Many of us are familiar with the uncomfortable feeling of entering a cocktail party at which none of our friends are present. We sidle in awkwardly, imagine others might be wondering what we are doing there and find ourselves not sure where to stand or who to look at. We gaze intently at our prosecco and hope the floor will swallow us up. In most instances we can push through and engage with someone at the party, often ending up having a great time. However, our initial discomfort allows us a window into what it’s like to live with social anxiety disorder (Sad), a ubiquitous and crippling mental health condition.
In a study involving thousands of participants aged 16-29 across different socioeconomic strata and from seven different countries, including Brazil, Russia, the United States and China, it was found that a staggering 36% met the threshold for Sad. While akin to shyness, Sad involves anxiety that is way more intense. It leads to the avoidance of social situations including work, family gatherings and even events the person believes they would enjoy if they did not feel so anxious. Research indicates Sad particularly afflicts young people. Explanations for this include neurocognitive changes in this age group as well as a developmental shift towards a focus on peer evaluation. One hypothesis for the apparent rise of Sad in the 21st century is the proliferation of social media and digital alternatives to face-to-face contact.
Regardless of its genesis, social anxiety disorder involves a cocktail of emotional, cognitive, behavioural and neuropsychological factors and it results in significant consequences for those afflicted. Emotional factors involve fear, dread and panic that may be experienced days and weeks before an event and can arise at the mere thought of socialising. Cognitive factors include holding oneself to unrealistically high social standards and then both observing oneself in the moment to see if these standards are being met as well as judging oneself retrospectively. This self-scrutiny leads to clumsiness, blushing or stammering which further heighten self-consciousness and increase retrospective ruminative imaginings of the judgment of others. Behavioural factors include avoidance of social situations, speaking quietly and dressing plainly to avoid being the focus of attention. These are referred to as safety behaviours.
The evidence for neurobiological involvement includes genetic studies and the sometimes helpful effect of antidepressants. Effective treatment usually requires a holistic approach, yet often those suffering from Sad do not seek treatment as it involves the very human contact they fear and avoid. Ironically, for these individuals the pandemic-enforced lockdowns were a relief as their naturally isolated state was validated and they did not need to justify their avoidance of social situations. However, in the long run this has made their condition worse as the reinforcement of safety behaviours makes it more difficult to change and the rebound effect of the pressure to socialise in a post-lockdown world adds complications.
Responding to pressure from her mother, 30-year-old Rochelle reluctantly approached me via email. She wanted telehealth sessions, preferably on the phone rather than on Zoom. While many clients request telehealth due to geographical distance and time constraints, not many specify so early that they prefer to speak on the telephone when they live as close to my rooms as Rochelle did.
It was soon apparent that Rochelle was suffering from Sad. In our first telephone session I had to strain to hear her as the quiet speech characterising Sad was omnipresent and there were long pauses as if Rochelle was needing a great deal of time to work out what to say and how to say it. When I gently probed what was happening in the pauses, she explained that she had just heard herself speak and she thought she sounded wooden and boring. She was wondering how to enliven her own speech. I asked whether she was also worrying that I wasn’t listening or was bored. She agreed this was so but clarified it was more that she couldn’t stand her own “monotonous whining”. On enquiry, it was apparent this was a thought that often came into Rochelle’s mind while speaking to others and certainly preoccupied her after the fact.
Thus, in this first session Rochelle not only described many signs and symptoms of Sad but she also manifested them in our interaction. The choice not to come into my consulting rooms allowed her to avoid feeling the centre of my attention and her preference for the phone over Zoom allowed the avoidance of eye contact, a signature feature of Sad. Despite this avoidance, Rochelle was warm and engaging. She was a fine wordsmith who related her difficulties with coherence, grace and humour.
Rochelle had already trialled several medications without success but was open to the possibility of exploring this option further. She had also attempted online programs aimed at helping to manage anxiety, challenge the negative thoughts associated with her social fears, and reduce her reliance on safety behaviours. Rochelle said she had not felt able to stick with these programs in the past, but we agreed my support might facilitate her following through with their suggested strategies. We also agreed our therapy relationship provided a great opportunity to experiment with the graded exposure to threatening situations that the treatment of Sad involves.
We contracted first to move to Zoom and finally to meet in the room, taking care that each transition was a positive one with ample room for Rochelle to be aided by me to reduce her fears. For example, initially we agreed to sit side-on so she did not have to have eye contact and I answered her questions about my thoughts so that she could disconfirm her assumptions about judgment. The pace of change is slow but over a year of weekly sessions Rochelle began to enjoy therapy and could sit facing me and speak easily. We are in the process of generalising the ease she feels with me to other social situations so she can enjoy life rather than watch it go by as an outsider to its pleasures and joys.
• Rochelle is a fictitious amalgam to exemplify many similar cases that we see. The therapist is a fictional amalgam of both authors.
• Prof Gill Straker and Dr Jacqui Winship are co-authors of The Talking Cure. Gill also appears on the podcast Three Associating in which relational psychotherapists explore their blind spots.
