Enhancing Exposure Therapy Part II – Generalization for Social Anxiety

Let’s resume our discussion series on enhancing exposures. Last time I discussed ways of making exposures fun and engaging. This will really help with doing actual treatment in session. However, a major focus of treatment should also be on a concept called generalization. This is simply helping to complete exposures in other settings so that improvements from treatment start showing in everyday life.

A concept I like to aim for by the end of treatment is called the “exposure lifestyle”. The idea of this is to live everyday by doing at least one exposure. If you beat social anxiety, make sure to continue to talk to a stranger each day, if you beat contamination OCD, eat when your hands feel contaminated. This will act as your mental health vitamin, which will prevent anxiety coming back. By living the exposure lifestyle, you keep your brain fresh and make it much less likely that you will ever relapse.

In order to live the exposure lifestyle, you need generalization: You need to do exposures in all aspects of your life, in all situations. In order to do this, one important thing to figure out is how to come up with ideas for exposures in every day life. This is an area that people can have a hard time with, and I can understand why, because we don’t often think about how we can turn everyday activities into something that creates anxiety. Why would we? Doesn’t that sound a little miserable? But it’s really not. For people who suffer from an anxiety disorder, this is actually key to completing treatment, ensuring generalization of gains. Another way I like to think of this is as a “mental vaccination”. By doing daily exposures in everyday settings, you are vaccinating yourself against that anxiety returning. You are not letting that weed grow again.

Not enough therapists do this, and it hinders treatment. To make treatment more effective, therapists should think about how to get exposures going in everyday life. If you are in treatment, you should be encouraged to do exposures in other settings than the therapy office. This will take the treatment that’s being done, and apply it in other areas of life such that generalization starts to occur. I’ve written extensively about how this prevents future relapse and maximizes gains, and the research strongly supports this.

So, how can we make sure that exposures are done in everyday life? To do this there are two routes. The first is to find out a person’s interests, the activities they do the most, and find ways to complete exposures within this. This will be a topic for another time. However, what we are going to focus on is how some common activities can be turned into exposure activities. That way, you will be equipped with ideas to help you generalize your treatment gains in everyday life. Today, I’ll just focus on social anxiety, but next week I’ll address other issues too (e.g. OCD, GAD, and panic disorder).

Social Anxiety Exposure Treatment

To my mind, there are a couple of important targets in social anxiety treatment.

1) First, there is the fear that people will judge you. When social anxiety is high, this belief is often a little too strong and we want to disconfirm that people are judging you all the time. We can test this by violating assumptions about how people react. For example, if I talk to someone and expect them to frown at me for asking a stupid question, imagine how surprising it might be if they instead smile. Because social anxiety often causes someone to withdraw and not interact a ton, or not interact in unsafe ways (e.g. asking dumb questions), there are not enough opportunities to violate these beliefs. Exposure therapy creates these opportunities.

2) The second is the belief that if people do judge you, it’s a terrible thing. Let’s face it, people do judge others and so exposures shouldn’t just be about proving that no-one has negative beliefs of others, as that simply isn’t true. Instead, we want to learn that it’s not the end of the world if others do judge you. That you can survive it. Because social anxiety causes social withdrawal or avoidance, there are often not enough opportunities to tolerate being judged by others as you play it safe. Exposure therapy also creates these opportunities.

A Couple of Tips:

Whenever you do an exposure, do it all the way. That means full eye contact, not hiding away, not apologizing etc. If you hide or shrink away in the moment (what we call avoidance) it undoes the exposure.

Before you do the exposure, know exactly why you are doing it and what you are testing. The most important thing to ask yourself afterwards is “what did I learn?”, and so if the exposure isn’t designed well then you’ll not get as much out of it.

Social Anxiety Exposure Ideas

Now we know our primary treatment targets, let’s look at a short list of exposure ideas in every day activities. Making sure that you do exposures in all of these areas will cause generalization. This will reduce social anxiety a lot more, and mean that in all aspects of life you have social anxiety under control. It will also prevent social anxiety coming back in the future. Not all the examples listed below will apply to everyone, this is simply meant to give ideas that you can adapt to specifically target whatever the fear is. If you think an area is missing, please comment and I’ll add some ideas. I could write a million different examples, but this is simply meant to provoke your own imagination. Happy exposure hunting ?

– Ask for help finding items (especially something that’s either really obvious or super obscure). Ask several times in one trip. This will target fear of burdening people or being judged. Hopefully you’ll learn that either people don’t seem to mind, or if they do that it wasn’t that bad!
– Try bartering for an item (damaged or not). You’ll learn that either it works and you save money, or that being told “no” is not so bad.
– Buy something and then return it. This will face your fear that the shopkeeper may think badly of you.
– Go into a shop that makes you feel uncomfortable. For me, that would be walking around Victoria’s Secret looking for a gift card. For others it could be a really quiet shop or a really busy one. Stay in the shop until your anxiety comes down, which it will.

