Help clients overcome social fears that lead to skewed perceptions of reality
“I wondered how many people there were in the world who suffered, and continued to suffer, because they could not break out from their own web of shyness and reserve, and in their blindness and folly built up a great distorted wall in front of them that hid the truth.”
– From Rebecca, by Daphne du Maurier
There was a palpable sadness about her: an invisible cloak of hopelessness. Her fear had made her lonely.
“It’s mainly when I meet new people, but I can even feel self-conscious and embarrassed with close friends,” she told me, dejected.
I asked Kay when she felt most anxious. She always tended toward anxiety, she said. But it seemed to peak and reach an excruciating, intense focus when she was around other people. “Parties are the worst. Meeting new people and knowing they’re judging me.”
Kay’s certainty as to what others ‘must’ think was impressive. It always is with chronically self-conscious people. I wish I had that confidence in my own ability to read people’s minds! But of course it’s fear, not perspicacity, that leads people to conflate their imaginings with genuine perception.
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Fear turns us away from truth, from the reality that lies beyond our created scenarios.
But first things first.
The antidote to fear
The antidote to fear is calm. That’s why any practitioner worth their salt will know how to relax their clients.
We may need to deal with the pre-cognitive effects of pattern matching and trauma resolution, both facets of human consciousness that don’t appear to be particularly amenable to cognitive behavioural therapy (CBT).
But used alongside interventions designed to help on the non-cognitive level of human emotional response, CBT techniques can have powerful effects for those suffering from social anxiety.
Here are 3 CBT approaches I used with Kay to help her leave loneliness behind.
Technique one: Breathe out and count
Unless we are calm, our thoughts tend to be cognitive distortions of what we feel rather than reflections of logical truth seeking.
For example, if I am feeling engaged or terrified then I am in ‘fight or flight‘ mode. Or, more accurately, we might call this mode ‘fight, flight, or freeze‘: sometimes during times of such acute stress we feel completely paralyzed. But the point is that such heightened levels of stress drive us into all-or-nothing thought.
Fight or flight is an all-or-nothing response. It moulds your thought processes to fit your prevailing emotions. Your emotions are extreme, so your thoughts are too.
All-or-nothing (sometimes known as absolutist, or black-and-white) thinking tracks alongside all emotional disorders1. The more stress we feel, the more all-or-nothing and extremist our language and thoughts become. This absolutism in turn tends to make us feel more anxious, angry, and depressed.
When we calm down physiologically, the jagged distortions of absolutist thinking tend to smooth over alongside our lowering stress levels.
It’s hard to think “Everybody is going to hate me!” or “I’m going to make an absolute fool of myself!” while feeling calm. This is because feeling calm creates a predisposition to more nuanced – and therefore less extremist – thought.
So how do we help our clients feel calmer?
Maybe the age-old advice to ‘breathe deeply’ springs to mind. But take pause – for some anxious clients, encouraging them to simply ‘breathe deeply’ may make them worse.
Breathe it out
The first thing that changes as we start to feel anxious is our breathing. It’s been found, for example, that breathing can start to alter up to 47 minutes before the onset of a panic attack6. But how does it alter?
It used to be thought that shallow breathing led to panic, but more recent findings5 indicate that deep breathing, that is, breathing deeply on the inhalation, can also disrupt the carbon dioxide balance in the bloodstream. This disruption can cause dizziness, tingling, a sense of unreality and other physical alterations associated with the stress response.
People who feel stressed often breathe in deeply but exhale rapidly. This kind of breathing corresponds to the way we need to breathe while exercising during a physically threatening situation – fight or flight.
So what is the antidote to that kind of breathing? Well, fortunately it’s something you and I probably already do more of when we are stressed.
Sighing away stress
People sigh more not just when they’re tired but also when they’re stressed9. When we breathe out we trigger the relaxation response. So increased sighing may be a sign that someone is instinctively trying to calm themselves down.
When we sigh we extend the outbreath, which is the opposite of the kind of breathing that occurs during the stress response. We can utilize the beneficial effects of sighing to help our socially anxious clients.
The 7/11 technique
If we want to have any hope of calming the stress response, we need to teach our clients the right form of breathing.
