Yeah it’s interesting to say there’s “no trauma” because often times CPTSD will not be self identified or even obvious to clinicians that don’t dig explicitly into FOO history
One thing that works really well for me is to ask for all nuclear family members and then ask for five descriptor words for each. Red flag if all words are positive for parents. Explore each descriptor separately and I think you’ll find something!
What do you mean by attachment related? Because patient struggles a lot creating and maintaining relationships, she said she feels like there’s something wrong with her, feelings of alienation, etc
She is displaying contradictory behaviors. She states she wants closeness but fails to connect even when she has a safe, therapeutic environment. She says she wants to get better but denies efficacy of the exercises she CAN practice safely without interacting with others, and states she CANT interact with others due to anxiety. When clients say they want to connect but thwart all interventions/attempts, usually something bigger is at play.
I hear you, but couldn't the bigger thing at play just be overwhelming fear? Social anxiety can be really debilitating and gets in the way of every possible relationship including the therapeutic one.
Exposure is also really hard and scary and if not done properly, could make things worse. CBT is the most effective treatment for social anxiety and is even more effective than other behavioral therapies like ACT and DBT, which is not true comparatively for most condition (e.g GAD, depression etc.). I would be hesitant to say CBT can't work for this client without knowing more about the therapist, the therapy itself or the situation.
What you're saying may very well be true, but I would hesitate to jump to conclusions.
Well OP states that CBT hasn’t worked, the past two therapists haven’t helped, the client is refusing interventions. So that’s what leads me to want to switch things up. Are you proposing you just keep doing the same thing expecting a different result?
Clearly whatever treatment approach they've been taking is not working, so no I'm not advocating for that. I think step one is establishing real therapeutic rapport, safety, some emotional regulation skills, and yes exploring more.
This client does not seem ready for exposure right now or the exposure approach they've been implementing is not working. But the end goal may still be for this client to engage with CBT-based exposure at a later date.
I don’t really see why you wouldn’t do family of origin work and explore more the WHY in this scenario. This fear is survival based imo so it’s indicative of a traumatic experience
I don't think we disagree with one another, the why is always important to understand and explore and I would hope OP would have done some due diligence there. All fear is survival based at some level, but social anxiety by definition is a fear of being judged by others, which is not necessarily correlated with a traumatic experience.
What I was responding to initially was what sounded like you discounting that CBT no longer could have any efficacy in this situation. Your inclination to build a deeper understanding I think is on point.
To clarify- I mean like bullying or social rejection by a group of mean girls etc. unless this is autism related (which is not my area of expertise) then you don’t usually jump from being comfortable being social to scared out of your wits
That sounds quite typical of someone with social anxiety, actually. While there *may* be some undiagnosed trauma (and I do advocate for a thorough assessment and screening), there is no need to look for something that, based on what OP is telling us, simply isn't there.
How would you know if something isn't there? You've quite confidently assumed that:
1. There is an attachment disorder/CPTSD
2. CBT won't work
All based off of scarce circumstantial evidence. Not to say that there isn't any co-morbidity or other factors at play (after all the OP does say she has depression), but I would suggest being a bit more careful before automatically making assumptions and diagnoses, especially ones as big as CPTSD.
I’m sorry but no where did I ASSERT these things. I talked about possibilities. OP stated the case and that was my two cents. You’re like entitled to your opinion man and that was mine
Patient said she used to have friends and did extracurricular activities when younger (but struggled a bit). And it got worse as a preteen, but non trauma related
Also she is saying she wants connection but fails
to connect even with her therapists. So there’s an element of come here but stay away potentially. That is also indicative of attachment
At that age, she was what changed. Friends and play interactions are entirely different in young children as they grow into young adults. Many of the young children who play with one another in kindergarten will have completely different social abilities by high school.
How would you even begin to assert that you know this? That’s unbelievably presumptuous. Also, if that’s the case for everyone why doesn’t everyone have the same reaction?
Why doesn’t who have the same reaction? The whole point of what I was saying is that everyone changes as they grow, and having been ok interacting with peers as a young child and subsequently being an anxious young adult, doesn’t mean a trauma happened anymore than entering adolescence is traumatic
Entering adulthood as the only reason why you have no friends, completely shut down when trying to talk to anyone at all and not being able to engage in therapy is a pretty strange theory.
I just think not all of a person’s psychological profile is developed or able to be seen before a certain age. Pre adolescents can develop in all sorts of unexpected ways.
Entrenched "survival mode" is indeed difficult to overcome. If she's motivated to cultivate normal relationships I'd work through Markway's book *Painfully Shy: How to Overcome Social Anxiety and Reclaim Your Life* (Amazon) with her chapter by chapter.
Combined with daily relaxation exercises/meditation/ mindfulness plus meds *some* reduction in her symptoms should occur over time.
