Angela Krumm, Ph.D. presents CBT Tools for Rapid Recovery from Social Anxiety: Self-Talk, Exposure and Shame-Attacking

In this free, one-hour webinar, Angela Krumm shares CBT tools for social anxiety. Exposure is a behavioral technique where individuals confront feared situations or stimuli in a controlled and systematic way. In the context of social anxiety, exposure involves gradually facing and approaching social situations that provoke anxiety. The goal is to help individuals learn that their feared outcomes are unlikely and that they can tolerate and cope with the anxiety.

In the case of social anxiety, exposures can include various activities such as initiating conversations with strangers, giving presentations, or attending social events. It's important to start with exposures that are challenging but manageable and gradually increase the difficulty.

We might design exposures that align with specific fears and avoidance behaviors. For instance, an exposure could involve initiating a conversation with a classmate, sharing thoughts in a group setting, or attending a social event without relying on a support person.

During exposures, individuals may experience heightened anxiety, but over time and with repetition, their anxiety tends to decrease as they learn that the feared outcomes are unlikely to occur. It's essential to combine exposure with cognitive strategies, as individuals need to challenge and restructure their negative thoughts while facing feared situations.

In summary, a comprehensive approach to treating social anxiety involves both cognitive and behavioral strategies. Cognitive techniques help individuals identify and challenge negative thoughts, while exposure helps them confront and overcome their fears in real-life situations. Combining these approaches can be a powerful way to address the complex nature of social anxiety. 

IN THIS VIDEO:

Jill: Okay welcome everyone! I can see a couple of people are just still joining us. But welcome to our presentation today: CBT tools for rapid recovery from social anxiety, self-talk exposure, and shame attacking. We have a lot of exciting material to try to cover in an hour, and we'll also take a couple of questions at the end. This is going to be presented today by Angela Krumm, Shiveta Gandotra, and LJ Davis. We always like to make sure we give credit to Dr. David Burns, who developed many of the methods that we'll be teaching you about today.

Let me start actually by welcoming our presenters. So, I'll introduce you first to Angela Krumm. Angela is a licensed counseling psychologist and the Global Clinical Director at the Feeling Good Institute. She's a certified level five Master therapist and trainer in Team CBT, with nearly two decades of unwavering commitment to the field. Dr. Krumm has cultivated a wealth of expertise in the application of CBT, with particular emphasis on addressing anxiety disorders and a special focus on enhancing social skills. She's been featured alongside Dr. David Burns, covering numerous topics, including curing social anxiety with flirting training. Dr. Krumm's dedication extends beyond her clinical practice as she imparts her knowledge to therapists locally and internationally.

Next, I'll introduce you to our other featured panelist, Shiveta Gandotra. She has a PhD in Psychology and is an associate marriage and family therapist (IST) and an associate professional clinical counselor. Shiveta taught psychology for 11 years at the university level in India and has published papers in the areas of stress coping strategies, resilience, mental health, and well-being. Her therapy experience includes working with adults, teens, and children who struggle with stress, anxiety, depression, habits, and addictions. She's a certified level one therapist in Team CBT and is also certified in the addiction and recovery program from Stanford University. She looks forward to sharing her insight and skills with you here today.

Finally, our last featured panelist, LJ Davis, is a licensed professional counselor serving clients online and in-person in Carlton, Georgia. He's a level four Team CBT trainer and therapist and has been treating clients for 15 years. LJ was named FGI's up-and-coming trainer of the year for 2023. He leads our core Skills Practice Group that accompanies our core skills of effective therapy course, and he assists with our comprehensive online CBT training for therapists. LJ has experienced social anxiety himself, and he loves helping others to overcome this challenge and looks forward to sharing his knowledge with you today.

I will just cover one more slide, and then I'm going to pass the reins over to Angela. Just to let you know who we are, who it is that's bringing you this presentation today. The Feeling Good Institute's mission is to alleviate suffering by elevating the practice of therapy. We started the Feeling Good Institute, Angela Krumm, myself. We have all been mentored by Dr. David Burns at Stanford University. We train and certify therapists in processes of evidence-based CBT that are known to be most effective, including the use of measurement, empathy skills, increasing motivation, and reducing resistance, and lots and lots of CBT strategies, which we'll be focusing on with you today. Our therapists are highly skilled and vetted, and we all engage in a weekly system of continuous improvement, practicing therapy skills in a deliberate practice model. We have flexible services to meet clients' needs. We have video-based treatment across the US and Canada, and we also have brick and mortar treatment centers in New York, Silicon Valley, Canada, and Israel. All of our therapists offer outpatient therapy, traditional kind of weekly therapy. We also offer intensive therapy, where people fly in from out of town or drive in from out of town to receive more concentrated therapy several hours a day, several days a week, in order to be more efficient and sometimes cost-effective. We also have lower fee options.

One more thing, sorry, I just realized. I'm also in charge of making sure that you all get your CE credit, and so I'll just remind you that at the very end of the presentation, you must be on at the end of the presentation. We will drop the link in the chat box to make it really easy for you to fill out the CE survey. So, make sure you're here for the whole presentation. You'll click the link in the chat box that will open up the CE survey. It will take you just a minute or two to complete that survey, and then we'll send you your CE certificate of completion within a week. Now, I'm going to pass it over to Angela. Thank you so much.

