Exposure Therapy for Social Anxiety

What Is Social Anxiety?

Social anxiety disorder (SAD), or social phobia, is a common mental health disorder experienced among diverse cultures and age groups. SAD affects 15 million adults, or 7.1% of the U.S. population.¹ A person with SAD has an irrational fear of being judged, scrutinized, or humiliated in social or performance situations; these symptoms negatively impact their overall functioning.

Symptoms of social anxiety include:

• Excess fear of situations in which one may be judged, evaluated, or scrutinized
• Intense fear of interacting with strangers
• Worry about embarrassment, humiliation, or rejection
• Concern about offending someone
• Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling, or having a shaky voice
• Experience a rapid heart rate
• Feel their “mind going blank” or feel sick to their stomach
• Find it difficult to make eye contact, be around people they don’t know, or talk to people in social situations, even when they want to.
• Avoid places where other people are present

Common Situations That Cause Social Anxiety

Numerous situations can trigger social anxiety symptoms. Bringing awareness to the settings and situations that trigger these symptoms is a great first step in learning to manage this condition. It’s important to remember that each person’s social anxiety disorder experience is unique; a situation that triggers one person may or may not trigger another.

Common situations or events that cause social anxiety include:

• Speaking or presenting in front of a group
• Having casual conversations with strangers
• Sharing personal information
• Meeting someone new
• Hanging out with a group of people
• Eating or drinking in front of others
• Talking with an authority figure
• Job interviews
• Dating
• Answering a question in class
• Talking to a cashier at the store
• Calling an establishment to make an appointment or reservation
• Attending a group work meeting

Why Is Avoidance Behavior a Problem for Social Anxiety?

Avoidance behaviors for those with social anxiety can look like making up excuses to avoid attending a social gathering or presentation/performance, leaving gatherings early, avoiding eye contact, not answering calls or texts, self-isolation, and more. Engaging in these behaviors often feels helpful at the moment but can cause more long-term harm than good. Whenever we engage in avoidance behaviors, we reinforce and strengthen the internal fear response over time.²

People use avoidance behaviors to distract themselves from uncomfortable or distressing thoughts, feelings, and situations. These behaviors are extremely common in those who struggle with social anxiety, as they can serve as a natural coping mechanism for the discomfort and pain associated with the disorder.

What Is Exposure Therapy?

Exposure therapy is used for disorders that cause high stress and worry. This treatment helps the client approach and engage with the source of their distress. Clients are taught that facing their fears (in a safe and structured way) rather than avoiding them decreases anxiety symptoms and increases comfort and confidence in various situations and experiences. Vividly imagining the feared situation, role-playing with the therapist, and using technology such as virtual reality can also deliver exposure.

A trained therapist normally conducts exposure therapy treatment in a clinical setting. Exposure therapy generally lasts between 6-12 sessions with 50-minute weekly sessions for milder psychological conditions, while longer-term treatment may be necessary for more severe cases. Length of treatment will often depend on the condition being treated, intensity of symptoms, complications during treatment, or the presence of co-occurring disorders.³

How Is Exposure Therapy for Social Anxiety Different From Other Approaches?

Exposure therapy for social anxiety differs from traditional talk therapy in that the approach is more hands-on and experiential. Through experience, clients can realize that the outcome they are most afraid of truly may not occur. And even more importantly, they know that if a feared outcome does occur, they are resilient enough to overcome it.

What Is Virtual Reality Exposure Therapy for Social Anxiety?

Virtual reality exposure therapy (VRST)  is a computerized exposure therapy. Sometimes, a virtual reality headset is used to induce a sense that a person is in a portrayed setting/experience. In a controlled and safe environment, the patient is exposed to their social anxiety triggers using computer graphics and body tracking. During a session, changes in the body are tracked by monitoring respiration and heart rate through biofeedback equipment.⁴

VRST is commonly used to help treat social anxiety and other specific phobias. Let’s say a client struggles with the fear of public speaking due to social anxiety. VRST has been adapted to stimulate the setting and environment of public speaking. Because public speaking may not be easily accessible in the real world for most clients, VRST is an excellent and accessible alternative.

How Does Exposure Therapy for Social Anxiety Work?

Exposure therapy can help reduce social anxiety without the use of medication, and can also be taken as a supplemental treatment alongside medication. Treatment begins by first creating a hierarchy and ranking feared situations in order from least to most anxiety provoking, starting at the bottom. You can use a scale  from 0-100 where 0 refers to no anxiety at all, and 100 refers to very high anxiety. Then the client will select a task lower down on the list to attempt, this task may be difficult but the client will feel confident they can succeed.

The therapist will teach the client helpful ways to cope with the discomfort that arises while they are exposed to their fears. The client will then stay in this situation until anxiety reduces and repeat it until the task becomes easy. Lastly, the client will reflect on their experience with the therapist and continue the exposure process as they move up their hierarchy of fears.

