How to Practice Exposure Therapy for Social Anxiety Disorder

CBT for Social Anxiety: How It Works, Examples & Effectiveness

How to Practice Exposure Therapy for Social Anxiety Disorder

Cognitive Behavioral Therapy focuses on the relationship between one’s thoughts, emotions, and behaviors. CBT attempts to help the individual understand the ways in which our behaviors are influenced by our thoughts and emotions relating to situations, as well as recognize and refute irrational thoughts that contribute to a decrease in healthy behaviors.

The overall goal of a CBT therapist is to help the individual learn to utilize the skills learned in therapy outside of the therapeutic session. Empowering the individual is a key part of CBT practice. 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.

How Can CBT Help With Social Anxiety?

Studies conducted on the efficacy of Cognitive Behavioral Therapy for treating social anxiety reveals that, not only is CBT an effective approach for the disorder, it is also considered at the top of the list of therapeutic methodologies that successfully treat anxiety disorders.2 CBT utilizes coping skills and exposure therapy to aid in the reduction of anxiety symptoms, including those associated with social anxiety disorder.

CBT aims to both 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 anxiety.

CBT uses homework assignments in conjunction with in-office skills training to help the individual develop confidence, applying CBT techniques to real life situations. 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.

Cognitive Behavioral Therapy uses many different models, exercises, and practices to elicit change. When working with anxiety disorders, specifically social anxiety disorder, there are certain aspects of CBT that tend to provide the most relief for the individual.

While there are many, some of the more common techniques include:

ABC Model3

The ABC model is designed to aid in evaluating situations and outcomes, often used to help predict ly outcomes beliefs and past behaviors.

  • A – Antecedent: The situation or activating event.
  • B –Beliefs: Your beliefs about the event, both conscious and subconscious.
  • C –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.

S.M.A.R.T. Goals4

S.M.A.R.T. goals are set by the individual with the aid of their CBT therapist.

  • S.M.A.R.T. goals are specific, or clearly defined: The individual should know exactly what it is that they are to accomplish.
  • They are measurable: The individual must be able to monitor their progress to know when they have reached their goal.
  • They are attainable: The individual must possess the skill and resources required to reach their goal.
  • They are realistic: The individual must be willing to devote their time and energy into accomplishing the goal.
  • And they must be time-specific: The individual 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 lihood of success.

Cognitive Restructuring5

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.

Exposure Therapy6

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.

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: 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.

Relaxation Exercises

Relaxation exercises are another important component of CBT used for treating anxiety disorders social anxiety disorder. Relaxation exercises include grounding exercises, breathing techniques, and muscle relaxation.

Relaxation training can be combined with other therapeutic approaches exposure therapy.

The combination of these two techniques is used in systematic desensitization, which works by learning to associate feared social situations with relaxation.

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.

Example 1: Steve

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 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. 

Example 2: Sara

Sara, an 18-year-old college freshman, is adjusting to starting her first semester of college. She had moved 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, working on group projects for class, she becomes extremely uncomfortable and has a difficult time interacting with her classmates. She always feels 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. 

Example 3: Abby

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 does not 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.

Treatment goals and timeframes can vary depending on symptoms and whether there are dual diagnoses present. But the average timeframe for CBT is generally between 4 to 6 months with one-hour, weekly sessions.

Is CBT Effective for Social Anxiety Disorder?

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.

The National Institutes of Health, the Mayo Clinic, and the American Medical Associate are among the many accredited organizations to provide research-based evidence of the efficacy of CBT for treating anxiety disorders.7

How to Find a CBT Therapist

Because of its high success rate, many providers use Cognitive Behavioral Therapy to treat a vast number of mental health issues. Finding a provider in your area can be done with an internet search. Using online directories 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. All CBT providers should hold appropriate licensure.

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. 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, exposure therapy, should be done with the help of an experienced cognitive behavioral therapist.


treatment of social phobia in general practice. Is exposure therapy feasible?

How to Practice Exposure Therapy for Social Anxiety Disorder

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Exposure therapy is an effective treatment for generalized social phobia. Most patients with social phobia are treated in primary care, but family doctors are not usually trained to perform exposure therapy.

We have conducted a study in primary care of the effect of exposure therapy alone or in combination with sertraline on generalized social phobia.

Objectives. The purpose of this article is to describe the training of GPs and the application of the treatment programme in general practice.

Method. Forty-five GPs were trained for ~30 h in assessing patients with social phobia and conducting exposure therapy. The training programme included scoring of videotaped interviews of five patients on several social phobia scales, and a videotape demonstrating different steps of an exposure therapy was used as a model for role play in group training.

