What is Cognitive Behavioural Therapy for Social Anxiety?

Cognitive Behavioural Therapy, commonly referred to as CBT, is an umbrella term for a type of therapeutic approach that is recommended for treatment of social anxiety amongst other mental health difficulties.

The NHS offers CBT as part of its Talking therapy program. The principles of CBT are also applied in other therapy scenarios – including self-help.

So, what does CBT mean and how does it work?

C stands for cognition (thought), B (behaviour) T (therapy). CBT is based on the idea that your thoughts, feelings, physical sensations and behaviour are all interconnected. This isn’t necessarily a problem, but with social anxiety, it can turn into a vicious cycle.

For example, we’re speaking to a friend (situation) and feel anxious (emotion), we then experience sensations such as feeling shaky or dry mouth (physical). We may worry (thoughts) about how we look or sound. We may keep quiet, play safe, or leave the situation (behaviours). Afterwards, we may worry even more about how we well we did, or what the friend may now think of us, and the cycle continues.

The central idea in CBT is that by learning the skills to tackle the various elements (thoughts, feelings, behaviours – and the relationships between them – we can break the cycle that keeps anxiety going.

CBT is sometimes referred to as having a ‘here and now’ focus, unlike other therapies. CBT will take account of your past, but sessions tend to be focused on the present-day difficulties.

What Should I Expect from therapist-led CBT?

CBT for social anxiety has several main elements:

NHS CBT is usually offered on a one-to-one basis but can sometimes be part of a group. One-to-one sessions are typically 12 one hour sessions with a trained NHS Talking Therapist. The exact number of sessions depends on assessments after referral (including self-referral). Sessions can be face-to-face or sometimes remote via online video call. Both the type of support available and how you access it will depend on local availability.

Why CBT for Social Anxiety?

CBT is considered to be the frontline evidence-based treatment for social anxiety. The UK National Institute for Health and Clinical Excellence (NICE) have surveyed and reviewed the efficacy and effectiveness of different treatments for mental health conditions and made recommendations for what should be made available in the NHS, which includes CBT for social anxiety. See NICE guidance for social anxiety.

Figures on CBTs success rate with social anxiety vary. However, it is the most successful evidence-based therapy to date for social anxiety disorder.

A meta-analysis in 2022 (a study that analyses all past research to date) shows moderate to large improvements in social anxiety symptoms with CBT compared to no treatment. In practical terms, that usually translates to around 50–65% of people showing significant improvement.

The improvements also tend to last – many studies show people maintaining gains a year or more after treatment ends.

There is no limit to the number of times you can do NHS CBT but some NHS regions may not let retake their programs for several years. Some people find one course is enough, and others need more. Each time, it can be a different experience, based on many factors. If CBT has not been helpful before, it does not mean it may not help again.

NICE periodically updates its recommendations and is a useful resource providing an overview of treatment options.

Not everyone finds CBT to be helpful. If you feel CBT is not for you, the NICE guidelines also include alternative approaches to treatment. There is also a newer, but growing, evidence base for EMDR. and ACT.

CBT protocols and interventions

On the recommendation of NICE, NHS CBT follows evidence-based protocols for social anxiety. Although there are guiding protocols for treating social anxiety, every client and therapist are different, and the therapy is tailored to the specific client’s needs.

There are usually a range of interventions e.g. behavioural experiments or gradual exposure alongside other skills such as acceptance, calming techniques, thought challenging or restructuring.  What works for you may not work for someone else with social anxiety, and vice versa. You and your therapist can work together and try out new techniques or interventions that work for you.

Changing what we do or how we think is often a powerful way to support changing our emotions and physical sensations, and in turn our overall psychological state. It is important to remember change can take time and practice. It is never as simple as turning a negative thought into a positive one. This is why CBT equips individuals with a range of practical tools and skills they can use independently to manage their emotions and behaviours even after therapy ends.

Common techniques that a CBT therapist might use in the treatment of social anxiety include:

• Avoidance and Safety Behaviours
• Challenging unhelpful thought patterns
• Focus of attention
• Behavioural experiments and hierarchies

You can try some of these techniques out for yourself as part of your CBT therapy.