– Beep your horn at someone! Or drive a little slower so you end up being followed by at least a couple of cars. You’ll learn that it’s not a big deal.
– Buy food in a drive through. You’ll have to shout louder than you usually would, and hopefully you’ll learn that it doesn’t seem to bother the staff.
– Play the music in your car very loud with your windows down when in traffic. People will probably look at you, and you may feel embarrassed about sharing your music. But mouth the words to the music anyway. Make sure to look at passers by, otherwise you are avoiding. That anxiety will subside, and you’ll see that people continue walking by.
– Take a Lift or an Uber and talk to the driver. Ask them about their day and see what happens. Odds are they will be happy to chat.

Taking the Bus
– Talk to the bus driver. You might find that contrary to your expectations they are happy to chat and that no-one on the bus really cares.
– Stand instead of sit, even though there are empty seats. People will probably ignore you and you’ll learn that every move you make is not being scrutinized.
– Get off the back door of the bus, and yell “thank you” when leaving. Count how many people frown or stare at you and compare this to how many people don’t seem to react.

– Smile at someone, or ask someone for directions (even if you know the way). You’ll learn that more people are nice that not, and that it becomes easier to interact with strangers.
– Drop something (e.g. a bouncy ball) in front of people and then make sure to make eye contact with someone while collecting it. Again, you’ll find it’s not that big of a deal.
– Wear two different pairs of shoes, your shirt of backwards, or a really bright hat, or something that makes you stand out. As you walk past people count how many people stare at you, and how many people judge you. Likely most people won’t even notice, and you’ll also learn that you can tolerate their judgments if people are looking at you.

Hanging out with Friends
– Ask someone, a stranger, to take a photo of the group. I bet people will actually appreciate you doing this.
– Leave your phone in your bag. If you are using your phone you are not engaging with others and it is likely avoidance.
– Compliment someone on what they are wearing. You may fear you’re saying something stupid, but I bet the person appreciates the comment.
– Bring some cookies when you meet up. People will love hanging out with you and you’ll be more likely to learn that it’s a positive experience.
– Plan another time to hang out. You may worry that others think badly of you and may not want to hang out. If people seem enthusiastic about hanging out this will contradict your fear.

Watching TV
– Ask a question or make a comment about what you are watching. It doesn’t matter it’s a terrible sports play, or how good looking a character is. You may fear you’re burdening others or ruining their enjoyment, but you’ll only learn the accuracy of this by testing it out to see how others react.
– Ask someone if they’ve seen a show you like. You may be afraid that the show you are sharing is “dumb”, but to overcome social anxiety you have to get used to tolerating this feeling.

– Eat a meal that others may judge you for. For example, at a restaurant ask for a modification to your meal. “Can I have the pancakes, but do you have pineapples instead of blueberries?”. You’ll learn that a “no” is not so bad, or that you’ll be surprised how much you can get just by asking.
– Change your order. Make it, and then one minute later decide that you want something else. You’ll probably worry that they will be annoyed, so let’s see what happens.
– At a coffee shop, ask for your order in a soft and mumbling voice. This will cause the person to ask you to repeat. You’ll learn that it’s not so bad, or they don’t seem to mind. Or, ask in a louder voice than normal so others hear your order. You’re learning what happens when you do this: Do others stare at you, laugh, or not seem to care?
– Pay in loose change. I like to order a drink and then pay in dimes. With a queue behind you, you’ll feel pressure but usually you’ll find that no-one seems to mind.

Getting Dressed
– Wear something that really stands out; make a fashion statement. Then walk outside and see how the world reacts. Post a photo online and see how your friends and family comment. Based on my own experiences, people often don’t notice or they make positive comments.
– Ask a friend, or even a stranger on the street, if they like what you are wearing. “Excuse me. I’m going on a date and I’m not sure if I look good. Do you think what I’m wearing is ok?”
– When shopping for clothes ask an employee to recommend some clothes. Then try on several and be a picky customer. Let’s try to violate the expectation that a person may be really annoyed, or that you can’t tolerate it if they are annoyed.
– Don’t put on makeup for an outing. Try to see how people react to you without it on.

– Speak up. In a meeting ask a question. Ask your teacher something in small groups or large groups. To go all the way, ask a question that you think is kind of dumb. For example, “What is the homework?” after a teacher has just said what the homework was. You may worry that others will laugh, think critically of you, or be annoyed. You may be right, or you may be surprised that they don’t. You’ll only find out if you try. And if you are right, keep your head up and make eye contact. You’ll learn that you can tolerate it and that people don’t judge your entire life based on one thing.
– Hand in work that’s a little incomplete. Or ask for an extension. This targets fear of disappointing others or not being smart enough to keep up.
– Ask a coworker or someone in school if they want to hang out. Or join an activity/club that’s already going on. You’re fear is that people judge you, and this is a great opportunity to be around others more and learn that even if they do, they can still like you. I play some really nerdy games, but rather than think badly of me, people just know that it’s something I like and there are other positive qualities to me too!

– Only kidding, you have to have some time off from exposures ?

Thanks again for reading, let me know if you have anything to add!

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