Results. All of the GPs completed the training programme.

The doctors expressed satisfaction with the programme and also found it useful in the treatment of patients with conditions other than social phobia.

There was a significant difference in response between the treatment groups (P = 0.001), and the combination of exposure therapy and sertraline seemed to be particularly beneficial.

Exposure, general practice, social phobia

Haug TT, Hellstrøm K, Blomhoff S, Humble M, Madsbu H-P and Wold JE. The treatment of social phobia in general practice. Is exposure therapy feasible? Family Practice 2000; 17: 114–118.


Social phobia is a rather new diagnostic entity; it was included as a separate condition for the first time in 1980 in DSM-III.

It is characterized by a persistent and exaggerated fear of humiliation or embarrassment in social situations, leading to high levels of distress and possible avoidance of those situations.

The fear may be of speaking, meeting other people, eating or writing in public, and relates to the fear of appearing nervous or foolish, making mistakes, being criticized or being laughed at.

Often physical symptoms of anxiety such as blushing, trembling, sweating and tachycardia are triggered when the patient feels under evaluation or scrutiny. Recent epidemiologic studies have shown a life-time prevalence of social phobia in the general population ranging from 2.4%1 to 16%.2

Social phobia is a chronic disorder with an early, insidious onset in adolescence and a continuous, unremitting course, resulting in a substantial degree of disability and suffering.3 Both pharmacotherapy and psychological treatment have been proven effective.

4–8 Exposure therapies are used commonly to treat social phobia, and treatment programmes including education and exposure instructions have been developed.9,10 Usually these programmes are applied in mental health care for individual or group treatment. There are no earlier studies of psychological treatment for social phobia by GPs.

We have conducted a study of the effect of exposure therapy, either alone or in combination with medication, for patients with social phobia in primary care.

Why in general practice?

In general practice, about one-third of patients have a psychiatric disorder, mainly anxiety and depression.

11 Only half of the patients with psychiatric disorders are identified by GPs mainly because primary care patients usually present somatic symptoms and only rarely mention their psychological problems.12,13 The diagnosis social phobia is almost never applied in general practice.

The patients are given more general diagnoses such as anxiety or depressive conditions, sleeping problems, substance abuse or somatization such as myalgia, gastritis or cardiac neurosis.

Nearly all patients with anxiety and depressive conditions are treated by family doctors, whereas only a few are seen by psychiatrists.

14,15 Given this distribution of care, it is important to ensure that GPs are well trained in psychiatric assessment, diagnosis and treatment.

Valid and reliable diagnostic procedures and efficacious treatment strategies for anxiety disorders have been developed in psychiatric settings over the past two decades.

Application of these diagnostic and treatment methods has not been well studied in primary care settings, although there is some indication that both presentation of illness and effective treatment interventions may differ from those in specialized psychiatric settings. There is, therefore, a need to facilitate dissemination of efficacious methodologies to primary care settings.

Recognition programmes of psychological problems in primary care have been developed where the physicians are taught skills enhancing their ability to recognize and respond to verbal and non-verbal cues, making empathic comments and using patient-directed, open-ended interviewing strategies.16 There are also several studies of brief psychological treatment for primary care patients. Barkham17 has described a three-session cognitive–behavioural intervention, and White and Keenan18 have applied a group didactic ‘course’ on anxiety management strategies. Brief problem-solving therapy has been proven to be as effective as benzodiazepine treatment of patients with anxiety,19 and Swinson et al.20 showed that panic disorder patients provided with psychoeducation and exposure instructions had a significantly better outcome than those not so informed.

Why exposure therapy?

There are now well proven efficacious treatments for social phobia using medication and psychotherapy alone and in combination.4,7,8 These treatments have not been well studied in primary care settings, and thus their effectiveness remains to be documented.

The psychotherapeutic approach in this study had to meet four basic criteria: (i) it must be possible to conduct the therapy within the frame of a GP consultation; (ii) the therapy had to be standardized in such a way that a manual was available for the instruction of the therapists; (iii) only a limited number of therapeutic interventions were to be applied; and (iv) there must be some evidence of efficacy for the approach for patients with social phobia. Exposure therapy has been proven effective in the treatment of social phobia,21,22 and brief treatment programmes with structured manuals have been developed. In exposure therapy, mainly behavioral techniques such as scheduling activities, graded task assignment, distraction and relaxation are applied, while cognitive strategies for managing the problematic situation are only used to a limited degree. On the basis of these considerations, brief exposure therapy a self-treatment manual developed by Isaac Marks9 was chosen as the psychotherapeutic approach. We wanted to test if it was possible to describe a standard psychological treatment for social phobia which could be applied in a primary care setting and if it was feasible to train GPs to conduct this therapy at an adequate competence level within a relatively short time.

