This Manual is both a guide to treatment and a workbook for persons who suffer from specific phobias. During treatment, it is a workbook in which individuals can record their own experience of their disorder, together with the additional advice for their particular case given by their clinician. After treatment has concluded, this Manual will serve as a self-help resource enabling those who have recovered, but who encounter further stressors or difficulties, to read the appropriate section and, by putting the content into action, stay well.

The nature of anxiety and phobias

A phobia is a particular type of fear. Just as people fear many things, there is a large range of things people can be phobic about. However, a phobia is different from a fear for three reasons. The first difference is that the fear is intense and includes many of the following sensations:

•  Bodily sensations

•  Heart racing

•  Sweating

•  Trembling

•  Rapid breathing

•  Breathlessness or shortness of breath

•  Muscular tension

•  “Butterflies” in the stomach

•  Nausea

•  Weakness in muscles

•  Tingling in hands and feet

•  Hot and cold flushes

•  Tight or sore chest

•  Actions

•  Feeling like fleeing or doing so

•  Feeling frozen to the spot

•  Crying or screaming

•  Thoughts

•  Fear

•  Worrying “what if…” something terrible happened

•  Embarrassed or irritated

•  Shame

•  Confused thinking

•  “Something might happen”

•  “This is dangerous” or “I might act in a dangerous way”

All of these actions, thoughts, and feelings are signs of fear and anxiety. It is important to note that, while they are unpleasant to experience, on their own they are not dangerous or life-threatening. We will discuss later why these experiences occur, but before we do, the second feature of a phobia needs to be described.

Phobias involve avoidance of what is feared or the object or situation is endured with distress. Because anxiety is unpleasant and people worry what might happen when they confront what they fear, people with phobias avoid the objects or situations that make them afraid. This avoidance may take many different and subtle forms, such as:

•  Not going near the feared object or situation

•  Escaping the situation

•  Making excuses for not doing what scares you

•  Imagining yourself somewhere else

•  Thinking about something else

•  Looking the other way

•  Drinking alcohol or taking other drugs

•  Taking antianxiety medications

•  Seeking the presence of others

•  Talking to the people you are with about anything

The final important characteristic of a phobia is that it seems unhelpful. As you may have found, people who do not have phobias have difficulty understanding those who do; they may say that the fears are silly, childish, and nonsensical. And, while you also know that the situation does not always involve a real danger, at another level you may believe that it could do so. You may even be able to agree with your family and friends and say that “I know that nothing will happen” but it doesn’t help. There is still this other part of you that is afraid of a nagging doubt that says “What if…”

To summarize what we have covered so far, three things characterize phobias.

•  First, there is an intense fear and anxiety about some object or situation.

•  Second, there is an avoidance of the feared object or it is endured with great difficulty.

•  Finally, there is a conflict between the knowledge that the situation is relatively safe and the belief that it may not be.

Rationale of the program

The program will focus on the three aspects of the phobia and you will be given skills that specifically target each of them. As such, the treatment is like a tripod. It requires all three legs to be present to stand firmly. This means that you will need to learn, practice, and keep using all of the techniques to control your anxiety. The three strategies that this program covers are techniques designed to help you (1) to control your physical sensations, (2) to face the things that you currently fear and avoid more comfortably, and (3) to modify what you say to yourself. (An optional module will cover skills that are relevant to controlling the fainting in the presence of blood and injury.)

It is important to realize that achieving control of anxiety is a skill that has to be learned. To be effective, these skills must be practiced regularly. The more you put in, the more you will get out of the program. It is not the severity of your fear or avoidance, how long you have had your phobia, or how old you are that predicts the success of the program. Rather, it is your motivation to change your reactions. Using all three techniques, you will be able to master your fear.

Anxiety: the life-saving alarm

People who have suffered with a phobia often become afraid of even small amounts of anxiety. But anxiety is useful.

Consider the following: a person is walking across a field that seems to be empty. Suddenly, a bull emerges, sees the walker, bellows, and then charges. The walker realizes the danger and starts running for the fence some distance away. Automatically, changes occur in the body so that the walker is able to run very quickly towards the fence.

Your brain becomes aware of danger. Immediately, adrenaline (epinephrine) is released to trigger the body’s involuntary nervous system, which causes a set of bodily changes. Every change enables you to act quickly, avoid injury, and escape danger. By examining each of the changes in turn, the advantages of this alarm response can be made clear.

•  Breathing speeds up and the nostrils and lungs open wider, increasing the oxygen available for the muscles.

•  Heart rate and blood pressure increase so that oxygen and nutrients needed by the body can be taken quickly to where they are needed.

•  Blood is sent to muscles. Less blood goes to areas that do not immediately need nutrition. For example, blood moves away from the face and you may “pale with fear”.

•  Muscles tense, preparing you to act quickly.

•  Blood clotting ability increases so that blood loss will be minimized.

•  Sweating increases to cool the body.

•  The mind becomes focused. It becomes preoccupied with the thought “Where is the danger and how can I get to safety?”.

•  Digestion is put on hold. Your mouth dries as less saliva is produced. Food sits heavily in the stomach and nausea or “butterflies” may occur.

•  Glucose is released into your blood to provide energy.

•  The immune system slows down. In the short term, the body puts all of its efforts into escaping.

•  Sphincter muscles around the bowel and bladder constrict so that no trail is left by which a predator could track you down.

It is the automatic activation of this flight or fight response that allows you to run and escape. The flight or fight response is an automatic reaction that will first lead you to flee from danger. When escape is impossible you will turn and fight for your life.

In contrast to this life-saving alarm, it is clear that not all anxiety is of the same intensity. The prospect of examinations or a job interview may increase anxiety but not usually to the same degree as if one were faced with a vicious dog. At these times the alarm is triggered, but to a lesser degree. Whatever the degree of anxiety experienced, it is controlled by the involuntary nervous system.

Anxiety: false alarms

Anxiety problems originate when the flight or fight response is too sensitive. Like an overly sensitive car alarm that goes off at the wrong time, when the body’s anxiety alarm is too sensitive, the flight or fight response is triggered at the wrong times. If your anxiety alarm goes off too easily, you will be more likely to become anxious in situations where most other people would not feel anxious. If you have become anxious in situations in which other individuals would not be so anxious, it suggests that your anxiety “alarm” (the flight or fight response) is too sensitive. The alarm reaction, designed to protect you from charging bulls and other physical dangers, was triggered at the wrong time.

The flight or fight response is useful in the short term, especially if the danger can be avoided by physical exertion. But it is of no use in the long term and certainly of little use in most stressful situations in the modern world. It does not help to run when the traffic cop pulls you over and it doesn’t help to fight physically when the boss threatens you. However, because the flight or fight response was useful when we were cavemen and cavewomen, it is still part of our bodily make up.

Why do I have false alarms?

If phobic fears are false alarms triggered because your flight or fight response is too sensitive, why do you have false alarms? Psychological research has revealed three causes of a sensitive anxiety alarm. The first is stress, which we all know can increase anxiety. The second is overbreathing (or hyperventilation), and we will discuss this soon. The third reason is your own history.

The effect of history and learning

One thing that stands out about phobias is the limited number of objects and situations that are feared when the total number of possible objects and situations is considered. Common phobias include:

•  Fear of the dark

•  Fear of heights

•  Fear of animals (e.g., dogs, insects, and reptiles)

•  Fear of enclosed spaces or being trapped

•  Fear of blood and injury

•  Fear of water

If you look over this list, one of the things that becomes obvious is that they are all sensible objects or situations to be wary of if one lived more as our predecessors did. For instance, those people who had a healthy respect for the dark would not venture into potentially dangerous caves, and so on. People who had these fears would be more likely to live to an age at which they could pass on the genes to their children. Over many years, human beings would all acquire a certain degree of fearfulness of these potentially dangerous objects and situations. In fact, children as a rule develop fears of the dark, heights, enclosed spaces, and so on. Thus humans seem to become afraid of objects and situations that have had the potential to be dangerous to humans for centuries. It is situations such as these that become the focus of a person’s phobia.