Angela: Yeah, thanks for going over that and for your awesome introductions, which always make me feel a little awkward and humble hearing all those nice things. I don't know, Shiveta and LJ, if you feel the same way, but I'm excited to be here today. I really love teaching about social anxiety disorder, and I love treating it. I also want to acknowledge that sometimes I get nervous when I'm presenting about anything, and I think today the nervousness I feel is just really wanting to do right by all of you. You showed up today and are here to receive information, and so I have this strong wish to make this really helpful and meaningful for you. Sometimes, the more I care about something, the more nervous I get, the more pressure I put on it. So, I come today just imagining all these familiar awesome faces who I love from the Team CBT Community, as well as new faces. I just want to welcome you to the community and hope to get to know you over time. We're glad you're here.

We have a couple of specific learning objectives today, and of course, I hope you learn more than just the two things mentioned here. At a basic level, the goal is for you to leave today being able to identify at least three common negative thoughts that are characteristic of social anxiety. Additionally, we want you to understand the purpose of shame-attacking exercises. We will also discuss other exercises.

So, what can you expect today? We will spend some time on the background of social anxiety disorder, followed by a discussion of two intervention models: the cognitive model and the exposure model. During the cognitive model, you will hear from Scha, and during the exposure model, you will hear from LJ. Throughout the presentation, we will use a recent case example from this past summer. We will try to save some time for Q&A as well.

Now, why is this important? Social anxiety disorder is one of the most common types of anxiety disorders in the US, with prevalence rates ranging from 7% to about 12%. It's important to note that these rates refer to individuals who meet diagnostic criteria. However, it is widely recognized that nearly all humans experience some degree of social anxiety or performance anxiety from time to time, even if they don't meet the criteria. Therefore, the prevalence of symptoms is often much higher. Social anxiety disorder is characterized by a persistent fear of negative evaluation by others in social or performance situations. It is a heterogeneous condition, meaning it can manifest differently in different people. Some may experience social anxiety in large groups, while others may only experience it in small settings. It can also vary with different social settings and relationships. Despite these variations, there is a shared fear of being rejected, appearing foolish, or being the center of attention. To meet diagnostic criteria, significant impairment is required in occupational, academic, or interpersonal areas.

— Live Discussion with viewers —

Now, let's talk about the background of social anxiety disorder from a cognitive-behavioral perspective. We know that social anxiety is developed and maintained by negative thoughts, behaviors, and physical symptoms. Negative thoughts can include beliefs such as "I'll make a fool of myself" or the perception that the stakes are high. Behaviors associated with social anxiety can vary, but common examples include hiding behind parents, avoidance or safety behaviors, using alcohol to manage anxiety, withdrawing or being quiet, leaving social interactions early, or avoiding socializing altogether. Physical symptoms are similar to those experienced in other anxiety disorders, such as rapid heart rate, flushing, sweating, and changes in vocalization ability. These three clusters of negative thoughts, behaviors, and physical symptoms can reinforce each other if left unchecked.

Unfortunately, they can actually increase the likelihood of experiencing disappointing social outcomes that the person fears. So, as these symptoms are racing around, the person may actually be more likely to create the outcome they're fearing. Maybe they end up feeling more distant or their awkwardness makes it hard to socialize. It's exciting to think of intervening at different levels here to help people start to feel more in control.

Next, I want to talk to you about our case example. I'm going to tell you a little bit about Kia, and then we're going to ask you to actually spot these examples of thoughts, behaviors, and symptoms in her story. But first, a bit of background about her. Of course, I've changed names and some details here to protect her safety, but this is a very real and important client to me. I had the pleasure of working with Kia just this past summer. She's a lovely young woman in her early 20s who has a long history of experiencing social anxiety. Her story really struck me because her social anxiety was tied up in people-pleasing behavior. Kia believed strongly that the way to win people over and have them drawn to her was to predict what they needed or expected from her and to try to be that person. So, she spent a lot of her life guessing how she should be in social situations, which caused her to feel stuck and super anxious.

The first time she actually came in as an in-person client, I saw her in the waiting room. She was visibly shaky, flushed, tapping her foot, and visibly anxious. The impetus for her starting therapy was her disappointing first year of college. Academically, she did fine, but socially, it was disappointment after disappointment. She desperately wanted to feel close and connected to others but was not succeeding.

Let me tell you a story about how things played out for her socially. Kia was invited to a party by her roommate. She often relied on her roommate as a support person and someone to introduce her to others. Even before going to the event, she started to worry, saying things to herself like, "I have to act perfectly or they will reject me. I'm not good at socializing like others are." Despite her worries, she went to the party because she was brave and motivated to connect. As the party went on, she stuck close to her roommate, and a conversation ensued about weekend plans. She could see that people were going around in a small circle, and she knew that there would be an expectation for her to contribute. Her heart rate increased, she started feeling flushed and sweaty, and she nervously giggled as she listened to others. Negative thoughts started spinning in her mind, thinking that everyone was noticing how awkward she was and that she should just shut up and find a way to escape. So, she excused herself to go to the bathroom before it was her turn to talk about weekend plans. She made an effort to pull herself out of the bathroom and tried again, but the same cycle repeated until she ultimately decided to leave the party. There was a momentary relief for her when she left, but shortly after, she started beating herself up, feeling regret, and worrying about the next time.

