Exposure Therapy for Social Anxiety

Many people struggle with social anxiety. It’s like having a tiny critic in your mind who will criticize and scrutinize you when you’re in social situations. It can make small things, like going to the grocery store, feel like an impassable challenge filled with fear of being judged or rejected. Often, those with social anxiety will do everything in their power to avoid situations that will trigger that intense discomfort. This can then lead to an impacted ability to pursue relationships and opportunities, and can sometimes make social anxiety worse.

If any of this resonates with you, know that you are not alone, and there is treatment for social anxiety. One of these treatments that we will be focusing on in this tip is “exposure therapy.”

What do you think of when you hear the term “exposure therapy?” Exposure therapy carries with it all sorts of stereotypes. Exposure therapy is an evidence-based treatment aimed at helping someone overcome a fear that they have while in a safe environment. Exposure therapy is a technique developed to address anxiety and fear-based disorders. It aims to reduce the maladaptive responses to stimuli by exposing a person to the thing they are afraid of in a controlled and gradual manner. When a client is in a safe space, like a therapy office, this treatment can begin to rewire the brain and decrease symptoms of anxiety.

An important note: Exposure therapy is not to be used when you are experiencing suicidal thoughts, exhibiting a psychotic disorder, or when experiencing dissociation. Exposure therapy is something that needs to be done with the help of a professional who can help walk you through the steps to make sure that exposures take place in a controlled and gradual manner.

Types of Exposure

Two main forms of exposure could take place in a therapy setting; imaginal and in vivo. Let’s dive in to better understand what exposure therapy for social anxiety might look like.

Imaginal exposures take place when a client creates imaginary confrontations of their feared thoughts, memories, or mental images. This can be helpful when addressing fears that are challenging, or impossible, to replicate in real life. Let’s imagine that imaginal exposure is being used to address a severe fear of going to the grocery store. In imaginal exposures, a therapist might ask a person to vividly imagine a scenario related to going to the grocery store that causes them anxiety. A client might imagine getting in the car to head to the store, putting items in their cart, or even making small talk with the cashier. The client would be encouraged to imagine the details of the scene, including the thoughts, emotions, and physical sensations that were coming up for them as they were imagining the scenario. Over time with repeated exposures, the goals would be for the client to gain a sense of control over their anxious thoughts and reactions, which would then lead to lessened anxiety related to going to the grocery store.

The other type of exposure is called in vivo exposure which involves real-life confrontation with anxiety-inducing situations or stimuli. Using the same example of fear of going to the grocery store, a therapist might ask a client to take a series of gradual steps to eventually approach the feared scenario. Starting with similar visualization techniques as imaginal exposures; a client might be asked to visualize getting in the car to head to the store, putting items in their cart, or even making small talk with the cashier, or even running into someone they know.

A therapist might ask the client to document their thoughts and feelings along each step. The next in vivo exposure might be for the client to visit the grocery store without the intention of speaking to anyone. Another step might be for the client to purchase a few things, say hello to their cashier, and then leave, thus allowing them to control their fear in a controlled and supportive environment, all the while addressing the thoughts and feelings that come up. Throughout each step, a therapist would provide support and help the client identify tools and strategies to manage their anxieties as they confront their fears.

The Anxiety Hierarchy

Creating an “anxiety hierarchy” is a pivotal step in exposure therapy for social anxiety. This is when the client and therapist work together to identify and rank situations or stimuli that trigger anxiety. This way the client has a roadmap that can serve as a guide to the progression of the exposure. Clients start with the least anxiety-provoking scenarios and gradually move up to more anxiety-provoking scenarios as they gain confidence and demonstrate mastery over their fears.

Exposure Activities for Social Anxiety:

Create a fear hierarchy: List situations related to social anxiety from least to most anxiety-provoking to better understand where you are in the hierarchy and where you could grow.

