Social Anxiety
Many years ago, I found myself chuckling at an advertisement related to social anxiety. Not that social anxiety is a funny thing, but about the ad itself. The advertiser was a drug company, pushing its anti-depressant to be used for a new purpose, diminishing the symptoms of “social anxiety disorder.” In its own way, this could be a good thing, if it works, and maybe it does. The funny thing was the pandering overbreadth of the ad. It went something like this: “Do you ever feel nervous before going to a party where you won’t know most of the people there? Do you sometimes decide not to go to the party or event because you are nervous about it? If so, you may suffer from ‘Social Anxiety Disorder,’ and should talk to your doctor about (our drug) which has been shown to help with this disorder.” It is possible I am exaggerating here, but not by much. I mean, c’mon! If this defines “social anxiety disorder,” then don’t we all have this “disorder” and shouldn’t we all be taking their drug? Obviously, the drug company and their ad agency want you to answer “Yes, yes, yes!” And then they can sell a lot more of their drug, to everyone. It was the kind of thing I would expect on Saturday Night Live.
Anyway, the ad seemed patently ridiculous, and harmful, in at least three ways. First, anything that encourages a vast portion of our population to take an anti-depressant for something that is at some level normal is not good. Second, it makes it seem like there is something inherently wrong about having any kind of anxiety at all, even if it is something we all experience from time to time. Third, it levels the playing field for social anxiety by casting such a wide net, which devalues the potency and severity of the relatively small percentage of people who truly suffer from the debilitating effects of excessive anxiety, including anxiety about social events and interactions. I’ve had clients with such severe social anxiety, they were barely able to function outside their homes. For others, it can mean foregoing career advancements by skipping important work events or even normal day-to-day interactions. Or it can mean personal relationships suffer from unresolved and protracted conflict—when the person suffering from true “social anxiety disorder” doesn’t “sometimes” skip a party, but avoids nearly all, or in fact all, social events their spouse might want to attend. This can lead to the anxious person feeling like an outcast with the world at large and in their own homes, and often reinforcing part of the basis of their issues with social anxiety in the first place (telling themselves, “there is something deeply wrong with me”), thus becoming a downward spiral that is highly destructive, feels inescapable, and likely cannot be solved with an anti-depressant drug, even if some of the symptoms can be reduced for some people.
So, what is “Social Anxiety Disorder?” First, it’s just a name given to a set of feelings in certain situations. So, please do not give the name “social anxiety disorder” more than it’s due. It is a phrase created by the American Psychiatric Association and included in their big book of names of “Mental Disorders” (shorthand: “DSM”) to categorize various mental health symptoms. Keep in mind, the main way most Psychiatrists make money is prescribing “medications” (drugs) to their patients, who must then continually come back for refills. I am not suggesting there are no benefits to psychotropic drugs for some people. There are. They can even be lifesavers (e.g. prevent suicides from people suffering from various mental health issues) and they can, for a time anyway, help to sufficiently reduce symptoms to assist people in making progress toward addressing the underlying causes of their mental health problems. I am suggesting that the DSM has limited use, and is created with a purpose that might not fit your situation very well. I am also suggesting that even if the symptoms described and given a name (a “disorder”) in the DSM does describe your situation, the remedy or benefit of a drug prescribed for that disorder is often (but not always) temporary and rarely (if ever) gets to the cause. It only reduces some of the symptoms.
I am not a doctor. I do not pretend to be. When clients ask, “do you think I should go on medications?” My answer is always more or less: “I am not a doctor so I cannot say. I can recommend, though, that if you do see a doctor, you ask them, “what is the plan?” (for taking this medication), and you might find they have no plan, that they do not actually know how to answer this question, and most likely will say something like “the plan is for you to take this medication for as long as it works (and do not tell you this might mean, you know, for a couple of decades or for the rest of your life).” If you have been down the road of anti-depressants for depression or anxiety, you might also have experienced the “trial and error” approach to these medications—meaning you will be prescribed one of these drugs to see if the benefit outweighs the side effects, and if not, then they tweak the dosage, and then if that doesn’t work, they try another drug, and maybe another, to see what might work—because the doctor (and everyone else) doesn’t really know why one particular drug works for some people and not others.
