Dr.

PamGarcy
REBTAppliedtoPatientswithSocial
AnxietyDisorder(SocialPhobia)

Introduction
Psychologist&lifecoachinpractice17years
Majorityofmypracticeishelpingadultswith
depression,socialanxietyandmaritalproblems.
Irun4groups(SMART,Fearless,REBT/CBT,and
SocialMastery)&conduct3workshopsayear
Irunamixedgendersocialmasterygroupfor
adultswithsocialanxietylastmembersjust
graduated&anothergroupisforming

MarriedtoRoger23years

Ourkids(2yearsago)

Overview
Symptomsofsocialanxiety,howitisa
problem,comorbidity
Usingresearchtoinformtreatment
REBTconceptsandtechniquestouse
Demonstrationiftherestime

SymptomsofSocialAnxiety
Persistentfearofoneormoresocialsituations
Fearofhumiliation/embarrassment/negative
evaluationinthese
Anxietyorpanicinresponsetothesocial
situation
Avoidanceorendurancew/distress
Significantinterferencew/normalroutine,
occupation,academics,relationshipsOR
markeddistressabouthavingtheanxiety

ProblematicPerformanceSituationgs

Publicspeaking
Writinginfrontofothers
Eatinginfrontofothers
Playinganinstrument/sport
Enteringaroomofpeople
Usingapublicrestroom

ProblematicSocialSituations
Socializing,smalltalk,eatingw/others
Initiatingormaintaing aconversation
Askingfordirections,help,instructions,
clarification(atschool,work,instores,etc.)

ComorbidDisorders
Mostcommonlyrunswith
Depression
SubstanceAbuseorDependence
EatingDisorders

CognitiveModelforSocialAnxiety
Thecognitivemodelappliedtosocialanxietyandsocial
phobiaproposesthatpatientsfocustheirattentiononthe
imagetheybelievethatothershaveofthemandtheir
performanceandontheirsubjectivesensationsinsocially
evaluativesituations.Asaresult,theybecomeobliviousto
objectivesocialcues.
Researchhasconfirmedthatthesepatientsnegatively
distorttheiractualevaluationbyothersandthattheir
recollectionofsocialexperiencesisalsonegativelybiased.
Furthermore,thepatients anxietyincreasesandtheir
objectiveperformancedecreaseswhentheyperceive
negative,asopposedtoneutral,imagesduringexposureto
sociallythreateningsituations.Beck,ArchGenPsychiatry.
2005;62:9539

IndividualizedTreatmentPlanningin
theContextofEmpiricalSupport
focustheirattentionontheimagethey
believethatothershaveofthem:Challenge
theirideaoftheimageothershaveofthem
andontheirsubjectivesensationsinsocial
situations:Helpthemtoreevaluateandcope
withthesesensations
oblivioustoobjectivesocialcues:Workon
thempayingattentiontosocialcuesthatare
(1)positive(2)comfortenhancing

(applicationexamples,continued)
negativelydistorttheiractualevaluationby
others:getthemtorecordtheirevaluationsand
lookforcontraryevidence
recollectionofsocialexperiencesisalso
negativelybiased: getthemtorecordandre
readpositivesocialexperience;increase
awarenessoftheirbias
patients anxietyincreasesandtheirobjective
performancedecreases:helpthemsearchfor
examplesofthistoenhancemotivation

CBT+Transdiagnostic modelfor
anxiety
Patientssufferingfromanxietydisordersshowedthemost
improvementwhentreatedwithcognitivebehavioral
therapy(CBT)inconjunctionwitha"transdiagnostic"
approach amodelthatallowstherapiststoapplyoneset
ofprinciplesacrossanxietydisorders.
Thefindingsaretheresultofadecadeofresearch,four
separateclinicaltrialsandthecompletionofafiveyear
grantfundedbytheNationalInstituteofMentalHealth.
UniversityofHouston(NortoninterviewScienceDaily,
2012,June28).Cognitivebehavioraltherapyeffectivein
combatinganxietydisorders,studysuggests.

CompensatingforaMisregulating
BrainThroughExposure
Functionalmagneticresonancetomographywasusedtomeasurethe
changesinthebrainactivityofsociallyphobicpatientsandhealthytest
subjectswhiletheywerelookingatfaces(confrontationsimulation).
Permanentconfrontationhasadiminishingeffectonanxiety
"Thestudydemonstratedthatpeoplewithsocialphobiainitiallyexhibit
greateractivityintheamygdala andinthemedial,prefrontalcortexofthe
brain,howeverafterafewfacesthisactivityrecedes.
Ledtoasolutiontothe"problem"beingfoundmorequicklyinthebrain&
brainbypassedthenormalanxietycircuit,includingpartsthatareusually
overstimulated,acharacteristictypicalofanxiety.
Sladky (researcher):"Wethereforeconcludedthattherearefunctional
controlstrategiesevenintheemotionalcircuitsofpeoplewithsocial
phobia,althoughthemechanismstakelongertotakeeffectinthese
individuals.
MedicalUniversityofVienna(2013,January30).Eventhebrainsofpeople
withanxietystatescangetusedtofear. ScienceDaily.