The following theories contribute to the effectiveness of exposure therapy for social anxiety:

• Habituation theory: When repeatedly exposed to a feared stimulus, the reaction to the stimulus reduces, and familiarity or comfort increases.
• Extinction theory: The feared response becomes “extinct” when the feared stimuli do not result in the projected negative outcome.
• Emotional processing: Difficult emotions can distort a person’s thinking and physiologically keep the nervous system in a state of “I’m in danger.” Through emotional processing skills learned in treatment, a person can learn to reframe limiting beliefs and perspectives.
• Self-efficacy: By increasing a person’s resilience and internal resources, they can feel more capable and confident in their environment. With increased self-efficacy, people feel more grounded and willing to take risks.⁵

Examples of Exposure Therapy Techniques for Social Anxiety

Exposure Therapy techniques for social anxiety are recommended to be performed and guided by a trained therapist, especially if your symptoms are severe enough to impact your overall functioning negatively. Some strategies can be tried at home, though, and exposure to these experiences can effectively decrease your overall SAD symptoms.

Common exposure therapy strategies for overcoming social anxiety include:

• Virtual reality exposure therapy: A computerized form of exposure therapy that utilizes biofeedback equipment to track and monitor respiration and heart rate during exposure.
• Ask someone what time it is: Stopping someone in the store or on the street to ask for the time is a great step/example of exposure therapy. Essentially, you risk stepping into the unknown, unsure how the person you approach will respond. The person will likely respond favorably, reinforcing safety in approaching others.
• Join a conversation: Take a deep breath and chime in during a conversation. This can reinforce the belief that your thoughts and opinions matter and are worthy of being heard. Also, you may realize that talking to others is less scary than you thought!
• Take an improv class: Improv is a form of theater, usually comedic, where everything is made up on the spot! Improv can help you become more present and less self-conscious and can help in desensitizing you to the fear of failing. Plus, you can meet others with a similar goal and have the guidance of a teacher to help.
• Record yourself: Record yourself giving a prepared short talk, then watch the recording. You can then post the recording on a social media platform, like YouTube or Instagram/Facebook. This can help you feel more comfortable speaking in front of others.
• Introduce yourself to people you don’t already know in your neighborhood: You can also use this strategy in your workplace or school. Not only are you practicing stepping out of your comfort zone and taking a risk, you’re gaining new connections along the way with this strategy!
• Share your opinion on social media, in an article, or online video: Share an intentionally different view, and practice expressing thoughts and ideas you’re passionate about.
• Role play with friends, family, or colleagues: Role-play a conversation that you may feel anxious about. Possible role-play topics: Asking someone out on a date, job interview practice, how to be assertive or set a boundary with someone, or even how to introduce yourself.
• Talk to store clerks or cashiers at any store of your choice: Both grocery and retail stores are great options for practicing asking the employees questions about products, store hours, etc.
• Call restaurants or other establishments: Ask about their hours and services as if you were to set up an appointment or reservation. At the end of the call, you can simply say, “Thank you, I’m going to give you a call back if I decide to reserve a spot.”   

What Is the Effectiveness of Exposure Therapy for Social Anxiety?

Exposure therapy is regarded as the gold-standard treatment for social anxiety disorder.⁶ According to EBBP.org, about 60 to 90 percent of people either overcome their social anxiety or have milder symptoms after completing exposure therapy. Additionally, combining exposure therapy with cognitive behavioral therapy (CBT) for social anxiety, relaxation techniques, and other treatments may also enhance the effectiveness.⁷

How to Find Exposure Therapy for Social Anxiety Treatment

Finding a trained therapist is your first step if you or a loved one can benefit from exposure therapy for social anxiety. You can find a therapist by asking people you know and trust for recommendations, checking with your health insurance for a referral list, or using an online therapist directory. Both in-person and virtual therapy are effective when utilizing exposure therapy for social anxiety.

In My Experience

I have seen that my clients who make the most progress are those who choose to practice getting out of their comfort zones while being highly compassionate with themselves at the same time. I have learned that somewhere along the line, a person with social anxiety internalized that it’s unsafe to share their voice or authentic selves with others.  At the core, someone with social anxiety may experience a more profound fear of rejection, a deep fear of being seen. To truly empower this person, guiding them to feel secure within themselves is key. Rather than ‘needing’ approval or validation from the external world, they can learn to look inward and receive that approval, validation, and sense of inner safety from themselves. Exposure therapy is a wonderful way to begin that process.

Within my personal life, I practice and perform improv comedy at an advanced level. I began this journey in 2020, intending to expose myself to discomfort, face my fears, and increase my confidence and ability to take risks. I experienced the powerful healing impact of improv on my belief systems and mental health and now utilize improvisation within my practice. I believe exposure therapy is a powerful tool for liberating yourself from a life guided by fear.