In the 1600’s, the famous French philosopher René Descartes set out on a journey in an effort to discover truth. The question he asked was: what can one know—with certainty—is real? At the end of this philosophical journey, he came to the conclusion that there was almost nothing in life of which he could be truly certain. His famous quote, “I think, therefore I am” reflects the end of an exhaustive search for certainty. Descartes’ conclusion suggested that the only thing in life that anyone can truly be sure of is that if we are able to think and reason, then surely, in some form, we must exist.
In coming to that conclusion, Descartes also theorized that everything else in our lives—from the air that we breathe to the touch of our mother’s hand—literally everything else we experience —may not actually be real.
Some might hear this and decide that Descartes must have been misguided. Others might think that his theories are nonsense—that surely if we can see it, touch it, smell it or hear it—that it exists! However, those suffering from anxiety disorders or obsessive compulsive disorder (OCD) are likely to better understand why Descartes made this philosophical journey. Perhaps even more importantly, those with anxiety disorders will likely understand the urge to be 100% certain of things before they take action…to have 0% doubt that things will be alright.
The Desire to be Certain
Social anxiety disorder, just like ALL forms of anxiety, is a disorder that is driven by a seemingly innate desire to feel certain; a wish that all humans have to know that things will be OK before taking a step forward. However, as we know, we are often faced with situations in which there can be little to no certainty.
Imagine the social situation of walking into the first day of a new job. We may feel somewhat confident that some aspects of our day will feel comfortable to us. But those who experience social anxiety disorder may find themselves overwhelmed by those parts of the day in which they have no certainty, and of which they have no control. As such, those who suffer from social anxiety may experience intense discomfort as they consider the many aspects of the day over which they have no control or certainty.
The Fear of “What If”
Social anxiety disorder is one of the most common problems treated in psychotherapy practices. As therapists, we hear about the many ways in which one’s desire for certainty triggers anxious anticipation of these types of events. Clients might say, “What if I do or say something embarrassing?”, “What if I turn red or start sweating?” and “What if people notice that I’m turning red and point and laugh at me?” Thoughts of experiences like these are extremely common triggers for those who suffer from social anxiety disorder.
Truth be told, none of us would probably enjoy the experiences described above. However, clients who suffer from social anxiety disorder often approach such circumstances with extreme fear and discomfort. They spend large amounts of time trying to figure out how to prevent embarrassing things from happening. They may decide that they will avoid talking in meetings so that they don’t have to risk saying something stupid. They might try to avoid eye contact so as to deter others from engaging them in small talk. They may choose not to participate in social gatherings at work (such as birthdays or retirement parties) to prevent social interaction.
Triggers are Inevitable
But at the end of the day, no matter how hard these clients try, there is no amount of preparation or avoidance that will completely eliminate uncertainty. Despite excessive planning, clients always end up in situations that cause them to feel conspicuous or embarrassed. Below is a list of common triggers for social phobia:
- Attending parties or other social gatherings
- Being the center of attention
- Being watched while doing something
- Being teased or criticized
- Being called on in class
- Being judged by others
- Being embarrassed or humiliated
- Being the center of attention
- Eating or drinking in public
- Going on a date
- Going to the bathroom at work or other social situations, where you might bump into someone on the way
- Going to work with other people
- Having to talk to people
- Having shaky hands
- Having others notice or point out your anxiety symptoms (eg blushing, shaking, etc.)
- Making small talk
- Making phone calls
- Meeting new people
- Offending someone
- Parties or family events
- Public speaking (whether to small or large groups).
- Performing on stage
- Speaking up in a meeting
- Talking with “important” people or authority figures
- Using public restrooms
Remarkably, this represents only a small fraction of the experiences that can trigger one’s social anxiety. As clients well know, almost any experience can trigger intense fear and discomfort if it means that others might point and laugh at them, or call public attention to their physical symptoms of anxiety.
There are many other articles on this blog which describe in detail the best evidence-based treatment for social phobia, which is called cognitive-behavioral therapy (CBT), including the core CBT strategy called exposure and response prevention (ERP). While this article does not explore all aspects of ERP treatment, it covers what is arguably one of the most essential components of the treatment: the cognitive process of embracing uncertainty.
The “exposure” in ERP typically refers to a behavior the client engages in. However, we cannot successfully treat social anxiety disorder without engaging in exposures that incorporate both behavioral and cognitive experiences. To omit the cognitive exposure piece of ERP can result in partial remission or treatment failure. It is only by engaging in both behavioral and cognitive exposure activities where one will truly find remission of social phobia.
Clients who participate in ERP might do a wonderful job of initially engaging in behavioral exposure activities. A good example of a behavioral exposure activity (using our previously described scenario) would be to sit in the front of the meeting room, to speak up during discussions, to eat lunch in the break room and engage in small talk, to ask questions or to look people in the eye instead of looking at the ground.
While these are all great examples of behavioral exposure activities, individuals who engage solely in these behavioral interventions are unlikely to achieve remission of their symptoms. In other words, no matter how much the individual faces their fears, they will continue to experience intense anticipatory anxiety as they approach feared situations. In these cases, what must be addressed is not whether or not the client is doing the exposure—it’s whether or not the client is truly embracing uncertainty as they approach these feared situations. It is only by including this cognitive intervention—embracing uncertainty—that social anxiety disorder can ever truly be conquered.
To demonstrate, let’s imagine the individual who decides to eat lunch in the lunchroom and engage others in small talk. If that individual chooses to chat with someone who they happen to know (and feel comfortable with), or if they spend time preparing what they will say ahead of time, then the exposure might have little impact on them. Instead of allowing them to feel the full uncertainty of the experience, a situation is created where one is unlikely to appear anxious or make a social blunder. They have figuratively stacked the deck in their favor so as to prevent facing uncertainty head-on. If one chooses a friend to chit chat with, it’s unlikely that they will be made fun of. And if one prepares for the situation ahead of time, how likely is it that they will say something silly or embarrassing?
Once again, in order to truly be “exposed” to a feared situation, clients must be exposed to situations in which the outcome is uncertain. They must engage in small talk with both people they know and complete strangers. They must participate in the discussion—even when they have nothing prepared to say and they have no clue if they will say something silly or be laughed at.
All human beings are hard-wired to try to reduce doubt and uncertainty when they feel unsafe. But in order to overcome social anxiety disorder, clients must do the opposite of what comes naturally. They must embrace uncertainty and act in ways that are counterintuitive. They must step forward into feared social situations without preparation and without knowing what the outcome will be. Ultimately, clients must risk embarrassment and humiliation.
It’s Worth the Risk
What is good to know is that the final rewards usually make these experiences worth it. The more often clients risk anxiety and embarrassment, and the more anxiety and discomfort one is forced to tolerate, the harder it ultimately becomes for life to trigger anxiety. By facing uncertainty and risking humiliation, clients will eventually become immune to their feared social situations until they no longer respond to them with anxiety.
In the end, there may be little of which we all are certain. According to Descartes, there is almost nothing that we can ever truly know for sure. However, we can learn to have confidence in our ability to tolerate whatever life throws our way.
Katy Manetta, PhD, A-CBT
National Social Anxiety Center – Long Beach
Crozier, R. (2010), “The Puzzle of Blushing”, The Psychologist, Vol 23. No 5, May 2010, pp. 390–393.