Once you do (if you do) find an anti-depressant that works relatively well at reducing symptoms and has side effects for you that are tolerable, the reason you might find yourself on this medication for a very long time is this: psychiatric medications do not resolve the underlying cause of social anxiety (or most other mental health problems). Put another way, what happens after you decide you don’t want to take this medication anymore or the medication loses its efficacy (which they often do) if you haven’t addressed the causes of your social anxiety? Those symptoms will be right where you left them, and they will come back. I will say once again, I am not making any suggestions that you or anyone else should or should not take psychiatric medications. They have their place. I am only suggesting you be an informed consumer of your doctor’s services, including their service of prescribing medications that are designed mostly for addressing symptoms, not causes, of many mental health disorders, including social anxiety issues. So, I see it as part of my work with clients to get to the root causes of their issues, including social anxiety issues, whether they are also taking medications to help them with their symptoms too. I suppose I should also point out that the same recurrence of symptoms will happen if instead of addressing the underlying causes of these issues, you self-medicate your social anxiety with nonprescription drugs or alcohol (turning to what Alfred in Batman, The Dark Knight, refers to as “liquid courage”). And the same question then arises: what happens if you decide you want or need to stop smoking weed or drinking?
Despite these serious concerns about the way our medical system addresses (and fails to address) mental health issues, the DSM does have some uses, and can give us a starting point on how to think about the symptoms (but not the causes or how to address them) of “social anxiety disorder,” which include:
- Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed or humiliated;
- Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety;
- Excessive anxiety that’s out of proportion to the situation; and
- Anxiety or distress that interferes with your daily living (in DSM language: causes “clinically significant impairment” of functioning).
This definition of “social anxiety disorder” comes from the Mayo Clinic website, and is based on the current version of the DSM.
These symptoms are pretty vague, and I think overly broad, but we can get to that in a bit. For the moment, I want to point out an important distinction that goes back to the first paragraph of this blog post and the ridiculous advertisement I mentioned—the distinction between “social anxiety” and “social anxiety disorder” (emphasis on “disorder”). “Social anxiety” is normal. We all have social anxiety. All of us. I simply wouldn’t believe anyone who told me they never feel nervous about going to a party or an event in which they are expected to interact with a relatively large number of people (more than 3-4) in which they will not know most or any of them. Well, okay, I’d be inclined to believe them if they first told me they were a sociopath, but then sociopaths don’t usually offer this up voluntarily. For some (non-sociopaths), their nervousness might be minimal and cause no disruption to their desire to be social. They might be overly gregarious, outgoing, and extroverted, and mostly look forward to such interactions, but it is not believable that no part of them feels any kind of nervousness upcoming interactions, ever. On the other hand, while some level of social anxiety is universal, and part of human nature, it becomes a real problem when the anxiety or nervousness is persistent (most or all the time), when it is intense (completely overshadows any excitement they might otherwise feel about the interaction), when the person can’t seem to put it way to enjoy the event (or at least tolerate it without the intense nervousness) and when it becomes so difficult to deal with that the person is not able to do basic and essential stuff in their daily lives. At this point, it goes from normal social anxiety to a “disorder” (a significant or even debilitating problem).