As you listened to that story, I hope you could hear how her negative thoughts, avoidance behaviors, and physical symptoms were interconnected. Now, let's think about how to be helpful for someone like Kia. We'll start by taking a good history and learning about their unique experiences of socializing. Each client is different, so it's important to gather details using tools like a daily mood log or record forms from common treatment manuals for social anxiety disorder.

I'll point you to one I like later today. We also want you to spend time learning about the client's cultural norms for social interaction so that you really understand the basis from which they're approaching socializing. You can do that by asking questions about what the client has learned about social expectations in various situations, what's expected of them, and how they believe normal socializing should be. You can ask questions about their beliefs with peers, elders, family, and dating scenarios. Additionally, ask about their own values and to what degree they want to uphold those values or move away from them. These types of questions will help you paint a picture of this person's values around socializing.

Another thing we want to attend to is if there are any traumatic experiences that could impact anxiety in social or performance situations. For example, has your client experienced bullying, prejudice, discrimination, a hostile work environment, or other forms of trauma? If that's the case, we want to pause and consider that it may not be as simple as teaching cognitive and exposure techniques. Instead, there may be a safety issue where they feel anxious because their wisest self is saying it isn't safe. In those cases, we might first need to work on interventions that increase safety through advocacy or other methods.

Assuming that we have done a thorough history and really gotten to know the client, and assuming that we have empathized with our client and connected with them, our approach at Feeling Good Institute offers a great model for teaching in-depth empathy with clients. Assuming that we're getting great scores on empathy and that we've worked through a client's motivation to change, we're ready to jump into the cognitive model.

Shiveta: The cognitive model is based on three simple ideas: you feel the way you think, when you are anxious you're fooling yourself, and anxiety results from distorted illogical thoughts. When you change the way you think, you can change the way you feel. Cognitive work generally, but not always, precedes exposure therapy. There are multiple steps that we cover with a client before starting exposure work for social anxiety. In order to best help someone like Kia or any of our clients, we need to first be familiar with common types of negative thoughts experienced by individuals with social anxiety. So, what are some common examples of negative thoughts that you or your clients experience? Please enter your responses in the chat box.

Jill: As the responses come in, I will share some examples. Some common negative thoughts include: "I'm not good enough," "They probably won't like me," "I'm a bad mom," "I'll sound silly for asking that question," "I'm a terrible friend," "I'm too much for people," "I never have anything to say," and "I have to act perfect." These are just a few examples, but there are many more.

Shiveta: Now, let's see what are some of the negative thoughts clients experience. Most people will experience some of these thoughts some of the time, but individuals with social anxiety disorder experience them in a more debilitating manner. Some examples of negative thoughts include: "I do not have anything interesting to say," "If he does not respond, that means my text was stupid," "He probably thinks I'm a loser," "I might freeze up, forget, sweat, etc.," "They can tell how nervous I feel," "I can't control my anxiety," "They're going to reject me," "I shouldn't socialize because I'm not good at it," and "I will get cancelled." These negative thoughts can create a lot of pressure and anxiety.

So, how do we help clients with these negative thoughts? It's not enough to just help clients know their negative thoughts. Instead, we need to help them learn how to talk back to these negative thoughts. At Feeling Good Institute, we use the Daily Mood Log, which is a very useful tool developed by Dr. David Burns. It helps us get specific with our patients and set ourselves up for effective cognitive therapy. If the Daily Mood Log is new to you, you can simplify by drawing three columns on a piece of paper. The first column is for writing down the specific moment, the second column is for the unique negative thoughts, and the third column is for identifying cognitive distortions in each specific thought. Cognitive distortions are internal mental filters or biases that increase our misery, fuel our anxiety, and make us feel bad about ourselves. There are many cognitive distortions, such as all-or-nothing thinking, overgeneralization, and labeling. By identifying these distortions, we can challenge and change our negative thoughts.

Nothing thinking over generalization mental filter jumping to conclusions includes mental read sorry mind reading and fortune telling emotional reasoning labeling should statements and fourth have the client write a rebuttal that puts the light on the negative thought. For example, it cleans up the distortions. The client has to believe the positive thought 100% and it has to address the negative thought. There is no fake positive stuff in this column. Fifth, the client will have to rehearse the new positive thoughts over and over again. The brain takes a while to unlearn the negative thoughts that have been rehearsed for years, so practice of the new positive thoughts is imperative.

Now let's take an example of Kia. For Kia, the upsetting event is attending a social event. In the First Column, the negative thought is "they are going to reject me." Cognitive distortions: jumping to conclusions, mind filter, mental filter, and all-or-nothing thinking. Helpful positive rebuttal: "They may or may not reject me. I surely do not know what others are thinking. People do not fully reject or approve of anyone. Most people like some things and dislike some things about others. There are many positive things that I offer to others socially, like being a good listener, making others feel good about themselves, and being open to adventures."