The purpose of this article is to describe the training of the GPs in the treatment programme, and its application in general practice.

Design of the outcome study

Three hundred and eighty-seven patients with generalized social phobia (mean age 40 years, female/male 234/ 153) were included in the study. A total of 238 patients were recruited from general practice and 149 from advertising in newspapers.

Requirements for inclusion were generalized social phobia (DSM-IV) of at least moderate severity (score ⩾34 on the Clinical Global Impression Scale, CGI-S), lasting for at least 1 year.

Exclusion criteria were other axis-I diagnoses, treatment for social phobia within the last 6 months, suicide risk, alcohol or substance abuse and expected bad compliance.


Assessments of anamnestic data, somatic symptoms and psychological factors were made by GPs and by self-rating. Forty-three GPs and two psychiatrists participated in the study. The ratings by the physicians were tested for reliability before the study.

The assessments were made in a screening interview and in a baseline interview after 1 week. Before the baseline interview, the patients performed self-ratings on several questionnaires.

The following instruments were applied: Mini International Neuropsychiatric Interview (MINI-R)22 assessed DSM-IV psychiatric diagnoses, CGI-S,23 Social Phobia Scale (SPS)24 and Marks Fear Questionnaire25 measured the level of generalized social phobia.

All patients also identified 1–3 ‘target complaints' which they assumed to be important and wanted to work on in therapy, if they were selected for the therapy group.

The targets covered a range of social situations where the patients feared a negative evaluation and had a substantial degree of avoidance such as attending lunch breaks, speaking up at meetings, going to parties, etc.

Each of the target complaints was scored on a scale from 1 to 4 where a higher score indicated a higher degree of the problem. At the end of treatment, the patients made an evaluation where they assessed the efficacy of the therapy.

Anamnestic data were also registered and the patients had a general physical examination. All patients signed an informed consent to take part in the study.


After the baseline interview, the patients were assigned randomly to exposure therapy or general medical care.

26 In the general medical care group, the interaction with the patients was limited to discussion of clinical history, explanation of the disease and general support, such as encouragement, acceptance, ventilation and abreaction.

The exposure therapy focused on the specific ‘target complaints' identified by the patients at the assessment interview. The patients also defined their own goals of treatment.

A booklet containing general information about social phobia and its treatment, describing the principles of exposure therapy including graded task assignment with coping strategies such as distraction, breathing exercises and rational self-talk, was distributed. The booklet also contained a self-registration task of anxiety symptoms and coping strategies usually applied by the patients themselves and forms for registration of daily homework assignments.

The therapy included eight sessions, each lasting 15– 20 min. The first four sessions were conducted weekly, and the last four sessions every other week. The time course of the exposure therapy was 12 weeks.

The aim of the exposure therapy was to let the patients expose themselves gradually to situations they usually feared and avoided and thus learn new coping strategies.

They were told to stay as long as they could in the phobic situations, ideally until the anxiety decreased.

All patients did homework between sessions where they continued to expose themselves to defined anxiety-provoking situations.

During homework, the patients made a written report of the training to bring with them to the next session for discussion.

The task of the physician was to help the patients to identify goals of therapy and new coping strategies, collaborate with the patients in planning realistic exposure tasks and to offer guidance and support.

In the first therapy session, the patients were given general information about social phobia and exposure therapy. They were given the self-treatment booklet and the first homework assignment was to read the booklet. In the second session, the practical goals for treatment were identified and the diary was introduced.

In the next sessions, the patients and physicians reviewed the homework done by the patient, discussed coping strategies and new homework was assigned.

In the last session, the focus was on relapse prevention The coping strategies the patient had learned during therapy were repeated and the patients were encouraged to continue to expose themselves to feared situations.

All patients additionally were randomized to medical treatment with sertraline (50–150 mg daily) and matching placebo according to a 2 × 2 design of the study. The patients were medically treated for 24 weeks.


Assessments were made at 12 weeks and at 24 weeks. Social phobia, social avoidance and ‘target complaints' were assessed applying the same scales as at baseline. Outcome variables were changes in degree of social phobia rated by CGI-L, severity subscale and improvement subscale, SPS and Marks Fear Questionnaire.

In addition, the effect of treatment was assessed by changes in scores on ‘target complaints'. Response was defined as a reduction of at least 50% on SPS compared with baseline, a CGI-L global improvement rating of 1–2 (markedly or moderately improved) and CGI-L overall severity in the range 1–3 (no–mild mental illness) at week 24.

Non-response was defined as


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