Now that we have a working definition of the problematic form of social anxiety, we should probably get to a looking at its cause. Let’s start with why “normal” social anxiety is actually a good thing, like all “normal” anxiety. All anxiety is about wanting to have adequate control, or at least predictability, over something that might cause us harm. When you cross the street, you should probably be concerned about getting hit by a car, you want to make sure there are no cars coming that might hit you. This mild anxiety causes you to “look both ways when you cross the street,” something your parents (hopefully) drilled into your head as a child. This is normal anxiety, and it is a good thing. It keeps us alive. In a social situation, “normal” anxiety helps us prepare for how to “show up” once we are there. It begins with things like, “what should I wear?” so I “fit in” with whatever the expectations might be. We obviously don’t want to show up in a tux at our neighbor’s barbeque, or shorts and a t-shirt at our sister’s wedding. Likewise, it is a good idea to know our audience. There’s a difference between acceptable behavior and decorum between close family and friends on the one hand and a work party on the other. So, a little anxiety goes a long way toward helping us navigate the complexities of social events and interactions. At a somewhat deeper level, social anxiety helps us prepare mentally for how we might want to respond to possible difficult or awkward interactions we can predict might come up once we are there. Let’s say you are going to a neighbor’s barbeque. Let’s say you don’t really want to go because you know there is another neighbor going that recently damaged your backyard fence while trimming a tree, and denies any responsibility, but you like the neighbor who is having the barbeque and don’t want them to feel slighted. So, you go, but you mentally prepare for having to “make things nice” with your butthead neighbor to keep things smooth with your other neighbors. Difficult, yes, but anxiety helps you get ready for this, so when your neighbor makes a joke about your “overreaction” to his tree trimming, you let it go (for now), and just ignore it. Without anxiety, and the mental preparation it invoked, you might have let him have it with a flood of insults right then and there, and then later seriously regretted your response. Thanks anxiety, nice work!
Social anxiety goes from being helpful to being a problem when it is “out of proportion” (as the DSM says) to the circumstances. When, for instance, you are so filled with dread about a possible confrontation with your butthead neighbor to the extent you cancel (again) going to the neighborhood party and you (and your spouse) now feel like and maybe look like you are not interested in being friends with the rest of your neighbors because you also so dread addressing any of this, you also refrain from explaining to your other neighbors why you keep cancelling. What can also make social anxiety problems so difficult to address is when these kinds of things happen in many contexts, and their causes are not so easily identifiable as the example here (one bad apple you are trying to avoid) and you find yourself avoiding social situations because seeing almost anyone causes you anxiety.
Broadly speaking, the problem of social anxiety (when it is no longer helpful and has become harmful) is caused by a significant difference between how you think you are and how you perceive others think you should be. A person with problematic social anxiety fears others will perceive in them the inadequacies they already perceive within themselves. In reality, then, this is not just one issue, it is two separate issues, or maybe even three. The first issue here is “how you think about yourself?” The second issue is “how you think others perceive you.” The third issue is why do you care so much about either of the first two issues.
To get some clarity around all of this, let’s say you’re going to a wedding. It’s outdoors, but it’s still a wedding, so you wear something relatively formal because the kid getting married is the child of a good friend and you want your friend to know you put some thought into it. When you arrive, you see that the only other people dressed formally are the people in the wedding. Nearly everyone else is dressed casually, far more casually than you. You worry, feel out of place, beat up on yourself internally, wish you could go home and do it over, or just not come. You suffer through it, plagued by what you imagine everyone else must be thinking about you for what you are wearing, how out of place you look. We can all imagine this, and have probably experienced something like this. Now let’s imagine that none of this is true, at all. The feelings are real, but the perceptions are all… off. You are not actually dressed formally. You are not in a suit or tux. “Relatively formal” means you showed up “Friday casual” in a sport coat, a buttoned-down shirt with a tie, dress pants, and penny loafers (if you are a woman reading this, imagine showing up in somewhat formal skirt, blouse and pumps). You might be dressed slightly more formal than some of the other guests, but there are actually others dressed as or more formally than you. The groom’s father and uncle are in suits. There are several other guests wearing sport coats. Several women are wearing skirts and dresses and they aren’t all summer dresses.
When the wedding is over and you are headed to the reception, it doesn’t occur to you that you can easily remove your tie, stuff it in your breast pocket, unbutton your shirt a little, even take your sport coat off, and not one person there will even notice any of it. But you don’t do any of this. You can’t let it go. You are so preoccupied with your “stupid” mistake, you can’t enjoy yourself, and just can’t wait to get out of there and go home. There was no dress mistake. No one cared. Only you noticed. Only you cared. You thought you should have worn something more casual. You thought others perceived you as weird, not fitting in, silly, whatever. None of it was real, except your internal thoughts, feelings and imaginations made it feel real. This is “social anxiety disorder.” Those internal feelings and perceptions are real, to you, even if what causes them are based on mistakes we make about ourselves and the way we think we are perceived (and caring more than we should about both).
