood during a busy time of day and saying hello to at least one other person during each walk.

As clients complete each task and return to their next counseling session, they process these interactions with Miller, discussing how the interactions felt to them and what went right or wrong. “Sometimes the client will come in and say, ‘I’m so bored with this.’ I say, ‘Great! That means it’s time to move on to something bigger,’” Miller says. “You need repetition with assignments. You need to do [tasks] over and over for your brain to get used to it. … The more you do it, [the more] it overwrites [old] patterns and anxious feelings.”

As a practitioner who specializes in treating social anxiety, Scott has a laundry list of exposure assignments that she uses with clients, ranging from making eye contact during a shopping trip to asking for directions from a stranger to calling into a radio talk show to singing karaoke. As clients progress, it can be helpful to assign them tasks that are certain to create some level of discomfort or awkwardness, such as going into Starbucks and ordering a hamburger, she says. This can be especially hard for clients who have a strong fear of being judged by others, but dealing with the responses they receive desensitizes these clients over time as they repeat the tasks.

Miller acknowledges that counselors may need to provide their clients with some ongoing motivation during exposure work. If clients come to session without completing their assigned tasks, she suggests asking leading questions to find out if they are avoiding the work or genuinely struggling to make it a priority among their other challenges.

“Who wants to go home and do anxiety-provoking things?” Miller says. “[We] have to find a way to motivate them. We want them to feel empowered to go out and do [an assignment]. Remind them that they’re in pain because something is not changing. … You can’t snap your fingers and make this go away. It’s going to be hard work and take time.”

It can be useful to circle back and remind clients of their core beliefs and the goals they want to achieve. For example, consider clients who say they ultimately want to start a family but whose social anxiety prevents them from entering the dating scene and potentially meeting a partner.

“They may not see how calling a drugstore [as an exposure assignment] is getting them to be able to date. But remind them that they’re building a foundation to be able to do that,” Miller says. “It may not have an immediate payoff, but the easier these things become for you, everything builds.”

Miller often uses the metaphor of training for a marathon to keep clients motivated. You don’t run 26.2 miles right away, she tells them. You start with one or two miles and then keep adding more distance, mile by mile.

Social skills

In addition to exposure work and cognitive restructuring, the counselors interviewed for this article recommend social skills training for clients with social anxiety. Avoidance behaviors may have kept these clients from learning and practicing social skills that are commonplace among their peers who do not deal with social anxiety.

“If you’ve been avoidant for years, you miss out on learning from all of the social interaction that others have had,” Miller says. “Sometimes they’ve built a life to minimize their pain, their anxiety.”

Goal setting and planning ahead, with support from a counselor, can help these clients navigate situations that are foreign to them and that naturally provoke anxiety. Miller suggests troubleshooting with clients. For instance, if their office holiday party is coming up, a counselor can talk through expected behaviors with clients and work on small talk and other exercises to help them get through the evening.

Setting realistic goals can also be comforting, Miller adds. “[They] don’t have to go in and work the room, [but] if they haven’t had a lot of social experience, they may not realize what’s expected,” Miller says. Instead, clients might set a goal of talking to three people whom they already know. Maybe at next year’s party, they can increase that goal from three people to five people.

Miller also reminds clients that a certain measure of social anxiety is simply part of being human. Even she, a therapist who makes a living talking to people, acknowledges sometimes being uncomfortable in social situations.

Kevin Hull is a licensed mental health counselor with a private practice in Lakeland, Florida, who specializes in counseling children, adolescents and young adults on the autism spectrum. Social skills training, along with group therapy, plays a large role in the work Hull does with clients around social anxiety, which he says often goes hand in hand with autism.

In individual counseling sessions, Hull uses puppets with clients to role-play social situations and work through what is expected. For example, Hull might instruct clients to verbalize a food order to his puppet without the usual help from mom or dad or ask his puppet for help finding a certain building on a school campus. Afterward, they process the experience together and talk about the emotions clients felt as their puppet had to interact and ask questions.