Phobias then seem to arise in one of four ways. First of all, some people have terrible experiences with potentially dangerous objects and situations that cause them to develop a phobia. For instance, being bitten by a dog may be enough to cause a person to become afraid of dogs. Second, a person may witness a terrible experience happening to another and this may cause them to develop a phobia. For example, watching a person get bitten by a dog may be enough to start a phobia. Third, a person may acquire their fear by being given information. That is to say, being told about the terrible consequences that could arise from a dangerous object or situation may be enough to start a phobia. Finally, there are some people who find that their phobia has always been there. They cannot recall any event that started the phobia. Rather, for as long as they remember, they have always been afraid. It is possible that the trauma occurred at an early age and this explains the lack of memory. However, it is also possible that some people’s fears have always been with them. Whichever one (or combination) of these causes started the phobia in the first place, what is now important is to identify what keeps the phobia going in the present.

We will discuss the factors that keep a phobia going as the program continues. However, by way of summary, it is clear that people with phobias worry more about the objects and situations that are the focus of their fear than others do and they worry more than is necessary. Another factor that maintains avoidance – fleeing from or never even facing what you fear. The problem is that avoidance helps in the short term, but in the long term it causes the phobia to grow. We will discuss avoidance and how to stop it causing phobias. Finally, phobic anxiety is excessive and unreasonable. Thus, by definition, the anxiety and fear is more intense than it should be. Two factors that we know can elevate anxiety and fear are muscle tension and overbreathing

Role of hyperventilation

Having talked about why a phobia may have developed, we shall focus on one aspect of the flight or fight response of concern in phobias, namely overbreathing (or hyperventilation).

As we discussed in the context of the fight or flight response, the anxiety alarm involves an increase in breathing. This overbreathing can make many of the symptoms that occur in phobias much worse than they would be otherwise. These symptoms are important among people with phobias, because some people fear the occurrence of the anxiety reaction at least as much as they fear the danger in the feared situation.

Overbreathing has the power to make anxiety symptoms worse. Let us see how this can happen. The diagram shows how the major components of breathing link together.

Whenever we breathe in, oxygen goes into the lungs. The oxygen travels to the blood where it is picked up by an “oxygen-sticky” chemical. This oxygen-sticky chemical, called hemoglobin, carries the oxygen around the body. Oxygen is released by the hemoglobin for use by the body’s cells. The cells use the oxygen and produce a waste product called carbon dioxide. The carbon dioxide is released back to the blood, taken to the lungs, and breathed out.

The puzzle is, if hemoglobin is “oxygen-sticky”, then how did the oxygen become unstuck? What is the key that unlocks the oxygen? The key is carbon dioxide. Whenever the hemoglobin meets some carbon dioxide, the oxygen is unlocked so that it can go into the body’s cells. Therefore, while it is important to breathe in oxygen, it is just as important that there is carbon dioxide in the blood to release the oxygen. Overbreathing makes anxiety worse, not because you breathe in too much oxygen but because you breathe out too much carbon dioxide.

Breathing “too much” has the effect of decreasing the levels of carbon dioxide, while breathing “too little” has the effect of increasing levels of carbon dioxide. The body works best when there is a balance between oxygen and carbon dioxide. When you overbreathe, you end up with more oxygen than carbon dioxide in your blood. When this imbalance happens, a number of changes occur in the body.

One of the most important changes is a narrowing of certain blood vessels. In particular, blood going to the brain is somewhat decreased. Coupled together with this tightening of blood vessels is the fact that the hemoglobin increases its “stickiness” for oxygen. Thus less blood reaches certain areas of the body. Furthermore, the oxygen carried by this blood is less likely to be released to the cells. Paradoxically, then, while overbreathing means we are taking in more oxygen, we are actually getting less oxygen to certain areas of our brain and body. This results in two broad categories of sensations: 1. Some sensations are produced by the slight reduction in oxygen to certain parts of the brain. These symptoms include:

•  Dizziness

•  Light-headedness

•  Confusion

•  Blurred vision

•  Feelings of unreality

2. Some symptoms are produced by the slight reduction in oxygen to certain parts of the body. These symptoms include:

•  Increase in heartbeat to pump more blood around

•  Breathlessness

•  Numbness and tingling in the extremities

•  Cold, clammy hands

•  Stiffness in the muscles

It is important to remember that the reductions in oxygen are slight and totally harmless.

Hyperventilation is also responsible for a number of overall effects. The act of overbreathing is hard, physical work. Hence, the individual may often feel hot, flushed, and sweaty. Because it is hard work to overbreathe, doing it for a long time can result in tiredness and exhaustion.

People who overbreathe often tend to breathe from their chest rather than their diaphragm. As the chest muscles are not made for breathing, they tend to become tired and tense. Thus these people can experience symptoms of chest tightness or even chest pains.

If overbreathing continues, a second stage of hyperventilation is reached. This produces symptoms such as:

•  Severe vertigo

•  Dizziness and nausea

•  An inability to breathe freely

•  A crushing sensation or sharp pains in the chest

•  Temporary paralysis of muscles in different parts of the body

•  Actual momentary loss of consciousness (“blackouts”)

•  Rising terror that something terrible is about to happen, for example, a heart attack, brain hemorrhage, or even death

The symptoms in the second stage of hyperventilation are produced by the body’s automatic defence reaction to decreasing levels of carbon dioxide. This defence reaction forcibly restricts the person’s breathing, allowing carbon dioxide levels to return to normal.

At the risk of repetition, the most important point to be made about hyperventilation is that it is not dangerous. Increased breathing is part of the flight or fight response and so is part of a natural biological response aimed at protecting the body from harm. Thus it is an automatic reaction for the brain to immediately expect danger and for the individual to feel the urge to escape.

Hyperventilation is often not obvious to the observer, or even to the persons experiencing it. It can be very subtle. This is especially true if the individual has

been slightly overbreathing over a long period of time. In this case, there can be a marked drop in carbon dioxide but, because the body is able to compensate for this drop, symptoms may not be produced. However, because carbon dioxide levels are kept low, the body is less able to cope with further decreases and even a slight change of breathing (e.g., a sigh, yawn, or gasp) can be enough to trigger symptoms.

Types of overbreathing

There are at least four types of overbreathing that you should learn to recognize. The first three tend to be episodic and are probably more common among people with specific phobias. That is to say, they occur only during episodes of high anxiety, such as when you are exposed to what you fear. The other is habitual: it occurs most of the time and is essentially a bad breathing habit or style.

•  Panting or rapid breathing: Such breathing tends to occur during periods of acute anxiety or fear. This type of breathing will reduce carbon dioxide levels very quickly and produce a rapid increase in anxiety.

•   Sighing and yawning: Sighing and yawning tend to occur during periods of disappointment or depression and both involve excessively deep breathing.

•   Gasping: Gasping occurs when people think of frightening things such as doing something that they have avoided for a long time.

•   Chronic or habitual overbreathing: This type of breathing involves slight increases in depth or speed of breathing sustained over a long period. Generally, this happens during periods of worry. It is not enough to bring on a sense of panic, but leaves the person feeling apprehensive, dizzy, and unable to think clearly. If such people are placed in the presence of what they fear and increase their breathing even by a little, this may trigger panic.

The relationship between phobic triggers and hyperventilation is summarized in the diagram overleaf.

Common myths about anxiety symptoms

When fear is intense, people often worry about the possible consequences of extreme levels of anxiety. They may worry that anxiety will escalate out of control or that some serious physical or mental problem may result. As a result, the sensations themselves become threatening and can trigger the whole anxiety response again. This accounts for why many people with phobias fear being anxious as much as, and sometimes more than, the potential dangers in their feared situation. It is therefore important to review the common misinterpretations about anxiety that some people have.

