CBT for Social Anxiety

Looking for information on cognitive behavioral therapy (CBT) for social anxiety? This article explores cognitive behavioral therapy for social phobia (now called social anxiety disorder), and it includes a list of CBT exercises for social anxiety to use with clients. 

What is cognitive behavioral therapy for social phobia?

Social anxiety disorder can be a debilitating mental health condition, causing individuals to feel intense fear of social situations that may feel so overwhelming that it feels beyond their control. 

Formerly called social phobia, social anxiety disorder is more common than you might think. 

According to the National Institutes of Health, social anxiety disorder affects an estimated 12% of American adults at some point in their lives, and it’s more prevalent among females than males.

The premise of CBT is that the beliefs you have influence your behavior. CBT for social anxiety is a structured approach that empowers clients to strengthen their ability to cope in social situations and reduce their overall social anxiety. 

For social anxiety disorder, cognitive behavioral therapy works by helping clients identify their maladaptive cognitions, and it uses specific treatment techniques to cognitively restructure negative thoughts and beliefs. 

CBT techniques include:

Identifying negative cognitions 

This technique focuses on negative core beliefs—about oneself, others, and the world—and the automatic thoughts that can contribute to anxiety. 

For example, a person may believe the core belief of “I am unlovable,” which may lead to the automatic thought: “It’s pointless going on a date because I’m going to get rejected.”

Cognitive restructuring

This CBT technique might involve challenging negative beliefs, automatic thoughts, and thought distortions by identifying evidence in support of them, examples where these beliefs or thoughts have been untrue, and other possible (and more realistic) ways to look at the situation.

Skills training

Learning skills like mindfulness or relaxation techniques can help clients to stay present in social situations, reduce physiological symptoms of anxiety, and distract them from unhelpful thoughts.

Social skills training

Sometimes social anxiety arises from social deficits, such as poor eye contact or a lack of communication skills. Therapy can be a great place to practice these social skills, such as learning to read facial expressions, practicing assertive communication strategies, and identifying and maintaining healthy boundaries.

Behavioral exposure

With the support of a therapist, clients can slowly expose themselves to social situations to overcome their anxiety by facing and confronting their fears. Over time, this helps to increase distress tolerance, improve social functioning, and provide evidence to counter maladaptive cognitions.

Benefits of CBT for social anxiety

CBT for social anxiety has many benefits, including:

• Reduces symptoms of anxiety
  
• Challenges negative cognitions and core beliefs
  
• Enhances self-awareness
  
• Improves functioning and quality of life
  
• Builds self-esteem
• Improves social skills
  
• Promotes social exposure
  
• Strengthens coping skills
• Creates long-term change

Effectiveness of CBT for social anxiety

There is a wealth of research demonstrating the effectiveness of CBT for anxiety disorders and higher response rates than other treatments. 

Specifically, CBT for social anxiety has been shown to have benefits that continue post treatment in comparison to control or waitlist treatments. In another study, researchers found that CBT can be a helpful alternative for individuals who don’t respond to antidepressants.

However, there are also some limitations of CBT for social anxiety. Some scientists, for example, state that meta-analyses of these studies have varied greatly regarding their control procedures and lack of randomization. Additionally, it can be hard to establish how controlled study results differ from “real-world settings.” 

An additional consideration for therapists is the co-occurrence of other conditions, which may impact the effectiveness (and appropriateness) of cognitive behavioral therapy for social anxiety-related symptoms. 

For example, social anxiety is a common feature of autism spectrum disorder, and while certain interventions—like relaxation techniques—may ease the discomfort of social interactions, it is not necessarily appropriate to “treat” autism with any interventions and the use of some techniques, like exposure therapy, could activate more symptoms. 

CBT exercises for social anxiety

There are several CBT-based exercises therapists can use to help clients with social anxiety, including:

Cognitive restructuring 

Exercises like thought records or evidence gathering may be helpful. These worksheets focus on identifying negative thought patterns and challenging the accuracy of thoughts and core beliefs. They can also help to restructure thoughts into more adaptive and balanced thinking.

Behavioral activation 

By using activity scheduling techniques, clients can combine enjoyable activities with a social element to counteract any social avoidance and increase evidence of positive social experiences.

Self-monitoring practices

Participating in daily journaling (like thought record worksheets or daily mood charts) can help clients counteract negative recollections of social situations, link their moods with activities, and track their progress.

Relaxation techniques 

Teaching clients relaxation exercises like square breathing or progressive muscle relaxation can help reduce symptoms of anxiety. These techniques can also equip clients with distress tolerance skills to use in social situations.

ABC model

This technique helps clients analyze situations to understand how it may negatively influence their thoughts, feelings, and behaviors. The acronym stands for:

• Activating or antecedent event: The situation triggering the negative thought or reaction.
• Behavior: Beliefs, thoughts, or attitudes about the situation or event.
• Consequences: The emotional or behavioral responses to the situation or event stemming from thoughts and beliefs.

CBT treatment plan for social anxiety

As a therapist treating social anxiety disorder, cognitive behavioral therapy may be used in the treatment planning process in several ways:

Assessment and goal setting 

The assessment should thoroughly note the client’s social anxiety, including history, triggers, symptoms, and how it impacts daily functioning. 

SMART treatment goals might include:

• Psychoeducation to support the client in understanding the CBT triangle and how it can help improve social anxiety.
  
• CBT for anxiety worksheets that explain cognitive restructuring, behavioral activation, or self-monitoring practices.
  
• Skills training to improve social skills, relaxation techniques, and coping skills.
  

Group therapy 

CBT group therapy may be helpful for clients to learn skills like relaxation techniques, social skills, cognitive restructuring, and behavioral activation. 

Sources

1. Heimberg, R. G. (2002). Cognitive-behavioral therapy for social anxiety disorder: Current status and future directions. Biological Psychiatry, 51(1), 101-108. https://www.sciencedirect.com/science/article/abs/pii/S0006322301011830
2. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3584580/
3. National Institute of Mental Health. (2024). Anxiety disorders. https://www.nimh.nih.gov/health/topics/anxiety-disorders
4. National Institute of Mental Health. (n.d.). Social anxiety disorder. https://www.nimh.nih.gov/health/statistics/social-anxiety-disorder
5. Otte C. (2011). Cognitive behavioral therapy in anxiety disorders: current state of the evidence. Dialogues in clinical neuroscience, 13(4), 413–421. https://doi.org/10.31887/DCNS.2011.13.4/cotte
6. Sokol, K., Fox, M, G. (2019). The comprehensive clinician’s guide to cognitive behavioral therapy. PESI Publishing. 
7. Yoshinaga N, et al. (2016). Cognitive behavioral therapy for patients with social anxiety disorder who remain symptomatic following antidepressant treatment: A randomized, assessor-blinded, controlled trial. https://www.karger.com/Article/Fulltext/444221
   

   

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