Social anxiety disorder is crippling — and common. Graduated exposure is the first step | Gill Straker and Jacqui Winship

Many of us are familiar with the uncomfortable feeling of walking into a cocktail party where none of our friends are present. We clumsily approach, figuring other people might be wondering what we’re doing there and not knowing where to stand or who to look at. We stare intently at our prosecco and wait for the floor to swallow us up. In most cases, we can move forward and hook up with someone at the party, usually having a great time. However, our initial discomfort allows us insight into what it’s like to live with social anxiety disorder (Sad), a ubiquitous and disabling mental health condition.

In a study involving thousands of participants aged between 16 and 29 from different socioeconomic strata and from seven different countries, including Brazil, Russia, the United States and China, a staggering 36% were found to have met the threshold for Sadness. Although similar to shyness, Sad involves much more intense anxiety. This leads to avoidance of social situations, including work, family gatherings, and even events that the person believes they would enjoy if they didn’t feel so anxious. Research indicates that sadness particularly afflicts young people. Explanations for this include neurocognitive changes in this age group, as well as a developmental shift towards a focus on peer assessment. One hypothesis for Sad’s apparent rise in the 21st century is the proliferation of social media and digital alternatives to face-to-face contact.

Regardless of its genesis, social anxiety disorder involves a cocktail of emotional, cognitive, behavioral and neuropsychological factors and results in significant consequences for those affected. Emotional factors involve fear, dread and panic that can be experienced days and weeks before an event and can arise with the mere thought of socializing. Cognitive factors include holding yourself to unrealistically high social standards and then looking at yourself in the moment to see if those standards are being met, as well as judging yourself retrospectively. This self-examination leads to clumsiness, blushing, or stuttering, which further heightens self-consciousness and heightens retrospective ruminative imaginings of the judgment of others. Behavioral factors include avoiding social situations, speaking softly, and dressing simply to avoid being the center of attention. These are referred to as safety behaviors.

Evidence of neurobiological involvement includes genetic studies and the sometimes useful effect of antidepressants. Effective treatment often requires a holistic approach, but often those suffering from grief do not seek treatment as it involves the very human contact they fear and avoid. Ironically, for these individuals, the lockdowns imposed by the pandemic were a relief, as their naturally isolated state was validated and they didn’t have to justify their avoidance of social situations. However, in the long run, this made their condition worse as reinforcement of safety behaviors makes it harder to change and the rebound effect of pressure to socialize in a post-lockdown world adds complications.

Responding to pressure from her mother, Rochelle, 30, reluctantly approached me via email. She wanted telehealth sessions, preferably over the phone rather than Zoom. While many clients request telehealth due to geographic distance and time constraints, many don’t specify anytime soon that they prefer talking on the phone when they live as close to my rooms as Rochelle does.

It soon became clear that Rochelle was suffering from grief. On our first phone session, I had to strain to hear her, as the quiet speech that characterized Sad was omnipresent and there were long pauses, as if Rochelle was taking a long time to figure out what to say and how to say it. When I gently investigated what was going on in the pauses, she explained that she had just heard herself talk and thought it sounded stiff and boring. She was wondering how to liven up her own speech. I asked if she was also worried because I wasn’t listening or was bored. She agreed that it was, but clarified that it was more that she couldn’t stand her own “monotonous whining”. Upon asking, it was clear that this was a thought that frequently came to Rochelle’s mind as she spoke to others, and it certainly worried her after the fact.

So, in this first session, Rochelle not only described many of Triste’s signs and symptoms, but also manifested them in our interaction. Choosing not to enter my offices allowed her to avoid feeling like the center of my attention, and her preference for the phone over Zoom allowed her to avoid eye contact, a trait of Sad. Despite this avoidance, Rochelle was warm and engaging. She was an excellent writer who related her struggles with coherence, grace, and humor.

Rochelle had already tried several drugs without success, but was open to the possibility of exploring this option further. She also tried online programs designed to help manage anxiety, challenge the negative thoughts associated with her social fears, and reduce her reliance on safety behaviors. Rochelle said that she has not felt able to maintain these programs in the past, but we agreed that my support could help her pursue the suggested strategies. We also agreed that our therapeutic relationship provided a great opportunity to experience the gradual exposure to threatening situations that Sad’s treatment involves.

We engaged first to move to Zoom and finally to meet in the room, making sure each transition was positive with ample room for Rochelle to be assisted by me to ease her fears. For example, we initially agreed to sit sideways so she didn’t have to make eye contact, and I answered her questions about my thoughts so she could refute her assumptions about the trial. The pace of change is slow, but over a year of weekly sessions Rochelle began to enjoy the therapy and was able to sit across from me and talk with ease. We are in the process of generalizing her ease with me to other social situations, so that she can enjoy life instead of seeing it pass by as an outsider to her pleasures and joys.

Rochelle is a fictional amalgam to exemplify many similar cases we see. The therapist is a fictional amalgamation of both authors.

Prof. Gill Straker and Dr. Jacqui Winship are co-authors of The Talking Cure. Gill also appears on the Three Associating podcast, in which relational psychotherapists explore their blind spots.

Social anxiety disorder is crippling — and common. Graduated exposure is the first step | Gill Straker and Jacqui Winship

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