Exposure Therapy for Social Anxiety

What Is Exposure Therapy and Why Is It Effective?

Exposure therapy is used to treat anxiety disorders that go beyond social anxiety. The basic idea is that if you're afraid of something, you can get over your fear by being "exposed" to that fear over time in very small, but gradually increasing, amounts. When you go to the gym to get stronger, you don't start off lifting a million pounds all at once – you start small and slowly increase the weight over time, getting stronger along the way. Your brain works the same way.

If you're afraid of spiders, that might mean starting by looking at a photo of a spider for 60 seconds without looking away. For most people, that'd be pretty manageable. It's not going get rid of your fear of spiders, but it is going to make the next activity slightly easier. Your progression might look something like this:

1. Look at cartoon images of spiders.
2. Look at a still photo of a real spider.
3. Read about spiders.
4. Watch a video of a spider.
5. Look at a spider behind glass.
6. Be in the same room as a spider (far away).
7. Hold a container with a spider inside.
8. Be close to a free-roaming spider.
9. Hold a spider in a controlled environment.

It may sound like your fears are too strong for exposure therapy to help you, but time and time again, the research shows that it does.

You need not rush through this progression. You're allowed to go at your own pace. If you want to spend a whole week repeating step one, go right ahead! In the context of social anxiety, an exposure progression might look something like this:

1. Ask someone in public if they know what time it is.
2. Ask someone for directions in public.
3. Say "good morning" to a stranger as you pass each other on the sidewalk.
4. Make a comment about the weather to a cashier or barista.
5. Compliment a stranger on something simple, like their dog or their shoes.
6. Attend a small, casual event and stay for at least 15 minutes.
7. Ask a question during a group discussion or meeting.
8. Introduce yourself to someone new at an event and exchange names.
9. Start a brief conversation with someone sitting near you at a gathering.
10. Attend a larger social event and aim to speak to at least two new people.
11. Initiate a conversation with someone and ask follow-up questions about their interests.

How It Helps

There are three main ways exposure therapy can be beneficial:

1. Practice – Obviously, exposure therapy gives you experience in real-life situations. The more you expose yourself to similar scenarios, the better you'll understand what to expect. Over time, this predictability reduces anxiety.
2. Identification of Negative Thoughts You Didn't Know You Had – During exposures, you may notice "hot cognitions": negative, automatic thoughts that arise in the moment. These thoughts give you new insight into what makes you anxious about a situation, and what you should work on with cognitive restructuring.
3. Testing Your Negative Thoughts — Exposure allows you to test your assumptions. For example, if you have the negative thought: "If there's a long silence in the conversation, I won't be able to handle it," exposure gives you the chance to learn: "I found a way to break the silence, so I don't need to worry so much about awkward silences" or "a silence happened, but it wasn't actually that awkward and the conversation flowed great afterward, so this fear isn't that rational".

Preparing for Your First Exposure

Choosing a Situation

Criteria for a Good Exposure:

• Not too hard, not too easy: It should challenge you but not overwhelm you. You never want to breeze through it, but you also never want to be so uncomfortable that you get stuck.
• Goal-related: The exposure should align with your therapy goals. For example, if you want to improve dating confidence, choose scenarios like asking someone out or initiating a conversation.

Preparing with Cognitive Restructuring

Before each exposure, use cognitive restructuring to prepare mentally. Follow these four steps:

1. Imagine the Scenario—Visualize yourself in the situation and write down at least 4-5 negative thoughts you experience. Note how these thoughts make you feel.
2. Identify Thinking Errors—Analyze your negative thoughts for distortions, such as catastrophizing, mind-reading, or overgeneralizing.
3. Challenge the negative thoughts—Use disputing questions to test the validity of your thoughts. For example, ask: "What evidence supports this thought? What evidence contradicts it?"
4. Develop Rational Responses—Summarize your challenges into concise, rational responses you can repeat during the exposure. For instance: "It's okay if there's a pause in the conversation—it doesn't mean I've failed."

For a more detailed look at the cognitive restructuring process, check out this post, and this AI-tool.

Setting Achievable Goals

Before starting an exposure, set a specific, behavioral goal. A good goal is:

• Observable: Focus on actions, not feelings. For someone giving a speech, an achievable goal might look like, "Describe the four main points" rather than "Communicate effectively."
• Achievable: Avoid perfectionist goals like "Don't feel anxious." Anxiety is a natural part of life and often unavoidable, especially in challenging situations.

Why Goals Matter

Without clear goals, it's easy to overlook your successes and focus on what went wrong—a cognitive distortion known as disqualifying the positive. Later on, your achievements act as evidence against your negative thoughts when you're analyzing a new situation.

During the Exposure

When you're in the exposure, you'll likely feel nervous. That's okay! Remember to:

• Focus on the task at hand, like listening and speaking, rather than analyzing how you're doing in the moment.
• Recognize that discomfort is part of the process and doesn't indicate failure.

After the Exposure

Once you've completed the exposure, take time to reflect and learn from it. Here's a structured way to do that:

• Write down the answer and avoid disqualifying the positive. If you didn't meet your goal, reflect on why and whether your reasoning is rational.

• Were they accurate? If not, log them under "untrue thoughts" and remember that you invalidated them the next time they come up.

Dealing with Post-Event Rumination

After social situations, people with social anxiety often dwell on perceived mistakes—this is called post-event rumination. To combat this:

• Reflect on what went well during the exposure.
• Identify negative thoughts driving any lingering negative feelings and challenge them using cognitive restructuring.
• Use rational responses to shift your perspective and take credit for your successes.

Recording Takeaways

Finally, think about what you learned from the exposure. Here are some examples of common takeaways:

• "If I hang in there, it gets easier."
• "Even though I'm very anxious, I can still carry on a conversation."
• "Shaking hands aren't as noticeable as I thought."

Logging these insights helps reinforce positive beliefs and gives you a record of your progress.

Final Thoughts

Exposure therapy is a gradual process. It's unlikely that a single exposure will dramatically reduce your anxiety, but repeated practice will lead to noticeable improvements. Each exposure builds your resilience, sharpens your skills, and challenges the thoughts fueling your anxiety. Celebrate your progress, no matter how small, and remember: every step forward is a success worth acknowledging.