Individuals suffering from social anxiety disorder (previously known as social phobia) experience persistent fear or anxiety concerning social or performance situations that is out of proportion to the actual threat posed by the situation or context. Situations that can provoke anxiety include talking in groups, meeting people, going to school or work, going shopping, eating or drinking in public, or public performances such as public speaking.
People with social anxiety believe that social situations pose a danger. They fear negative evaluation, believing in particular that “(1) they are in danger of behaving in an inept and unacceptable fashion, and, (2) that such behavior will have disastrous consequences in terms of loss of status, loss of worth, and rejection” (Clark & Wells, 1995). People with social anxiety worry excessively about these events and outcomes, both before social situations and afterwards. Common fears include speaking or acting in ways that they think will be embarrassing or humiliating, such as shaking, sweating, blushing, freezing, appearing stupid or incompetent, or looking anxious. They fear that other people will judge them negatively, for example that they appear anxious, stupid, crazy, boring, dirty, or unlikable. They therefore make efforts to ensure that their fears do not materialize, resulting in clinically significant distress and impairment, often across multiple domains of their life.
Clark & Wells’ model of social phobia, published in 1995, provides a cognitive behavioral formulation of social anxiety. Clark (2001) describes how the model attempts to solve the ‘puzzle’ of why social anxiety persists despite regular exposure to feared social situations.
The model proposes that entering a feared situation activates a set of beliefs and assumptions that have been shaped by one’s earlier experiences. These beliefs and assumptions concern both the individual, and how they think they should behave in social situations. Holding these assumptions predisposes socially anxious individuals to appraise particular social situations as dangerous, and to make predictions that they will not meet their own (often high) standards for performance. Once a situation has been appraised in this manner, Clark & Wells propose that an ‘anxiety program’ is activated automatically. This program leads to automatic changes in affective, attentional, behavioral, cognitive, and somatic processing which are intended to protect the individual from harm, but which are accompanied by unintended consequences that serve to maintain the social anxiety.
An important insight of the model is that when people with social anxiety enter feared situations their focus of attention changes. They become preoccupied with highly detailed monitoring and observation of themselves, and they “use the internal information made accessible by self-monitoring to infer how they appear to other people and what other people are thinking about them” (Clark, 2001). Clark argues that this results in a vicious cycle whereby “most of the evidence for their fears is self-generated and disconfirmatory evidence (such as other people’s responses) becomes inaccessible or is ignored”.
A detailed account of the model can be found in Clark & Wells (1995), Clark (2001), and Clark (1997). A summary of important components of are given here:
- Dysfunctional beliefs & assumptions. Early and/or significant experiences shape our beliefs and assumptions. Clark & Wells propose that it is possible to distinguish three categories of assumptions in social anxiety including: excessively high standards for social performance (e.g. “Other people must see me as intelligent, calm, and confident”), conditional beliefs concerning social evaluation (e.g. “If I make a mistake then other people will humiliate me”), and unconditional beliefs about the self (e.g. “I’m weird”, “I’m not as good as other people”). These beliefs and assumptions are self-maintaining because they drive/activate the ‘anxiety program’ which leads to faulty/incomplete feedback and schema maintenance.
- Perceived social danger. Influenced by their underlying beliefs and assumptions, people who are socially anxious are prone to: appraise social situations as dangerous, make predictions that they will come across badly or fail to meet a desired standard of performance (e.g. “I will shake”, “I will come across as boring”), and evaluate their performance negatively (e.g. “I am mixing my words up”, “People think I’m boring”). According to the cognitive model these appraisals lead to affective and behavioral responses.
- Somatic and cognitive symptoms. Anxious arousal results in a wide range of bodily sensations including sweating, blushing, shaking, or an unsteady voice. All of these are areas which the socially anxious individual may fear will be evaluated negatively by others. People with social anxiety are hypervigilant for these symptoms, which can increase their subjective intensity. When these sensations are noticed they are likely to interpreted negatively (e.g. “Other people will notice my hands shaking uncontrollably and think badly of me”) which leads to an escalating cycle of more fear, and exacerbation of the somatic symptoms.