Explore Root Causes of Social Anxiety in Therapy: There are many different reasons that someone might be experiencing social anxiety. One helpful place to start might be exploring some root causes of your social anxiety in a safe, supportive, and non-judgemental space.

Join a Club or Group: Finding a group that shares your interests can help create a common ground to make social interactions more comfortable. This group could be anything, a book club, a fitness class, or a hobby group. Take a moment to check in with yourself. What would joining a club or social be like for you? Does it bring on some anxiety? It is exciting to think of the possibility of joining with others.

Online Interactions: Consider engaging in an online social space. This might be a helpful first step as it allows you to practice socializing from the comfort of your own space! With intentional practice, this might help you feel more comfortable transitioning to in-person interactions.

At the Center for Growth, we strive to provide a place for people to navigate their social anxiety both through individual therapy and group therapy. You can find more about our Anxiety and Depression support group offered on Tuesdays at 6 pm.

Practicing Social Scenarios: With a therapist or trusted friend, practice role-playing social scenarios that often ignite your social anxiety. This can help you anticipate and manage anxiety-provoking situations.

Volunteer Work: Joining a volunteer organization can be a great way to work on your social anxiety. When volunteering, you are working with others towards a shared goal. This can help make interactions to be more natural!

One place to start might be volunteering with your local SPCA.

Attending Small Gatherings: In exposure therapy, we always start small and work towards bigger goals. One way to start small might be to focus on going to smaller gatherings where you can have a more intentional interaction with someone. This could look like going to dinner with a few friends or attending a casual get-together.

Coping Skills for Social Anxiety:

Coping skills are tools that you can learn to help manage your social anxiety. While there are many different kinds of coping skills, the few mentioned below are a helpful place to start when working towards lessening the symptoms of your social anxiety.

Mindfulness and Relaxation Techniques: When faced with stressful social situations consider using techniques such as box breathing or progressive muscle relaxation. These techniques can help calm yourself down and have a less judgmental approach to your environment.

Box Breathing: Box Breathing is a simple yet effective relaxation technique that might be useful when you feel yourself enter a flight reaction. As your body is preparing you to respond to a threat, you can practice box breathing to calm down your nervous system, activate your soothing system, and tell your body that there isn’t a threat. To practice box breathing imagine following the sides of a square shape. As you go along the top of the box from left to right you inhale for a count of for. As you go down the right side of the box you hold that breath for four counts. As you go along the bottom of the box from right to left you slowly exhale for four counts. And then as you follow the left side of the box from bottom to top, you hold that breath for four counts. You can repeat this technique as needed until you feel your body start to calm down.

Progressive Muscle Relaxation: Progressive muscle relaxation is a helpful technique when entering into a fight response. This involves tensing and then gradually releasing different muscle groups in your body. When you intentionally relax your muscles you can teach your body that you are safe and do not need to prepare for a fight. This can help promote a greater sense of calmness and activate a soothing system in your body to counteract the physical tension that often accompanies the fight response. Start with your toes; curl them tightly for a count of five and then release the tension and relax completely. Repeat the process with your feet, calf muscles, thighs, buttocks, abdomen, chest (take a deep breath, hold for five, and then exhale slowly), hands and forearms, biceps, shoulders, neck, face, and then the whole body.

Understanding Cognitive Distortions: Cognitive distortions are exaggerated or irrational patterns that can contribute to social anxiety. These kinds of thoughts can distort how we view ourselves and others in social situations. A common example of a distortion is “mind reading” where someone assumes that everyone around them is thinking of them negatively. A good way to challenge these distortions is to recognize them when they are happening. Asking yourself questions like “What evidence do I have to back this thought up?” and “Is this thought helpful to me” can be a good first step in stopping the thought in its tracks. Understanding cognitive distortions is especially useful when using exposure therapy for social anxiety since it allows you to have a defense for thoughts that come up during exposures.

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Exposure therapy for social anxiety might seem daunting, but know that it’s ok to take small steps, and celebrate wins, large or small!