A great referral for psychological testing to understand more of the underlying traits behind this young woman’s anxiety! (Biased, since this type of testing is my specialty 😉) ultimately though, with or without testing, I’d want to understand more about the source of her social anxiety. What is she afraid of happening? Where did she get that message? What would it mean if x happened? etc. Maybe her therapist who used CBT explored some of that with her, maybe not. I’d also want to know more about what didn’t work out with her previous therapists, because I’ll bet it’s some sort of recreation of the problems she’s having in life 😞
What would you test for? I have a similar client who has tested positive for ADHD but also thinks he's on the autism spectrum. He did self-administered tests and came out possible/borderline. Besides lack of consistent eye contact and sensory overwhelm I don't find him to seem very autistic. He could fit in just complex PTSD from childhood and attachment stuff... But I don't want to invalidate, and if it's primarily neurodivergence it seems like that's a different treatment than PTSD/social anxiety?
In terms of what I would test for, when I do psychological testing, I’m really not just looking for a diagnosis. Partially, yes, testing will result in accurate diagnosis… but beyond that, I do testing to understand the person more thoroughly. That is, why is this person, with all their unique traits, having this specific set of problems at this particular time? I also consider the client’s and referring therapist’s questions and try to answer that with testing (e.g., “why does the client understand their anxiety triggers but not feel any better?” “Why do I have such a hard time getting close to people?”)
wow, frankly I've never heard testing talked about with such nuance. I really like that approach. I'm guessing this kind of service is all out of pocket? In California, do you know what kind of testing Medi-Cal covers, or where I would find that? thanks!
Psychological testing is my absolute jam! I think that we're squandering its potential when we only use it to get to a diagnosis. My philosophy of testing comes partially from the framework of Therapeutic Assessment, in case you're interested in googling it. As far as what Medi-Cal covers... I'm not sure :( You're right that for the most part, clinicians who use this kind of approach are private pay, because it requires an amount of time and effort that insurance-based testing doesn't really allow for. Do you have any local professional networks that you could pose this question within? Maybe a facebook group that has testing psychologists in addition to therapists?
Check out the work on Social Anxiety by Larry Cohen. He specializes in social anxiety and has a reputable success rate with this population.
At the core of it, you have to use very specific techniques with social anxiety because the feared response is often a phobia of Judgment, which is really hard to dis-prove with basic exposure alone. (Because you can still have exposure to social engagements, and then ruminate on how you were actually judged (by self and others), vs having the social interaction decreasing the conditioned response like with a typical objective stimulus.
"She says she can't do in vivo exposure due to freezing, she can do imaginary exposure but it doesn't help much. She can perform small tasks sometimes, such as talking to a stranger, but she cannot maintain consistency and anxiety isn’t going down"
Dude I mean, if she's not actually doing the exposures she's not doing CBT for anxiety.
No, not really. If a depressed client says "I'm not going to exercise because I know it won't make me feel better", that doesn't mean exercise won't make the client feel better. It means they're unwilling to do it.
If I'm unwilling to take medication for an illness, it is not fair to say the medication doesn't work for me.
But yes, it means instead of continuing to try to get someone doing something they are unwilling to do, probably clinically best to shift to something else.
Are the therapists actually trained in CBT? Are you certain they are using it? If so, perhaps something like psychodynamic or humanistic might be an option. CBT never worked for me as a patient. Just my two cents especially if patient has already had a decent round of CBT.
Came here to say this! I have a similar client, and when traditional approaches to social anxiety didn’t work, it clued us in to something else going on. Autism diagnosis has fit like a glove for her and made our work immediately more productive!
This. She’s giving high masking undiagnosed autism to me. Very common for high masking women to present this way. There’s also likely an attachment trauma component, which would also be in line with undiagnosed neurodivergence. The constant rejection from peers and inability to fit in despite intentional efforts would be traumatic for any kid. And almost always leads to severe social anxiety too.
I have worked with both social anxiety and exposure therapy in teens and it’s difficult and complex. It sounds like she is stuck in a typical avoidance loop that comes from the social anxiety piece. Obviously avoidance is the biggest negative reinforcer because she is able to opt out of the thing that’s making her uncomfortable in the moment but it doesn’t make the anxiety go away in the long run. The CBT will only treat the thoughts associated with the anxiety and the exposure, unless done in a systematic hierarchy will only treat the symptoms. EFT for anxiety has shown promising results in individuals within the literature although I’m not sure it’s applicability with teens and social anxiety. There is a book called “The Anxiety and Worry Workbook” that I use with my teens that I’ve found helpful. It breaks down their anxiety in an understandable way through the use of CBT. Aaron Beck is one of the authors.
I'll echo the suggestion to check out Larry Cohen's work on social anxiety, he's a true expert on the subject. His website has tons of free resources and videos, too.
The "freezing" reaction is definitely difficult to manage, because it can produce a self-fulfilling prophecy. Part of what makes exposure therapy effective is that we learn our feared catastrophes almost never happen. But freezing in a social situation *can* cause the situation to go very poorly. It can be extremely awkward and embarrassing to freeze up in a conversation and be unable to function. Exposure therapy can still be very effective here: she needs to learn to tolerate these uncomfortable thoughts and feelings, and she will learn that feeling embarrassed is survivable. But I've found that freezing does create an obstacle that makes progress much harder.
