A surprisingly poetic description of social-anxiety disorder can be found in the DSM — that is, the Diagnostic and Statistical Manual of Mental Disorders, sometimes referred to as psychiatry’s “bible”: It’s an “illness of lost opportunities.” Much has been said about the trendiness of boasting online about your reclusive tendencies — about your relief over canceled plans, or your belief that “staying in is the new going out.” Everyone needs to retreat from the world from time to time, but for some, a tendency to avoid social situations can become debilitating.
People with social-anxiety disorder have extreme and often irrational fears about interacting with their fellow humans, says Stefan Hofmann, director of the Social Anxiety Program at Boston University’s Center for Anxiety and Related Disorders. “They believe that there are these social standards that everybody’s following, and social rules,” he said. “And so they sort of live in this very tiny confine of their belief that overstepping these kinds of invisible social boundaries would lead to disastrous, long-lasting social consequences.”
Hofmann takes his patients’ concerns seriously, thinking deeply about the way they are imagining looking unintelligent or ridiculous in front of others. He listens to those fears. And then, he makes his patients run headlong into them.
Hofmann and his fellow clinicians take their patients through a kind of exposure therapy, part of an overall cognitive-behavioral therapy approach to treating social anxiety. Think of the most embarrassing, most excruciatingly awkward thing you can imagine happening while you’re out in public. Now imagine actually having to do that thing.
These are specifically called “social mishap exposures,” but they work just like any kind of exposure therapy you’ve heard of before. “You present the stimulus or situation that people are afraid of, either repeatedly or for a prolonged period of time,” he explained. “And the person, as a result — or the animal, or any organism — as you repeatedly present the feared stimulus over and over again, or for a prolonged period of time, the fear response eventually decreases.” If, through repeated exposures, spider phobics can get to the point where they can not only be in the same room as a tarantula, but pick one up and hold it with their bare hands — well, he reasons, why shouldn’t the same idea work for social phobia?
The exposures take all forms, as they are tailored around each individual’s deepest social fears, but everyone starts with the same basic task: public speaking. (Despite everything else there is to fear in the world, 25 percent of those surveyed in Chapman University’s annual survey of American fears, published last month, said they were either afraid or very afraid of public speaking.) Most of the people in treatment for social anxiety work together in groups, providing a natural audience for each other. Each patient’s speech is structured so that it addresses the specific things that person fears most. Are they afraid of looking dumb? Okay, then they have to talk about a subject they know very little about, with minimal time to prepare: a subject vast and unknowable like black holes, or dating. Or, are they afraid of tripping over their own words, or losing their train of thought? Great — that means they have to intentionally stutter, or take a long pause right in the middle of their speech.
But that’s just step one. Soon afterward, they enter the real world. Each patient works with a therapist to, again, specifically tailor the exercise to address each person’s deepest social fears, things like looking silly, being the center of attention, causing a scene.
Here’s a list of some actual exposure scenarios patients Hofmann’s clinic have used:
• Going to a book store and saying to an employee, “Excuse me, I was looking for books about farting.”
• Interrupting a group at a restaurant and asking them to serve as an audience for you so you can practice a maid-of-honor or best-man speech.
• Standing directly in front of Fenway Park (remember, this clinic is in Boston) and asking ten people if they know where Fenway Park is.
• Calling a nearby five-star hotel to negotiate a vacation package, complete with tickets to a ballgame, a horse-drawn carriage tour of the city and rose petals strewn on the bed, then rejecting the offer — and making no apologies for it — because you’ve “changed your mind.”
• Going to a crowded restaurant and sitting at the bar, then asking the person next to you if they’ve seen the movie When Harry Met Sally and if they know who the actors were.
• This one, sadly, is no longer relevant, but it is still hilarious: Renting a DVD from Blockbuster, walking out and then immediately walking back in, telling the same employee you rented from, “I would like to return this because I just realized I don’t have a DVD player.”
• Asking a pharmacist for some condoms, then saying, “Is this the smallest size you have?”
• Standing on a street corner and loudly singing “God Bless America” or “Mary Had a Little Lamb” for ten straight minutes.
Actually, there’s video proof of that last one:
The point is not to terrify patients. The point is to get them to think carefully about what, exactly, it is they’re so afraid of, and whether their fears are overblown. Often, in discussion sessions following the social-mishap exposure, patients will realize the high standards they’ve set for themselves are, at least partially, in their own heads. Even when they purposefully embarrass themselves in front of others, people often turn out to be more generous and forgiving than they assume; either that, or the people around them barely registered their odd behavior in the first place.
In about 70 percent of cases at his clinic, Hofmann says, this admittedly ridiculous-sounding approach works when used as part of CBT. In a 2013 paper published in the journal Cognitive and Behavioral Practices, Hofmann and three Boston University co-authors detail their theories on social-mishap exposures, and present a relevant case study about a 41-year-old social phobic named Mary (not her real name). As I read about some of the things Mary had to do — including the maid-of-honor speech scenario listed above — I couldn’t help it; I laughed. And then I felt awful about laughing. I told Hofmann that, and he said that this is at least partially the point: to help people stop taking themselves quite so seriously. “If I want to simplify it, we want them to develop a healthy sense of making fun, of keeping humor in your life, and just being able to laugh about that,” he said. “Because it happens to absolutely everybody.”
He added: “You can really make a huge difference in people’s lives by using these kinds of exposure treatments in combination with other cognitive behavioral principles. So I would go as far as to say nobody needs to suffer from social-anxiety disorder anymore. We really know how to treat them.”