Explainer: what is exposure therapy and how can it treat social anxiety?

Most of us experience a level of social anxiety at some point in our lives. We worry about what people think of us, about being excluded, about being judged or humiliated.

Social anxiety is characterised by an excessive fear of negative evaluation or judgement, triggered by social or performance situations. For social anxiety to be considered a disorder, the person must also be distressed by their social concerns or report a disruption in their life. They may find it difficult to interact with work colleagues, to make friends, or even to have brief conversations with others.

Excessive social anxiety makes us feel lonely and reduces our quality of life. Social anxiety disorder is the most common anxiety disorder and begins as early as 11 years of age.

Exposure therapy – where people face their feared social situations, with the guidance of a therapist – is one form of treatment that can be used to reduce excessive social anxiety symptoms. So how does it work?

Avoidance and safety behaviours

Although it’s normal to want to avoid social situations that make us uncomfortable, social fears almost always become worse when we avoid those situations.

Avoidance can mean a conscious decision to avoid a dreaded social situation, such as deciding not to go to a party, or it can mean using “safety behaviours” to cope with or avoid a perceived threat.

Overt safety behaviours might include wearing a hat to cover your face, away from scrutiny. Covert acts involve mental actions, such as excessive effort in memorising a speech before giving it.

People with excessive social anxiety often attribute feeling safer or averting a distressing social situation to the fact they carried out these safety behaviours. For example, “no one looked at me in a weird way because I wore a hat”, or “the speech went OK because I made the effort to memorise it all”.

The problem is, when safety rules becomes established, actions become conditional on them. For example, “the only way I can be safe from scrutiny is to keep my face hidden”. Safety behaviours need to be addressed, or they can undermine treatment and end up maintaining the person’s anxiety levels.

What is exposure therapy?

Exposure therapy is where people face a feared social situation until their anxiety decreases or the anxiety-related expectancies are disrupted.

It’s a well-researched treatment for anxiety disorders and is usually done within cognitive behaviour therapy, which also addresses the underlying unhelpful thoughts.

Exposure to the source of social anxiety is confronting, but it’s possible to achieve your goals with professional guidance. A trained therapist is able to identify the source of these social concerns, how severe they are and whether this has stopped you from doing what you would like to do.

More importantly, a trained therapist can identify and address any unhelpful thoughts and beliefs you may carry.

There are different variations of exposure strategies and the choice of which type to use is dependent on the situation. Real world confrontation, such as speaking in front of a large audience, is one possibility, but it may not always be possible.

Vividly imagining the feared situation, role-playing with the therapist and using technology such as virtual reality can also deliver exposure. Other modes of delivery include flooding (tackling the most difficult task straight away) or systematic desensitisation (often combined with relaxation exercises).

Therapists often grade the level of exposure to social situations that make the person distressed, from easiest to hardest, to ensure the process is safe and tolerable. There is, however, a risk that therapists deliver these treatments too quickly and too much, which can cause distress and a reluctance to try again. Treatment may also be approached in an overly cautious way, which slows down its effectiveness.

How does it work?

Say your feared social situation is going to a party. Here’s an example of how graded exposure therapy might play out:

1) Rank how anxious you feel about going to different types of parties. You can use a 0 to 100 scale (0 refers to no anxiety at all or 100 very anxious) or rank it from lowest to very high anxiety (as below).

2) Select a task lower down on the list. This is a task that you find difficult but feel you can succeed in. If you are unable to stay engaged with this task, go back and select an easier task.

3) Stay in the situation until your anxiety reduces.

4) Repeat it until the task becomes easy. Only move to a more difficult task when you feel comfortable with your current task.

5) Reflect on what happened and what you can take away from the exercise. Some of your predictions of social disasters, for instance, may not have occurred.

Always target something you can succeed in. In this example, option two or three may be too difficult for you to work on. But you may be able to manage option four (having lunch with colleagues).

Don’t rely on your safety behaviours. For example, you may find that you spend a lot of time fiddling with your mobile or drinking too much alcohol to feel more comfortable. If you feel a need to use any of your safety behaviours, first select a task you feel more comfortable with.

Don’t feel like you have to get rid of all your anxiety. It is normal to feel socially anxious. And don’t expect your social anxiety to go away immediately.

Finally, practise again until you feel more comfortable. You can move to a more difficult task only after you feel comfortable with the previous task.

Keep in mind that individual cognitive-behaviour therapy is the single most effective treatment for those with social anxiety disorder, more so than exposure therapy alone. So while exposure therapy may help, it’s best if it forms part of an individual cognitive-behaviour therapy plan.

Michelle H Lim receives funding from the Barbara Dicker Brain Sciences Foundation.