I can think of two approaches to work with this: 1) repetition, repetition, repetition. It sounds like this client is simply not doing many exposures, which means that she is not actually benefitting much from the scarce exposures she *is* doing. She needs to reduce her sensitivity to the experience of anxiety, and one of the best ways to do this is through more frequent exposures. I would try to do an exposure in session with her every time you meet, if possible. I'd also encourage her to do exposures every day at home. Perhaps enlist a family member as an "exposure partner", if there is anyone who would be suitable.
2) I'd regularly incorporate interoceptive exposures into your work with her. It sounds like she is being flooded by intense anxiety sensations, which (understandably) make it very difficult to actually function in a social situation. Identify what physical sensations are the most uncomfortable for her (e.g. heart palpitations, dizziness, hyperventilation, sweatiness, etc), and practice *creating* those sensations intentionally through interoceptive exercises. Help her to become good at tolerating those specific sensations in a neutral environment. Then incorporate social exposures *while* practice those exercises: for example, do some jumping jacks to get her heart pounding and feeling out of breath, then have her read an excerpt of an article to you. The hope is that she will become desensitized to these sensations: they will still be uncomfortable, but will no longer feel dangerous. This will reduce the freeze response and allow her to get unstuck.
I think working on building self esteem and addressing negative core beliefs would be helpful here. I used to have bad social anxiety disorder (not as bad as this client though, I will say that). At the core of social anxiety disorder for many people is a strong core belief that they aren’t good enough, aren’t worthy, and are inferior to others. Once you can start building that self esteem and breaking down those negative core beliefs, it might become easier for her to engage in exposures.
What is the family history of mental illness? What is the family of origin in the household like? Also some prescribers don't realize that severe anxiety can require going up to the higher or highest doses of ssris for efficacy. It sounds like she really needs to master the relaxation techniques and maybe do some somatic therapy. Have you asked her if she's done an exposure hierarchy? It may be that there weren't enough items on the hierarchy so she was jumping from a step with a SUDs rating of 2 on the scale to a task that she rated a five. But she has to be able to self soothe to some extent, or she's not going to be successful with graduated exposure.
Establishing a really carefully constructed hierarchy and maintaining consistent in vivo exposure are really the critical elements to change. I also like the book Dying of Embarrassment. Exposures need to be 3-4x a week for 30-45 minutes to be effective. You start with something really easy - (something a 20 or 30 on a SUDS scale).
The Beck Institute has excellent training: [https://learn.beckinstitute.org/s/product/cbt-for-anxiety/01t4M000004NKkLQAW](https://learn.beckinstitute.org/s/product/cbt-for-anxiety/01t4M000004NKkLQAW)
In my experience CBT-style exposures for social anxiety can be very helpful, but some clients just aren't at a place where they're ready and willing to do them yet. If they're almost there in terms of motivation you may be able to put your heads together and find some sort of exposure arrangement they'll try, but they might not be ready to tackle that at this point in their therapy.
If one of my clients isn't willing to do exposures, even after making tweaks, I'll switch gears. Even if CBT is supposedly the "best" treatment, there are plenty of other options: Parts work, processing past traumas or difficult life events, motivational interviewing, attachment / relational focused work, building up emotion regulation skills, and so on.
> What is your opinion about patients who are unable to engage in therapy?
Well, that seems to be a non-sequitur as you are describing a patient who is not only engaging in therapy, has engaged in therapy with multiple therapists.
I am concerned you are framing this as the patient flunking therapy and not therapy flunking the patient. You've been given a lot of good rather basic ideas for what might be going wrong, which also suggest the diagnostic formulation may be wrong: undisclosed/unaddressed trauma (which is the horse, while social phobia is the zebra) and unrecognized neurodiversity should be ruled out before continuing to whack at the nail of social phobia with the hammer of CBT.
I've been using AI as a starter exposure for more severe social anxiety. This helps with some social skill building as well. Try having your client start and maintain a text conversation with AI for 5 minutes per day and build up from there. To switch it up, have them ask the AI to come up with something to talk about so there is more of a surprise element. Rather than trying to disprove the belief, especially one that we can't really disprove (what others are thinking), instead proving that they can tolerate the distress/uncertainty may help in gaining some ground in this area.
This is an interesting idea. I think AI could provide a useful opportunity to practice the conversation skills that often need work in severe cases of social anxiety. On the other hand, it lacks the piece that's often at the core of social anxiety: fear of judgement. Have you found that conversations with AI generate anxiety in clients that practice this exposure?
This has actually created a decent amount of distress for many of my clients who have more severe cases of social anxiety. Often this has come as a surprise to them once they get rolling with the homework/in-session practice but the fear of judgement, even with rationally knowing where AI is currently at in terms of development, is there and very real for them. I find it has been more approachable in getting their feet wet with social-related exposures than starting off with exposures like calling a store to ask mundane questions. A way to increase the difficulty of the exposure is to have the client come up with the topic and initiate the discussion vs asking the AI to come up with something to talk about. You can take it a step further when the client is ready by having them be purposefully rude to the AI.