Humor can also be a great tool for overcoming the fear associated with social anxiety, says Hull, a member of ACA. He often shows clips of TV shows or movies (via YouTube) in client sessions as a lighthearted way of starting conversations about what is and isn’t appropriate when it comes to social skills. Particularly popular with clients are scenes with The Big Bang Theory’s Sheldon Cooper wrapping himself in bubble wrap to stay safe or wearing a second set of “bus pants” over his work outfit when taking public transportation. Another favorite is the title character in How the Grinch Stole Christmas, who initially can’t stand being around the Whos but ends up transforming over the course of the story.

“Using humor is a great thing to counter the fear,” Hull says. “When you can laugh at something, that gets people opening up and listening.”

Group work

Group therapy — a format in which clients are expected to interact with others and contribute to a discussion — would seem to be a nightmare for individuals who are socially anxious. But that’s not necessarily the case, according to Hull.

Although it can take clients some time to warm up to the idea, group therapy can play a powerful role in imparting the skills needed to navigate social anxiety, says Hull, an assistant professor and faculty adviser in Liberty University’s online master’s counseling program. In addition to helping participants sharpen their social skills, group counseling can instill perspective — something with which Hull’s clients who are autistic sometimes need extra help.

“With autism, clients have a hard time putting themselves in others’ shoes, so group is a great way for them to hear from the mouths of peers [and] hear them talk about what they’re going through,” Hull says. “Maybe someone [in group] had to ride a different bus than usual. It was terrifying at first, but they were OK and actually ended up talking to the person they sat next to.”

The group format, in which participants take turns offering comments, can model and teach the back-and-forth “tennis match” that is the basis of healthy conversation, Hull adds. It can also help clients learn to tolerate and listen when someone is talking about a subject that doesn’t interest them — a circumstance that previously would have triggered their fight-or-flight response and caused them to exit the situation.

Hull often has group participants speak for five minutes each on something they are passionate about. Afterward, he urges all of the group members to ask questions or make a comment about what was said.

“This is really hard with autism. If they don’t like something, it’s utterly meaningless to them,” Hull says. “This has them put themselves in others’ shoes and imagine how it’s like [something that they] like. This can transfer to social situations outside of group, such as a dinner party where other people are talking about whatever. Can you listen and learn something? It’s teaching their brain to overcome fear and learn a new normal. Everyone is scary when you first meet them, but you can do it. If you can do it in group, it’s the same as at school or a new job.”

Hull also uses video games in sessions as a way for participants to learn about group dynamics, leader/contributor roles and overcoming frustration (see sidebar, below).

It is important to prepare individuals with social anxiety for the group setting as much as possible ahead of time. Hull often shows clients the group room at his office (or emails them photos of it) and explains the format and what sessions will entail before they join group counseling.

“I walk back to the [group] room with the client and their caregiver before a group session so they can see it,” Hull says. “I explain, ‘Everyone who is coming here feels what you feel, and they’re all struggling with this.’”

When new clients join a group, he never makes them introduce themselves or speak right off the bat. He also allows them to bring anything that might boost their courage, such as a favorite stuffed animal or even a parent in the cases of younger clients. With social anxiety, it is important to allow clients to warm up and contribute at their own pace, he says.

“I can see group members five or six sessions in and they haven’t talked yet. I never stop trying to get them to engage or open up, even if all they can do is a head nod or fist bump,” Hull says. “[I emphasize that] I’m just happy they can be in the room.”

Hull acknowledges that group counseling isn’t a fit for every client who struggles with social anxiety. Social anxiety falls on a spectrum, and for some clients, the disorder is so severe that a group setting would be too much, he says. It is important to continue individual sessions with these clients, with group counseling becoming a possible long-term goal for some of them, he says.

When it comes to group counseling and social anxiety, it is crucial to take things step by step and to celebrate little victories, Hull emphasizes. With clients on the autism spectrum “the victories are fewer and far between,” he acknowledges, “but when they happen … you feel like you’ve won the Super Bowl.”