I taught Kay to breathe in to the (quick) inward count of 7 and out to the count of 11. The exact numbers don’t matter: it could be in to the count of 5 and out to the count of 7. The point is that when the exhalation is longer than the inhalation the body relaxes – and the mind follows. Rehearse this with your client, and make sure they are breathing slowly and regularly.
Kay started using 7/11 breathing before social events and also sometimes during them, and reported feeling calmer and more in control of her emotionality.
All this is great, but it’s still self-focus. To really kick social anxiety out, something more is needed.
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Technique two: Focus away from the inside of your own head
Mental health corresponds to our capacity to contextualize reality.
Research has found that socially anxious, shy children tend to recall less about their surroundings, including details about other people8. They are inwardly, not outwardly, focused. They tend to focus on their imaginative representation of what they feel is happening or might happen rather than what is actually there. But it’s not just children who do this.
It’s also been found that adults who suffer public speaking anxiety tend to over-focus on themselves at the expense of focusing their attention outwardly3.
If the context we apply to everything is our emotionally-based representation rather than a mindful view of what is, then of course this self-absorption (used here descriptively, not judgmentally) will trip us up.
On the positive side, consciously focusing on our environment rather than ourselves can help us in all kinds of ways – even retrospectively.
Soothing bad memories
It’s been found that recalling the incidental details of painful memories – the context, not the feelings – can help ease the effects of those memories4.
For example, if someone has overwhelmingly sad feelings about a memory we might ask them to widen the context of that time by helping them describe what people were wearing, what the decor was like, and other such incidental details. This can be a highly effective way of helping people contextualize the feelings around a memory and therefore process it and move on.
So how can we use this to help our socially anxious clients relax?
Notice what there is to notice
Kay had an end-of-year work party coming up. I asked her to practice her 7/11 breathing before and during the event if necessary, but also to notice and remember:
- what colour the walls in the venue were (she had not been there before)
- what artwork was on display
- what colour people were most commonly wearing
- something about at least two other people that she had never noticed before.
She completed this task successfully and reported that, along with the 7/11 technique, it helped. In fact, she said, not only could she recall details she wouldn’t have usually noticed, but she had felt much calmer – and even began to enjoy herself!
Technique three: Catch and challenge cognitive distortions
Heightened feelings produce simplified and extremist thoughts that can be so far from reality as to be considered cognitive distortions. We can discuss how this happens with our clients and point out the more obvious ones, such as…
All-or-nothing, extremist, or absolutist thought
- “Everyone is better than me! They’re so perfect!”
- “I am completely weird!”
If your clients report using all-or-nothing thinking, then task them with spotting times when they do and get them to, first, challenge those thoughts, and, second, replace them with more moderate ideas or simply relax with uncertainty enough to wait for actual evidence before leaping to conclusions.
Overgeneralization
- “I felt anxious last time I was out with people, I’m always going to feel anxious with people!”
- “I was rejected by that person, no one will ever want to know me!”
Overgeneralizing the negative is one of the more common cognitive distortions. We often see this in depressed clients.
Ask your client to, first, spot when they overgeneralize, and, second, look for counterevidence. For example, if they catch themselves thinking, “I’m always so afraid of people!” they can think of a time they haven’t been so afraid.
The ‘propaganda’ of the emotional state only likes to feed us examples that fit the state itself. But when we look for counterevidence, we gain power and perspective.
Catastrophization
- “This is going to be a disaster! I’m going to make such a fool of myself!”
- “No one will ever like me. I will die alone!”
When we assume the worst, we conjure all sorts of scary scenarios in our minds. We come to believe that the very worst we can possibly imagine will happen. We feel that all is hopeless. We are shackled by an unwavering belief that negative aspects of reality are fixed but positives are fragile and ‘too good to last’. This is a common negative bias.
Remember, all cognitive distortions ride on the back of fear and anxiety. One way you can help your socially anxious clients challenge such distortions is through Socratic questioning, which simply asks them to expand the context of their cognitive distortions.
For example, we might ask: “Is it possible for someone, do you think, to believe they are not liked as much as they are?” This doesn’t tell your client how to think but rather enables them to loosen up their own thought processes and examine an idea calmly.
This brings us onto the final thinking distortion I want to address here.
Mind reading
- “They must hate me!”
- “They think I’m a total loser!”