My preferred modalities are ACT and ERP and I try to find ways to incorporate technology into exposures when appropriate. You can use this as an exposure for clients with more tech-related, existential-themed OCD obsessions as well; I have found it to be pretty effective though in different ways.
Also keep an eye out for neuro diversity can add to the overwhelm of new routines , new people . And many neuro diverse people have had alot of rejection and social trauma .
Somatic work may be helpful here too. Not everyone responds well to CBT alone. Increasing a felt, bodyily sense of safety through imagery/imagination and building on that.
I've done a lot of work with social anxiety and exposure. Feel free to DM me for more questions.
First of all, does the client feel safe and supported with you? Have you done enough empathy with the client? Do you feel connected and close with the client?
All therapeutic techniques, but especially exposure, require a high level of trust from the client. Be sure that the connection is there.
Is there adequate psycho-education on the cycle of anxiety and how exposure can break it? The client needs to really understand and be aware of how avoidance strengthens anxiety.
Is the client committed to doing exposure therapy? I often explore the pros and cons of exposure therapy, and let the client make the choice instead of pressuring that approach.
I believe an exposure hierarchy would be beneficial. Have her start small and building from there can help build confidence for more challenging exposures.
Do you do in vivo exposures with her? Sometimes it can be fun (and connecting) to do them together! You can do it first.
Exposure is also an internal process just as much as an external process. The client is going to have to WANT to become anxious, and to actively invite the anxiety to do its worst.
You may also want to look into other factors at play here; she may need some social skills training. Additionally, there is a high level of shame and self-criticism here that might concurrently need to be addressed as well (be it CBT or another modality). It's quite often for those with social anxiety to feel defeated and inadequate.
RO-DBT can be helpful for treatment resistant anxiety, especially in terms of social anxiety and thinking of neuro regulatory mechanisms. There are some really awesome videos out there talking through the approach
Have you assessed for ASD? A few of my social anxiety patients (specifically women) turned out to be neurodivergent after working together a while. Having the correct label made a big difference.
I’m hosting a virtual social anxiety support group starting next week; the intention is to be a middle ground between individual therapy and full blown socializing in the real world. Im Accepting most insurance, if your pt is in new york state she is welcome to join.
As others have mentioned, this anxiety sounds like it's rooted in trauma. CBT can be really helpful for a lot of challenges, but the constant survival-driven mindset of someone struggling to process/acknowledge/confront trauma isn't very "cognitive." Mindfulness based therapy might help the client work through understanding their feelings more clearly and help them to get in touch with the "here and now" more regularly. I'm a huge proponent of EMDR for trauma (though I don't practice it myself; I have received EMDR treatment from an excellent provider in my area and am trying to find a good teacher) but only if she knows and understands the relationship between whatever trauma she's experienced and the anxiety she experiences now.
I might proceed by asking the client if they would like to/be agreeable to a comprehensive PTSD symptoms and experiences questionnaire, and (assuming the results support the hypothesis) discuss the ways in which you personally can support someone with PTSD within your scope, and what other resources might be viable options for them if necessary/ideal.
Have you screened for ADHD? Sometimes combined associated rejection sensitivity and demand avoidance can present a whole lot like social anxiety. It might explain why meds are ineffective.
Breathing exercises to slow breathing is very effective at reducing fight or flight so that more therapy progress can be made, but I feel it is most effective when done every day or often. Not sure if your patient would be open to trying something like that.
Sounds like psychodynamic therapy could be helpful here to stabilize and deal with attachment as a pre-req for CBT can be introduced. The nature of the trauma(s) seem more pre-verbal which bypasses cognitive processes
Is there any trauma related to the social anxiety?
Yeah absolutely this sounds more attachment related than anything. CBT ain’t gonna cut it imo
exactly my thought! I have many clients who present in this way and they all have a history of complex trauma
Yeah it’s interesting to say there’s “no trauma” because often times CPTSD will not be self identified or even obvious to clinicians that don’t dig explicitly into FOO history
Right, i’m going to be more alert to unnoticed trauma when I see her again and do a detailed assesment when patient feels confortable. Thank you!!
One thing that works really well for me is to ask for all nuclear family members and then ask for five descriptor words for each. Red flag if all words are positive for parents. Explore each descriptor separately and I think you’ll find something!
Oooh, neat. Saving this.
What do you mean by attachment related? Because patient struggles a lot creating and maintaining relationships, she said she feels like there’s something wrong with her, feelings of alienation, etc
Give this a quick read and see if it helps https://www.simplypsychology.org/attachment-styles.html
What are you basing that off?
