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Introduction
Cognitive behavioural therapy has been a form of therapeutic treatment for persons with several mental disorders for quite some time. It is described as a talking therapy since it involves the use of psychoanalytical facilities testing certain behavioural and cognitive elements (Saunders, 2005).
Social phobia is a manifest form of disorder that hampers an individual’s interaction with the wider society (Leahy, 2003). Social phobia can be specific where it relates to only one aspect e.g. fear of talking to strangers, it can be social anxiety where the individual is generally apprehensive about being in a situation requiring social interaction or it can be social anxiety disorder which is an excessive fear of interaction that borders on mental illness and has to be treated clinically with the help of mental health professionals.
While it is common for people to feel self-conscious or nervous on occasion, social phobia which in this case refers to social anxiety disorder is an extreme form that goes beyond occasional nervousness or shyness (MHF, 2011).
Normal social anxiety occurs commonly during interviews, while anticipating a public speech, meeting strangers e.t.c. However, people with social anxiety disorder have an unfounded fear of embarrassing themselves before others so much so that they go to extraordinary lengths to avoid any kind of social contact that would trigger a moment of social anxiety.
Social phobia can prevent an individual from leading a normal life and thus it needs to be rectified clinically with the help of mental health professionals. It has at times been related to autism and Asperger’s Syndrome (Howlin, 2004).There are several effective treatments for social phobia that involve therapy and other self-help strategies. Of all the kinds of treatments available for social phobia, cognitive behavioural therapy popularly known as CBT has been found to be the most effective.
Understanding social phobia
Before treating social phobia, it is important to understand what it is and what causes it (Rowland, 2000). We also need to know how to identify persons suffering from generalized or specific social phobia from those with an intense form of social anxiety disorder. In general, social anxiety disorder differs from other forms of social phobia by the manner in which the persons suffering from it go to great lengths to avoid social triggers for their condition.
The situations known to trigger social anxiety disorder include simple activities such as public speaking, participating in group activities, making small talk with strangers, debating, performing or even taking foods or drinks in public. These situations act as triggers since they put the individual on the spot yet they prefer to stay away from other people’s focus and attention.
When confronted with the above situations, persons with social phobia develop nervousness and feel jittery. However, for those with mild forms of social phobia i.e. generalized or specific, they can still make it through these activities without incident or resulting to avoidance tactics (Persons, 1989).
For persons with social anxiety disorder, they will exhibit the following psychological symptoms; excessive fear that they will embarrass or humiliate themselves, intense anxiety and worry days, weeks or even months before the social event, extreme self-consciousness in their day to day social encounters, excessive caution while talking to others, avoidance of triggering situations to such a level that ordinary social life becomes hindered or disrupted and excessive fear that others will notice their anxiety and that they will be judged or criticized (Janet, 1976).
There are several physical symptoms that are exhibited by people who suffer from social anxiety disorder. These include chest constriction, muscle tension, a high heartbeat, a trembling that is uncontrolled, nausea, stuttering, faintness, stammering, dizziness, hurried breathing as well as blushing. In children, social anxiety disorder causes the child to avoid playing with others, truancy and feigning sickness to avoid going to school (Jackson, 2002).
Using a CBT Model to understand social phobia
As stated earlier, Cognitive Behavioural Therapy (CBT) is one of the most effective and popular methods for combating social phobia. CBT works on the notion that the various recurring behaviours and thought patterns of individuals are intrinsic to the physical and emotional symptoms of social phobia (Scott et al, 1991).
The CBT process involves the identification, analysis and change of these behaviours and thought patterns with an aim to achieve a counter effect on social phobia and anxiety. The therapy has been effectively applied to assist people with social anxiety producing better results than any psychological technique or medication. This is because of its simple theoretical framework that thoughts affect outward behaviour and vice versa which means that if both are re-programmed, the condition can be reversed.
There have been several cognitive and behavioural models that seek to solve forms of social phobia especially social anxiety disorder. However, the most popular CBT model is the one designed by Clark and Wells (1995). The model attempts to show the various processes that are involved in development of social anxiety. It can assist us to understand the causes of social anxiety/phobia.
The model refers to a trigger situation which relates to the social situation that causes or brings about the feeling or bout of anxiety in the person suffering from social phobia. These situations are as described above and they are all activities that bring about nervousness and jitters even in normal people.
According to Clark and Wells (1995), the trigger situation is responsible for activating the beliefs and assumptions that the individual has about himself or herself, the previous social experiences in the same situation and the specific trigger situation itself.
The second element which is the activation of beliefs and assumptions refers to the ideas, notions and opinions that the individual holds about himself/herself, previous social experiences and the specific trigger situation. Examples include; ”They think I am a nerd”, “they must be judging me negatively”, “I’m not good at this”, ‘there is something wrong with me’ or “people think I am inferior to them.” (Melinda & Ellen, 2011)
The third element “The situation is perceived as socially dangerous” is the cumulative effect of the trigger situation and the negative thoughts that the individual has accumulated about a particular situation and the perception by the person that the situation is threatening or dangerous.