So actually, there are a few resources where you can learn about how to use the daily mood log, identify distortions, and talk back to negative thoughts. In our free webinar on FGI website, there is a paid course called "Skills for Effective Therapy" and also there is the David Burns book which is called "When Panic Attacks" which definitely works through the DML and many cognitive skills. Next, Angela is going to talk with you all about exposure.

Angela: Thank you so much, Shiveta, that was awesome and really clear and well explained. I appreciate that. And yeah, it just got me reflecting as you were talking about Kia's example specifically. The cognitive work was really powerful. She had never actually occurred to her, as is true for many clients I work with, that her thoughts are just thoughts and that they might not be entirely valid. So, um, there were various cognitive techniques we used to help her get to those positive thoughts. Things like examining the evidence for a thought that says she has nothing to offer others. And actually, as she made these lists of evidence for and against that and became really aware of all the things she has to offer to other people she's meeting, she felt really empowered by those things and talking back to thoughts, just like the example Shiveta gave you. However, with most anxiety disorders, cognitive work is not usually enough. We can't be sure, and so often we need to bring in the exposure model.

So, um, we'll be talking about some examples of how to do exposure for social anxiety. Let me give you a bit of background first so you know, before we can jump into doing exposure work with clients, there are a number of things we need to prepare the clients for. And so, I won't have time to go into detail on all of these. This is kind of a high level of things you want to think about before starting exposure. We'll talk about item one the most, um, but at a high level, we want to discuss the rationale for exposure with the clients so that they fully understand and buy in. Without that, they often won't follow through anyway. We need to construct a hierarchy, which is really deciding which activities will confront what they've been avoiding and that have been fear-inducing for them. We want to banish avoidance and safety behavior, so take away those things they're doing to create a false sense of safety so that they actually have to expose themselves to the scary situations. We also want to prepare for both in-session and out-of-session exposures that we can do. I'll give you some examples of those in a moment and then build an expectation for repeated practice. Right, so one round of exposure is rarely enough. Sometimes you'll get a really powerful exposure session and it will be life-changing. Often clients need to continue to repeat the exposures and get practice over time to really gain the benefit. So we want to build that expectation from the beginning.

Okay, so let's talk in more depth about the rationale. As I said, it's really important that clients understand why we are doing this. And I surely don't think we can explain it until we get it right. So therapists, we have to really understand the rationale first to then be able to explain it to others. Luckily, if this is new to you, a lot of these treatment manuals will offer whole chapters that the client can read to help them understand the rationale.

And of course, you can read those as well. So there's lots of help out there. But here in front of you is a list of five ways in which exposure can be helpful. Our rationale for doing it.

The first here is that we can identify new anxious thoughts that were missed. Most of your clients, when you're doing a daily mood log or thought record, will be able to remember the thoughts that plague them when they're anxious. Once in a while, they'll miss some that they're just not quite aware of. And when you start exposure, boom, those thoughts just pop right up because it's in real time. And then we can address those thoughts as we need to.

We also have the opportunity to test the anxious thoughts for once. So instead of just assuming that a negative outcome is real, like people will judge me harshly, bad things will happen if I make a mistake socially, right? We get to actually find out what happens if we do these things. So that's an important part of it.

Another important part is building tolerance for anxiety, so we'll do that through exposure by measuring subjective units of distress or some other measure of anxiety that you prefer to use. I suggest keeping it simple. The value of measuring anxiety before, during, and after exposure is that the client gets to see how anxiety can fluctuate across exposure, rather than staying the same. Ultimately, they'll see that with repetition of exposure, anxiety decreases, which is a powerful and important learning for our brain.

The fourth point here is building tolerance for social mistakes instead of avoiding them. This is crucial, so I want you to focus on this part. Many cognitive therapists who don't use exposure spend a lot of time trying to convince clients that people won't judge them or that they won't make mistakes. However, the truth is that people do judge, and socializing can be awkward. It's a disservice to clients to imply that they can avoid social mistakes. Instead, we should invite social mistakes, meaning awkward moments or goofy things, as they are key to recovery. By doing so, we can build up our tolerance for these situations and realize that we can survive them without needing to avoid them.

Exposure is also helpful for practicing social skills. Not all clients will need it, but there are common struggles for socially anxious individuals, such as starting and ending conversations or deepening them beyond chitchat. These are important skills to practice.

Here are a couple of examples of things you can do in sessions with clients, whether in person or via video. You can roleplay conversations with clients, pretending to be a peer, a teacher, a dating partner, or whoever is relevant. This may seem easy to you, but for someone with high social anxiety, even roleplaying with you can be challenging. Opening conversations, ending conversations, handling awkward moments, and anything else that is difficult for them can be practiced in this way.

Outside of sessions, the sky's the limit. You can practice greeting others, making eye contact, requesting recommendations or help from strangers, and other activities that draw attention to the self as a way to work on anxiety.

Now, I'll hand it over to LJ to discuss some specific examples. Are you ready to jump in, LJ?

LJ Davis: Yes, thank you Angela. I'm excited to be here, but also a little nervous. When I look at this slide and think about smile and hello practice, I remember what Angela said earlier about hierarchy and how smile and hello can be a great starting point for out-of-office exposures. In fact, I often start with clients doing smile and hello even in the office. It may feel a bit awkward, but that's part of what makes it a great first step. Even in a familiar environment like the office, looking each other in the eye, smiling, and saying hello can feel a bit weird. It's a great way to get started, and then we can progress to doing it in the community.