- Behavioral symptoms. Safety behaviors are actions which are intended to reduce the risk of negative evaluation. They are problematic because they “prevent unambiguous disconfirmation of their unrealistic beliefs about feared behaviours … or the consequences of these behaviors” (Clark & Wells, 1995). Non-ocurrence of the feared catastrophe is attributed to the safety behaviour, rather than the socially anxious person concluding that the situation is less dangerous than they had previously believed. Additional unintended consequences of safety behaviors are that: some actions can make feared consequences more likely to occur (e.g. trying to hide shaking by holding tightly, can result in more shaking), they can increase self-focused attention and reinforce the negative self-impression, and they can draw other people’s attention towards the self (e.g. covering one’s face with one’s hand while eating can look unusual and draw more glances). Other behavioral strategies that are thought to influence social anxiety include:
- Anticipatory anxiety leading to worry. Clark & Wells describe how, by reviewing in detail what might happen the individual’s thoughts can become focused on memories of past failures, negative images of themselves in the situation, and negative thoughts, predictions, and expectations about how they will perform.
- Post-event processing. Sometimes described as ‘postmorteming’ this describes the process by which people with social anxiety will review a social interaction in detail. Clark & Wells propose that the postmortem is likely to be biased by an undue focus on the individual’s feelings and negative self-perceptions (which they find easily accessible), and a relative lack of focus on an impartial view of the encounter. This biased perception can serve to maintain unhelpful beliefs and assumptions.
- Processing of self as a social object. Clark & Wells propose that socially anxious people construct a negative impression of themselves and assume that this is an accurate representation of what other people notice and think about them. They describe this self-impression as a “compelling feeling, but which is sometimes also accompanied by images in which phobics are able to see themselves as though from other people’s point of view. Such images contain visible exaggerations (such as hands shaking or humiliated posture)”. When socially anxious people are exposed to a triggering situation their focus of attention shifts inwards, and they begin detailed monitoring of their performance, feelings (emotions and body sensations), and negative thoughts, and images. The result of this detailed self-monitoring is that this information – although only a biased representation of their social performance – is very accessible and compelling. It serves to maintain their negative self-impression. For example, one client reports that feeling hot reinforces a self-image of themselves dripping in sweat; another who closely monitored their speech fluency was acutely aware of any mistakes, which reinforced her self-impression of sounding incomprehensible. Clark & Wells describe a number of ways in which such self-focused information is biased: If a client has an image of themselves seen from an observer’s perspective, then they may mistake this as ‘proof’ of what others are seeing; Feelings are often taken as facts or proof. Clark & Wells draw attention to the cognitive bias of emotional reasoning, e.g. feeling humiliated is equated with being humiliated; The negative impression is a compelling feeling which is often accompanied by mental images.
Clark & Wells (1995) describe a variety of therapeutic interventions for social anxiety. Subsequent research has led to the refinement of treatment techniques for this condition. For a contemporary review see Warnock Parkes et al, (2020). Cognitive behavioral interventions for social anxiety might include:
- Helping clients to develop specific and measurable goals for therapy.
- Developing an idiosyncratic version of the formulation, and helping clients to understand how the components of the model maintain their anxiety.
- Manipulating safety behaviors and self-focused attention with behavioral experiments. A recommended approach early in therapy is to video-record the client taking part in two brief social interactions with a stranger: first while focusing attention on themselves, monitoring their performance, and using safety behaviors; and second, while focusing externally and dropping safety behaviors. Client ratings of attention, anxiety, and self-consciousness are taken during both conditions.
- Video and photographic feedback to update negative distorted self-images.
- Attention training which can consist of formal training in shifting the focus of attention, prior to conducting behavioral experiments where the focus of attention is directed outwards during conversations.
- Behavioral experiments to test negative predictions and assumptions, and negative self-images and self-impressions. Warnock-Parkes et al. (2020) recommend that while early experiments focus on dropping safety behaviors, experiments later in therapy focus on decatastrophising – intentionally testing what happens if the thing that the patient is afraid of were to happen (e.g. deliberately appearing sweaty in a conversation, deliberately saying something boring and monitoring other’s reactions).