More common examples of the problem of social anxiety do not have easily identifiable triggers or causes like our choices in attire, but the results are the same, or worse. We tell ourselves that we are somehow inadequate, that we are not “as (insert ideal here) as we should be.” We are not “as successful,” “as interesting,” “as funny,” “as creative and artistic,” “as good at dancing, or golf, or cooking,” “as charming,” “as engaging,” “as attractive,” “as smart,” “as knowledgeable,” “as comfortable and relaxed,” “as involved in world affairs or the neighborhood planning committee,” as we should be. Then, we add to this, “and others will see these flaws in us,” and then we will feel even worse.
When I work with clients who suffer from social anxiety as a mental health problem, we try to identify: 1. what they might tell themselves about themselves that are overly critical, overly focused on negative traits or deficits, or that undervalue their actual capabilities and 2. where these mistaken beliefs about themselves might come from (e.g. parents, elders or people in positions of authority in the community, siblings, peer groups as kids or earlier in life). Having identified these causes, I encourage the client to come up with reassessments of themselves, more accurate and expansive messages and stories they can tell themselves, that are both true (and believable to the client) and not destructive. The truth is no one is good at everything or can be what everyone else might want from them. But most people are good at some things. And everyone has something valuable to offer to some people, the right people (for them).
After we have begun to identify the sources of specific messages of inadequacy and the client is able to see how they are either overly critical, or too fixated on just one part of themselves, we then also begin to explore circumstances in which they project onto others the internally experienced inadequacies they think others perceive about them. I want you to focus on the word “project” and what this means. It means we are attributing to others feelings we have about ourselves, regardless of the very real possibility that these “others” that are the target of the projection do not have these feelings or perceptions at all.
I have a client who is very successful in her career. Carrie (not her real name of course) has been the recipient of numerous accolades and promotions in her very competitive career. She has also been given relatively large responsibilities to connect with other departments in her large corporate environment, both within and outside the company. Based on her position and authority, Carrie can offer others significant opportunities in their careers just by contacting them and including them in the work she is doing. Earlier in our work, before she had obtained these promotions and responsibilities, Carrie hoped that someone above her, someone in the position she now holds, would contact her and offer her exactly the kinds of opportunities she now has the capability of offering to others. Yet, she continues to struggle greatly with picking up the phone or writing an email to colleagues based on her projection onto them that they will be irritated with her call or email, that they will think she is wasting their time, doesn’t want to hear from her, or that they will respond.
I remind Carrie how she used to want someone just like her to contact her then, that she would not have perceived it as a waste of time, but as an opportunity. She knows this, can see it, readily acknowledge it. We also explore why she makes this projection onto others, where it comes from, and how to identify it when it is happening, so that, even when she suffers from this specific example of her overall social anxiety, she can see it for what it is, cope with it in the moment, tell herself a different story of how others will respond, and pick up the phone to call a colleague and invite them to a presentation she is giving on a new product she is working on. As Carrie continues this work, her perception of her inadequacies lessen, and the “volume” of the tapes that play in her head about the perceptions of others goes down, while the volume of new tapes based on actual responses goes up, so each phone call, each email, each lunch with colleagues becomes a little less worrisome, a little less scary to her.
Although Carrie is making real progress in the two primary areas that cause social anxiety problems (undervaluing herself and incorrect projections onto others), her work will not be done until she can let go of the importance she places on the projected or actual perceptions of others. This is the third problem associated with social anxiety—why we care so much about how others perceive us, to the extent it defines how we feel about ourselves or dictates our choices. With Carrie, it often comes up when her communications to colleagues go unanswered. She ruminates and stews about why this might be the case. What doesn’t seem to occur to her when she occasionally gets a negative response is this: “who cares, their loss.” There might be innumerable reasons a colleague doesn’t get back to her (or get back to her soon enough). They have other priorities. The email was incorrectly put into a junk folder. The colleague is having personal issues. Whatever. Carrie takes it personally, and then tries to find a reason within herself, or something she did (wrong) that is THE reason this other person isn’t responding. When, all the while, she is humming along with a whole cast of others who welcome her contacts, respond diligently, even profusely, with gratitude for the opportunities she affords them.