There are several rationales behind smile and hello. First, it helps to address specific thoughts like "socializing would be too difficult for me" or "I couldn't handle it if somebody rejected me." By doing smile and hello practice, we may experience small rejections and test these thoughts. It also challenges ideas that people aren't friendly or that nobody would want to talk to us. We can test these beliefs by engaging in smile and hello practice. Additionally, it allows us to tolerate the anxiety of meeting new people or doing unfamiliar things. Smiling and saying hello to strangers on the street may be uncommon, but doing something that's a little out of the ordinary helps us confront anxiety and realize that we can move through it.

As for how to do the technique, it's all in the name. We go out, smile, and say hello to people. However, there are some important details to consider, mostly related to banishing avoidance, as Angela mentioned. One important aspect is attempting to engage with everyone we pass by.

Otherwise, a very subtle avoidance is that I will choose people who I think look friendly or who I think look like they would be interested in somebody like me. Then, I'm kind of rigging the results and later I can discount the experience by saying, "Well, it only really worked because I chose those three friendly people." Another one is that we want to make sure to make eye contact. Looking down or avoiding making eye contact is another common way to just lower the intensity a little bit and avoid some of the full impact of the exposure.

Similarly, with audible voice, to really take it up another notch, we can add some gestures. We can smile, say hello, and wave, really practicing bringing that attention to ourselves. Before we leave the office, like I said, I would often start by doing this in the office, but then we want to talk about what might be the outcomes.

So, I will usually tell my clients that we're going to do this with at least 10 people, and there are probably three kinds of outcomes we can anticipate. Two that are fairly common and one that's actually less common, but we might run into it. The most common ones are the first two.

We're going to hope that we meet at least some friendly people, and I don't think I've ever done this where we didn't have some people who seem genuinely glad to have somebody smile and say hello to them. It's probably not going to be everybody. It may or may not be the majority, just depending on where you are and who you run into. It can vary.

The other outcome that's fairly common is that we're going to run into a lot of people who are on their phones, have their earbuds in, or who are just not interested in talking. So, we'll have some people who won't respond, they'll just walk on by, and that's another great chance for us to see, "Okay, I can do what I can do and I can tolerate it when things don't go exactly the way I was wanting it to go."

I don't think it very often, but occasionally you might run into somebody who's grumpy or who just doesn't have a great expression on their face, and so we can be ready for that too and just be ready to say, "Well, that's one person. I know there are lots of people, and really, it's good news that I had somebody who was like that on my route today, so that I get to practice being okay with just a little bit of rejection." We can go on to the next intervention where we will start working our way up the hierarchy of things that are uncomfortable to do, at least for most people.

So, the next one is self-disclosure, and it's another one where the name kind of encapsulates, but there are subtleties to it. Instead of trying to hide that we're feeling anxious, you, Shiveta, and Angela and I all do this today. Instead of trying to hide it, we're just going to acknowledge it and say, "You know what? I actually am feeling a little bit anxious about this." Because the problem is not really that we're feeling anxious. The thing that would really make things a lot worse would be if we were to try and hide that anxiety, and then we would maybe start to feel shame. If we think about it like Kia from before, one of her worries was that people could see that she was feeling anxious and that they would then reject her. So, this self-disclosure is going to be a powerful way for her to face that fear instead of trying to hide it and act like she's not nervous or tell people like, "Oh no, I'm good. Everything's great." She can just tell people, and then she'll get to find out, do people reject her because that was also another part of it, that if people could see she was anxious, they would then reject her.

So, by telling people in a skillful way, she gets to test that belief, and then this also gets around some of the other subtle avoidance that she may have. She has this idea perhaps that if she presents herself perfectly or she presents herself as always being cool, calm, and collected, that people will accept her. But if instead she presents herself not quite so cool, calm, and collected, she'll get to test whether people really have as high standards for who they want to socialize with as maybe she was believing.

If we look at the next slide, we'll get to see some of the skillful ways that people will do that. Here are just some really direct quotes, and I always find it helpful to ask people permission. Again, I would probably practice this with a client in the office once or twice just to get used to it. Then, I also recommend people to write down what they want to say on a card or, of course, everybody now uses their phones. I suggest writing it on a card, and people look at me like I'm crazy because they have their phone right there. But write it down on your phone, and it's not that we're going to want them to go read it to people when they go out into the community.

Instead, they can read and refresh themselves between conversations with people because we want to talk to a limited number of people. I usually suggest around 10, although we don't always reach that number. When you talk to someone, you may start feeling anxious or nervous, which can make it harder to find the right words. If we can prepare ourselves before each conversation, it will make it easier to communicate skillfully.

Here's what Kia could potentially say: "Could I speak to you for a moment? I wanted to let you know that I've struggled with shyness since I was a kid, and I used to feel really ashamed of it. But today, I've decided not to be ashamed or hide my anxious feelings anymore. Instead, I'm open about being shy. What are your thoughts on being shy? Is it something to be ashamed of?" This approach is powerful and helps Kia establish a connection.