This perception activates three kinds of responses. The first kind is a safety response. Safety behaviours are those that the individual develops to reduce the anxiety of the time or further exposure to the trigger situation. A good example is running away from a conversation, skipping school or work on the day scheduled for public speaking or changing the subject in the course of a discussion to a more comfortable or general topic.
The second response is one of self-consciousness. Here the individual’s senses become heightened when they become a centre of attention. They become aware of their own responses to the trigger situation such as noticing that they are talking in a shaky voice, their hands are sweaty e.t.c.
The last response is the physical reaction to the trigger situation. It includes a pounding heart, tight chest, sweaty hands, quivering voice, heavy breathing and shaking. The three types of responses are correlated. Anxiety increases with self consciousness and this is reflected in the individuals increased perception of danger which causes him to display the physical symptoms of anxiety.
Using Cognitive Behaviour Therapy to solve social phobia
Using the cognitive behavioural model from Clark and Wells, we have identified the causes and process of social anxiety that eventually lead to social phobia. From what we have learnt, it is now possible to recommend solutions for the problem of social phobia using cognitive behaviour therapy. These solutions are meant to be self-help measures for the individual to use to reduce or totally eliminate social anxiety.
Butler (1999) states that more often than not, people are referred to a psychiatrist by their doctors when they exhibit social anxiety disorder. Butler is of the opinion that such a referral is already difficult enough for the person suffering from the disorder since they find it difficult talking to strangers about their condition in the first place.
Another problem is that the demand for therapists may cause the individual to be placed in a long waiting list. Instead, Butler (1999) recommends that the individual might benefit more from group therapy and self help programmes of cognitive behavioural techniques.
The first step in CBT is the identification of the individual’s beliefs. This is because an individual’s perceptions play a huge role in social anxiety. These thoughts can be divided into beliefs, attitudes and assumptions and grouping thoughts into these three categories is the first step in knowing how to change them. Beliefs form that category of thoughts that the individual holds to be true. Butler (1999) states that most of these beliefs are informed by previous bad experiences especially those that occur during childhood and adolescence.
While many socially anxious people hold so many beliefs about their predicament, they have never taken time to examine and question the validity of their beliefs. Some beliefs may be very hard to identify since they may have been formed a long time ago as a response to a traumatic situation which has since been forgotten (Padesky & Greenberger, 1995b).
These beliefs influence behavioural responses greatly e.g. people who perceive others as being hostile are likely to avoid talking about themselves before these people or make small talk with them.
The best way to identify ones beliefs is to think of a specific occasion where one felt socially anxious. Reliving such a situation enables the individual to take particular note of the feelings and thoughts that come to their mind. These feelings and thoughts especially those concerning the individual’s perception of his or her shortfalls, other people’s judgements and attitudes help the individual in identifying their beliefs.
Once the individual has identified his or her beliefs, the next step is to question them to see whether they are valid. More often than not, these beliefs though subconscious are often misplaced and once the individual finds out that their beliefs are false, then they are able to change them appropriately.
Change of belief transforms the individual’s behaviour when confronted by the same situation e.g. when one believes that another is hostile and then finds out that they are actually very friendly, they are more likely to interact with them in a more relaxed and freer way.
The third step in CBT is the identification of behaviour. This involves the individual’s analysis of their reaction when faced with an anxious situation. Again the individual should try to relive a situation when they were socially anxious and then identify the negative behaviours in reaction to the situation.
These negative behaviours may have included; rehearsing words before saying them, locking knees to avoid shaking, holding on tightly to things, keeping a keen eye on an escape route, avoiding full involvement, sticking with persons considered ‘safe’, not taking chances and doing a post-mortem after a bad situation (critically analyzing socially anxious situations after they have happened).
More often than not, these behaviours are informed by incorrect or misplaced beliefs about people or situations. These behaviours usually act as a counter to the threat of social anxiety. Once the individual analyzes their thoughts and behaviours, then they become aware of the causes of their anxiety and can then change their behaviours.
Changing behaviour is the last step in CBT. Heimberg et al (1995) describe a guide to changing behaviour by first listing ones changed beliefs and also becoming aware of one’s behaviours in anxious situations. The individual should then attempt to act differently in the same situation.
The best strategy would be for the individual to take up the role of a behavioural scientist. This would involve placing oneself deliberately in socially anxious situations and avoiding safety behaviours or any other avoidance tactics. Regular exposure to uncomfortable situations helps to grow the individual’s confidence and reduce self consciousness. Growth in self-confidence would lead to a remarkable reduction in social anxiety.
Other strategies for tackling social phobia
One of the most crucial and beneficial techniques for solving anxiety problems that arise out of social phobia are relaxation techniques (Roth & Fonagy, 2003). Relaxation helps to calm the individual down and avoid a panic mood that comes with social anxiety. These techniques should be practiced on a daily basis to produce the best effect and if properly utilized, they can greatly reduce the intensity or frequency of anxiety throughout the day (Wills, 2008).