- Handling anticipatory worry and post-event rumination. This might include exploring the advantages and disadvantages of worry & rumination, rehearsing answers to common worries, and switching to actively testing out worries by using behavioral experiments.
- Updating negative self-images and impressions. Warnock-Parkes et al (2020) suggest that attempts should be made to update self-images and impressions during the course of gathering new information from behavioral experients. Some patients benefit from interventions which directly process and update their self-image, especially where such images are linked to past experiences of social trauma.
- Addressing dysfunctional negative beliefs and assumptions. The cognitive model suggests that dysfunctional assumptions predispose socially anxious individuals to appraise social situations in a negative light. These beliefs are addressed directly throughout the course of therapy to incorporate new information gathered from behavioral experiments and other interventions.
This information handout describes the original Clark & Wells (1995) cognitive model of social phobia. Their original figure caption states “Figure 4.1 graphically represents (by lines of varying thickness) the idea that much of social phobics evidence for their negative beliefs comes from their own impression of how they appear to others, rather than from observation of others’ responses. The greater importance of the former process is signified by broad lines between Perceived social danger and Processing of self as a social object and by thin lines, between Perceived social danger and the Social situation” (Clark & Wells, 1995).
“It would be helpful to explore and understand how your anxiety in social situations has developed and what is keeping it going. I wonder if we could explore some of your thoughts, feelings, and reactions to see what kind of pattern they follow?”
- Social situations. Help the client to explore what situations lead to anxiety, and what aspects of these situations are most anxiety provoking for them. Prompt the client for a recent time when they stayed in a social situation despite feeling anxious.
- Can you tell me about a recent time when you have felt uncomfortable and anxious in a social situation? For example, when you were with a group of people. Who were you with? Where were you? What was happening?
- What situations tend to make you most anxious? When you are at work? With friends? With family? With people you don’t know? Can you talk me through an example of one of those?
- Activated assumptions (dysfunctional beliefs and assumptions). Clark & Wells outline three categories of assumptions, including: excessively high standards for social performance (e.g. “Other people must see me as intelligent, calm, and confident”), conditional beliefs concerning social evaluation (e.g. “If I make a mistake then other people will humiliate me”), and unconditional beliefs about the self (e.g. “I’m weird”, “I’m not as good as other people”).
- I wonder if we could clarify some of the ‘rules’ that you have about what makes for an acceptable social interaction?
- How could we put into words some of the beliefs you have about yourself? What words would you use to describe yourself?
- What do you worry most about in these situations?
- What do you expect of yourself in a social situation like this? What would make for a ‘good’ performance?
- What is your fear about how others will see you? Do you worry about how they might react?
- How do you think other people perceive you? What is your worst fear about how others perceive you? How do you think you come across to other people?
- What do you think of yourself as a person?
- Perceived social danger. This step of the model describes how the individual with social phobia appraises a social situation as being dangerous. During this step of the model the client is helped to describe how they think in a social situation. Their appraisals might be reflected as negative automatic thoughts or predictions. The therapist can explore their concerns about how other people will see them, judge them, or react to them. The therapist might use techniques such as guided discovery or downward arrow to explore the client’s concerns. Therapists can also use the Social Cognitions Questionnaire as another means of gathering relevant concerns.
- What were your anxious thoughts when you were in that situation?
- What went through your mind?
- What was the worst that you worried might happen?
- What were you concerned that people might notice?
- If people were noticing that thing about you – like your blushing or sweating – what did you worry that they would think about you?
- Somatic and cognitive symptoms. People often appraise symptoms of anxiety very negatively, and can lead to exacerbation of the symptoms. The therapist’s task is to help the client to explore the body sensations associated with anxiety that they notice (and which they worry other people will notice), and to help clients make links back to their negative thoughts and predictions of these experiences. For example, a client who is very aware of shaking might worry that other people will notice and think they are weird.
- Did you feel any anxiety when those negative thoughts or predictions went through your mind?
- When you felt the anxiety in that situation, what did you notice in your body?
- Which of those body sensations bothered you the most?
- Which of those sensations do you think are most noticeable by other people? (e.g. shaking, sweating, blushing)
- If other people did notice, what do you worry they would think of you?