Going crazy

Many people fear they are going crazy when they experience the physical sensations of a panic attack. They may think they have the severe mental disorder called schizophrenia. However, schizophrenia and panic attacks are quite different. Panic attacks begin suddenly and tend to occur again and again. Schizophrenia begins gradually and once the symptoms are present, they do not come and go like panic attacks. The experience of panic is also quite different from that of schizophrenia. People with schizophrenia experience disjointed thoughts and speech, delusions or strange beliefs, and hallucinations. This is not the same as having your mind go blank or worrying about things that other people do not worry about. The strange beliefs might include the receiving of bizarre messages from outer space. Examples of hallucinations may be the hearing of voices that are not really there. Additionally, because schizophrenia runs strongly in families and has a genetic base, only a certain number of people can become schizophrenic and in other people no amount of stress will cause the disorder. Finally, people who develop schizophrenia usually show some mild symptoms for most of their adult lives. Thus, if this has not been noticed in you, then it is unlikely that you would develop schizophrenia. This is especially true if you are over 25 years of age, as schizophrenia usually first appears in the late teens to early 20s.

Losing control

Some people believe that they will “lose control” when they panic. Sometimes they mean that they will become totally paralyzed and not be able to move. Other times they mean that they will not know what they are doing and will run around wild, hurting people or swearing and embarrassing themselves. It is clear where this feeling may come from when you remember our discussion of the fight or flight response. Your body is ready for action when the anxiety response is triggered and there is often an overpowering desire to get away from any danger. The problem is that when you do not use the anxiety response to flee or fight, you may feel confused, unreal, and distracted. Nevertheless, you are still able to think and function normally. You are still able to decide what action to take in response to panic; that is, whether to stay or leave.

Heart attacks

Many people misinterpret the symptoms of the fight or flight response and believe that they must be dying of a heart attack. This is because most people have never experienced a heart attack and therefore never know how this differs from a panic attack. The major symptoms of heart disease include breathlessness and chest pain but these symptoms are generally related to effort and will go away fairly quickly with rest. This is very different from the symptoms associated with a panic attack that can happen at any time. Certainly panic symptoms can occur during exercise and feel worse with exercise, but they are different from a heart attack. Lastly, if a doctor has checked your heart with an electrocardiogram (a device that measures electrical changes in the heart) and has given you the “all clear”, then you can safely assume that heart disease is not the cause of your attacks. Heart disease will produce very obvious changes in the electrical activity of the heart that are not produced during a panic attack.

Other fears

Another fear that individuals with certain types of phobia report is the fear of fainting. This is especially common among people who fear blood, injections, illness, and injury and will be discussed in greater detail later in the program.

Control of hyperventilation

Recognizing hyperventilation

The first step in preventing and controlling hyperventilation is to recognize how and when you overbreathe.

Try monitoring your breathing rate now. Count one breath in and out as 1, the next breath in and out as 2, and so on. It may be difficult at first, but don’t try to change your breathing rate voluntarily. Write the answer here. As part of treatment you will be required to monitor your breathing rate for 1 minute during various times of the day.

Now consider the following:

• Do you breathe too quickly? The average person only needs to take 10 to 12 breaths per minute at rest. If your rate of breathing is greater than this, then you must reduce it.

•  Do you breathe too deeply? Does your chest sometimes feel overexpanded? You should breathe from the abdomen and through the nose, consciously attempting to breathe in a smooth and light way.

•  Do you breathe from your chest? Sit with your arms folded lightly across your tummy and while breathing naturally observe your arms, chest, and shoulders. While all three will move, the main movement should be in your tummy if you are breathing correctly from your diaphragm.

•  Do you sigh or yawn more than others? Become aware of when you sigh or yawn and avoid taking deep breaths at these times.

•  Do you gasp or take in a deep breath when, for example, someone mentions what you fear? Taking one deep breath can trigger the hyperventilation cycle in many people.

•  Do you breathe through your mouth? You are more likely to hyperventilate if you breathe through your mouth. Whenever you notice this, you should consciously revert to breathing through your nose.

Slow-breathing technique

This technique is to be used at first signs of anxiety or panic.

You must learn to recognize the first signs of overbreathing and immediately do the following:

•  Stop what you are doing and sit down or lean against something.

•  Hold your breath and count to 10 (don’t take a deep breath).

•  When you get to 10, breathe out and mentally say the word “relax” to yourself in a calm, soothing manner.

•  Breathe in and out slowly in a 6-second cycle. Breathe in for 3 seconds and out for 3 seconds. This will produce a breathing rate of 10 breaths per minute. Mentally say the word “relax” to yourself every time you breathe out.

•  At the end of each minute (after 10 breaths), hold your breath again for 10 seconds, and then continue breathing in the 6-second cycle.

•  Continue breathing in this way until all the symptoms of overbreathing have gone.

If you do these things as soon as you notice the first signs of overbreathing, the symptoms should subside within a minute or two and you will not experience any panic attacks. The more you practice, the better you will become at using it to bring your phobic fear under control. Remember that your goal should always be to stay calm and prevent the anxiety and fear from developing into panic. You need to identify the very first symptoms of hyperventilation, and the moment you experience any of these, use the above slow-breathing techniques immediately.

Daily record of breathing rate

Instructions: Your breathing rate should be monitored at the times shown below unless you are performing some activity that will inflate your rate, such as walking upstairs. In this case wait for about 10 minutes. Try to be sitting or standing quietly when you count your breathing. Each breath in and out counts as 1: so, on the first breath in and out count 1; on the next breath in and out count 2, and so on. Count your breathing rate in this way for 1 minute, then do the slow-breathing exercise for 5 minutes. After this, count your breathing rate again for 1 minute. Your therapist will be able to check whether your breathing rate remains low following the exercise.

Relaxation training: Specific Phobias

Graded Exposure: Specific Phobias

Thinking Straight

Blood and Injury Phobia

Keeping Your Progress Going

Coping with setbacks or difficulties in making progress

Setbacks or difficulties in making progress are generally the consequence of either poor management or poor planning of goals and steps. If you should experience such difficulties, you must carefully analyze the way in which you carry out these two exercises.

Managing anxiety and hyperventilation

•  Are you regularly monitoring your breathing while performing activities?

•  Are you using the isometric relaxation exercises and the slow-breathing technique when you experience the first signs of anxiety?

•  Are you regularly practicing the progressive muscle relaxation exercises, especially prior to entering a situation?

•  Are you too obsessed about having antianxiety medication with you?

•  Are there mounting background stresses in your life that need to be defused, e.g., marital, family, or financial problems?

•  Are you suffering from any form of physical stress, e.g., illness, premenstrual tension, poor diet, lack of sleep, or overwork?

Planning of goals and steps

•  Are you trying to progress too quickly or too slowly?

•  Is the difference between levels of difficulty at each step too great?

•  Do you need to develop in-between steps of gradually increasing difficulty that lie between the last step you completed successfully and the step with which you are now having difficulty?

•  Do you need to practice new steps more frequently and for longer periods before moving on to more difficult ones?

•  If your objectives are too easy or too difficult, you will not make progress.

•  Are you sure that you are not expecting too much of yourself? Make sure that you give yourself sufficient praise for your achievements. Remember that the key to success is gradual but regular progress.

Emotional problems during setbacks

Setbacks do occur occasionally, even in persons who are making excellent progress. When this happens, some people become alarmed and despondent, fearing they have gone back to their very worst. Remember, no matter how badly you feel during a setback it is very rare for you to go all the way back to your worst level of incapacitation. For most people, the apparent setback is only a passing phase, due to factors such as outside stressors, the flu, or school holidays. In such cases, the setback is often viewed as devastating because it has a lot of emotional meaning for the person, who has put considerable effort into recovering. This effort is not wasted, and after the stressors pass you will find it easier to get yourself out and about again. This pattern has been demonstrated again and again. Therefore, if you have a setback, don’t add to the problem with all the old catastrophic, emotional, and self-destructive ideas. Keep practicing all the techniques you have been taught and you will be able to make progress. If you feel that you have genuinely lost the skills necessary to control anxiety and panic, then you may want to consider retreatment. Most people do not lose the skills but need some fine-tuning of their skills. “Booster” sessions or follow-up meetings are the best way to receive this form of assistance.

Expect a lapse occasionally

Here, a lapse means that you stop listening to your relaxation tape, start to worry about having a panic attack, or stop slow breathing. Most people will have some sort of lapse when they are trying to change their behavior.

