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Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: more on avoidance, social skills & compassion (5th post)

In a recent blog post - "Self-practice, Self-reflection (SP/SR) & treatment for social anxiety: avoidance & safety behaviours (4th post)" - I discussed identification of avoidance & safety behaviours using questionnaires like David Clark's "Behaviours questionnaire" and Ronald Rapee's "Subtle avoidance frequency examination (SAFE)".  I mentioned too that David Moscovitch's "Negative self-portrayal scale (NSPS)" could help alert us to aspects of the self that a social anxiety sufferer might be particularly invested in trying to keep "hidden" from anticipated judgement by others. Once one has a sense of what kinds of fears and concerns are particularly troubling a client, then one can ask avoidance & safety behaviour eliciting questions like "Are there things you do or avoid doing to try to keep yourself safe in this area ... or to keep this self-judged aspect of yourself from being observed by others?"  As is often the case, going into a recent illustrative episode of distress in considerable detail may well throw up a series of external & internal avoidance and safety seeking practices that could be targets for therapy.  Using the "Social anxiety flow chart" may be particularly useful here.  Giving clients "detective" homework to look for and note down safety behaviours may well also be useful.  Simple measures like the "Work & social adjustment scale (W&SAS)" and the "Pittsburgh enjoyable activities test (PEAT)" can also help.  

I find it brings these issues to life for myself when I consider my own long-term patterns.  When I was a teenager, I was occasionally bothered by blushing.  In many ways I was a pretty confident, extrovert kid but I hated being seen to blush.  In classic Moscovitch "Negative self-portrayal" style, this was an aspect of myself that I was ashamed of and didn't want others to observe and (I assumed) judge negatively.  When I try to remember how I felt & acted back then and how this pattern has evolved since, it really helps me get a potentially very useful insider view of social anxiety disorder. Paradoxically, although I can still sometimes be "ambushed" by episodes of blushing & sweating, I actually score considerably less socially anxious than typical general population averages on measures like the "Negative self-portrayal scale" and the "Liebowitz social anxiety scale".  This fits.  I score high on the personality trait of extraversion and actually seek out opportunities to give parties for friends or lecture on subjects that seem important to me. Despite this, when I go looking for safety & avoidance behaviours, fascinatingly I find long-term patterns that I no longer even particularly think of as ways of avoiding blushing or sweating excessively.  These include preferences for cooler clothing & cooler rooms.  Additionally the private boys' boarding school I was sent to as a teenager was, in many ways, a pretty unpleasant, snobby environment.  At a parents' visiting day, I remember boys leaning out of an upstairs school window and quietly ridiculing anyone who didn't arrive in expensive cars & expensive clothes.  My dear parents weren't of this "upper class" type and certainly didn't drive a particularly smart car.  I remember feeling ashamed ... and now, of course, a bit ashamed that I was ashamed!  It surfaces very rarely, but I notice echoes from those experiences in tending to avoid very smart restaurants, "top" hotels or other similar environments.  It's a little complex because I actually don't like these places anyway for a series of ethical & political reasons ... but I suspect that such situations could still trigger ex-school teenage feelings of not "making the grade". Well this could lead to some interesting safety behaviour challenges for me ... possibly going to the smartest restaurant in town while insisting on not taking off a very shabby but extremely warm coat!   

More broadly, I do think that questionnaires like the "Negative self-portrayal scale (NSPS)" (and the "Subtle avoidance frequency examination (SAFE)") along with associated discussion can ferret out safety & avoidance behaviours that could be maintaining an underlying sense that certain situations aren't "safe".  David Clark's model of social anxiety disorder hypothesises that "In-situation safety seeking behaviours and self-focused attention prevent disconfirmation of social phobics' negative beliefs and maintain social phobia" and also that "In-situation safety behaviours and self-focused attention can contaminate social interactions by making social phobics less appealing to others."  As an aside here, Clark's treatment of social anxiety doesn't typically focus on teaching social phobics better interaction skills ... it's usually just assumed that as safety behaviours reduce then the unobstructed social skills that emerge need no improvement.  This isn't necessarily so ... or it isn't necessarily the case that it's always therapeutically "enough" just to encourage dropping safety behaviours.  Sometimes encouraging more externally-focused action may add usefully to an approach that mainly looks at reducing forms of avoidance.  As is illustrated in this year's study by Voncken et al - "Socially anxious individuals get a second chance after being disliked at first sight: The role of self-disclosure in the development of likeability in sequential social contact" - people suffering from social anxiety may project "coldness" or "standoffishness" through a whole series of mechanisms from body posture, facial expression, clothing, & lack of eye contact to vocal tone, level of self-disclosure, warmth & empathy.  The paper's abstract reads "Socially anxious individuals (SAs) not only fear social rejection, accumulating studies show that SAs are indeed judged as less likeable after social interaction with others. This study investigates if SAs already make a more negative impression on others in the very first seconds of contact. The study further investigates the development of likeability and the role of self-disclosure herein in two sequential social interactions: first after an unstructured waiting room situation and next after a ‘getting acquainted’ conversation. Results showed that high SAs (n = 24) elicited a more negative first impression than low SAs (n = 22). Also, although high SAs improved from the first to the second task, they were rated as less likeable after both interactions. The level of self-disclosure behaviour was the strongest predictor for the development of likeability during the sequential social tasks. The absence of an interaction between group and self-disclosure in predicting the development of likeability suggests that this is true for both groups. Thus, high SAs can improve their negative first impression if they are able to increase their self-disclosure behaviour. However, SAs showed a decreased level of self-disclosure behaviour during both social interactions. Targeting self-disclosure behaviour may improve the negative impression SAs elicit in others."