RationalEmotiveBehaviorTherapy
FoundedbyDr.AlbertEllisin1955
PrecededCognitiveTherapy,whichfollowedin
1960s,foundingbyAaronBeck
Ellistaughtthatitiswhatweallowourselves
tobelievewithoutquestionthatleadsusto
unhealthynegativeemotionsandmaladaptive
behaviors

ABCTheoryofEmotion
A=ActivatingEventorAdversity
B=BeliefsaboutA
C=Consequences(emotionalandbehavioral)
FollowingtheidentificationoftheABCs,wecan
usecognitiverestructuringtohelpthepatient
tothinkscientificallyabouttheirthinking.
ThisiscalledDordisputation.

CoreBeliefsofSocialAnxiety
EllisandBeckbothtalkaboutCoreBeliefs.
Ellissaysthattherearethreebasicmuststhat
leadtoallpsychopathologyandthisincludes
socialanxiety.
Mustsontheself,others,lifeconditions
Imustperformperfectly
Youmustloveme
Lifemustbehasslefree

DisputationQuestions
Wecanhelpourpatientstoquestionany
beliefsthataregettingintheway,oneata
time:surfaceorcorebeliefs
Askquestionstochallenge(1)thevalidityof
thebelief(2)theutilityofthebelief(3)the
logicofthebelief
Whatistheevidencefor/against?
Howsthisideaworkingforyou/againstyou?
Whatisanalternativeview?

EffectiveNewWaysofThinking
Iftheclientisabletoanswerthese
disputationquestions,theymaybereadyto
developaneffectivenewwayofthinking
abouttheirsituation
Example:Itisuncomfortabletoeatinfrontof
others,butIcanstandit,itisnttheworst
thingintheworld,andothersareprobably
focusedmoreontheirfoodthanonme.

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ShameAttacking
Thisisaninvivoexposureexercisedeveloped
byEllis.Thepersonattackstheirshame
throughcognitivebehavioralflooding.
Hugebenefitifthepatientiswilling
Askthepatienttodosomethingthatisnot
illegalorimmoral,butthatwillbeshamefulto
him/her
Askthepatienttotalkhim/herselfoutofthe
shameuntilthepatientfeelsunashamed

StrengthBombardment
Havepatientswritealistoftheirsocial
strengths
Youcanalsodothis
Gooveritwiththem
Evenmorepowerfulingroups
Haveeachpersontalkaboutsuccesseswhile
otherswritedownpositives&laterreadback.

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Mirrorwork:Buildingselfacceptance

SocialSkillsTraining+Feedback
Askthepatientwhatareastheyhavea
difficulttimewithsocially
Teachtheskillsthatarelacking
Examples:eyecontact,smiling,introductions,
usingpeoplesnames,smalltalk,personal
space,handshakes,askingquestions,inviting,
acceptingno,sayingno,etc.

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RelaxationTraining
Teachpatientstousediaphragmaticbreathing
toreducesympatheticactivationand
encourageparasympatheticresponse
Helpfultodothispriortoimaginal exposure&
duringthisexposuretohelpthepatient
desensitizeimaginally

GroupTherapy

Offersmultipleadvantagesincluding
Exposure
Practice
Feedback
Skilltraining&learningthroughmodeling
Affirmation&connection
Ideasfromotherswhoareintheirshoes

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Challengeofsocialanxietygroups
Thebiggestchallengeisavoidanceofexposureto
fearedsituationsindividualtherapyisoften
requiredtoprepareforandsupportgroupwork
Thisisahugechallenge&soitisoftendifficultto
getagrouptogether
Havememberssignacommitmenttoparticipate
foratleast8sessionsandhavethemprepayhalf
atthebeginningofeach4sessionclusterto
diminishavoidance

WhentoRefertoaPsychologistwho
specializesinREBT&SocialAnxiety
Whenyouhavesomeonewhohasimpairmentthat
iscausingdistress who
1. Wantstolearnandpracticeskills
2. Patientswithpoorresponsetoantidepressants
whoalsowanttoavoidorlimituseofanxiolytics
throughskillacquisition
3. Patientswithpersistentbeliefswhoneed
additionalsupportinchallengingthese
4. Patientswithcomorbid diagnoseswhowould
benefitfromREBTorCTapproachestotherapy

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Questions/contactinfo

Dr.PamGarcy
ClinicalPsychologist+LifeCoach
drgarcy@aol.com
(972)2483861

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