The trick is not to turn a lapse into a relapse and exaggerate the lapse into being bigger than it really is. If you have noticed that you have stopped using your panic control skills, don’t say things to yourself like: “I’m really hopeless; I’m right back where I started from; I’ll never be able to change.” Instead, you should view your lapse in the following light: “I’m disappointed that I have let things slip, but I can cope with that and I’m not going to turn it into an excuse for giving up altogether. Now I’ll get out my Manual and start again.”

Of course, some people do stop things like relaxation training or slow breathing when they have been feeling okay for some time. This is fine, as long as you keep aware of any stress or anxiety that may be creeping back into your life, and restart the training as soon as you become aware of any increase. Also, it will be important to reinstate such techniques if you have recently experienced any stressful life event.

Conclusion

You now have three skills that you have been taught and now need to practice. You need to use the various exposure tasks, working up the fear stepladder, to reduce your fear. Relaxation will help to reduce your general levels of tension before the exposure task, and the isometric exercises will regulate tension during exposure. Slow breathing will help to keep control of any anxiety that you may experience and by thinking straight you will be able to stop anxiety from spiraling out of control.

The importance of relaxation training

Human beings have a built-in response to threat or stress known as the flight or fight response. Part of this flight or fight response involves the activation of muscle tension, which helps us to perform many tasks in a more alert and efficient manner. In normal circumstances, the muscles do not remain at a high level of tension all the time but become tensed and relaxed according to a person’s needs. Thus a person may show fluctuating patterns of tension and relaxation over a single day according to the demands of the day, but this person would not be considered to be suffering from tension.

If you remain tense after demanding or stressful periods have passed, you remain more alert than is necessary and this sense of alertness ends up turning into apprehension and anxiety. Constant tension makes people oversensitive and they respond to smaller and smaller events as though they were threatening. By learning to relax, you can gain control over these feelings of anxiety. In this program, you will be taught how to recognize tension, how to achieve deep relaxation, and how to relax in everyday situations. You will need to be an active participant, committed to daily practice for 2 months or longer.

Since some tension may be good for you, it is important to discriminate when tension is useful and when it is unnecessary. Actually, much everyday tension is unnecessary. Only a few muscles are involved in maintaining normal posture, e.g., sitting, standing, walking. Most people use more tension than is necessary to perform these activities. Occasionally, an increase in tension is extremely beneficial. For example, it is usually helpful to tense up when you are about to receive a serve in a tennis game. Tension is unnecessary when (1) it performs no useful alerting function, (2) it is too high for the activity involved, or (3) it remains high after the activating situation has passed.

In order to be more in control of your anxiety, emotions, and general physical well-being, it is important to learn to relax. To do this you need to learn to recognize tension; learn to relax your body in a general, total sense; and learn to let tension go in specific muscles.

Recognizing tension

When people have been tense and anxious for a long period, they are frequently not aware of how tense they are, even while at home. Being tense has become normal to them and may even feel relaxed compared with the times they feel extremely anxious or panicky. However, a high level of background tension is undesirable, because other symptoms, such as hyperventilation and panic, can easily be triggered by small increases in arousal brought on by even trivial events.

Where do you feel tension? For the next 12 days we want you to monitor the tension in your body. Use the following form to indicate the location of your tension and the degree of tension. Always choose approximately the same time each day to monitor your tension. Before your evening meal is usually a good time for this. In each box place the number corresponding to your level of tension

Progressive muscle relaxation

Progressive relaxation means that the muscles are relaxed in a progressive manner. This section will outline how to use both progressive relaxation and “isometric” relaxation. You should master both forms of relaxation, because the progressive muscle relaxation exercises are useful for becoming relaxed (before you confront your fears) and the isometric relaxation is useful for remaining relaxed (while you confront your fears).

Relaxation exercises should be done at least once a day to begin with, preferably before any activity that might prove difficult. Select a comfortable chair with good support for your head and shoulders. If a chair does not provide good support, use cushions placed against a wall. Some people prefer to do the exercises lying down, but do not use this position if you are likely to fall asleep. These relaxation exercises are not meant to put you to sleep, since you cannot learn to relax while asleep. Sleep is not the same as relaxation. Consider those times when you have awakened tense. When possible, it is advisable that you use a relaxation tape as a preparation before you expose yourself to what you fear.

You will need to commit yourself to daily practice in order to achieve really longlasting effects. Some people continue daily relaxation many years after leaving treatment. If you can do this, we strongly advise it. However, not all people continue relaxation in this way. People who benefit most from relaxation either practice regularly or practice immediately after they notice any increase in tension or anxiety.

Isometric relaxation

Isometric relaxation exercises can be done when you experience fear. Most of the exercises do not involve any obvious change in posture or movement. This is because isometric refers to exercises in which the length of the muscle remains the same. Because it stays the same length, there is no obvious movement.

The most common mistake that people make with isometric exercises is putting the tension in too quickly or putting in too much tension. These are meant to be gentle and slow exercises. The aim of the exercise is to relax you, not get you even more tense. If circumstances do not allow you to hold the tension for 7 seconds, you can still benefit from putting in the tension slowly over some period of time and releasing it in the same manner.

When sitting in a public place:

•  Take a small breath and hold it for up to 7 seconds.

•  At the same time, slowly tense leg muscles by crossing your feet at the ankles and press down with the upper leg while trying to lift the lower leg.

Or

•  Pull the legs sideways in opposite directions while keeping them locked together at the ankles.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  Close your eyes.

•  For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow out of your muscles.

•  Choose other parts of the body to relax, e.g., the hands and arms.

•  Take a small breath and hold it for up to 7 seconds.

•  At the same time, tense hand and arm muscles by placing hands comfortably in your lap, palm against palm, and pressing down with the top hand while trying to lift the lower hand.

Or

• Place hands under the sides of chair and pull into the chair.

Or

• Grasp hands behind chair and try to pull them apart while simultaneously pushing them in against the back of the chair.

Or

• Place hands behind the head, interlocking the fingers, and while pushing the head backward into hands try to pull hands apart.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  Close your eyes.

•  For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.

If circumstances permit, continue with various muscle groups. When standing in a public place:

• Take a small breath and hold it for up to 7 seconds.

•  At the same time, straighten legs to tense all muscles, bending the knees back almost as far as they will go.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  Close your eyes.

•  For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.

Other exercises for hand and arm muscles:

• Take a small breath and hold it for up to 7 seconds.

•  At the same time, cup hands together in front and try to pull them apart.

Or

• Cup hands together behind and try to pull them apart.

Or

• Tightly grip an immovable rail or bar and let the tension flow up the arms.

•  After 7 seconds, breathe out and slowly say the word “relax” to yourself.

•  Let all the tension go from your muscles.

•  Close your eyes.

•  For the next minute, each time you breathe out, say the word “relax” to yourself and let all the tension flow from your muscles.

Further isometric exercises

Various muscles can be tensed and relaxed in order to make up additional isometric exercises. You need first to decide which of your muscles tense up most readily. (If you have difficulty deciding, consider what people say to you: “Your forehead is tense”; “You’re tapping your feet again”; “You’re clenching your jaw.”) Once you have decided on a muscle or muscle group, decide how you can voluntarily tense these muscles, and finally how you can relax them. In this way, you can design your own tailor-made set of isometric exercises.

Instructions: Some example exercises are given below. Write down some suggestions for putting tension in the muscle area and then suggestions for relaxing that muscle. Give the suggestions a try, but remember to tense gently and slowly.

Site of tension	Manner of tensing	Manner of relaxing
Shoulders and neck	Hunching shoulders up towards the head	Letting shoulders drop and let arms hang loose
Hand tension	Make a fist	Let all fingers go loose. Place hands palm facing upward on lap

Important points about learning to relax quickly

1.  Relaxing is a skill – it improves with frequent and regular practice.

2.  Do the exercises immediately whenever you notice yourself becoming tense.

3.  Develop the habit of reacting to tension by relaxing.

4.  With practice, the tensing of your hand and leg muscles can be done without any movement that would attract attention. It helps to slowly tense and relax the muscles.

5.  When circumstances prevent you holding the tension for 7 seconds, shorter periods will still help but you may have to repeat it a few more times.

6.  Do not tense your muscles to the point of discomfort or hold the tension for longer than 7 seconds.

7.  Each of these exercises can be adapted to help in problem settings such as working at a desk or waiting in a queue. Use them whenever you need to relax.