One of the rules of exposure therapy is that if you ask your clients to do something, you should do it too. So, self-disclosure is something I've practiced as well. I used to have a tendency to appear emotionally perfect, but once I went to a park and talked to several different people, using a similar approach: "Can I speak to you for a second? I wanted to let you know that I've always felt like I was supposed to be emotionally perfect, so I hid my feelings of fear, sadness, or anger. But I've decided not to be ashamed of my feelings anymore, which is why I'm telling you about this." It was an incredible day, and I experienced a range of outcomes. One person I talked to immediately gave me a hug, but then realized they weren't a hugger. However, as we talked, they shared their similar struggles, and it was one of the fastest connections I've ever made. Another person and I sat on a bench and talked for a while, and they opened up about their sister's problems. On the other hand, there was a third person who turned around and asked, "Why do you do that?" It felt a bit judgmental at first, but as we talked, I realized that his partner had the same pattern, and he was frustrated with them. So, I had a range of experiences and got to see what it's like to talk to people and share something, with some loving it and others being unsure. If we look at the next slide, we can see another example of self-disclosure.

Angela mentioned earlier that Kia would start sweating and shaking and would want to leave and go to the bathroom to compose herself. Instead of avoiding these symptoms, we want to twist it a bit and let people know about them. For example, "I don't know about you, but sometimes I get really anxious at these networking events. It can be so awkward, and I can already feel myself blushing and shaking. Do you ever feel nervous at these events?" Putting the question at the end is beneficial because it allows you to share your symptoms and also creates a connection. Looking at our survey, over 95% of us feel at least a little socially awkward and nervous at these kinds of events. This gives the person permission to talk about themselves, and it helps start a conversation where things will flow naturally, and our anxiety will often decrease. I'll pass it back to you, Angela.

Angela: Thank you so much, LJ. I'll just add one more anecdote about Kia that reminds me of when you shared that. There was a time she actually used self-disclosure regarding symptoms so effectively. She had been hesitating to meet up with two friends who had reached out to her after there had been a bit of a rift in the relationship a while back. She was feeling eager to reconnect with them and cared a lot about them, but she was really awkward and just kind of petrified of showing up. She kept saying, "You know, I'm going to get there and I can't even imagine. I'm probably going to be crying before I get to the dinner table, and I'll be shaking, and they're going to think I'm so weird." We remembered the power of self-disclosure, so in the session, she took a huge step to send a text message to these two women in advance. She said, "I'm so excited to reconnect with you two, and it means so much to me. I also know I'm going to be a nervous wreck. Please expect me to be crying and shaking when I show up at the table."

And of course, the result, as you can imagine if you got that text from someone you wanted to see, was just this outpouring of love from these two friends of hers. They greeted her in the parking lot with big hugs. She said in the end she cried, but it was more like joyful tears of reconnection. She just felt so much relief from having put that out there even before showing up. It was such a celebration and success point for her, and she tells me she's continued to use that with all kinds of situations going forward. So thank you, LJ.

Okay, shame attacking. This is the big money exciting technique here that, um, if we're thinking of a hierarchy, tends to be one that's harder for folks. If you haven't heard of this term before, it's possible you've heard of something called The Comfort Crusher movement.

Comfort Crusher has been kind of popularized through social media, a movement of folks doing things that might involve challenging themselves to do tough things in public, embarrassing or outrageous things. Shame attacking was actually a term coined by Albert Ellis many years ago and really popularized by David Burns in his book "When Panic Attacks." In the Team CBT Community, what is it? Well, we purposefully do things that could be perceived as outrageous or goofy in public to draw attention to the self and to banish that avoidance that normally happens. So instead of fearing some social mishap, we invite them. We do something goofy to draw attention, hoping that we'll learn to tolerate the anxiety or discomfort and find out whether people will judge or not. And learn that we can tolerate the outcome either way because remember, my secret is some people will judge. We don't want to naively assume no one will judge. We want to say that's okay, some will judge, some won't, and I can be okay regardless.

So what are examples of this? Well, really, the sky is the limit. You and your client should be creative. You can look up Comfort Crusher movement for examples. You can read "When Panic Attacks." The Team CBT Community, both the FGI therapists and our larger community that we've trained, are really skilled at doing this. We've been there's a shame attacking Olympics once in a while where people submit their best. We had a retreat for our therapists this fall and did a bunch of Shame attacking together, and there were some real winners. So let me give you some examples of the types of things folks have done. Dancing on the street, at a park, singing out loud (not hopefully if you're not a great singer, otherwise it's less shameful to do it, right?), one of my favorites, Arnie Olivera, one of our therapists in Florida, stood at the beach and he took one of those huge signs of all the beach rules, you know, no litter, no campfires, and in his full volume just announced all the rules to everyone who could hear him on the beach, and everyone's looking and odd, and he's bright red as he does it. I'm so proud of him. Outrageous clothing, you know, the key is what feels embarrassing to the client, what feels different to them. People do fake marriage proposals. I mean, again, the sky is the limit.

