What is Cognitive Behavioural Therapy (CBT)?
Cognitive Behavioural Therapy (CBT) is the talking treatment of choice for social anxiety, and you will probably be offered this on the NHS if you go to your GP. Please see the NHS overview about CBT here. It should be a type of CBT that has been specifically designed to treat social anxiety disorder, usually the Clark and Wells Model named after the people who designed them.
CBT consists of a variety of techniques. It is based on the idea that your thoughts, beliefs, feelings and behaviour are all interconnected. Treatment begins by developing awareness of how you tend to think and behave in situations you find difficult, and then trying to break negative patterns and replace them with more positive/helpful ones. With CBT, you can re-examine problematic, socially anxious thoughts and find more balanced or helpful ones (the cognitive part) and try out new ways of behaving (the behavioural part). Gradually, this should allow you to act more as you would like to in social situations.
Unlike some other talking treatments, CBT deals with your current problems, thoughts, feelings and behaviours. Although treatment may involve some discussion of how social anxiety developed, there is less focus on an in-depth examination of the past than with other therapies.
Although there are guiding protocols for treating social anxiety which form the main basis of the therapy, every client and therapist are different and the therapy is always tailored to the specific client’s needs.
How CBT therapy works
CBT generally involves talking through issues with your therapist and then doing exercises or ‘homework’, in order to practice techniques and get used to new ways of thinking and behaving.
CBT aims to help you deal with the issues by breaking them down into smaller parts. You’re shown how to change negative patterns of thinking and behaving, alongside anxiety management techniques, to improve the way you feel.
A rough outline of some of the techniques used in CBT therapy for social anxiety are given below:
Challenging Negative Thinking
This involves looking at the thoughts associated with social anxiety and examining them to see if they are really ‘rational’, or if there are other, more helpful ways of looking at things. You may be able to identify the thoughts that upset you, or you may need to spend some time trying to recall what goes through your mind when you feel anxious. If that is the case, think back to a situation that you recently found difficult, and identify what came into your mind when you began to feel nervous or embarrassed. Which thoughts was it that triggered your anxious feelings?
Modifying the way you think is accomplished by regularly completing thought records, where you write down the thoughts that are upsetting and then trying to come up with alternatives that make you feel better. These thoughts should be rational and realistic, so that you are able to believe them, rather than unrealistically positive.
For example, if you were at a party, talking to another guest, and the conversation dries up, you might be thinking something along the lines of ‘I’m so useless’ or ‘I never have anything to say’ or ‘they must think I’m so boring.’ You might consider the following alternative thoughts: ‘Many conversations don’t necessarily go anywhere; the other person is also not saying very much’ and ‘I don’t know what they are thinking – they could also be worrying the gap in conversation is their fault!’ You will also record things such as how much better (or not) the alternative thoughts make you feel, and how you might approach things differently in the future if you are struggling to make conversation.
An example of a thought record sheet can be found here.
Trying to be more balanced in thinking can help disarm unhelpful thoughts and lead to healthier behaviours. For example, instead of thinking “Something might go wrong, and it will be an awful disastser” it might be more helpful to think “something might go wrong, but I’m sure it won’t be horrible, and I will survive”, or “something might go wrong, or it might not; I’m sure I will be alright”. The idea is not to convince yourself that everything will go perfectly, but to create a kinder and more balanced thought process which leads to being able to face more situations.
Re-examining your thoughts can also include identifying whether you tend to automatically fall into particular patterns of biased thinking, such as:
Mind-reading assuming you know what others are thinking about you: ‘they must think I’m so anxious/quiet/ridiculous/boring’
Fortune telling predicting the future: e.g. you will never be able to feel comfortable in conversation, or you will never be able to make a telephone call to someone you don’t know
Discounting the positive ignoring all the positive feedback you received for something and focusing on the one negative comment
Projecting in the context of social anxiety, believing that because you believe something negative about yourself, other people think that about you as well
Overgeneralization thinking that if one situation had a negative outcome, all other similar situations will also have negative outcomes
Catastrophizing where you believe that if anything goes wrong it will be a disaster.
Emotional reasoning mistaking your feelings for facts: if you feel inadequate, assuming that you must be inadequate.
Over time, the repeated practice of new ways of thinking can change neural pathways in your brain, meaning that you automatically think more positively!
Focussing attention and reducing self-consciousness
If you have social anxiety, it may be hard to focus on what’s actually happening in social situations. You may feel excessively self-conscious, which means you might try to monitor other people’s reactions to you, worry how you are coming across, and get distracted by your own negative thoughts and feelings. This in turn can make you want to escape from the situation as quickly as possible.
In CBT you will practice shifting your attention away from nagging negative thoughts and learn to direct more of your attention outwards to what is happening around you. This is similar to mindfulness, which is about learning to pay attention to the present moment. Not the present moment in terms of anxiety feelings, but to the people and situation you are engaging with. You can start with easy situations where it is relatively easy to shift your consciousness from your own thoughts or feelings, to something outside yourself, such as a piece of music or the street you are walking on, or anything that interests you in your surroundings. Then when you are able to do this in easier situations you can practise the same techniques in social situations.