8.  Using these exercises you should in a few weeks be able to reduce your tension, prevent yourself from becoming overly tense and increase your self-control and confidence.

Difficulties with relaxation

Some people report that they can’t relax, or they can’t bring themselves to practice relaxation. Since all human beings share the same biological make-up there is no purely physical reason why relaxation should work for some and not others. The reason relaxation may not work for some people is usually due to some psychological factor or insufficient practice. These problems can be overcome. If you are experiencing difficulty relaxing you should discuss this with your therapist. Some examples of difficulties are given below.

1.   “I am too tense to relax.” In this case the individual uses the very symptom that needs treating as an excuse for not relaxing. Relaxation may take longer than expected, but there is no reason why someone should have to remain tense. It might be useful to consider whether there is some other factor getting in the way of relaxation.

2.   “I don’t like the feelings of relaxation.” About 1 in 10 people report that when they relax they come into contact with feelings they don’t like or that frighten them. These feelings indicate you are coming into contact with your body again and noticing sensations that may have been kept under check for many years. You do not have to worry about losing control during relaxation sessions. You can always let a little tension back in until you get used to the sensations. As you keep practicing these sensations will pass.

3.   “I feel guilty wasting so much time.” You need to see relaxation as an important part of your recovery. Relaxation exercises take time, just like many other therapies.

4.   “I can’t find the place or time.” Be adaptive. If you can’t find 20 minutes, find 10 minutes somewhere in the day to relax. If you do not have a private room at work, go to a park. You may need to consider whether other factors are preventing you from relaxing if you keep making the excuse that there’s no time.

5.   “I’m not getting anything out of this.” Unfortunately, many people expect too much too soon from relaxation training. People often exaggerate the speed of recovery. You cannot expect to undo years of habitual tensing in a few relaxation sessions. Impatience is one of the symptoms of anxiety and often indicates a need to continue with relaxation training. Give the training time to take effect.

6.   “I haven’t got the self control.” You need to realize that quick, easy cures for phobias calling for no effort from you do not exist. The longest-lasting treatment effects occur when an individual takes responsibility for his or her recovery. Responsibility means self-control, but self-control is difficult if you are not motivated.

One of the hallmarks of a phobia is that the feared object or situation is avoided or endured with considerable distress. Remember that the sorts of avoidance that we are talking about are not only the obvious ones (e.g., running away from or not going near what you fear) but also the more subtle ones (e.g., thinking about something else). However, avoiding the feared object or situation is good in the short term but its longer-term implications are not good. Whether you avoid in a subtle or obvious way, the result is the same. Each time a person with a phobia approaches some situation and then avoids it, in whole or in part, the fear subsequently increases because the drop in anxiety (which follows the “escape”) is rewarding. Thus the avoidance is rewarded: after all, if you can avoid the fear by avoiding, why not do so? Unfortunately, the fear really doesn’t stop, you just find more and more situations that could be “dangerous” and avoid them also.

What, then, is the way out? If leaving the situation strengthens the fear, what would happen if you stayed put? Actually, if you stayed in the situation for an hour or so, the fear would eventually go and the fear the next time you entered that situation would be less. But few people with situational fears can actually stay in the situation for the time required for intense fear to wear off. So they keep avoiding those situations.

The best remedy is to control the level of the fear using hyperventilation control, relaxation, and straight thinking , and then stay in a situation until you are calmer. Obviously, intense fear will take substantially longer to decrease than would lower levels of anxiety. For this reason, it is recommended that you begin with situations associated with small amounts of anxiety and work up to situations associated with higher levels of anxiety. In this way, you will experience anxiety, but only levels that you will be able to manage relatively quickly. As a result, you will have more successes in managing your fear. But how do you organize such experiences? First, you make a list of all the situations in which you are likely to ever have your phobic fears. Next, you rank those situations in terms of the fear associated with them. Put them into a fear “stepladder”, beginning with the least fear provoking and moving through to the most feared situations. Then, you work your way up the “stepladder”, staying again and again in a situation at each level until the situation loses its power to evoke excessive anxiety. This procedure is discussed in more detail in the following sections.

Facing your fears

Situational fears are fears of places or situations that the person with a phobia thinks are dangerous or fear provoking. Once situational fears are established, avoidance often develops. It is the goal of treatment to have you overcome avoidances. The process is a gradual one, as fears can often be made worse if the person suddenly forces himself or herself, without sufficient preparation, to confront something he or she may have avoided for years.

If the associations are instead to be weakened, exposure to the feared situations is managed most easily when it is gradual. First, the person must learn to master situations associated with only mild anxiety and then progressively master situations associated with greater anxiety. It should be remembered that anxiety is different from fear and panic, and moderate anxiety in new or previously feared situations is a perfectly normal and reasonable response. Thus we do not expect you to wait until you have no anxiety at all to enter a situation. Instead, identify specific goals that you wish to achieve and then break them down into smaller steps. Each step is practiced and mastered before moving onto the next. The skills you have learned for the control of anxiety and hyperventilation are to be used in practicing each step.

Planning your program

1. Draw up a list of goals that you would like to be able to achieve. These should be specific goals that vary from being mildly to extremely difficult. You may have many goals but the ones that are relevant are those which involve anxiety in specific situations. Examples of general goals that do not lend themselves to graded exposure could include:

•  “I want to get better.”

•  “I want to know what sort of person I am.”

•  “I want to have purpose and meaning in life.”

Although they are appropriate goals to have, they do not allow you to work out practical steps by which such problems can be solved. Your goals should be precise and clear situations that you can approach in a series of graded steps. The following examples are based on fears that some individuals with phobias have:

•  To travel to the city by underground train in rush hour.

•  To be able to hold a nonpoisonous spider for 5 minutes.

•  To swim out of one’s depth for 15 minutes.

2.  Break each of these goals down into easier, smaller steps that enable you to work up to the goal a little at a time. Note that the first goal comes from an individual with a fear of traveling by train. In order to be able to work towards eliminating this fear, you would need to start with (1) small trips by train, starting with traveling one station above ground, and (2) uncrowded trains. Then, gradually you would increase the number of stations, the number of people likely to be on the train, and eventually go under ground. The first goal mentioned above could be broken down into the following steps:

•  Traveling one stop on an above-ground train, quiet time of day.

•  Traveling two stops in an above-ground train, quiet time of day.

•  Traveling two stops in an above-ground train, rush hour.

•  Traveling one stop on an underground train, quiet time of day.

•  Traveling two stops in an underground train, rush hour.

•  Traveling five stops in an underground train, quiet time of day.

•  Traveling five stops in an underground train, rush hour.

The number of steps involved depends upon the level of difficulty of the task involved. To make the above steps a little easier, you might wish to do them in the company of a friend or partner to begin with, and then do them alone. For other people, these steps might be too easy. In that case you would eliminate those that are too easy. You should always be working on those activities that you can perform, knowing you have a reasonably good chance of managing the anxiety that you experience. All of your goals can be broken down into smaller steps within your capabilities. Use this method to more easily achieve your goals.

3.  You may also need to consider the practical aspects of how you are going to organize your exposure tasks. For example, if you need to be in the presence of a spider, how are you going to get one into a jar for the exercise if you have a spider phobia? Often a useful strategy is to recruit the assistance of someone without your phobia – maybe a partner or a reliable friend.

Implementing your program

•  Make sure that you perform some activity related to your phobia every day. Avoidance makes fears worse. If you are having a bad day, you should always do something, but you need only go over the steps that you have already mastered.

•  Confront a situation frequently and regularly until you overcome the fear. Many fears need to be confronted frequently (i.e., three to four times per week) at first, otherwise your fear will rise again by the time you do it next. Once you have largely overcome the fear, you need only do it less frequently.

The general rule is: The more you fear it, the more frequently you need to confront it.

• Carefully monitor and record your progress. Keep a diary of your goals, steps, and achievements, together with comments about how you felt and how you dealt with particular situations. This will help you to structure your progress and also to give you feedback as to how you are doing.

Practicing the steps

•  Use the progressive relaxation exercises before you perform the activity.