Yoga is another recommended solution for social anxiety problems. Some therapists recommend Yoga especially the relaxing type that includes meditation (Salkovskis, 1996a; Beck, 1995; Clark & Fairburn, 1996). It is known to soothe the mind and revitalize the body making the individual generally calm and relaxed which eases anxious moments.
Medication could be another solution for social anxiety disorder. While it may relieve the symptoms, it does not cure the disorder. It should thus be used in addition to self-help techniques or therapy (MHF, 2011). Generally, there are three kinds of medication that can lower social anxiety (Salkovskis, 1996b). These are; Beta Blockers which relieve anxiety by blocking the flow of adrenaline released when one is nervous.
They are effective in controlling the physical signs of anxiety but not the emotional symptoms. Antidepressants are used in treating the worst forms of social anxiety disorder. Examples are Effexor, Zoloft and Paxil which have been recommended by therapists as being effective in countering the effects of social phobia. Finally, there are Benzodiazepines which usually provide quick relief for anxiety. They are often addictive and sedating in nature and should therefore be used as a last resort (American Psychiatric Association, 2004).
Another excellent way to relax the mind is hypnotism. However, private hypnotherapists are quite expensive and one session may cost up to £50 sterling (Melinda & Ellen, 2011). Roth & Fonagy (1996) suggest that changing one’s lifestyle can also help to relax the mind and reduce social phobia. This could be by ensuring one gets enough sleep, avoiding caffeine, drinking alcohol in moderation and avoiding smoking.
These measures are recommended by the World Health Organization (WHO,1992).Though these measures may lower the intensity of social phobia, they cannot completely cure it. Finally, one can reduce their social anxiety by joining group clubs such as drama and debating which boost one’s stage confidence and expose him or her to more anxious moments until they learn to cope (McKenna, 2006).
Conclusion
As we have seen above, CBT is a very effective method of reducing social phobia. This condition limits the individual’s interaction with others which may hinder their day to day social life. However, CBT provides simple and practical solutions to the problem. The effectiveness of CBT however relies on the individual’s openness to learn and willingness to change (Padesky & Greenberger, 1995a). It is an involving process that requires an individual’s zeal to become a socially healthy person.
References
American Psychiatric Association, (2004). Diagnostic and Statistical Manual for Psychiatric Disorders. Washington DC, USA.
Beck. J. S (1995). Cognitive Therapy, Basics and Beyond. New York: Guilford Press
Butler, G., (1999). Overcoming Social Anxiety and Shyness: A self help guide using Cognitive Behavioural Techniques. London: Robinson
Clark, D.M., & Fairburn, C.G. (1996). The Science and Practice of Cognitive Behaviour Therapy. New York: Oxford University Press
Clark, D. M. and Wells, A. (1995). A cognitive model of social phobia. New York: Guilford.
Heimberg, R.G., Liebowitz, M.R., Hope, D.A., Schneier, F.R., (1995). Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guildford Press
Howlin, P., (2004). Autism and Asperger Syndrome: preparing for adulthood. USA & Canada: Routledge
Jackson, L., (2002). Freaks Geeks and Asperger Syndrome: A User Guide to Adolescence. London: Jessica Kingsley
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Leahy, R.H. (2003). Cognitive therapy techniques. New York: Sage
McKenna, P. (2006). Instant Confidence: The Power to go for anything you want. Bantam Press
Mowrer, OH. (1960). Learning theory and behavior. Wiley: New York.
Neale, John M.; Davison, Gerald C. (2001). Abnormal psychology (8th Ed.). New York: John Wiley & Sons
Persons, J.B. (1989). Cognitive Therapy in Practice: A case formulation approach. New York: Norton & Co
Padesky, C. A. and Greenberger, D (1995 a). Clinicians guide to mind over mood. New York: Guildford Press
Padesky, C. A and Greenberger, D (1995 b). Mind over Mood. New York: Guildford Press
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Roth, A. and Fonagy, P. (2003). What works for whom: A Critical Review of Psychotherapy Research. New York: Guilford Press
Rowland. N, S. (2000). Evidence-Based Counselling and Psychological Therapies: Research Applications. London: Routledge.
Salkovskis, P. (1996 a). Trends in Cognitive and Behavioural Therapies. New York: John Wiley & Sons
Salkovskis, P. (1996 b). Frontiers of Cognitive Therapy. New York: Guildford Press
Saunders, D. & Willis, F. (2005). Cognitive Therapy, An Introduction. London: Routledge
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World Health Organisation (WHO) (1992). International Classification of Mental Disorders. (ICD 10). Geneva: WHO
Wills, F. (2008). Skills in Cognitive Behaviour Counselling Psychotherapy. London: Nelson-Jones
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