NHS Guided self-help

Some NHS regions may also offer ‘guided self-help’. This is when some professional support is included (for example, brief check-ins with a practitioner). In mild to moderate cases some regions may even offer materials you can work through entirely on your own.  Research suggests that guided CBT self-help can be helpful for many people with mild to moderate social anxiety, particularly when they are motivated to practise regularly and apply the techniques consistently. While it may not be suitable for everyone, especially those with more severe difficulties, guided self-help can be an accessible first step for some.

What about self-help CBT?

The NHS social anxiety webpage states “self-help can help reduce social anxiety and you might find it a useful first step before trying other treatments”. Although therapist led NHS Talking Therapy (via CBT) is the key recommendation, self-help CBT approaches can be useful if you are not yet ready to see a therapist, on a waiting list, or if you prefer to start working on your social anxiety at your own pace. See our pages on self-help.

How to access CBT?

You can access talking therapies, including CBT, through the NHS. You can refer yourself directly to your local talking therapy service without a referral from your GP. Alternatively, your GP can refer you if you prefer.

You will then be offered an opportunity to speak with a clinician about your difficulties and consider what treatment and/or service would be best suited to support you and your current needs. The NHS NICE guidance recognises that attending a doctor’s appointment – or talking to a clinician – can be very difficult for those with SA. It provides a series of recommendations to make communication and appointments easier. You may be able to ask your GP to ring you rather than you having to attend the GP practice in person. You could ask friends or family to help you make the first phone call. You could ask your health and social care team to communicate with you over text or email.

You can also self-refer to a NHS Talking Therapies service here.

Different areas often have different services and policies, and the waiting times might vary. This might mean you want to choose a different way to access therapy, and you might want to work with a therapist privately, through means of self-funding or a health insurance policy.

If you are going to work with a private therapist, it is important to find the right one. In the UK, ‘therapist’ is not a protected title which means anyone can call themself a therapist. We recommend checking if they are ‘accredited’, which means they are governed by a professional body (in the UK, this is BABCP for CBT therapists). More information is included on our pages on finding a private therapist.

Common Misconceptions

The idea of simply changing our thoughts might suggest CBT is a simplistic therapy.

“It’s just positive thinking”.

CBT is not simply learning to think more positively. It involves identifying and changing unhelpful thinking patterns into more realistic and balanced thoughts to see if there are other ways to view ourselves or situations. It’s not about ignoring problems but addressing them in a constructive way.

“CBT is too short, I can’t fix all my problems in this time”.

When we have been experiencing our difficulties for a long time, we can often feel like a short-term intervention is not enough support. While CBT is often more short-term compared to some other therapies, it’s not an overnight solution. It requires commitment and practice over time to see lasting results.

“It ignores the past”.

CBT does focus on ‘the here and the now’. However, it will involve exploring past experiences that influence current thought patterns. But the emphasis remains on the present and future.

“It’s too structured and rigid”.

While CBT has a structured framework, it’s not overly rigid. Not every technique works the same for everyone. Therapists can adapt the approach based on individual needs, circumstances, age and personalities.

Conclusion and Links

For further exploration and a deeper understanding of CBT:
NHS website: Overview – Cognitive behavioural therapy (CBT)
NHS website: How it works – Cognitive behavioural therapy (CBT)
British Association for Behavioural and Cognitive Psychotherapies (BABCP) website: What-is-CBT
MIND provide valuable insights into the nature and practice of CBT including video: Cognitive behavioural therapy (CBT)

References

Kennerley, H., Kirk, J., & Westbrook, D. (2016). An introduction to cognitive behaviour therapy (3rd ed.). SAGE Publications.

Overview: Social anxiety disorder: Recognition, assessment and treatment: Guidance. NICE. (2013, May 22). https://www.nice.org.uk/guidance/cg159

Roth, A., & Fonagy, P. (2005). What works for whom: A critical review of psychotherapy research (2nd ed.). Guilford Publications.

Butler, Gillian (1999). Overcoming Social Anxiety and Shyness: A Self-Help Guide Using Cognitive Behavioural Techniques. London: Constable & Robinson Ltd.

National Institute for Health and Care Excellence (NICE), Social anxiety disorder: recognition, assessment and treatment, Full Guidance, Section 6.11.2