Cognitive Behavioral Therapy (CBT) is a research-based, short-term treatment approach for many mental health concerns, including social anxiety disorder. CBT is one of the most practical and results-oriented approaches used for treating social anxiety, and those who use this method to treat social anxiety have a remarkably high success rate.1
Social Anxiety Disorder is characterized by intense fear or anxiety related to social situations in which someone fears they may be judged by others. CBT for social anxiety usually consists of weekly, one-hour sessions, and usually lasts between four to six months.
How Can CBT Help With Social Anxiety?
Cognitive Behavioral Therapy helps people understand the ways in which behaviors are influenced by thoughts and emotions. It can also help people recognize and refute irrational thoughts that contribute to a decrease in healthy behaviors. CBT utilizes coping skills and exposure therapy to reduce anxiety symptoms, including those associated with social anxiety disorder.
CBT aims to help the individual understand what their irrational thoughts are and provide skills and techniques for debunking the irrational thoughts. Relaxation and mindfulness training are also key components to CBT that can help reduce social anxiety.
Goals of CBT for Social Anxiety Disorder
The overall goal of a CBT therapist is to help the individual learn to utilize the skills learned in therapy outside of sessions. CBT therapy is designed to be short term because the individual is learning to use practical skills that can be generalized and applied throughout their life. A large part of predicting success in therapy comes from the willingness of the individual to put forth the effort required for change to occur.
Common CBT Techniques for Social Anxiety Disorder
CBT uses many different techniques, exercises, and practices to elicit change. When working with someone who has social anxiety, there are certain aspects of CBT that tend to provide the most relief for the individual, like cognitive restructuring and setting S.M.A.R.T. goals.
Some of the more common CBT techniques used for social anxiety include:
Psychoeducation
Psychoeducation is a core tenet in most modalities including cognitive behavioral therapy (CBT) that involves providing the client with knowledge regarding their psychiatric condition, symptoms, and how CBT can help. The therapist also explains the rationale for interventions being used to treat social anxiety while also fostering a collaborative relationship that will lend favorable treatment outcomes.2
ABC Model
The ABC model is designed to aid in evaluating situations and outcomes, often used to help predict likely outcomes based on beliefs and past behaviors.3
- Antecedent: The situation or activating event.
- Beliefs: Your beliefs about the event, both conscious and subconscious.
- Consequence: Your behavior or emotional response to the event.
When we break down past situations into these categories, we can begin to understand how our beliefs, whether rational or irrational, determine the outcome of the situation. We can then begin to make changes to both our beliefs and behaviors to create more desirable outcomes.
Example: Someone is invited to a friend’s birthday party but doesn’t know a lot of the other guests attending, making them feel hesitant to go. The ABC model can help them identify past experiences of parties with mostly strangers and work through likely scenarios of this current party by dissecting conscious thoughts and subconscious thoughts about the party and what the response could be.
S.M.A.R.T. Goals
S.M.A.R.T. goals are set by the individual with the aid of their CBT therapist.4 S.M.A.R.T. stands for:
- Specific: The client should know exactly what it is that they are to accomplish.
- Measurable: The client must be able to monitor their progress to know when they have reached their goal.
- Attainable: The client must possess the skill and resources required to reach their goal.
- Realistic: The client must be willing to devote their time and energy into accomplishing the goal.
- Time-specific: The client needs to set a clear and specific end date to complete their goal.
While S.M.A.R.T. goals are set by the individual, it is done so under the supervision of the CBT therapist. The therapist’s role is to ensure that the parameters for a S.M.A.R.T. goal are met to ensure the likelihood of success.
Example: The same person mentioned above has a big group meeting coming up at work and is reluctant to speak up about a topic they are an expert in. They could benefit from setting a SMART goal to combat the social anxiety and speak up and take ownership of a subject matter they are an expert in. They can do this by remembering they are going to speak on one topic at the meeting (specific), which is 30 minutes (measurable). This person is the expert on the subject and will have the resources available in the office to present on this topic (attainable and realistic), and will only have to present once (time-specific).
Cognitive Restructuring
Often, the cause of many anxiety problems is our faulty thinking about ourselves and our environments. For this reason, cognitive restructuring is a key component of a CBT therapist’s technical approaches. Cognitive restructuring involves discovering, challenging, and replacing negative or irrational thoughts with positive, rational ones.5
Example: Someone was invited to go to a concert with a friend but is hesitant because the crowds for this particular band are very large and loud. Cognitive restructuring can help to identify the dysfunctional thought (fear of having to talk with or be in close proximity with strangers) with a functional thought (these are strangers and I will never see them again, this moment is fleeting and this situation will end soon). To add, cognitive restructuring can also help to reframe the consequence of the dysfunctional thought to a potential reward with the functional thought.
