The Invitation

The primary purpose of this chapter is to help the client understand his or her diagnosis in the context of normal and excessive social anxiety. Social anxiety is feeling tense, nervous, or frightened in situations that involve other people. The workbook describes a step-by-step therapy approach for overcoming social anxiety. The therapist will help the client gain an appreciation that cognitive–behavioral therapy (CBT) is effective and provide a basic understanding of the nature of CBT, including the investment of effort and energy required for the therapeutic alliance. The therapist will work to enhance motivation for change and build this therapeutic alliance.

Settling Into the Journey

After the first in-session exposure, treatment enters a middle phase in which sessions revolve around the routine of in-session exposures and review and completion of in vivo (real-life) exposures for homework. Exposures are guided by the client’s Fear and Avoidance Hierarchy. For clients to benefit from this treatment, the emphasis for clients will shift from exposures done in session (with the therapist) to tackling real-life situations on their own. Guidelines for picking exposure situations are provided, and the relationship among exposures, cognitive restructuring, and homework is presented. Homework for the rest of the program is discussed, and learning to overcome social anxiety is introduced as a habit.

Getting Into the Pool

This chapter introduces the next component of treatment—therapeutic exposure to feared situations (facing the situations that make someone anxious). Therapeutic exposure is a powerful technique that helps with the three components of social anxiety: behavioral, cognitive, and physiological. How exposure works and why it is such a crucial step in overcoming social anxiety are reviewed. The chapter presents the steps involved in completing a first in-session exposure, including picking the situation, doing the cognitive restructuring, setting an achievable behavioral goal, entering the situation, and processing what was learned from the exposure. The first in-session exposure is a highlight of this therapy.

Tools to Challenge Your Automatic Thoughts

This chapter covers the two remaining major steps in cognitive restructuring. The first of these is questioning whether automatic thoughts are really true. A list of all-purpose questions called “disputing questions” is presented. Some of these questions are particularly appropriate for automatic thoughts (ATs) with certain thinking errors, and others work for a variety of thoughts. The next step in the cognitive restructuring procedure is to develop a rational response, which is a statement that summarizes or highlights the key points a client has discovered working through the Anxious Self/Coping Self dialogue. Often the rational response is a shorthand reminder to stay focused and think more rationally. When people are in a situation that makes them anxious, they can repeat the rational response in their head as ATs arise.

Getting Ready to Continue the Journey on Your Own

This final chapter focuses on assessment of progress, relapse prevention, and termination. After approximately 15 sessions of treatment for the typical client with moderately severe symptoms, it is time to stop and assess progress. Regardless of how much progress an individual has made in overcoming social anxiety, there are important habits to develop to continue making progress. If treatment ends at this time, this chapter discusses when it might be necessary to call the therapist for a booster session. If it is the end of treatment, this is the beginning of the client’s personal journey equipped with a toolbox full of skills and increased confidence to continue to take life in a new direction.

Public Speaking

Fear of public speaking is nearly always listed as the number 1 fear experienced by the general public in national surveys in the United States. It has been found that fear of public speaking is extremely common among individuals with social anxiety disorder. Over 90% reported at least some fear about speaking in front of a group, and for most of those individuals, the fear is moderate or severe. There are many forms of public speaking that most people confront much more frequently. Common automatic thoughts reported by individuals with public speaking fears usually center on the visibility of anxiety symptoms or concerns about the quality of one’s performance.

Everything Starts With Small Talk

Many individuals in treatment for social anxiety have some difficulty with casual conversations, even if it is not the primary focus of treatment. The chapter explores why it is important to be able to make casual conversation and then examines some of the automatic thoughts that socially anxious individuals often have in casual conversation and how to challenge those automatic thoughts. This chapter presents psychoeducational material about the importance of small talk in everyday life. Two primary messages from this material are (a) casual conversations are the gateways to more significant relationships and (b) such conversations are, by definition, about inconsequential topics. The chapter talks about two key types of situations in which many people experience social anxiety—conversations and public speaking.

Identifying the Thoughts That Cause Anxiety

Cognitive restructuring is a procedure that helps to examine how people are thinking and to consider whether there may be a more useful way to look at a situation that makes them anxious. Clients learn to identify the thinking errors in the automatic thoughts (ATs) they have when they get anxious. They also have the opportunity to see if they tend to use particular thinking errors when they have anxious thoughts. Clients are taught (a) what they think influences how anxious they feel and (b) how to change what they are thinking so that they can better manage their anxiety and do the things they want to do in life. This chapter introduces the idea of information-processing biases using the “amber-colored glasses” metaphor. As people learn to change their ATs, they feel less anxious and depressed.

The Origins of Social Anxiety

The primary purpose of this chapter is to finish presentation of the cognitive–behavioral therapy (CBT) model with a discussion of the etiology and maintenance of social anxiety. Clients vary on how much they want to know about some of the details. However, nearly everyone asks about etiology at some point in treatment. Possible causes of social anxiety include a genetic component, family environment, and important experiences. However, most psychologists agree that social anxiety disorder, like most other psychological disorders, is not caused by just one thing and results from a combination of factors. This chapter includes the beginning of monitoring progress using the SASCI (Social Anxiety Session Change Index). From this point in therapy forward, at the beginning of each session, clients complete the SASCI.

Advanced Cognitive Restructuring

This chapter delves deeply into clients’ automatic thoughts (ATs) and examines some of their core beliefs that underlie these ATs. As individuals work through various exposures and associated cognitive restructuring, both therapist and client may notice that certain themes keep reoccurring. Themes in automatic thoughts reflect core beliefs that drive all of the difficulties a person is experiencing. People who have difficulty with anxiety and depression usually have one or more dysfunctional core beliefs about themselves, other people, the world, or the future. Therapists often talk about finding these core beliefs by searching through the layers of ATs and emotions, similar to the process of peeling an onion.