•  Mentally rehearse successful performance of your activity. A good time is at the end of the relaxation session.

•  Perform all activities in a slow and relaxed manner. This means giving yourself plenty of time.

•  Monitor your breathing rate at regular intervals during the activity. This may be once every 5 or 10 minutes for an extended activity, or more frequently if it is shorter.

•  When the circumstances allow it, stop your activity at the point at which you become anxious. Stop and implement the strategies you have learned to overcome your fear and then wait for it to pass.

•  Do not leave a situation until you feel your fear decline substantially. This means you need to agree with yourself (and anyone who accompanies you) exactly how long or exactly how much your anxiety must decrease before you leave the situation. Never leave the situation out of fear. Face it; accept it; let it fade away; and then either move on or return. If you do not do this, you may see it as a failure and lose confidence.

•  Try to remain in the situation as long as possible.

•  Congratulate yourself for successful achievements.

Coping with difficulties

It is important to acknowledge that many phobic objects and situations are potentially dangerous or at minimum need to be dealt with effectively. You will need to work out the ways in which you can cope with various difficulties associated with what you fear. By way of illustration, consider a person who has a phobia about being trapped in elevators. Exposure to the elevator will reduce the anxiety associated with elevators but it is possible, though not very probable on any day, that the person could get trapped in an elevator. In such a situation, the person is faced with two difficulties. The first is coping with any anxiety and fear, which would involve breathing control, relaxation, and thinking straight. The second problem is how to get out of the elevator. Being prepared to cope with this eventuality will help to minimize worry about what may happen and also would make responding more efficient.

A planned coping strategy could include:

•  Begin breathing control and isometric relaxation.

•  Challenge any unhelpful thoughts (we will see how to do this later).

•  Try pushing the “door open” button or the button for the level to which you wish to go.

•  Look for the emergency bell and ring until someone responds.

•  Use the emergency telephone if present.

•  Continue using anxiety-management strategies where necessary.

Think about what you fear and how you may choose to cope with any possible difficulties. Remember, this is an exercise in planning helpful and effective coping strategies for possible eventualities, not a chance to worry about everything that you fear.

Facing fears in imagination

In a few instances, it may be difficult to approach your goal in a series of real life steps. In such cases, some steps can be practiced in imagination. This is slower than real-life exposure, but it does provide a useful way of adding in-between steps in some “all-or-none” types of activity. In order to use desensitization in imagination, you will need to specify the characteristics of the type of step you would ideally like to perform, write this on a card or series of cards, and then practice the activity specified on the card in your imagination after your next relaxation session. You will need to use cards so that you can read predetermined details about the situation that you are “rehearsing”. We do not want you to let your imagination run riot. Simply imagine yourself performing the activity in a calm, collected manner. If you imagine yourself getting overly anxious or panicking, continue the session, using one of the various techniques outlined in previous sections to control anxiety.

Remember, you imagine yourself in these scenes operating in a competent manner. Even if you do not think you would, you imagine that you are. In this way, you can rehearse competent behavior at the same time as facing your fears.

Only imagine one scene at a time. You do not have to imagine all scenes in a single session.

Exercises in planning activities

An essential skill in overcoming situational fears is the ability to establish clear, helpful goals for yourself and to break these down into a number of smaller, easier steps through which you can progress. Nothing will encourage you like previous success.

A goal can always be broken down into a series of smaller, easier steps by varying the following:

•  Whether you do the activity in company or with a companion.

•  How far you are from help.

•  How long you stay in the feared situation.

•  How many things you do while you are there.

•  How close you go to what you fear.

Using various combinations of these, you can easily build up a set of steps that enable you to more easily achieve your goals.

This part of the program is designed to help you to control the kinds of thoughts that occur when you are in the presence of something you fear. These thoughts not only accompany your anxiety reactions but can also promote them. You will achieve this control by learning procedures that reduce the frequency, intensity, and duration of upsetting emotional reactions by labeling the situation more appropriately and accurately. Simply put, the procedures you will practice involve learning how to “think straight.”

The importance of the way you think

Humans are thinking, feeling, and behaving beings. These three aspects of our make-up interact with each other. However, thoughts can often go unrecognized.

Consider the following example:

Peter is on an errand from work and enters an office building. He approaches the elevator and thinks to himself, “Here we go again, another elevator. I hate elevators. Maybe if I got inside I may get anxious and panicky. What if someone saw me, I would be so embarrassed because they would see what a weak person I am. What if the elevator was to breakdown. I might get stuck in there for weeks. A few weeks without food, I am bound to die. Maybe it would be better to take the stairs.” Peter then looks slightly anxious and turns around and climbs 15 flights of stairs to reach his destination.

Why did Peter become anxious and climb the stairs? The most accurate answer is “Peter made Peter anxious”. To make this clear, consider another version of the same story:

Peter is on an errand from work and enters an office building. He approaches the elevator and thinks to himself, “The office is on the 15th floor. What if the elevator broke down? Chances are that it will not, and even if it did, I would be able to use the telephone in the elevator to call for assistance. There is no need to worry unnecessarily.” He becomes less anxious and enters the elevator.

As you can see, the situation is exactly the same in the two stories except for two important features. First of all, Peter’s thoughts have changed. Second, Peter’s emotional reaction has changed: in the first scene he became anxious; in the second he remained in a pleasant mood. Peter’s emotional reaction is no accident: the elevator hadn’t made him afraid. Rather, it was the catastrophic thoughts that Peter had that caused him to feel afraid.

Putting this all together, there was an activating event, i.e., the elevator. This was presumed to lead to the consequence of Peter feeling afraid and later angry with his boss. However, in the expanded story, it was apparent that Peter’s explanation was incomplete because there were a number of intervening beliefs or thoughts that he had. Thus, the way in which emotions are produced can be written as As, Bs, and Cs. A is the Activating event, В is the Beliefs or thoughts that a person has about the activating event and its meaning, while С is the emotional and behavioral Consequence of having those beliefs and thoughts about the event. In other words, the activating event does not cause the consequence on its own, but, rather, it is the way we think about the activating event that causes the emotional consequence.

Misinterpretation and mislabeling

Many people realize that their emotional responses to various situations differ from others around them. This occurs because the people with phobias label some situations as threatening or dangerous, and therefore feel anxious. It is important to realize that it is appropriate to feel anxious in response to objectively threatening or dangerous situations. The problem in a phobia is that the label is incorrect and is based on an exaggerated estimate of the severity of danger or the probability of danger.

Individual with phobia	Individual without a phobia
Activating event Spider in a jar	Activating event Spider in a jar
Beliefs “What if it is poisonous?” “Any movement means that the spider is about to kill me “	Beliefs “I’ve been told it is harmless” “I’ve never been so close to one of these spiders before”
Consequences Anxious and refuse to touch it On edge and desiring to escape	Consequences Relaxed Settles down to study the spider

At its heart, the unhelpful thinking that makes the fears of people with phobias much more intense than they need to be involves overly pessimistic ratings of the probability and cost of danger. The greater the chance of something bad happening (i.e., the probability) and the worse that the event will be (i.e., the cost), then the more a person is going to worry about it. For example, a person with height phobia may start to climb a steep ladder and think that the probability that they will fall from the fifth step is about 80% (i.e., the probability is high) and that they will almost certainly die from the injuries (i.e., the cost is high). Quite reasonably, the person will be afraid of climbing the ladder.

Sometimes a person with a phobia will be afraid because their estimates of probability and cost are both high. Other times, the worry may arise because one or other is excessively high. For instance, a person who is afraid of flying may agree that the airplane they may fly in is less likely to crash than the car they drove to the airport in, but they may think that the cost of a crash is greater in an airplane because most car accidents are not fatal.

However, this isn’t the whole story. Estimates of probability and cost change as a person gets closer to what it is that they fear. Interestingly, estimates of the probability and cost of danger are higher when people consider confronting what they fear than when they are actually in its presence. You may have noticed this yourself, that you can be more worried when thinking about facing your fears than when you actually face them.