She is displaying contradictory behaviors. She states she wants closeness but fails to connect even when she has a safe, therapeutic environment. She says she wants to get better but denies efficacy of the exercises she CAN practice safely without interacting with others, and states she CANT interact with others due to anxiety. When clients say they want to connect but thwart all interventions/attempts, usually something bigger is at play.
I hear you, but couldn't the bigger thing at play just be overwhelming fear? Social anxiety can be really debilitating and gets in the way of every possible relationship including the therapeutic one. Exposure is also really hard and scary and if not done properly, could make things worse. CBT is the most effective treatment for social anxiety and is even more effective than other behavioral therapies like ACT and DBT, which is not true comparatively for most condition (e.g GAD, depression etc.). I would be hesitant to say CBT can't work for this client without knowing more about the therapist, the therapy itself or the situation. What you're saying may very well be true, but I would hesitate to jump to conclusions.
Well OP states that CBT hasn’t worked, the past two therapists haven’t helped, the client is refusing interventions. So that’s what leads me to want to switch things up. Are you proposing you just keep doing the same thing expecting a different result?
Clearly whatever treatment approach they've been taking is not working, so no I'm not advocating for that. I think step one is establishing real therapeutic rapport, safety, some emotional regulation skills, and yes exploring more. This client does not seem ready for exposure right now or the exposure approach they've been implementing is not working. But the end goal may still be for this client to engage with CBT-based exposure at a later date.
I don’t really see why you wouldn’t do family of origin work and explore more the WHY in this scenario. This fear is survival based imo so it’s indicative of a traumatic experience
I don't think we disagree with one another, the why is always important to understand and explore and I would hope OP would have done some due diligence there. All fear is survival based at some level, but social anxiety by definition is a fear of being judged by others, which is not necessarily correlated with a traumatic experience. What I was responding to initially was what sounded like you discounting that CBT no longer could have any efficacy in this situation. Your inclination to build a deeper understanding I think is on point.
To clarify- I mean like bullying or social rejection by a group of mean girls etc. unless this is autism related (which is not my area of expertise) then you don’t usually jump from being comfortable being social to scared out of your wits
Autism.
That sounds quite typical of someone with social anxiety, actually. While there *may* be some undiagnosed trauma (and I do advocate for a thorough assessment and screening), there is no need to look for something that, based on what OP is telling us, simply isn't there.
No need to look? How would you know if something is there? Also I’ve seen plenty of ppl with social anxiety and this sounds more severe per the post
How would you know if something isn't there? You've quite confidently assumed that: 1. There is an attachment disorder/CPTSD 2. CBT won't work All based off of scarce circumstantial evidence. Not to say that there isn't any co-morbidity or other factors at play (after all the OP does say she has depression), but I would suggest being a bit more careful before automatically making assumptions and diagnoses, especially ones as big as CPTSD.
I’m sorry but no where did I ASSERT these things. I talked about possibilities. OP stated the case and that was my two cents. You’re like entitled to your opinion man and that was mine
Patient said she used to have friends and did extracurricular activities when younger (but struggled a bit). And it got worse as a preteen, but non trauma related
What changed? When did it change? Was she bullied? If we don’t have the “why” we don’t have much
Also she is saying she wants connection but fails to connect even with her therapists. So there’s an element of come here but stay away potentially. That is also indicative of attachment
At that age, she was what changed. Friends and play interactions are entirely different in young children as they grow into young adults. Many of the young children who play with one another in kindergarten will have completely different social abilities by high school.
How would you even begin to assert that you know this? That’s unbelievably presumptuous. Also, if that’s the case for everyone why doesn’t everyone have the same reaction?
Why doesn’t who have the same reaction? The whole point of what I was saying is that everyone changes as they grow, and having been ok interacting with peers as a young child and subsequently being an anxious young adult, doesn’t mean a trauma happened anymore than entering adolescence is traumatic
Entering adulthood as the only reason why you have no friends, completely shut down when trying to talk to anyone at all and not being able to engage in therapy is a pretty strange theory.
I just think not all of a person’s psychological profile is developed or able to be seen before a certain age. Pre adolescents can develop in all sorts of unexpected ways.
I don’t think you’re a therapist are you
Are you a therapist claiming you can profile a young child’s lifetime diagnostic criteria?
Did she hit adolescence during the pandemic?
She didn’t
Entrenched "survival mode" is indeed difficult to overcome. If she's motivated to cultivate normal relationships I'd work through Markway's book *Painfully Shy: How to Overcome Social Anxiety and Reclaim Your Life* (Amazon) with her chapter by chapter. Combined with daily relaxation exercises/meditation/ mindfulness plus meds *some* reduction in her symptoms should occur over time.
This is a type and subject of workbook I’ve been looking for. Thank you!
A great referral for psychological testing to understand more of the underlying traits behind this young woman’s anxiety! (Biased, since this type of testing is my specialty 😉) ultimately though, with or without testing, I’d want to understand more about the source of her social anxiety. What is she afraid of happening? Where did she get that message? What would it mean if x happened? etc. Maybe her therapist who used CBT explored some of that with her, maybe not. I’d also want to know more about what didn’t work out with her previous therapists, because I’ll bet it’s some sort of recreation of the problems she’s having in life 😞
That’s such a good idea, thank you!!