Assuming we know what others must be thinking is tantamount to believing we can read minds. When we are anxious we can be quite uncharitable in assuming others are cruel in their thoughts.
I spoke to Kay about research that showed that when people first meet us, they like us more than we imagine they do2. The researchers called this the “liking gap”. It seems we consistently underestimate how much our new conversational partners like us. I think we can all be prone to this type of cognitive distortion.
I have noticed that people can feel better and calmer simply by being aware that they actually do see through a distorted lens. Paradoxically, what we really want is for our clients to be less sure of themselves when it comes to catastrophic and simplistic interpretations of reality.
Of course, for some clients these self-management techniques aren’t enough. They may need a little more.
Going back to basics
Sometimes we might need to teach shy and socially anxious clients social skills. It’s been found, not surprisingly, that shyness correlates with low social skills7. Certainly this isn’t the case for everyone, but consider whether it might be for your client.
For some clients, a crash course in how to put others at ease, how to engage with people, even how to make ‘small talk’ may be a big part of easing their social anxiety. We tend to relax more with what we are good at.
Connected in the deep
The CBT techniques, among others, that I used with Kay helped her relax the emotional parts of her mind so other, more nuanced and context-widening parts could finally have some input.
Kay began to breathe more easily and so think more easily. She started to notice what other people had to say and forget herself long enough to enjoy herself. And when she caught the old habitual distortions trying it on with her, she even started to find their “crass tricks” almost laughable.
She wrote me a card to tell me that life was much better for her. She no longer feared people or what she might be, or seem to be, to them.
And she also wrote something else – a quote from American psychologist William James:
“We are like islands in the sea, separate on the surface but connected in the deep.”
Helping a UPTV client overcome trauma and fear
This client was traumatized some years before when a boy in a school she was working in wheeled into her aggressively from behind. She has felt vulnerable and anxious since this event. She has issues with her knees and is a “small” person, as she describes herself, standing under four and a half feet in height.
She says she has worked on that memory but Mark ascertains the memory has not been properly deconditioned as it still has some traumatic effects. She also feels anxious when out and about especially when walking through the park to work. The goal of the session is to decondition the memory of being attacked at school years before and enabling her to be confident enough to walk in her local park without undue fear.
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About Mark Tyrrell
Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.
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Notes:
(1) Al-Mosaiwi, M., & Johnstone, T. (2018). In an absolute state: Elevated use of absolutist words is a marker specific to anxiety, depression, and suicidal ideation. Clinical Psychological Science, 6(4), 529–542.
(2) Boothby, E. J., Cooney, G., Sandstrom, G. M., & Clark, M. S. (2018). The liking gap in conversations: Do people like us more than we think? Psychological Science, 29(11), 1742–1756.
(3) Daly, J. A., Vangelisti, A. L., & Lawrence, S. G. (1989). Self-focused attention and public speaking anxiety. Personality and Individual Differences, 10(8), 903–913.
(4) Denkova, E., Dolcos, S., & Dolcos, F. (2015). Neural correlates of ‘distracting’ from emotion during autobiographical recollection. Social Cognitive and Affective Neuroscience, 10(2), 219–230.
(5) Meuret, A. E., Rosenfield, D., Hofmann, S. G., Suvak, M. K., & Roth, W. T. (2009). Changes in respiration mediate changes in fear of bodily sensations in panic disorder. Journal of Psychiatric Research, 43(6), 634–641.
(6) Meuret, A. E., Rosenfield, D., Wilhelm, F. H., Zhou, E., Conrad, A., Ritz, T., & Roth, W. T. (2011). Do unexpected panic attacks occur spontaneously? Biological Psychiatry, 70(10), 985–991.
(7) Miller, R. S. (1995). On the nature of embarrassability: Shyness, social evaluation, and social skill. Journal of Personality, 63(2), 315–339.
(8) Roebers, C. M., & Schneider, W. (2010). Individual differences in children’s eyewitness recall: The influence of intelligence and shyness. Applied Developmental Science, 5(1), 9–20.
(9) Vlemincxa, E., Taelman, J., Van Diest, I., & Van den Bergh, O. (2010). Take a deep breath: The relief effect of spontaneous and instructed sighs. Physiology & Behavior, 101(1), 67–73.