Focusing your attention outwards will help you to engage with others more fully and to give less weight to your unhelpful thoughts and feelings. When you get better at this, you may find that other people do not pick up on your social anxiety as much as you expected, as it mostly feels worse than it appears outwardly. Or, if they do, they may not be as judgemental about it as you fear.
Behavioural experiments and hierarchies
Behavioural experiments are intended to test out negative predictions about social situations, and to help you stop using safety behaviours so that you are more free to be ‘yourself’ (or a version of yourself with less social anxiety).
Using hierarchies to confront your fears and gently expanding your comfort zone needs to be done carefully. Too much behavioural exposure too soon can be unhelpful! It’s important to start small with situations that don’t cause too much anxiety and build up gradually.
Hierarchies usually involve making a list of anxiety-provoking situations, and scoring them from lowest to highest according to how anxious they make you feel. These may be situations that make you uncomfortable, or ones you would avoid altogether. For example:
You then work your way through the hierarchy, starting with the least scary and ending with the most terrifying. For each situation, you write down your predictions about what you think will happen, and identify in advance the things you may try and do in order to ‘prevent’ negative occurrences. The latter are known as ‘safety behaviours’.
Safety behaviours actually increase anxiety in the long term, because they give the illusion that they are protecting you from the negative judgements of others, and that social situations are indeed dangerous. If you avoid speaking in meetings, every time it happens you feel you have avoided something bad happening, and that you need to continue the behaviour. But if you don’t speak up, you might never learn that your contributions are as welcome as anyone else’s. We need safety behaviours at times: they are part of fight or flight mechanisms that help us run away from predators and avoid oncoming traffic. But they are less helpful when you run away from that attractive person you’d really like to get to know, or when you’re trying to make friends, or in the vast majority of social situations.
You record the results of behavioural experiments on worksheets similar to thought records. Once you have practised dropping safety behaviours and behaving differently, you may find that situations turn out better than you thought, and you may begin to feel less anxious about them. And also that even if things do go wrong, or less smoothly than you’d like, it is generally not as catastrophic as you predicted.
For example, you may be conscious of your shaky hands in social situations and grip items tightly to prevent others from seeing them. You may have the thought “if I loosen my grip people will see my shaking hands and think something is wrong with me”.
As an experiment to see whether this is the case, you can stop trying to conceal your shaky hands and focus on the social activity. After the experiment you can note if your shaky hands were noticed by others. Did your predicted outcome take place, did you cope in the situation regardless?
To help create confidence, you can think of these as experiments as gathering evidence. More experiments can be done to monitor what happens if you continue to act freely without monitoring for physical symptoms of anxiety and focus on the situation in question.
Experiments may help someone with social anxiety gather evidence to challenge unhelpful thoughts and realise that some thoughts aren’t true, and even if they are they survived regardless.
CBT also examines beliefs. Our thoughts and behaviours stem from our beliefs, which are a set of underlying assumptions about ourselves and other people. Beliefs that perpetuate social anxiety might include things such as ‘other people never like me’, or ‘other people are mostly hostile and critical’. They are probably based on negative experiences you have had in the past, or you may not know why you came to hold them. But beliefs can also be outdated and unhelpful, even if at one time they seemed useful (such as keeping quiet to avoid being bullied). But in the long run they can prevent you from making progress with social anxiety.
As with negative thoughts, the process starts with trying to identify the difficult negative beliefs you hold that may stop you from making progress. Then try to re-examine them: are things really as absolute as you think? Are you forgetting that no one is perfect? Or jumping to conclusions because of your experiences when you were younger? Unhelpful beliefs can be challenged in a similar way to unhelpful thoughts. You can start to look for new information: very often we only notice things that confirm our beliefs (this is known as confirmation bias). You may notice the person that frowned at you, and ignore the one who smiled.
Building up new and more positive beliefs should help you to feel more confident in yourself. As with previous techniques, you need to work out which new beliefs are going to work best for you. It’s important that the beliefs are realistic and you can actually believe them.
Practising and repetition
Regular and consistent practice is one of the most important factors in using CBT. This can be difficult, as it may initially increase anxiety, and maintaining the motivation to confront feared situations, even when some may not go well, is key. It can also be quite time-consuming.
You may find that while you can agree with new thoughts intellectually, you find it hard to ‘feel’ them and believe them. This is why CBT can be quite repetitive: the more you practise new thoughts and behaviours, the more they will start to become second nature, until gradually they become automatic, and you begin to feel better.
A CBT example situation: always in the kitchen at parties?
People respond differently to social opportunities like parties. Some people look forward to them but if you have social anxiety, you might not be able to think of anything worse. Your reluctance to go to a party probably stems from thoughts you have about it, and what you predict might happen. You may worry that no one will speak to you, that you will embarrass yourself, or end up being a crashing bore. These may be ideas you obtained about yourself and other people as you grew up, or from past negative experiences. If you have these kinds of thoughts, they will affect your behaviour. If you do go to the party, you may do a number of things such as avoid eye contact, avoid talking to people who make you feel nervous, ask questions but say nothing about yourself, or find other ways of subtly avoiding interactions. Or you might decline the invite altogether.