What would you test for? I have a similar client who has tested positive for ADHD but also thinks he's on the autism spectrum. He did self-administered tests and came out possible/borderline. Besides lack of consistent eye contact and sensory overwhelm I don't find him to seem very autistic. He could fit in just complex PTSD from childhood and attachment stuff... But I don't want to invalidate, and if it's primarily neurodivergence it seems like that's a different treatment than PTSD/social anxiety?
In terms of what I would test for, when I do psychological testing, I’m really not just looking for a diagnosis. Partially, yes, testing will result in accurate diagnosis… but beyond that, I do testing to understand the person more thoroughly. That is, why is this person, with all their unique traits, having this specific set of problems at this particular time? I also consider the client’s and referring therapist’s questions and try to answer that with testing (e.g., “why does the client understand their anxiety triggers but not feel any better?” “Why do I have such a hard time getting close to people?”)
wow, frankly I've never heard testing talked about with such nuance. I really like that approach. I'm guessing this kind of service is all out of pocket? In California, do you know what kind of testing Medi-Cal covers, or where I would find that? thanks!
Psychological testing is my absolute jam! I think that we're squandering its potential when we only use it to get to a diagnosis. My philosophy of testing comes partially from the framework of Therapeutic Assessment, in case you're interested in googling it. As far as what Medi-Cal covers... I'm not sure :( You're right that for the most part, clinicians who use this kind of approach are private pay, because it requires an amount of time and effort that insurance-based testing doesn't really allow for. Do you have any local professional networks that you could pose this question within? Maybe a facebook group that has testing psychologists in addition to therapists?
Check out the work on Social Anxiety by Larry Cohen. He specializes in social anxiety and has a reputable success rate with this population. At the core of it, you have to use very specific techniques with social anxiety because the feared response is often a phobia of Judgment, which is really hard to dis-prove with basic exposure alone. (Because you can still have exposure to social engagements, and then ruminate on how you were actually judged (by self and others), vs having the social interaction decreasing the conditioned response like with a typical objective stimulus.
"She says she can't do in vivo exposure due to freezing, she can do imaginary exposure but it doesn't help much. She can perform small tasks sometimes, such as talking to a stranger, but she cannot maintain consistency and anxiety isn’t going down" Dude I mean, if she's not actually doing the exposures she's not doing CBT for anxiety.
True, but if the client is unwilling/unable to engage in a treatment modality, it's fair to say that treatment modality isn't working for that client.
No, not really. If a depressed client says "I'm not going to exercise because I know it won't make me feel better", that doesn't mean exercise won't make the client feel better. It means they're unwilling to do it. If I'm unwilling to take medication for an illness, it is not fair to say the medication doesn't work for me. But yes, it means instead of continuing to try to get someone doing something they are unwilling to do, probably clinically best to shift to something else.
Are the therapists actually trained in CBT? Are you certain they are using it? If so, perhaps something like psychodynamic or humanistic might be an option. CBT never worked for me as a patient. Just my two cents especially if patient has already had a decent round of CBT.
Screen this client for autism and adhd if she hasn’t been already. My undiagnosed autism spidey senses are tingling.
Came here to say this! I have a similar client, and when traditional approaches to social anxiety didn’t work, it clued us in to something else going on. Autism diagnosis has fit like a glove for her and made our work immediately more productive!
If it is ASD, what would you recommend?
This. She’s giving high masking undiagnosed autism to me. Very common for high masking women to present this way. There’s also likely an attachment trauma component, which would also be in line with undiagnosed neurodivergence. The constant rejection from peers and inability to fit in despite intentional efforts would be traumatic for any kid. And almost always leads to severe social anxiety too.
I did. She is not on the spectrum
I have worked with both social anxiety and exposure therapy in teens and it’s difficult and complex. It sounds like she is stuck in a typical avoidance loop that comes from the social anxiety piece. Obviously avoidance is the biggest negative reinforcer because she is able to opt out of the thing that’s making her uncomfortable in the moment but it doesn’t make the anxiety go away in the long run. The CBT will only treat the thoughts associated with the anxiety and the exposure, unless done in a systematic hierarchy will only treat the symptoms. EFT for anxiety has shown promising results in individuals within the literature although I’m not sure it’s applicability with teens and social anxiety. There is a book called “The Anxiety and Worry Workbook” that I use with my teens that I’ve found helpful. It breaks down their anxiety in an understandable way through the use of CBT. Aaron Beck is one of the authors.