The long haul

Hull says that counselors should view social anxiety as a process rather than something to “fix.” Neuroscience tells us that the brain responds better to slow and steady change rather than forced or rushed adaptation. This is especially true for clients who struggle with social anxiety in addition to neurodevelopmental issues, past trauma or other mental health diagnoses, Hull notes.

Something else that counselors should avoid is projecting their assumptions onto clients with social anxiety. Just because the counselor went to prom as a teenager doesn’t mean that should automatically become a goal for every teenage client or, for that matter, even be considered the rite of passage that it once was, Hull says.

Counselors should really get to know their client’s world first before doing anything else, Hull says. “Avoid putting your agenda or perceptions on a client. We often see the potential in our clients, and it’s hard not to say, ‘Just do it!’ It can be discouraging and slow going at times, [but] be patient.”

 

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Technology and social anxiety: A double-edged sword

We live in a world where a person can text a happy birthday message to a friend, order a week’s worth of groceries for delivery and apply for a loan with the click of a button — all without having to speak to another human.

So, when it comes to social anxiety, technology can be a double-edged sword. Clients can certainly use it as an easy escape route to avoid social situations. At the same time, mental health practitioners can use it as a teaching tool with clients and as a bridge to overcoming long-held behavioral patterns.

“As great as it can be, technology can be part of avoidance,” says Robin Miller, a licensed professional counselor (LPC) who specializes in treating adults with anxiety. “Learn how to have conversations [about technology]. Make sure a client isn’t too reliant on it and unable to do things in a more social, direct way.”

Miller suggests that professional clinical counselors ask clients about their technology use at intake along with other questions about avoidance behaviors. Counselors can prompt clients to provide examples of situations where they feel most anxious and then listen for overreliance on technology, such as texting to ask someone out on a date or habitually using the self-service checkout line when shopping.

Social media can also exacerbate the assumption of judgment that often accompanies social anxiety, Miller adds. Clients who see photos and posts about friends’ and peers’ vacations, children or happy life events may come to believe that their lives pale in comparison.

Elizabeth Shuler, an LPC and an international school counselor, agrees. She says social media has created a new layer of social anxiety “centered around likes, comments and followers” in many of the adolescents with whom she works.

“I see students every day who are upset — to the point of panic attacks — that they’ve lost followers or that no one is liking their Instagram pictures. Instead of being afraid of being seen as stupid, these kids are afraid of not getting likes. It is a whole new world of judgment that has been unleashed on our teens, and it is taking a toll,” Shuler says. “However, many people who find face-to-face interaction intimidating can benefit from starting with digital interactions. Using texting, video and other digital means of conversation can help people with social anxiety learn social skills and give them a chance to practice new skills in a safer, lower stakes environment.”

Kevin Hull, a licensed mental health counselor in private practice, finds technology — specifically, video games — a natural tool for working with his young clients, many of whom are on the autism spectrum. In group counseling, Hull uses multiplayer games such as Minecraft to introduce clients to interacting and working together in a way that provokes less anxiety than face-to-face conversation might. Group members take turns being a “foreman” and leader in Minecraft sessions. The group learns to communicate and work together while dealing with frustrations and the nuances of the leader/contributor roles. “If technology wasn’t there, these kids would be even more regressed,” Hull says.

Conversations about technology use can also be an important part of social skills training in counseling, Hull adds. For example, young clients might claim that they are “dating” someone when they are actually just texting or playing video games together over the internet.

Hull often talks with clients about how texting is a good place to start communication but that it should not become their be-all, end-all. He’ll say to the client, “It’s great you’ve made a connection through texting, but what about the next level? Your brain’s process to communicate in text is the same as in speech. It’s just a different route.”

— Bethany Bray

 

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Social anxiety and college

The transition to college — leaving home, living with a roommate and establishing a new social circle, all while navigating academic responsibilities — doesn’t have to be paralyzing for students with social anxiety. Read more in our online exclusive, “Heading to college with social anxiety.”