Exposure Therapy
Since people with social anxiety disorder tend to avoid situations that cause their anxiety, the use of exposure therapy as part of their treatment is highly effective. Exposure therapy involves exposing the individual to the stressful stimulus until their level of anxiety decreases. With continued practice they begin to become desensitized to the stimulus.6
There are several variations of exposure therapy:
- In vivo exposure: Involves directly facing the anxiety-provoking stimulus in real life. With social anxiety, this would involve exposing the individual to a social situation known to elicit fear.
- Imaginal exposure: Involves intensely visualizing or imagining the stimulus. When using this type of exposure with social anxiety, the individual would be asked to describe a social situation that would trigger their anxious response.
- Virtual reality exposure: Virtual reality exposure uses technology to aid in exposure. This could be used to create a virtual social situation, such as giving a speech in front of a large crowd, where the individual would be virtually exposed to the stimulus.
There are also different paces of exposure therapy:
- Graded exposure: This involves ranking an individual’s fears in a fear hierarchy, and exposure begins with the lowest ranking, or least provoking fear and working up toward higher-ranking fears.
- Flooding: Also involves fear hierarchy ranking, but starts by exposing the individual to the fear that is the most anxiety-provoking first and working down the list.
Example: The same person invited to the concert could use exposure therapy to work through social anxiety. They could work with the guidance of a therapist who would slowly introduce them to small groups then to crowds, either directly or through guided visualizations. For this to work, the person must continue this exercise until they are desensitized to crowds.
Assertiveness & Problem-Solving
People with social anxiety disorder often feel that they lack social skills or have difficulty using these effectively which may further perpetuate their negative self-view and social avoidance. Developing assertiveness and problem-solving skills can be key in counteracting these maladaptive thoughts and behaviors that feed into the disorder.
Developing assertiveness skills can enhance communication and help you establish healthy social interactions. Becoming a better problem solver can boost your self-confidence and help you feel less anxious when dealing with life and social stressors. These skills are taught and rehearsed in therapy and encouraged to be practiced after sessions.7
Relaxation Exercises
Relaxation exercises are another important component of CBT used for treating anxiety disorders like social anxiety disorder. Relaxation exercises include grounding exercises, breathing techniques, and muscle relaxation. Relaxation training can be combined with other therapeutic approaches like exposure therapy. The combination of these two techniques is used in systematic desensitization, which works by learning to associate feared social situations with relaxation.
Example: Someone is meeting the family of their significant other over the holidays and has a lot of anxiety about both meeting the family and anxiety over the large number of people. Relaxation exercises can really help to soothe social anxiety. When the person is in close contact with others, they can use breathing exercises and muscle relaxation to help ground themselves. They can do this until they can begin to feel calmer and with repetition of this practice and time, the individual can begin to associate being with their significant other’s family with a positive feeling.
Is Cognitive Behavioral Therapy for Social Anxiety Disorder Effective?
Cognitive Behavioral Therapy is one of the most empirically researched treatment methodologies, and the research supports CBT as a highly effective treatment for anxiety disorders, including social anxiety disorder.
- In a random control trial, over a series of 12 sessions, it was found that CBT was more effective than ACT in improving social anxiety symptoms9
- In another study aimed at looking at maladaptive self-beliefs of those with social anxiety, it was found that over 12 weeks of CBT, these maladaptive self-beliefs decreased and reduced the severity of social anxiety symptoms.10
- In a study examining individuals with SAD with co-occurring psychosis, it was found that group CBT helped to reduce symptoms of social anxiety and depression.11
How Long Does CBT Take to Treat Social Anxiety?
Seeing results from CBT treatment depends on the person and the variability of their symptoms, which can impact how long they participate in CBT treatment. The standard treatment model of CBT is 10 to 12 weekly sessions, each session lasting about an hour. CBT effectiveness can take time, depending on other mental health issues the individual is dealing with or other traumatic histories which may be at play. It’s important to go in with an open mind and with hope that, with the guidance of a therapist, you can work through these issues.8
Finding a Social Anxiety Therapist
Because of its high success rate, many providers use Cognitive Behavioral Therapy to treat a vast number of mental health issues. Finding CBT counseling for social anxiety in your area can be done with an internet search or by asking for a referral from your primary care provider. Using an online therapist directory can help, as they allow you to narrow your search by location and type of therapy, as well as a list of other factors you may want to consider.
When searching for a CBT provider, you may want to ask about their CBT training as well as how long they have been practicing using this type of therapy and how much experience they have treating social anxiety. All CBT providers should hold appropriate licensure.
Can CBT Work Online?
Online CBT can be very effective in treating social anxiety disorder due to the issues pertaining to this specific disorder being rooted in being around new people and situations. Online therapy can give individuals with social anxiety the outlet they need from the safety and security of a place they know, which can make therapy both more appealing and practical. In a meta-analysis of in-person CBT versus online CBT, it was found that online CBT had a significant impact on reducing social anxiety and that it can be just as effective online as it is in person.12
How Much Does CBT Cost?