These worries that are based upon overly high ratings of the probability and cost of danger can encourage a person to avoid fear-provoking situations. Avoiding situations only strengthens unhelpful and fear-producing thinking habits, as it prevents individuals from getting new, helpful information that the probability and cost are not as high as you may be thinking.

Given the thoughts a person with a phobia is having, the fear is reasonable. The problem is that the thoughts are not appropriate to the situation. They have labeled the situation as more threatening than they need to or they have worried that danger is more likely than it is. By changing the way a person labels or interprets events, a person can gain more control over their feelings in a more helpful and adaptive way.

It is important to recognize that unhelpful thinking patterns are habits, and that habits can be changed with effort and practice. Identifying unhelpful thoughts associated with anxiety is the first step in changing your thinking.

Step 1:        Identify anxiety-provoking thoughts.

Step 2:        Challenge unhelpful anxiety-provoking thoughts.

Step 3:        Generate helpful, more helpful alternatives.

Step 1: Identifying anxiety-provoking thoughts

It may be difficult to spot anxiety-provoking thoughts at first, especially if they have been around for a long time. In situations where you feel anxious or uncomfortable, ask yourself:

1.  What do I think about myself?

2.  What do I fear will happen?

3.  What do I think about the situation?

4.  How do I think I will cope?

5.  What will I do?

Some common errors in thinking that produce anxiety in individuals with phobias include:

1.  Overestimating the chances or probability of danger: Individuals with phobias often believe that danger is more likely to occur than it really does.

2.  Exaggerating the feared consequences (or cost): Individuals with phobias often worry that the consequences of facing up to the feared object or situations are more serious than they are.

3.   Underestimating their own ability to cope: Individuals with phobias often judge themselves as being unable to cope. For some people, it is the worry that they will be unable to control their own anxiety, while for others it is the worry that they will be unable to control the feared object or situation.

Individuals can also apply anxiety-provoking thoughts about one situation to other situations, and then start to become more anxious in those situations. This process is known as generalization. For example, an individual who is worried about panicking on a train may start to generalize this worry to being on buses and airplanes. This is understandable, because all three of the situations share some features: other people, limited opportunities to leave, and limited control over their direction.

Step 2: Challenging anxiety-provoking thoughts

It may be difficult to challenge anxiety-provoking thoughts, especially when they have been present for a long time. Some thoughts may even appear to be automatic. One of the best ways to challenge unhelpful thinking is to write them down, and replace the unhelpful beliefs with more helpful or helpful alternatives. Some important questions to help you challenge unhelpful thoughts are:

1.  What is the evidence for what I fear?

2.  How likely is what I fear to happen?

3.  What is the worst possible thing that will happen?

4.  What alternatives are there?

5.  How helpful is the way I’m thinking?

Step 3: Generating alternative thoughts

Through the process of challenging unhelpful thoughts, you may have started to generate more helpful thoughts. We will begin by starting with an example of unhelpful thinking. After this, we will look at specific examples from your own experience.

Consider the following example.

Description of situation	Anxiety-provoking thoughts and initial anxiety rating	Helpful thoughts and subsequent anxiety rating
Catching an express train, where I couldn’t get off if I wanted to	I’ll panic – being on a train makes be lose control and panic I’ll go crazy if I can’t get out What’ll people think of me? If I can’t get out I’ll do something stupid or out of control I won’t cope No-one else feels this way	I probably won’t lose control; I’ll just feel anxious Even if I do feel anxious and uncomfortable that doesn’t mean the situation is dangerous I’ve never done something out of control on a train, and probably won’t do something this time either I can use my techniques to manage my anxiety People won’t notice me, and, even if they do, they’ll just think I’m a little tense
	I must be loopy to feel this way	I’m not loopy, just anxious, and I’m doing something about that

Now think of a recent situation where you felt anxious because of your phobia. Write down a description of the situation and any anxiety-provoking thoughts that you may have had. Then write down some more helpful thoughts that could be applied to that situation, in order to reduce your anxiety. There is also space for an additional individual example.

This technique should be used with the technique of graded exposure, to help you re-enter situations that you currently avoid because of anxiety.

Helpful thinking is not simply positive thinking; it does not reject all negative thoughts. It is looking at things in a way that is most helpful given the facts. It is therefore important to distinguish helpful thinking from unhelpful positive, or wishful, thinking.

Some examples of the difference between unhelpful, helpful, and wishful thinking are:

Unhelpful	What if I can’t cope with this? I just know I’ll do something wrong.
Wishful	It’ll be easy this time.
Helpful	I’m going to give this a try. I’ll do my best, and see how it goes.

If you have an unpleasant experience or event, go through the questions listed earlier in this section. At the same time, check whether your response is reasonable. If so, face your disappointment, but don’t make a catastrophe of it either! It is sometimes difficult to tell the difference between unhelpful, wishful, and helpful thinking. Here are some clues to help clarify these:

Unhelpful thinking

I must…

I’ve got to…

What if… [something happened] … that would be terrible. I couldn’t stand it if… Wishful thinking

It’ll work out.

I don’t care…

It wouldn’t have done any good anyway.

I won’t be anxious at all. Helpful thinking

I’d like to…

I’d prefer not to…

It’s unlikely that… [something] … will actually happen.

If things don’t go the way I want, I might be disappointed, but I’ll use my anxiety management skills to help me cope.

Troubleshooting

1.   “I don’t know what I’m thinking – I’m too scared.” Ask yourself “What am I scared of? What am I scared might happen?”. It is difficult to identify unhelpful fears, especially to begin with. It may help to wait until the anxiety has dropped, then think about the situation and associated fears. Re-entering a situation may make the fears clearer.

2.   “I can’t think of alternatives.” After many months to years of having anxiety-provoking thoughts, it may be difficult to think up less threatening alternatives. Look at all available evidence, especially evidence that contradicts your thoughts. Ask yourself why others around you do not fear the situation, and try to consider what they might be thinking about the situation.

3.   “I’m doing it and it’s not working.” Use all available techniques, including relaxation and slow breathing, to reduce your anxiety. Do not expect to be perfect at controlling your thoughts or expect the technique to work immediately. Changing well-established patterns takes time and effort.

4.   “I still feel anxious.” Straight thinking is designed to provide more helpful and appropriate responses to given situations, events or interactions. If the reality is that a particular situation is associated with some anxiety for most people, do not expect to use the technique to reduce all anxiety.

5. “I don’t believe my new thoughts.” This may occur if you have not addressed all of your anxiety-provoking thoughts. Go back and look at the original thought, and try to think whether there are any related thoughts that still cause anxiety. Also, you don’t have to believe your new thoughts immediately, as part of the exercise is to disprove your old, unhelpful thoughts. Try to act as if your new thoughts are true, and see what happens.

Coping statements

There are times when you may need some shortcuts to coping with feelings. Here are a few:

1.  Have a cue that makes you turn a potentially bad feeling into a coping one. For example, if you feel butterflies in the stomach, instead of saying “Oh no, I’m really getting anxious and upset” say “I know what these feelings mean. They mean I’m getting anxious. That means: slow down, regulate my breathing and do some isometric exercises.”

2.  Develop some personal self-statements, such as “Take this step by step”, “Don’t jump to conclusions” or “This fear can’t hurt me – I can tolerate it”. Make these statements up yourself so that they are relevant to your life.

3.  Don’t always put yourself down. Don’t say, “A baby should be able to do this”, “I’m hopeless” or “I’ll never get the hang of this”. As long as you say these sorts of things to yourself you make them come true (but only for as long as you say them, fortunately).

4.  Praise yourself. Say things like “That was good” or “I felt I was having a bad day this morning, but I still managed to get on the crowded train.” Remember the most important source of praise is from inside you, because you know yourself best and what your actions mean to you.

Putting it all together

Having discussed previously how unhelpful thoughts can be identified, challenged, and disputed we shall move on to see how you can use this to challenge your phobia. It is not enough to think helpful thoughts when there is nothing to be afraid of. You must be able to think helpful thoughts when you confront what you fear. In other words, it is not enough to engage in a mental exercise of weighing up the evidence, you must actively go out and seek evidence for and against the belief. You now have three skills that you have been taught and now need to practice. You need to use the exposure tasks, working up the fear stepladder, to reduce your fear of the phobic situations. Relaxation will help to reduce your general levels of tension before the exposure task and the isometric exercises will regulate tension during exposure. The slow breathing will finally help you to keep control of any anxiety that you may experience during the exposure, and by thinking straight you will be able to wait in the feared situation until the anxiety levels have decreased significantly to levels that are mild to moderate.

