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Social Anxiety Formulation

Worksheet

People 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. They fear negative evaluation and worry excessively about social 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. This worksheet is designed to help therapists and clients to develop an idiosyncratic formulation of a client’s social anxiety. The core purpose is to help clients to understand how their experiences map on to the cognitive model, and how their social anxiety is maintained.

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Description

People who suffer 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 in anticipation of 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. People with social anxiety 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. 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 (2001) 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 the important components is 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 uncon- ditional 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”), or to 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.
    • Processing of self as a social object. Clark and Wells propose that socially anxious people construct a negative impression or 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 reported that feeling hot reinforced 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 and 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.
    • 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 behaviors … or the consequences of these behaviors” (Clark & Wells, 1995). Non-occurrence of the feared catastrophe is attributed to the safety behavior, 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:
      • Can make feared consequences more likely to occur (e.g. trying to hide shaking by holding tightly, can result in more shaking).
      • 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 and 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.

This worksheet is designed to help therapists and clients to develop an idiosyncratic formulation of a client’s social anxiety. The core purpose is to help clients to understand how their experiences map on to the cognitive model, and how their social anxiety is maintained. Adapted from the Clark & Wells (1995) cognitive model of social phobia it focuses on developing a cross-sectional account of a recent anxious experience (or an amalgamation of multiple such experiences, to build up a picture which reflects the client’s social anxiety).

Instructions

“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?”

  1. Social situations. Help 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?
  2. Negative thoughts and predictions. 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?
    • When you felt anxious in that moment, what went through your mind?
    • What was the worst thing 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?
  3. Emotions and body sensations. 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?
  4. Safety behaviors. Help the client to 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 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)
  5. Self-consciousness. Clark & Well’s 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 deliberately about the moment in time that the client became highly self-conscious, specifically exploring: their focus of attention, 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-perception.
    • What we know about socially anxious people is that when they feel anxious they start to feel self-conscious. They start to 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?
  6. Impression or image of yourself. Clark & Wells’ model proposes that people with social anxiety have an impression of themselves and how they appear to others. They suggest that in people with social anxiety, this image is distorted as a result of, formative or important early experiences, focusing on negative aspects of own performance, a focus on anxiety and un- comfortable body sensations, and 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, 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?
  7. Earlier experiences. Sometimes the impression clients have of how they come across to oth- ers stems from earlier life experiences. These experiences might include social trauma such as bullying, rejection, humiliation by others. Help the client to explore early experiences that might have contributed to the development of the negative impression or image the client has of themselves.
    • When is the first / worst time that you remember having that impression of yourself?
    • Can I ask you, when is the first time you remember thinking you look that way to other people?
    • Can you remember the first time you remember feeling this way?
  8. Socialization to the model / exploring interactions between components. Help the client to explore the impact of their anxious feelings, body sensations, and safety behaviors on their self-consciousness and their negative self-impression or image. For further details regarding the sequencing of treatment interventions see Wells (1997) and Warnock-Parkes (2020).
    • Would I be right in thinking that your feelings and body sensations of anxiety make you more self-conscious?
    • Is your negative impression of yourself brought on by feeling anxious?
    • When you’re doing all of your safety behaviors, do you notice that you become even more conscious of yourself and what you are doing?
    • What we know from speaking to other people with social anxiety is that when they are doing their safety behaviors and focused on their performance, they become even more self-conscious. This is often the case with anxious feelings too – do you notice that your anxious feelings make you more self-conscious?

References

  • 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.