This post has been authored by Pamela Hagues, LPC, CSOTP, CC as part of our guest post series. Learn more about Pamela at the bottom of this post.
Therapeutic Interventions for Social Anxiety
Coming from an inpatient residential and community-based background for 15 years, as a clinician, I was used to providing mental health treatment for various populations with more complex issues than what the average individual copes with in society today. These clients typically received dual diagnoses such as depression and substance abuse, were trauma and abuse victims and several had even committed sexual offenses. So, after several years of working in these settings, I became experienced and knowledgeable and was ready to take that leap of faith into my own practice. I was prepared to serve clients in the ‘regular community’ after years of working in a more intense environment.
The Social Anxiety Picture…
I began my outpatient mental health practice almost three years ago. Early on, I began receiving client referrals who were presenting with heightened anxiety issues; particularly social anxiety. These clients came from all walks of life and were different races, ages, had various spiritual backgrounds, socio-economic classes, and cultures. However, the presenting issues remained the same. They were often afraid to be in crowds or groups of people. They usually assumed others would be disinterested in what they had to say or believed they were stating something “stupid”. They had significant difficulty controlling their racing thoughts (often very negative thoughts about themselves in the situations) and would become mute in any given scenario. These clients generally avoided social interactions and felt socially awkward when around others. Ultimately, they wanted to change this way of behaving and thinking about themselves as their social lives were suffering; leaving them with growing feelings of loneliness. This social anxiety sometimes even spilled over into their careers, making it challenging to advance, get promoted (usually being overlooked by supervisors) or handle conflicts with others.
Writing A Script
A common theme amongst my clients I noticed was they felt more at ease when following a script. For example, those working in call centers could better handle displeased customers when they had a script to follow. The scripts would prevent the racing thoughts from occurring; so, they did not believe what they were saying was “stupid”. Since there was a script, they would convince themselves it was not them actually responding to the conflict. They were not responsible for the outcome. I began assisting them in therapy to develop scripts for various situations they would encounter. For instance, if attending a party, a client’s script might read:
“Hello, my name is Pamela. How are you enjoying the party? (Pause for response and then Reply) Do you party often? (Pause for response and then Reply) What are some other things you like to do for fun?”
I worked with my clients on asking open-ended questions and being patient while listening to others’ responses without always believing they must engage in a lot of talking to fit in.
Creating an Escape Route
Many times my clients revealed they were afraid of social engagements because if their anxiety heightened, they would feel trapped and ultimately humiliate themselves when looking stuck or confused. This led to me assisting them with developing escape routes whenever necessary. An escape route is just a fancy way of excusing yourself (either for a short time period or for the rest of the evening). A client could easily state, “Excuse me, I need to go to the restroom” and be able to exit without any issues. Since it is common for people to go to the bathroom during social events, clients could more easily buy into this intervention. The plan was to go into the restroom and/or even step outside to get fresh air to better be able to collect their thoughts. There, they could glance over their scripts, engage in deep breathing exercises, meditate, engage in positive self-affirmations, etc. until they felt confident and comfortable enough to re-enter the event. Other examples of scripted escape routes could include:
- “Excuse me just for a moment, I need to get a drink of water.”
- “Hey, I’ll be right back.”
- “I have to call it an early night because I have an early start tomorrow morning.”
The list goes on and on depending on the person and the circumstance.
Developing a Balance
Through observation, it was becoming clear my clients would go through periods of making good progress but then they would get overwhelmed socially and just stop cold turkey altogether. Nevertheless, this typically led them to become reclusive all over again. Then, their old negative thoughts and feelings would return; loneliness, boredom, disappointment, shame, guilt, irritability and/or depressed mood and loss of interest in normal activities. Therefore, it is important to find balance in all of this. Clients with social anxiety appear to do and feel better when they are experiencing some connections to the world; but, it cannot be too much connecting in an extended period of time. If and when they decide to pull back from the social scene, it is important they do not stop interacting all together. A healthy balance is necessary and it looks different for each individual. They should always be working on ways to be social with others even if it is simply initiating a “Hello” to a colleague as they pass during the hallway.
In therapy, my clients and I engage in modeling and role-playing exercises, as well as homework assignments, to get them more comfortable with interacting with others. For instance, my male clients who are intimidated by the dating process, we role play how to approach women. As a female clinician, I pretend to be the woman they are approaching; at the same time, I model what is normal and appropriate while giving them constructive feedback about their approaches and communication (verbally and nonverbally). Homework generally consists of scripts to initiate conversations with women. Once therapy reconvenes, we process how they did when initiating these conversations, to include their thoughts and feelings before, during and immediately following the interactions. Any tweaks or modifications to their approach and communication takes place in therapy.
I generally utilize an eclectic therapeutic approach because I believe in treating the individual holistically and not using “cookie-cutter” approaches. Each person responds differently and each situation may warrant a different approach. I have discovered not all people suffering from social anxiety are equally disturbed. Some are more sociable than others. Some are more sociable for longer durations of time. They all have different personalities, so I adjust my approach based on these factors.
Nonetheless, my default approaches include Cognitive Behavioral Therapy (this is like the umbrella approach to several other approaches), Strength-Based Perspective, Person-Centered Therapy, and Reality Therapy. With Cognitive Behavioral Therapy (CBT), I give assignments such as journaling to gain an understanding of the social situations they encounter; determine what they believed, thought or felt during the situation; and what did they do in each scenario.
We review and process in therapy to point out any dysfunctional beliefs and/or irrational thoughts they presented with, in order to gain self-awareness and work on improving these beliefs, thoughts, and behaviors. I believe it is important I assist my clients in identifying their strengths to improve their self-confidence and motivation to engage in social situations. For instance, if they see themselves as intelligent, competent, attractive, strong, hardworking and financially responsible (to name a few) individuals, they will approach different situations more appropriately.
As a Therapist
As a therapist, my job is to solely serve my clients to the best of my ability. I am committed to their success and it does not benefit me at all if they feel less than or unsuccessful. Because it is all about them, I work hard to listen to their concerns, empathize with their feelings and affirm and encourage them to try their best. I also offer them assistance and support as necessary. Lastly, the reality is, they learn in therapy if they want to increase positive social interactions and develop healthier relationships with others, it is their responsibility to do the work. If they never try, they will continue to feel lonely, bored, depressed and awkward.
In Summary, Social Anxiety is a common disorder without discrimination to a person or situation. With assistance and support from a licensed clinician, an individual can learn sound strategies to combat this disorder and be able to establish and maintain healthier relationships across all dimensions. A person does not have to suffer from social anxiety while living healthy and content lives!
Pamela Hagues, LPC, CSOTP, CC has been providing a wide range of mental health services for the past 15 years. Licensed since 2003, she has also been a certified sex offender treatment provider since 2007. She can help with issues such as domestic violence, sexual assault, depression, anxiety, and managing life transitions, such as college, divorce, parenthood, and job changes. She enjoys providing training about mental health issues to lay people and clinical supervision to developing counselors.
To schedule with Pamela Hagues, call (804) 586-9399 or email email@example.com.