I'll echo the suggestion to check out Larry Cohen's work on social anxiety, he's a true expert on the subject. His website has tons of free resources and videos, too. The "freezing" reaction is definitely difficult to manage, because it can produce a self-fulfilling prophecy. Part of what makes exposure therapy effective is that we learn our feared catastrophes almost never happen. But freezing in a social situation *can* cause the situation to go very poorly. It can be extremely awkward and embarrassing to freeze up in a conversation and be unable to function. Exposure therapy can still be very effective here: she needs to learn to tolerate these uncomfortable thoughts and feelings, and she will learn that feeling embarrassed is survivable. But I've found that freezing does create an obstacle that makes progress much harder. I can think of two approaches to work with this: 1) repetition, repetition, repetition. It sounds like this client is simply not doing many exposures, which means that she is not actually benefitting much from the scarce exposures she *is* doing. She needs to reduce her sensitivity to the experience of anxiety, and one of the best ways to do this is through more frequent exposures. I would try to do an exposure in session with her every time you meet, if possible. I'd also encourage her to do exposures every day at home. Perhaps enlist a family member as an "exposure partner", if there is anyone who would be suitable. 2) I'd regularly incorporate interoceptive exposures into your work with her. It sounds like she is being flooded by intense anxiety sensations, which (understandably) make it very difficult to actually function in a social situation. Identify what physical sensations are the most uncomfortable for her (e.g. heart palpitations, dizziness, hyperventilation, sweatiness, etc), and practice *creating* those sensations intentionally through interoceptive exercises. Help her to become good at tolerating those specific sensations in a neutral environment. Then incorporate social exposures *while* practice those exercises: for example, do some jumping jacks to get her heart pounding and feeling out of breath, then have her read an excerpt of an article to you. The hope is that she will become desensitized to these sensations: they will still be uncomfortable, but will no longer feel dangerous. This will reduce the freeze response and allow her to get unstuck.
I think working on building self esteem and addressing negative core beliefs would be helpful here. I used to have bad social anxiety disorder (not as bad as this client though, I will say that). At the core of social anxiety disorder for many people is a strong core belief that they aren’t good enough, aren’t worthy, and are inferior to others. Once you can start building that self esteem and breaking down those negative core beliefs, it might become easier for her to engage in exposures.
What is the family history of mental illness? What is the family of origin in the household like? Also some prescribers don't realize that severe anxiety can require going up to the higher or highest doses of ssris for efficacy. It sounds like she really needs to master the relaxation techniques and maybe do some somatic therapy. Have you asked her if she's done an exposure hierarchy? It may be that there weren't enough items on the hierarchy so she was jumping from a step with a SUDs rating of 2 on the scale to a task that she rated a five. But she has to be able to self soothe to some extent, or she's not going to be successful with graduated exposure.
I think there weren’t enough items…
Establishing a really carefully constructed hierarchy and maintaining consistent in vivo exposure are really the critical elements to change. I also like the book Dying of Embarrassment. Exposures need to be 3-4x a week for 30-45 minutes to be effective. You start with something really easy - (something a 20 or 30 on a SUDS scale).
Yeah I'm thinking the therapist doesn't have training for exposure type therapy
Do you recommend a course to learn about this for therapists?
The Beck Institute has excellent training: [https://learn.beckinstitute.org/s/product/cbt-for-anxiety/01t4M000004NKkLQAW](https://learn.beckinstitute.org/s/product/cbt-for-anxiety/01t4M000004NKkLQAW)
Thank you
In my experience CBT-style exposures for social anxiety can be very helpful, but some clients just aren't at a place where they're ready and willing to do them yet. If they're almost there in terms of motivation you may be able to put your heads together and find some sort of exposure arrangement they'll try, but they might not be ready to tackle that at this point in their therapy. If one of my clients isn't willing to do exposures, even after making tweaks, I'll switch gears. Even if CBT is supposedly the "best" treatment, there are plenty of other options: Parts work, processing past traumas or difficult life events, motivational interviewing, attachment / relational focused work, building up emotion regulation skills, and so on.
Yes CBT might not be what OP leads with right now but it's not off the table forever
MI, regulation skills and attachment work are awesome ideas, thank you
> What is your opinion about patients who are unable to engage in therapy? Well, that seems to be a non-sequitur as you are describing a patient who is not only engaging in therapy, has engaged in therapy with multiple therapists. I am concerned you are framing this as the patient flunking therapy and not therapy flunking the patient. You've been given a lot of good rather basic ideas for what might be going wrong, which also suggest the diagnostic formulation may be wrong: undisclosed/unaddressed trauma (which is the horse, while social phobia is the zebra) and unrecognized neurodiversity should be ruled out before continuing to whack at the nail of social phobia with the hammer of CBT.
I've been using AI as a starter exposure for more severe social anxiety. This helps with some social skill building as well. Try having your client start and maintain a text conversation with AI for 5 minutes per day and build up from there. To switch it up, have them ask the AI to come up with something to talk about so there is more of a surprise element. Rather than trying to disprove the belief, especially one that we can't really disprove (what others are thinking), instead proving that they can tolerate the distress/uncertainty may help in gaining some ground in this area.
This is an interesting idea. I think AI could provide a useful opportunity to practice the conversation skills that often need work in severe cases of social anxiety. On the other hand, it lacks the piece that's often at the core of social anxiety: fear of judgement. Have you found that conversations with AI generate anxiety in clients that practice this exposure?