So you would decide to do this with your client, and you would decide if you're able to do it together. If so, I say do it together. If you do in-person sessions and have physical access to your client, it's a great service to them to do the first round together and then assign some. If you do not have physical access to your clients for whatever reason, whether it's video therapy or some other limitations, then you assign them to do this on their own. Start with what they're able to do. Some folks will go along on a video feed. If you have a mobile version of a video feed, to do these things together. Often, doing it with someone is easier than doing it alone. So you'll just put that in our hierarchy.

As you move up the steps, let's look at some of Kia's examples. We had a pretty simple day of shame attacking. We did about two hours worth of shame attacking and focused on these three activities. She actually didn't find smiling and saying hello hard at that phase, so maybe we did a bit of those as warm-ups, but they didn't even make it officially on our hierarchy. So we focused on three things: asking questions without ordering anything. Some of you might be perplexed by that and ask why is that challenging, but for Kia's social anxiety, it was like never being a burden to anyone. So the idea of going into a bakery and asking questions about what's in the case and not ordering anything felt really hard for her. So we did that multiple times. We did silly walking down the street. We define silly walking as just goofy movement. It eventually morphed into the next item, which was dancing down the street and dancing on street corners. Silly walking might involve doing squats while you walk, walking backwards, high knees, marching, you know, just all kinds of combos of things.

So what were some of her learnings? Let me give you some examples.

For the first item, asking questions without ordering anything, I should mention that I always have them write down the learnings. They jot them down on their phones because the learnings actually cycle all the way back to Schu's daily mood log. Remember how she's having them write positive thoughts? When you do an activity like this, they're going to have new positive thoughts that they've learned, and we want them to add those back to that mood log. So some examples of what she learned from asking questions without ordering anything were that actually no one was upset, that people seemed to like to be helpful, even if they seemed mildly annoyed. It was okay, and she felt empowered to be allowed to have her own needs.

She also noticed that she felt less anxious when she kept doing it. So the themes there were no horrible outcomes, it got easier over time, even if people were mildly annoyed. I didn't sense any annoyance at all, but she said maybe this one person was, and she decided she was okay with that. She could tolerate his annoyance.

The silly walking and the dancing also had some great learnings. She said things like, "We did have at least one person give us a weird look," and that often happens when you're doing these things, right? Because it is unique and different. So she said, "The person who gave me the weird look doesn't have any power over me." That was a big win. Most people smiled and seemed to admire me, and that was a huge revelation. She realized that some people were kind of impressed, right? Like they'd give us a high five or they'd be like, "That's amazing," kind of acknowledging the bravery or courage. That was really exciting to her.

Another really powerful learning was, "I can do hard things despite my anxiety," and that being silly felt free. So overall, her report is that we're wrapping up treatment at the end of the summer. She's saying that normal socializing suddenly felt so much easier because she kept remembering doing these really hard things, dancing on the street corner, and saying, "If I can dance on the street corner and tolerate people's reactions and be okay, I can talk about my weekend plans at a party. I can take that risk. I can speak up in these more normal social situations." And that really stuck with her. Okay, great.

So let's talk about some summary points. And actually, as I do this, feel free to start chatting any questions you have to Jill. We can kind of get ahead. She's probably already getting questions. It's possible. But if you have anything you wanted to ask, go ahead and put those in. I'll just spend a moment summarizing here.

So today, we want you to leave with some of these points. Social anxiety is quite common. Common themes to the negative thoughts, I'll give you a lot of them, but common themes are a low belief in their own social abilities, like "I can't do it, I'm not good at it," and a high belief in the costs of making social mistakes. This will be catastrophic. There will be a horrible outcome if I don't do a good job. We also want you to remember that anxiety is maintained by avoidance, and so exposure exercises work against that. And I always want you to know that more help is available if this is new to you.

We've mentioned a couple of resources, which I'll summarize again now.

So, "When Panic Attacks" by David Burns is a great book. It's actually written for clients as a self-help book, but secretly serves as an amazing training tool for therapists as well. So please read it.

My favorite treatment manual for social anxiety is from the "Treatments That Work" series. It's called "Managing Social Anxiety: A Cognitive Behavioral Therapy Approach". Again, "Managing Social Anxiety" is all you have to remember there, and that it's the series called "Treatments That Work". They have both a workbook for the client and a therapist manual, which, if you like to follow instructions, is really comprehensive and a great guide. That's by Hine Bargain Turk.

You can also refer to FGI for consultation. We have trainers here who can provide consultation, and of course, we have great therapists who can work with your clients in intensive therapy model, which is like a high dose of therapy over a short period of time, or in traditional weekly therapy.

So hopefully, those are all helpful resources for folks who want to learn more. Let's take some questions, shall we?

Jill: First, I will say that we have way more questions than we will have time to answer. Actually, I had several sent to me throughout, and then when Angela, you just made that, and I got a whole host that I can't even read right now because I already have a list of so many. So what I'll say is we will capture all the questions that you've sent me, and it's been suggested to me that we even do like a blog or something after these kinds of webinars where we answer some of your questions. So I'm gonna pitch that to the team, and we're going to try to maybe get to some of these questions, and maybe we'll do a follow-up because there's so much interest in what you guys are teaching. So I will just spend a couple of minutes reading you guys some questions, and then we'll wrap up.

How about this one for LJ? I feel like you've already answered this, so maybe just a quick response to what if I myself have social anxiety and I'm nervous about doing role play with my patients?