And it's not just about encouraging people struggling with social anxiety to be more self-disclosing and also (as the full text of this research study makes clearer than the abstract does) show real interest in others' self-disclosure through questioning and caring, empathic responding.  I remember a personal example.  My brother & sister are both older than me.  One evening when they were in their late and I in my mid teens, they had invited a load of their friends round to the house for a (rather inhibited) party.  I was "hiding" in the kitchen, half-heartedly helping my mother with the food.  My mum was a very loving & supportive woman but, on this occasion, she rather shocked me by speaking to me pretty directly & a little sharply saying something like "These people are your guests too.  Some of them are struggling a bit.  As their host you should be out there, welcoming them, and helping them feel more at ease here."  My memory is of rather creeping out of the kitchen with my tail between my legs feeling very self-conscious.  Sure enough there seemed to be some guests who looked pretty shy and a bit isolated.  I went up to one or two of them and made encouraging, polite conversation.  A few minutes later I was startled to notice that all my personal shyness seemed to have evaporated as I focused on being considerate and welcoming for these other people.  Mm ... !  

Over five years ago I quoted the Beatles words "The love you take is equal to the love you make" in a blog post - "Recent research: egosystem & ecosystem" - about Jennifer Crocker's inspiring work at Ohio State University.  As she wrote last year in her paper "Consequences of self-image and compassionate goals" - "Interpersonal goals are a key mechanism through which people and their social environments influence each other. Two goals - self-image and compassionate goals - the motivational systems that energize these goals, their measurement, and how they relate to other constructs in the literature are described. Results of three longitudinal studies of first-year college students suggest that when people have self-image goals - that is, when they try to manage the impressions others have of them - they create a cascade of unintended negative consequences for both themselves and others. In contrast, when people try to contribute to the well-being of other people, they create a cascade of positive consequences for both themselves and others. Over time, for better or worse, by changing what they experience, people actually change themselves - the beliefs they hold and their goals, self-esteem, and even dispositional tendencies. We describe a variety of processes through which people's interpersonal goals shape their own and others’ experience and raise several remaining issues for this program of research."  Fascinating.  And researchers are exploring these issues - see, for example, the recent research paper "Relational treatment strategies increase social approach behaviors in patients with generalized social anxiety disorder" or books like "The mindful path through shyness" and "The relationship cure".

The possibility of incorporating some social skills and compassion work into social anxiety treatment is appealing, but one also needs to be cautious.  As they say "It's important to keep an open mind, but not so open that one's brains fall out."  It is Clark & colleagues' current model of social anxiety treatment that leads the pack just now - see, for example, the clearly superior results obtained by CBT in "Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: A randomized controlled trial."  This means that we should be focusing treatment - in a whole series of ways - on challenging excessive fears of negative judgement by others.  But there's still room for improvement in our treatment results.  As the "Cognitive therapy competence scale for social phobia (CTCS-SP)" has shown, client "resource activation" by the therapist is likely to improve outcomes.  With social phobia, it's important to be task focused rather than self-focused - and it's likely to be more effective if this "task focus" dovetails with the client's values.  As James Hollingworth put it so memorably "Courage is not the absence of fear, but rather the judgement that something else is more important than fear."        

For the next post in this sequence on social anxiety disorder, see "Treating social anxiety disorder: video (and still) feedback (6th post)". 

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