Speech language pathology and autism
Social phobia (also called social anxiety disorder) is characterized by a persistent and intense fear of social situations. At the core, people with social anxiety disorder are often concerned with being judged, humiliated, or rejected due to perceived imperfections they have about themselves.
Social phobia is surprisingly common, with about 7% of adults in the United States meeting criteria in the past year. Additionally, nearly 70% of those diagnosed report moderate to serious impairment in their lives caused by social anxiety.
What is cognitive therapy for social phobia?
Fortunately, cognitive therapy for social phobia has been shown to be a powerful and relatively short-term treatment. It’s useful for both children and adults, and can reduce symptoms and improve day-to-day functioning.
While cognitive behavioral therapies have been around for a long time, the Clark and Wells model of social anxiety specifically improved upon earlier versions of general cognitive therapy to provide a comprehensive way to understand how social anxiety is maintained and treated.
The Clark and Wells model of social anxiety
One of the most valuable aspects of the Clark and Wells model of social anxiety is the six-step anxiety cycle that they proposed. Understanding this cycle naturally paves the way for utilizing the powerful cognitive behavioral techniques to help clients overcome the hold social anxiety has over them.
Each step below reflects a process described in the Clark and Wells model of social anxiety and marks a point where clients tend to get stuck.
Step 1: Social anxiety triggers
There are typically one or more (usually more) specific situations that trigger a client’s social anxiety fears. Examples of triggering situations include public speaking, talking to strangers, going to a party, ordering food, or visiting friends.
Step 2: Negative thinking and beliefs
The triggers evoke negative thoughts and beliefs about the social situation, such as “people won’t like me if I seem anxious” or “I’m a boring person.”
Step 3: Perceived social danger
These beliefs lead clients to fear that others will judge or negatively evaluate them. For instance, they might assume others can see their face flushing or hear their voice shaking, reinforcing their belief that others perceive them negatively and will judge them for it.
Step 4: Heightened inward focus on the self
This perceived danger creates a self-focus where the client will hyperfocus on themselves and their performance. For instance, they might notice their hands are shaking, that they have thoughts like “I am so awkward,” and how uncomfortable they feel in their body.
Step 5: Thoughts, feelings, and sensations as data
The client is then likely to use the “data” collected in their self-focus as further “proof” that they are failing socially. For instance, somebody might assume that because they were shaky and felt awkward, the interaction truly was a failure.
Step 6: Safety behaviors and avoidance fuel the anxiety fire
Finally, due to the high anxiety and concerns that they are performing poorly, clients will engage in various types of avoidance or safety behaviors (e.g., not going to a party, holding tightly onto a cup) which reinforces the anxiety in the long run.
Evidence-based cognitive therapy techniques for social phobia
The Clark and Wells model of social anxiety suggests several highly effective, evidence-based techniques that can help clients break the hold social anxiety has over them. These interventions target thoughts, feelings, behaviors, and attentional processes.
Cognitive restructuring for social anxiety
The first step in cognitive restructuring for social anxiety is helping individuals identify their thoughts and beliefs. This is often done with simple thought-tracking records. You can then guide clients with the “downward arrow technique” to identify deeper core beliefs about themselves or others.
With this information, you can use techniques like Socratic questioning to help the client take new perspectives on their beliefs. Another helpful intervention is to help clients identify and challenge the cognitive distortions that are present in their thinking.
Attentional training for social anxiety
One particularly useful intervention that the Clark and Wells model of social anxiety emphasizes is the role of attention. Since social phobia hijacks one’s attention and brings it inward, cognitive therapy for social phobia emphasizes teaching people how to notice where their attention is and learn how to shift from an internal focus to an external one.
Behavioral experiments and exposure therapy
In cognitive therapy for social phobia, behavioral experiments are similar to exposure therapy, but clients are testing specific predictions. Clients are encouraged to expose themselves to increasingly uncomfortable situations without using any safety behaviors.
To set up behavioral experiments, you can guide clients to predict what scary or unwanted outcome might happen if they enter an anxiety-provoking situation. After facing their fear and processing what happened, clients are directed to consider how their actual experience was similar to or different from their prediction, and how they can use this information going forward.
Therapists also commonly help clients develop an exposure hierarchy for social anxiety so they can start with lower-intensity situations and build up to more challenging ones.
For example, imagine a client is terrified that saying something awkward will lead to unbearable embarrassment. One intervention might be to purposely go out into the world and ask uncomfortable questions to strangers, thereby allowing them to see that usually people are much nicer than their beliefs make them feel, and also that even if the interaction doesn’t go well, almost always they can handle it and feel better off in the long run.
Another behavioral experiment often used in cognitive therapy for social anxiety is having clients predict how poorly they socialize, then video record an interaction, and have them watch it with instructions to “rate it objectively as though this was a random stranger in a research study.”
Interoceptive exposures
Interoceptive exposures can be an effective way to help people learn how to disentangle from social anxiety. According to the Clark and Wells model of social anxiety, when people focus inwardly, they become afraid and uncomfortable of various sensations (especially a flushed face, heat, sweatiness, and shakiness). Interoceptive exposures are designed to purposely elicit these uncomfortable sensations so that when the person experiences them during interactions, they won’t be as afraid of them or interpret them as something catastrophic.
For example, a client might run up and down stairs while practicing a speech if the feeling of breathlessness is aversive to them.
Anti-rumination techniques
Finally, the Clark and Wells model of social anxiety discusses a really important element of social anxiety known as post-event rumination. This happens when, after a client has experienced an anxiety trigger, they may spend hours and hours replaying the situation in their mind (often with the intention of trying to find any flaws, reassure themselves, or feel a sense of control).
To address this, cognitive therapy for social phobia utilizes several techniques:
It teaches clients how to notice the function of rumination. For instance, they may be ruminating to make meaning of the situation or reassure themselves that things are OK.
It helps clients to reflect on the consequences of rumination, showing them that rumination doesn’t help them feel better in the long run.
It aims to teach clients specific skills like mindfulness, acceptance, and attentional flexibility to allow that memory to exist in the background of awareness while shifting their attention back to the here and now.
Cognitive therapy for social phobia gives clinicians a clear map: identify the cycle described by the Clark and Wells model of social anxiety, then use cognitive behavioral therapy techniques and an exposure hierarchy for social anxiety to break it. Building social anxiety treatment plan goals around those same targets keeps progress measurable.
Sources
Clark, D. M., Ehlers, A., Hackmann, A., McManus, F., Fennell, M., et al. (2006). Cognitive therapy versus exposure and applied relaxation in social phobia: A randomized controlled trial. Journal of Consulting and Clinical Psychology.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Social phobia: Diagnosis, assessment, and treatment. The Guilford Press.
Hall, M., Luo, A., Bhullar, N., Moses, K., & Wootton, B. M. (2024). Cognitive behaviour therapy for social anxiety disorder: A systematic review and meta-analysis investigating different treatment formats. Australian Psychologist.
Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: A comprehensive model and its treatment implications. Cognitive Behaviour Therapy.
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., et al. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet Psychiatry.
National Institute for Health and Care Excellence. (2013). Social anxiety disorder: Recognition, assessment and treatment.
National Institute of Mental Health. (n.d.). Social anxiety disorder.
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