Here’s the problem: Carrie went into the interaction primed to believe the other person would have a reason to not respond that is related to something negative Carrie believes about herself. She is primed to believe this because Carrie herself continues to doubt herself, or continues to believe these things about herself as well and is therefore vulnerable to these beliefs when she perceives a nonresponse as rejection, of her. Carrie suffers from a negatively reinforced “confirmation bias”—she has a pre-existing negative belief about herself which leads her to focus most of her energy and attention on the evidence that supports that belief (negative or no response), while obscuring or ignoring the evidence that contradicts the negative beliefs she has about herself (welcome and encouraging response).
Here’s the solution: “I am….” Not kidding. This is it. Simple. Very simple. Not easy though.
As in “I am fine,” “I am okay,” “I am Carrie, and Carrie is fine, with or without your approval, your response, your favorable review of me.” If Carrie could go into these interactions with the belief that she is fine, she is completely fine (not perfect, but fine) and the things that make Carrie just fine will continue to exist before, during and after the communication, then no matter what the reaction, she will continue to be fine and think she is fine. If Carrie can come to believe that no one else can define her, or take away anything from her that she already feels confident she possesses, she will have significantly less anxiety going into such interactions (making that phone call) and will be far less likely to feel deflated or give into ruminations when she doesn’t get the response she’d wanted.
As a therapist, I often suggest to clients they create a short cheat sheet of some of the more prominent aspects of themselves that they believe to be true and greatly appreciate about themselves. When I was still practicing law, I used to use this exact strategy before an important event (trial, hearing before a judicial panel, presentation to a group of other lawyers). I would tell myself, before the event, things like “you are honest, competent, hard-working, well-prepared, attentive to details, a good speaker, a good father, a good friend, a good person.” I believed these things to be true. I would tell myself, “these things about you will continue to be true after the (trial, hearing, presentation) even if you lose (the trial, the hearing or the audience) and you don’t get the outcome you wanted.” I believed the other people I’d be dealing with had no power to take away from me the things I knew to be true about myself. I would also accumulate evidence of times when things did go well, and remember them going into, during and after the event. Since this worked for me, and I have seen this work countless times for many others, I continue to suggest these same things to clients to address, cope with, and diminish the fears they face when confronting social events that cause them anxiety. Knowing a thing and feeling it are two different things. In order to feel what we know, we must internalize that knowledge until it becomes something engrained, automatic, almost instinctual, something that becomes a part of us. It takes time, and lots of practice, to hone in on messages that are you know are true and also feel are true, especially when other messages are false (“I am not adequate”) but also feel true.
“I am…” is really all about how to get to a place of self-respect and self-acceptance. I discuss the issue of self-respect in the context of relationships with others in my chapter, “It all comes down to self-respect,” in Firewalking on Jupiter. If someone who suffers from social anxiety problems is able to get to a place of strong self-acceptance, all three of the issues associated with social anxiety will diminish and go away. A person who is able to accept themselves as they currently are, and by acceptance I mean feels they are just fine as they are (even if they also know personal growth is a lifelong endeavor), then there will be no discrepancy between “how they think they are and how they perceive others think they should be.” They will be able to say they already are how they think they should be and it doesn’t matter if others perceive them otherwise. Either way, they can say “I am,” “I am just fine,” and let others take it or leave it, which is also just fine.
There’s the silver lining too. While what I am about to tell you might seem counterintuitive, the problem of social anxiety has nothing to do with other people. It is related to other people, or triggered by our encounters with other people, but it is not about them or caused by them at all. Sure, other people can be a real problem sometimes, but that issue is not a social anxiety issue. Social anxiety is about you, 100% you. This means you can own it. You have the power change it, without anyone else needing to change at all.