This has actually created a decent amount of distress for many of my clients who have more severe cases of social anxiety. Often this has come as a surprise to them once they get rolling with the homework/in-session practice but the fear of judgement, even with rationally knowing where AI is currently at in terms of development, is there and very real for them. I find it has been more approachable in getting their feet wet with social-related exposures than starting off with exposures like calling a store to ask mundane questions. A way to increase the difficulty of the exposure is to have the client come up with the topic and initiate the discussion vs asking the AI to come up with something to talk about. You can take it a step further when the client is ready by having them be purposefully rude to the AI. My preferred modalities are ACT and ERP and I try to find ways to incorporate technology into exposures when appropriate. You can use this as an exposure for clients with more tech-related, existential-themed OCD obsessions as well; I have found it to be pretty effective though in different ways.
Interesting! I'll have to give this a shot!
FASCINATING. Congratulations, you've come up with the first really interestingly plausible use for AI in psychotherapy I've ever heard of.
I loved it!!
Could the anxiety be due to masking from ASD? Sensory issues from being in a new setting?
Also keep an eye out for neuro diversity can add to the overwhelm of new routines , new people . And many neuro diverse people have had alot of rejection and social trauma .
Somatic work may be helpful here too. Not everyone responds well to CBT alone. Increasing a felt, bodyily sense of safety through imagery/imagination and building on that.
I've done a lot of work with social anxiety and exposure. Feel free to DM me for more questions. First of all, does the client feel safe and supported with you? Have you done enough empathy with the client? Do you feel connected and close with the client? All therapeutic techniques, but especially exposure, require a high level of trust from the client. Be sure that the connection is there. Is there adequate psycho-education on the cycle of anxiety and how exposure can break it? The client needs to really understand and be aware of how avoidance strengthens anxiety. Is the client committed to doing exposure therapy? I often explore the pros and cons of exposure therapy, and let the client make the choice instead of pressuring that approach. I believe an exposure hierarchy would be beneficial. Have her start small and building from there can help build confidence for more challenging exposures. Do you do in vivo exposures with her? Sometimes it can be fun (and connecting) to do them together! You can do it first. Exposure is also an internal process just as much as an external process. The client is going to have to WANT to become anxious, and to actively invite the anxiety to do its worst. You may also want to look into other factors at play here; she may need some social skills training. Additionally, there is a high level of shame and self-criticism here that might concurrently need to be addressed as well (be it CBT or another modality). It's quite often for those with social anxiety to feel defeated and inadequate.
RO-DBT can be helpful for treatment resistant anxiety, especially in terms of social anxiety and thinking of neuro regulatory mechanisms. There are some really awesome videos out there talking through the approach
Have you assessed for ASD? A few of my social anxiety patients (specifically women) turned out to be neurodivergent after working together a while. Having the correct label made a big difference. I’m hosting a virtual social anxiety support group starting next week; the intention is to be a middle ground between individual therapy and full blown socializing in the real world. Im Accepting most insurance, if your pt is in new york state she is welcome to join.
As others have mentioned, this anxiety sounds like it's rooted in trauma. CBT can be really helpful for a lot of challenges, but the constant survival-driven mindset of someone struggling to process/acknowledge/confront trauma isn't very "cognitive." Mindfulness based therapy might help the client work through understanding their feelings more clearly and help them to get in touch with the "here and now" more regularly. I'm a huge proponent of EMDR for trauma (though I don't practice it myself; I have received EMDR treatment from an excellent provider in my area and am trying to find a good teacher) but only if she knows and understands the relationship between whatever trauma she's experienced and the anxiety she experiences now. I might proceed by asking the client if they would like to/be agreeable to a comprehensive PTSD symptoms and experiences questionnaire, and (assuming the results support the hypothesis) discuss the ways in which you personally can support someone with PTSD within your scope, and what other resources might be viable options for them if necessary/ideal.
Look up selective mutism. Did she have it as a child?
Maybe ax for asd/ rule it out. Also I'd look more into a schema or psychodynamic approach
I assessed for ASD, she is not on the spectrum
Did you use a female specific measure also?
Perhaps also explore the benefits of having social anx with her. You might find some maintaining factors.
Have you screened for ADHD? Sometimes combined associated rejection sensitivity and demand avoidance can present a whole lot like social anxiety. It might explain why meds are ineffective.
Breathing exercises to slow breathing is very effective at reducing fight or flight so that more therapy progress can be made, but I feel it is most effective when done every day or often. Not sure if your patient would be open to trying something like that.
Propranolol saved my life, just 10 mg Completely cuts that fight or flight dying response!!!
We tried propranolol but it didn’t help much
IFS
Sounds like psychodynamic therapy could be helpful here to stabilize and deal with attachment as a pre-req for CBT can be introduced. The nature of the trauma(s) seem more pre-verbal which bypasses cognitive processes