LJ Davis: Well, I think finding somebody else to do the role play with first might be a great idea, but starting to really go through all the steps we've talked about, you could use Schuett's cognitive things and try to find out what are the thoughts that are getting in your way and then talking back to those. But you'll also, at some point, have to do some exposure and practice role plays, maybe with a friend or colleague, and then also eventually start to do them with your clients. Great.

Jill: Another question, let's see. A couple of people asked this question. I think it's a good one. They were worried that telling people, that self-disclosure, that telling people that you're anxious or have a social anxiety disorder is some form of reassurance seeking or actually avoidance. Someone said, in a different way, wouldn't the advanced texting ahead of the social situation be considered a safety behavior? And Angela, I wonder if you have a thought on that. I'm gosh, I'm happy also to respond to LJ. Will now respond to that question. That's a great question. Yeah, right. Well, I would say that really what our goal is to help our patients to be more connected, and so I just think you have to think to yourself, what is the function of this behavior? And I think the function of sharing your vulnerability or your flaws with another person is actually connection, and it's reducing your own shame. And so I think it serves a very helpful function, you know, in this purpose. But I think it's reasonable if someone is compulsively telling someone after, like, before every interaction, "Oh, I just wanted to remind you, I have social anxiety," if they're very clearly using it to sort of let themselves off the hook or if it's interfering in their connection with other people, then it seems problematic. And did you have anything else to add to that, Angela?

Angela: No, I think that was a great way to think about it.

Jill: Okay. What if clients insist that they already know how it's going to play out since they've already had bad experiences before? I don't know, Angela or LJ, do one of you guys want to take a stab at that?

Angela: Yeah, I mean, my first thought is it sounds like that's a negative thought, right? That they're saying some version, they're having the thought that this will turn out badly, it's been bad before, right? And so they're using, there's some distortions in that line of thinking, right? That they're jumping to conclusions. And it would be our job to put that thought on the mood log and work on it, right?

The truth is they probably have had a lot of bad, challenging, not all, many may have had a lot of really challenging, hurtful experiences, maybe they've been rejected a lot. And so they also may need just a lot of empathy from you in that moment to really know that you're hearing the extent of their suffering and pain and how scary it is, right? But if we give into that line of thinking and kind of become hopeless ourselves, then we're actually validating the fear and the anxious thought.

And so by doing empathy and then putting it on the mood log to work on it, it really gives us a path to avoid the hopelessness about it and to stay on the path of talking back to that thought. And if needed, again, some people do need some skill building as a way to help them shift how socializing is turning out, right? We can reduce the anxiety. Sometimes skill building is also needed. And there's a bit of a, there's plenty of approaches to help with that.

Jill: Thanks, Angela. I was just noticing another question I had about the survey, but I think Mike, maybe you can drop it in one more time, but I think people are, it's working for people now. Let's see. I'll ask, I'll do one more question for you guys. And then, like I said, we'll consider how to, you know, maybe offer another Q&A on this. Might be a great idea. We've already got plenty of questions we could use for that. And then I'll go to the next slide. So somebody asked, let me just see this one. Sorry. Yeah, this is great.

What one pattern I've noticed is folks experience difficulty challenging their thoughts because they are judging others in the way they don't want to be judged. For example, they might think others are scrutinizing my clothing, and I know this because I'm scrutinizing their clothing. Do you have recommendations for helping folks with this line of thinking?

And I'll just give you guys, you know, you guys can answer this, but I just want to say, I think the goal that we've tried to convey today is that a lot of working on social anxiety is acceptance. We're not actually telling people that everything is going to go great, that everyone is going to love you. Actually, working on people accepting that people might judge me, and that's okay, right? If I do goofy things in public, people might actually think that's goofy. And my goal is actually to help my patients to feel okay with that, right? So maybe they judge people, maybe people judge them, and that's okay. Do you have any other thoughts to add to that?

LJ Davis: That sounded perfect to me, Jill. That's exactly what I was thinking, is that, well, I don't need to convince them that people won't judge them. I need to convince them or help them learn that they can be okay with being judged.

Angela: Yeah, yeah, right. And some of the most powerful outcomes are when folks, you know, realize, like, kind of this attitude too, that maybe they're okay with people judging because they don't even want to be close to people who would be that judgmental. And sometimes it shifts their internal sense of judgment too. I've watched socially anxious people who really spend a lot of time judging others become accepting of others in the process as well, right? Giving other people space to be them, their messy selves, and to be imperfect. And that's a really joyful outcome when that works as well. And the cognitive and exposure model will help move people in that direction if we just work the model. It'll help them through this.

Jill: So, Angela, I'll have you just forward to the last. We'll follow up with people. We have lots of great training opportunities, and we'll follow up with you to give you some information via email. But we hope that you'll join us the first Wednesday of every month for our didactics and our Q&As. So, as always, it's our commitment to be helpful to you. We really believe strongly in the power of sharing knowledge and building meaningful connections and building a community of skilled therapists.

So, if you have any questions for us, any feedback, don't hesitate to get in touch with us. We're really here to support you in any way that we can.

We hope you have a wonderful day, and thanks to everyone for joining us. Thank you, everyone.