 

 

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Contact the counselors interviewed for this article:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Helping clients with post-date anxiety

By Kathleen Smith October 15, 2018

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As a counselor, I have a front-row seat for watching anxiety develop in new relationships. It is truly fascinating to observe how quickly two people can become emotionally stuck together. A therapy client will leave for a week and return reporting that he or she has started dating someone new. This former stranger now has the power to make my client very happy or very anxious. Thanks to their phone, my client might spend all day analyzing a text they received — or worrying about the lack of one.

Not a week goes by without me having multiple conversations with people about texting in relationships. For instance, a person is seeing someone who doesn’t quite contact them as frequently as they would like, so their brain sounds the rejection alarm. When the other person finally does text them, their anxiety level goes down. But within a day or two, they need more reassurance. They’ve surrendered their capacity to calm down to someone who was a stranger to them a week ago. And the only way they know how to get that capacity back is to end the relationship.

I don’t think that texting causes emotional dependence, but it can certainly accelerate it and reinforce it. People used to have to wait much longer to hear from a prospective romantic partner. Now people want to hit the eject button if there’s been radio silence for 24 hours. There is an expectation that someone who is interested in us must also be available to us at all times. We are in such a hurry to lock things down as a way of managing our own anxiety and insecurity.

I’m in no position to throw a stone here. After my husband and I went on our first date, he waited five days to ask me out again. Five. Days. For millennials, five days is the equivalent of somebody going off to war and coming back home. Now, of course, I know that he was a mature human being who was simply living his life at that time. But if you retrieved my phone records from that week, I bet you would see a blizzard of worried texts to friends.

When our counseling clients become more anxious in a new relationship, they don’t suddenly become more insightful. They usually just double down on whatever they’ve already been doing. That usually means anxiously focusing even more on this new person. They might stalk them on social media, or stare at their phone trying to decipher old texts. They’ll talk to all their friends about whether they should dump this person for taking so long to reply. They’ll come to a counseling session and ask me to guess what this person — whom I have never met coincidentally — is thinking.

When we feel the potential to be hurt, it makes sense that we focus more on the threat and how to avoid it. This works great if a lion is chasing us. It’s not so great for being in a relationship.

People see a lot of lions when they date, simply because dating is such an anxious endeavor. They interpret a lack of constant contact in a new partner as a sign of flakiness, disinterest or duplicity. People don’t stop to consider whether less contact might be a potential sign of maturity. This is why people tend to end up with other people who are at the same level of emotional maturity as themselves. People who have a higher degree of maturity in their family relationships are likely to seek out a partner who wants the same amount of contact.

I would never say to a someone, “Have you considered that this person is not texting you as much because they’re more mature?” Because that would be a guess based on zero facts. What I do challenge people to do, however, is to see their part in the relationship. Often, if people can stay focused on being the person they want to be rather than on trying to control this new love interest of theirs, then their anxiety will go down. And most of the time, people do not want to be the kind of person who is glued to their phone 24/7.

So, the goal isn’t for clients to change their new crush or to teach the person how to text that Goldilocks (just right) amount. The goal is to lower clients’ anxiety enough to where they can actually think objectively and decide whether a relationship is right. That decision is impossible to make when anxiety is very high, because then we interpret even the smallest behavior as a threat. People will blow up a relationship quickly in order to lower their anxiety.

Anxiety isn’t just present in romantic relationships, of course. We all want people to like us, reassure us and agree with us, but we ultimately can’t control them. People in our lives are not always going to respond as quickly as we would like. They’re not always going to RSVP to the party or share our level of enthusiasm for a television show. If clients can see how the anxiety they feel is a possible sign of emotional interdependence, they might be less likely to act immaturely or irrationally in their relationships. The rejections or silences won’t feel so threatening, and they won’t have to cancel that party out of spite or send a passive-aggressive message.

The simple truth is that we enjoy relationships more when we aren’t as anxiously focused on them. By being more of an individual, we can actually get closer to the people we love. Who doesn’t want that?

 

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Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. Read more of her writing at kathleensmith.net.

 

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