CBT is generally covered by mental health insurance. The cost of therapy can depend on your location and the provider’s credentials, and there is still usually a copay for mental health services, which can range from very low to upwards of $100 depending on the network. Looking at “in-network” providers might be able to help with the out-of-pocket costs with copays and keep it on the lower end. Out-of-network providers or therapists who do not accept insurance may charge anywhere from $80 to $200 a session, some of whom may have a sliding scale option.
Coverage for online CBT depends on the individual’s health insurance and specifically the mental health benefit. Many insurances are beginning to cover online therapy costs as well, but this is not universal, so it’s important to contact your insurance company and ask about this coverage if you’d rather find a CBT therapist online.
Examples of CBT for Social Anxiety
Social Anxiety Disorder can present in different ways for individuals depending on their specific social fears. Treatment often involves taking a close look at the types of environments that are causing anxiety.
Trouble Conducting Meetings at Work
Steve is a 46-year-old male who was recently promoted at work. One of his new responsibilities is conducting weekly staff meetings. In these meetings, Steve must stand in front of coworkers and present information related to company functioning. Steve had never been comfortable with public speaking, always fearing he would make a mistake or say the wrong thing and appear incompetent.
Before the first staff meeting that Steve was to present, he experienced symptoms of rapid heart rate, heavy breathing, nausea, and difficulty concentrating. Steve immediately went to the emergency room thinking he was ill. After being evaluated by a doctor, Steve was informed that what he had experienced was a panic attack. The doctor referred him to a CBT therapist to help him understand what had led to the panic attack.
Steve had a panic attack, but the underlying condition is social anxiety. While Steve may also need to work on CBT coping strategies to combat future panic attacks, such as relaxation exercises, he may also find exposure therapy beneficial in helping him overcome his fear of public speaking.
Adjusting to College Life & Making New Friends
Sara, an 18-year-old college freshman, is adjusting to starting her first semester of college. She had moved out of state and away from her friends and family, and she is having trouble making new friends because of her shy personality. When in social situations, like working on group projects for class, she becomes extremely uncomfortable and has a difficult time interacting with her classmates. She always feels like the others are judging her or talking about her behind her back.
She became so preoccupied with their scrutiny that she began missing classes, which led to poor academic performance. She called her mom crying after weeks of feeling anxious and isolated. Her mother convinced her to make an appointment at the university’s counseling center.
Sara’s social anxiety makes it difficult for her to engage with others as she fears that they may be secretly judging her. Sara could benefit from a skilled cognitive behavioral therapist working with her to challenge her irrational thoughts about being judged by her peers.
Trouble in a Classroom Setting
Abby is 7 years old and in first grade. At her parent-teacher conference her teacher informs her parents that Abby is very bright and does well academically. She then addresses concerns for her social development. Abby’s teacher says she doesn’t like to read aloud in class or share stories during story time, and she even tried to hide when it was her turn for show and tell. She also said Abby prefers to play alone at recess instead of engaging with the other children. The teacher advised Abby’s parents to seek therapy for Abby to work on social skills.
Abby may find help from a CBT Therapist who specializes in working with children, who can help her understand the ABC model and how her thoughts and emotions help her make decisions. She can also learn how to use relaxation techniques during exposure therapy conducted in anxious social interactions, and begin replacing her anxious feelings with these new feelings of relaxation.
At-Home CBT Exercises for Social Anxiety
If you are experiencing social anxiety, it is best to seek professional help. However, there are some CBT exercises you can do on your own which may alleviate some symptoms. Like any other new skill, they may feel uncomfortable at first. But the more they are practiced, the more effective they wIll be in reducing anxiety.
Deep Breathing Exercise
There are an abundance of simple deep breathing exercises that can be performed at home.
To do one of these exercises at home:
- Breathe in through your nose for 5 seconds.
- Hold the breath in your lungs for 5 seconds.
- Breathe out through your mouth for 5 seconds.
- Repeat.
You can practice this technique for 5-10 minutes at a time and can be used to calm your breathing and slow your heart rate when you are feeling anxious in social situations without drawing attention to yourself.
Grounding Exercise
Use a grounding exercise to keep your focus on the here and now in social situations by seeking out sensory stimuli in your current environment.
To do a simple grounding exercise, focus on finding:
- Five things you can see
- Four things you can touch
- Three things you can hear
- Two things you can smell
- One thing you can taste
These are just a couple of CBT techniques that you can try for yourself. Of course, other aspects of CBT, like exposure therapy, should be done with the help of an experienced cognitive behavioral therapist.
For Further Reading
CBT for Social Anxiety Infographics
