Amy wanted to walk out of her office and never come back. Her heart was pounding, her hands were sweaty, and she could feel herself blushing and shaking. She would give anything to avoid this presentation at work today, but her job depended on it. Ever since she was told about it, she had been so nervous that she could barely even make it through an office meeting. By the time she had to stand up and speak, all she could think about was how humiliated she would be, and how stupid everyone would think she was, if she made the slightest mistake.
What is described above is a common scenario for someone with Social Anxiety Disorder (SAD). Eating, writing, or reading in front of others, talking to others at a social gathering, and formal speaking are events that frequently cause distress, such as sweating, shaking, increased heart rate, and blushing. Adults with SAD are not afraid of others–but are really afraid of revealing their anxiety or of being judged as incompetent or unlikable.
SAD is a serious psychological condition that can range from mild to severe. Symptoms related to SAD often impact many areas of life and functioning, including isolation from social relationships, negative self-image, increased general anxiety and tension, depressed mood, and impairment to or interference with goals at school and at work. There is good news; effective treatments that can decrease symptoms and improve quality of life are available.
Exposure Therapy Can Help You Break the Cycle of Anxiety and Avoidance
Imagine you have an intense fear of dogs. To overcome your fear, you eventually need to come into contact with a dog. The process of facing your fear through direct contact is called exposure. It is the active ingredient in Exposure Therapy (EXP), a type of therapy that can be used with someone who experiences social anxiety to help that person confront his/her social fears. How and why does it work? When a person feels anxious about something, if they can avoid the feared stimulus, they often do. Immediately, the person feels a sense of relief because they have avoided confrontation with the issue. Although avoidance may decrease feelings of anxiety in the short-term, it strengthens the fear response and prevents opportunities to learn that the anxiety is a false alarm that can be coped with effectively. When avoidant coping becomes a habit, individuals also miss out on important social learning opportunities.
Exposure Therapy is a well-established treatment for SAD and is designed to keep individuals in contact with feared social stimuli until the anxiety naturally subsides, through a process known as habituation. With each repetition, fear and avoidance diminish, indicating that extinction of the fear has occurred. Exposure Therapy sessions are individualized to address unique aspects of an individual’s core fear (e.g., fear of being seen as incompetent, anxious, undesirable). Treatment can be done gradually or intensively, in imagination or in real life, to tackle the person, places, and situations that trigger a person’s social anxiety. While most people experience initial discomfort when confronting their fears directly, positive results are typically seen within a brief period, often within twelve-to-sixteen weeks.
Social Skills Training Can Help You Socialize with Confidence
To overcome your social fears and to socialize with confidence, you may need to do more than simply interact with others. People learn how to navigate social interactions by regular contact with others and corrective feedback. Some adults with SAD have appropriate social skills, but are too anxious to use them. Many struggle to know what to say and how to say it, regardless of their anxiety level. Research comparing adults with and without SAD shows that adults with SAD have weaknesses in social skills compared to adults without SAD. Feeling less effective in social situations or having actual social skill deficits may contribute to greater social anxiety and negative social interactions.
To enhance social success, adults with SAD can participate in Social Skills Training (SST). This treatment is often conducted in a group format and involves education, modeling, role-play exercises, feedback, and homework practice. Social awareness skills involve understanding when, where, and why one might initiate, maintain, and terminate social interactions. Interpersonal skills focus on the verbal and nonverbal aspects of successful social encounters, such as body language, topic transitions, and assertiveness. Presentation skills include the mechanics of public speaking with a focus on speech construction and delivery. And homework is assigned to increase the likelihood that treatment will transition from the therapist’s office to real-life settings (e.g., making small talk in the elevator, initiating conversations with coworkers).
Social Effectiveness Therapy is An Effective Combination
If Exposure Therapy decreases social anxiety and avoidance in adults with SAD, does reducing social anxiety and avoidance lead to the emergence of appropriate social skills? Or, do we need to explicitly teach social skills to socialize effectively?
My research team and I conducted a study1 to determine whether Social Effectiveness Therapy (SET), a treatment that combines Exposure Therapy with group Social Skills Training, would be more helpful than Exposure Therapy alone for adults with SAD. In this study, 106 adults with SAD were randomized to one of three conditions (each condition lasted 12 weeks): Exposure Therapy alone, Social Effectiveness Therapy (Exposure Therapy plus Social Skills Training), or a waitlist comparison. Waitlist participants received no treatment for 12 weeks, at the end of which time they could select treatment with either Exposure Therapy alone or Social Effectiveness Therapy. The results presented below for the waitlist group reflect their participation during the waitlist period only (not during their ensuing treatment with either Exposure Therapy alone or Social Effectiveness Therapy).
Improvement was evaluated based on self-reported measures, clinician ratings, and observer ratings of social behavior. Observer and clinician ratings were made without knowledge of which treatment the study participant received. The results of our study suggest that:
- More adults treated with Social Effectiveness Therapy (67%) and Exposure Therapy alone (54%) no longer met diagnostic criteria for SAD, compared to only 10% in the waitlist group.
- Both Social Effectiveness Therapy and Exposure Therapy alone reduced social anxiety, but the waitlist condition did not.
- Social Effectiveness Therapy improved observable social skills, but the others did not.
- Social Effectiveness Therapy showed greater improvements than Exposure Therapy alone for clinician-rated severity, behavioral avoidance, and depression, as well as for participants’ self-rated social anxiety, and observer-rated anxiety during social encounters.
Break the Cycle of Anxiety and Socialize Confidently
This study suggests that for adults with Social Anxiety Disorder (SAD), the combination of Social Skills Training with Exposure Therapy can be more effective than either treatment alone, and certainly, more effective than no treatment at all. The reason is that to recover from SAD, you must break the cycle of anxiety and avoidance to ultimately, socialize with confidence. When combined, Exposure Therapy and Social Skills Training can help with both. If you experience social anxiety and believe it is negatively impacting your life, consider discussing Social Effectiveness Therapy with your therapist.
1Beidel, D. C., Alfano, C. A., Kofler, M. J., Rao, P. A., Scharfstein, L., & Sarver, N. W. (2014). The impact of social skills training for social anxiety disorder: A randomized controlled trial. Journal of Anxiety Disorders, 28(8), 908-918.
This research was supported by NIMH Grant R01MH062547 to the first author and Samuel M. Turner, Ph.D.
Lindsay Scharfstein, Ph.D., is a Licensed Clinical Psychologist, founder of Rockville Therapy Center. She specializes in treating anxiety disorders, with expertise in selective mutism and social phobia. Dr. Scharfstein earned her Ph.D. from the University of Central Florida and completed fellowships at Yale University Child Study Center. She conducts psychological assessments and offers evidence-based treatments like CBT, Trauma-Focused CBT, and Family Therapy. She runs the Confident Kids Camp-DC Metro and provides workshops, publications, and consultation programs for professionals. Collaborative and communicative, she optimizes treatment success and quality of life.