- Behavioral symptoms. Help the client explore what they do to keep themselves safe in situations which they find threatening. Explore the intended and potentially unintended consequences. Note that safety behaviors might be overt or covert.
- Safety behaviors are things that we do to prevent the worst from happening in situations that we find threatening. For example, some people keep quiet so that they don’t draw attention to themselves. Is there anything that you do in social situations to prevent the worst from happening?
- Is there anything you do with your body? For example, your posture, what you do or say, how you hold yourself, any of your other behavior?
- Do you do anything to control your symptoms? (e.g. hold on tightly to something in your hand)
- Do you do anything to improve your performance? (e.g. planning and rehearsing what you are going to say and do)
- Do you do anything in an effort to avoid drawing attention to yourself? (e.g. stay on the edge of a group, asking lots of questions)
- Do you do anything before a social event to prepare yourself for it?
- Is there anything you do after the event? (e.g. playing the worst parts back in your mind)
- Processing of self as a social object. Clark & Wells’ model proposes that during an acute episode of social anxiety, the anxious individual will process themselves as a social object – a key marker of which is an increase in self-consciousness. Wells (1997) recommends that the therapist should ask specifically about the moment in time that the client became highly self-conscious, attempting to explore: the contents of self-consciousness, the client’s appraisal of how conspicuous their symptoms were, and determining whether safety behaviors were linked to particular self-perceptions.
- What we know about socially anxious people is that when they feel anxious they start to feel self-conscious. They pay detailed attention to their own internal feelings, body sensations, and thoughts about how they are coming across to other people. Does that sound familiar to you?
- When you were self-conscious, what were you paying attention to?
- What aspect of yourself were you most aware of? (e.g. your performance, your body, your feelings, how are coming across to others).
- Do you notice yourself making any judgements about your performance? For example, thinking to yourself “I shouldn’t have said that” or worrying that other people will notice something that you are doing?
Clark & Wells’ model proposes that people have an impression of themselves and how they appear to others. They suggest in that in people with social anxiety this image is distorted as a result of: formative early or important experiences, focusing on negative aspects of own performance, a focus on anxiety and uncomfortable body sensations, thoughts about how we appear to others. They argue that self-focused attention and internal monitoring has the effect of biasing which information the individual is aware of: crucially, individuals with social anxiety do not receive corrective information such as an unbiased external view of their appearance or performance, and which is why providing corrective information via video feedback is a key intervention.
- When you’re feeling self-conscious, do you have an impression or image of how you look to other people?”
- In that moment, did you have an image, impression, or feeling of how you were coming across to other people?
- If there was a video of you in that situation, what do you think I would see?
- Socialization to the model / exploring interactions between components. Wells (1997) recommends using guided discovery to socialise clients to the cognitive model of social phobia, with an initial focus on the role of safety behaviors and self-focused attention on symptoms and performance. Warnock-Parkes et al (2020) recommend the use of an in-session self-focused attention and safety behaviors experiment very early in therapy to consolidate these points. This is also emphasized by Wells (1997) “behavioral experiments are used as early as possible in treatment to facilitate assessment, socialisation, and testing of predictions based on patients’ negative thoughts” . For further details regarding the sequencing of treatment interventions see Wells (1997) and Warnock-Parkes (2020).
- Clark, D. M. (1997). Panic disorder and social phobia. In D. M. Clark & C. G. Fairburn (Eds), Science and practice of cognitive behaviour therapy. Oxford: Oxford University Press.
- Clark, D. M. (2001). A cognitive perspective on social phobia: In W. R. Crozier, L. E. Alden (Eds). International handbook of social anxiety: Concepts, research and interventions relating to the self and shyness. Chichester: John Wiley & Sons.
- Clark, D. M., Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment. New York: Guilford Press.
- Warnock-Parkes, E., Wild, J., Thew, G. R., Kerr, A., Grey, N., Stott, R., … & Clark, D. M. (2020). Treating social anxiety disorder remotely with cognitive therapy. The Cognitive Behaviour Therapist, 13.
- Wells, A. (1997). Cognitive therapy of anxiety disorders: a practice manual and conceptual guide. Chichester: John Wiley & Sons.