A CBT approach to this situation might involve trying to answer some of the following questions: if you go to the party, what is the evidence that no one is willing to talk to you? Is it a fact, or is it an assumption you have made? If no one is talking to you, is that entirely your fault? What would happen if you started behaving differently, e.g. by starting more conversations: would people talk to you? Could you go for an hour and see how things felt? Could you trying stepping outside your comfort zone and asking someone you have never met before how they know the host? Or start talking to people a little about yourself and what you like doing?
How to undertake NHS CBT
If you have CBT on the NHS, there are guidelines on the National Institute for Clinical Excellence (NICE) website about how CBT for social anxiety should be conducted. These include what happens within CBT sessions but also how to make referral and attendance as easy as possible, given the fact you have SA, as face-to-face contact with NHS services may be anxiety provoking in itself.
NHS CBT is intended to be relatively short-term treatment. For instance NHS NICE documentation quotes “you should have up to 12–16 meetings with your therapist over 4 months although particular regions may vary. Each meeting should last an hour to an hour and a half”
The NHS NICE information for the public, which includes what to expect from NHS CBT, can be found here.
To find out more about NHS CBT, including how to self-refer, please see our pages on what the NHS offers.
We would appreciate feedback on your experience with NHS CBT here.
How to find a private therapist
If you are going to work with a private therapist, it is important to find the right one. This means that they specialise in social anxiety, and that you feel comfortable and understood by them, as far as your anxiety permits. This may mean shopping around, or changing therapist if you don’t feel their treatment is right for you. A lot of research has shown that the most important factor in successful therapy is having a good relationship with your therapist, regardless of the form of treatment you are having.
Please see our pages on finding a private therapist here
CBT-based supported self-help and other CBT options
If you decide not to have NHS face-to-face CBT and wish to try another psychological therapy you should be offered CBT-based supported self-help where you work through a self help book or manual with healthcare professional support. They should support and check your progress either face to face or by telephone, for a total of 3 hours during the treatment.
Other CBT options include working through CBT on your own, which can be very effective for some. There are several good self-help books for this, some of which are listed here.
Possible problems with CBT
Not everyone feels that they are helped by CBT. There are a number of possible reasons for this. For some people other psychological therapies, medication or alternative therapies may simply be a better fit for them. Also, whilst the premise of CBT (thoughts and behaviour) seems simple, it still needs to be used appropriately. It is quite easy for the principles to be misapplied or misunderstood.
It also depends on your own life circumstances – it does require a good combination of the right therapist, patience, determination and persistence to make progress. We tend to have bad ingrained habits, thoughts and behaviours that are resistant to change. If there are other work, personal or life issues affecting your ability to make positive changes even the best CBT may not work.
Some people can find CBT invalidating. It can feel as if you are being told problems are all in your head, and that your own impressions and understanding of situations are wrong. It is part of therapy to directly counter ‘irrational’ thoughts and feelings and replace them with more ‘rational’ and positive ones. However, not all negative thoughts are irrational, and at times it might be pointless to try and apply CBT to an objectively negative situation. Sometimes it can be a better idea to accept a difficult situation and try to find other ways of dealing with it.
It’s also the case that identifying which thoughts are ‘irrational ’ isn’t always clear-cut. The most useful “alternative thought” is one that you (rather than anyone else) can buy into. A thought that works for you, even if it’s just a tiny shift, or 5% improvement is a useful alternative thought.
Please see our pages on what good CBT looks like and finding a private therapist for more information.
CBT for Children
See our section on Children and Social Anxiety here.
CBT Group therapy for social anxiety
NHS NICE Guidance states that NHS organisations should not routinely offer group CBT in preference to individual CBT. The guidance reads “Although there is evidence that group CBT is more effective than most other interventions, is less clinically and cost effective than individual CBT”. See our pages on Group therapy for social anxiety here
The idea behind CBT is that your social anxiety can be lessened and better understood by changing the way you think and behave. It encourages you to challenge the automatic negative thoughts, habits, safety behaviours and avoidance that keep social anxiety going. It encourages you to write down and rationalise thoughts, have a curiosity about trying new things, to gently take more risks and try new ways of thinking and behaving.
It encourages more rational thinking. For instance, remembering that everyone occasionally puts their foot in it, or says too much or too little. No one is socially perfect, and treatment is not about becoming ‘perfect’ or more sociable than you naturally are. Its more about helping you to be more accepting of yourself, trying new things and letting other people get to know you rather than hiding behind safety behaviours. Working with a therapist, or in a group, or on your own, CBT can be a very effective treatment for social anxiety.
Butler, Gillian (1999). Overcoming Social Anxiety and Shyness: A Self-Help Guide Using Cognitive Behavioral 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