Over the next few weeks you will need to keep a record of your daily activities. This will help you to remember what you did, the steps forward, and the difficulties. To help in planning, below is a schedule that you can complete. On the first page, you can plan what you are going to do. Remember that your aim should be to attempt a graded exposure exercise and a relaxation session every day. Following the plan is room for you to write any comments that you may have about the activities. On the pages after the plan are tables for you to write in the unhelpful thoughts and level of fear that occurs during your graded exposure exercises. You can then write down helpful thoughts so that you will be better able to manage your fear.

Fear and fainting

Blood and injury phobias are relatively common, being found in about 4% of people. People with blood and injury phobias can be divided into two overlapping groups. On the one hand, there are those who experience fear when faced with blood or injury. On the other hand, there are those who faint when faced with blood or injury. Therefore, some people experience only fear, some only fainting, and others both.

The skills that have been covered in the Patient Treatment Manual so far have addressed fear and how to cope with it. These same skills are just as applicable for dealing with blood and injury fears as for any other phobia: you must continue to expose yourself to the distressing situations and wait for the discomfort to decrease. What has not been covered is how to control fainting when in the presence of blood or injury. This requires additional skills, but, before describing these, we shall consider why the fainting occurs.

Among individuals with blood and injury phobias, fainting is extremely common and is associated with a characteristic pattern of physiological responding. The particular pattern of responding has been called “vasovagal syncope”. The vasovagal syncope involves a two-stage process. In the first stage, an increase in heart rate and blood pressure occurs. This happens because there is an increase in arousal caused by the sympathetic part of the involuntary nervous system. It is the sympathetic branch of the involuntary nervous system that is responsible for the flight or fight response and activation of it will trigger the fear reactions described in Section 1 of the Manual. However, the involuntary nervous system has another branch that opposes the sympathetic branch. This so-called parasym-pathetic branch of the involuntary nervous system serves to regulate the body and does the opposite to the sympathetic part of the nervous system. In people with a blood and injury phobia, this compensation is very rapid and tends to be an overcompensation. The heart slows too much and the blood pressure falls too low. Therefore the blood (obeying gravity) will run away from the brain, causing a deficiency in oxygen for the brain cells. If you do not lie down at this stage, the brain will shut down and you fall unconscious. This reaction, when you think about it, is really quite sensible because you are forced to lie down and the blood can return to your brain cells.

As you can see from this description, the fainting is beyond your control. The changes in heart rate and blood pressure are controlled by the autonomic part of the nervous system, which is not under direct conscious control. The reason why your brain responds this way is not entirely clear but some parts of the puzzle are available. It is now known that just under half the number of people with blood and injury phobias have other members of their family who faint. Interestingly, it was also found that while people who fainted were more likely to report a parent who also did, people who reported fear of blood and injury did not report that their parent did. This suggests that the fainting may be inherited but the fear is not. It has also been found that people who faint tend to be more empathic; that is, they are more able to see things from another person’s point of view. It is possibly the ability to be able to “get inside another person’s shoes” that leads to people fainting when they witness, think, or hear about injuries.

Hearing these facts about fainting may lead you to feel frustrated. “If I have inherited it from my family and it is controlled by the nonconscious part of my brain, what can I do?” The answer is that just because the fainting may be inherited and controlled unconsciously does not mean that you cannot control it. Think for a moment: can you increase your heart rate and blood pressure at will? If you run quickly up a steep flight of stairs, your heart rate and blood pressure will increase. If you sit down and do relaxation exercises, they will decrease. Thus you can engage in certain activities that can change these processes. Section 6.3 will therefore go on to describe what techniques you can do to avoid fainting. These activities are a little more practical and unobtrusive than running up stairs.

Fainting control skills

It is important to learn to control fainting because people with blood and injury fears often tend to avoid medical situations because of the possibility of fainting. You will learn two techniques that can help you to avoid fainting. The first we have already covered but a reminder is in order.

Slow breathing

People with blood and injury fears may increase their breathing rates when a needle is placed on their arm. As you will remember, overbreathing has a number of results one of which is feeling faint. You should monitor your breathing rate and check to see whether it is elevated before you start your “fear stepladder”. Also check to see whether it is subtly increasing during exposure. In order to counter these experiences, you will need to use your hyperventilation control exercise.

The most important point to remember is that slow breathing will be of most use early in the physical reaction.

As the heart rate increases and the body prepares itself for danger, slow breathing will help to restore the normal level of arousal to the body. However, once you are aroused you need to stop the rapid decrease in heart rate and blood pressure. For this, a different skill is needed.

Applied tension

The second technique you will need to learn and master is “applied tension”. The aim of applied tension is to counteract the drop in blood pressure so that you have control over your reactions. Essentially it aims to increase physical arousal, much the same as running up a set of stairs would do, in a manner that is appropriate to most medical settings. The steps involved require you to:

•  Tense muscles in the arms, chest, and legs simultaneously.

•  Continue to apply the tension until there is a feeling of warmth in the face (usually about 10 to 20 seconds).

•  Release the tension and relax to starting level (without becoming too relaxed remember the technique is applied tension).

•  Wait 20 seconds.

•  Repeat the whole cycle a minimum of five times and always until the feeling of faintness has significantly decreased to manageable levels.

•  You will need to be able to identify your particular signals of fainting, which may include light-headedness or dizzy feelings.

This technique will need to be incorporated into your exposure tasks and combined with relaxation and slow breathing. As you develop your skill with breathing control and applied tension, you will become able to discriminate when the best time is to apply the slow breathing and the applied tension. The rule of thumb is that you begin with slow breathing to keep you relaxed as you move into the situation but then switch (still keeping an eye on your breathing rate) as you approach the blood or injury stimulus or when you notice the very first signs of faintness. The first signs are different for different people, but some commonly reported ones include dizziness, a cold sweat (across the forehead), a queasy feeling in the stomach, or nausea.

A commonly reported problem with applied tension is headaches. This indicates that you are applying too much tension. This problem is solved by increasing the length of time between muscle tensions from 20 seconds to a time when the headaches do not occur. Also you can try to avoid tensing muscles in the face (e.g., the jaw and eyebrows) that constrict and cause pressure to be applied to the head. Another problem is difficulty in identifying the muscles to tense and how to make them taut. Looking back at the isometric exercises for some ideas may be helpful. Many people find it useful to imagine they are a bodybuilder and think about how a bodybuilder would tense those muscles. One other problem is that tensing muscles can make receiving injections more painful. You will need to be able to relax the muscle group in which the injection will be given (typically the non-dominant arm) while maintaining tension in your other arm, torso, and legs.

This Manual is both a guide to treatment and a workbook for people who suffer from social phobia. During treatment, it is a workbook in which individuals can record their own experience of social phobia, together with the additional advice for their particular case given by their clinician. After treatment has concluded, this Manual can serve as a self-help resource when challenges or difficulties are faced.

Social phobia is a treatable condition. This Manual takes you step by step through a cognitive behavioral program. By working through it you will learn about the nature of social phobia, anxiety, and panic. Not only will you learn skills that will enable you to develop more control over your anxiety, you will also learn to worry less about appearing anxious and about being evaluated.

To learn these skills will require time and effort. To be effective, they will need to be practiced regularly. The more you put in, the more you will get out of the program. However, you are unlikely to be completely cured by the time you reach the last page, or even the last session of your treatment program. To get lasting improvement you need to be prepared to go on working. Research around the world has demonstrated the possibility of long-term achievements, as well as continued improvement.

What is social phobia?

Social phobia is a fear of being scrutinized, evaluated, or the center of attention. However, the real underlying fear is of being evaluated negatively. People with social phobia commonly fear that others will find fault with them or think that they are incompetent or strange. They may worry that this will occur during social interaction with one or more other people, when they are doing something under observation or even in situations where there is just the chance that they may attract attention. Sometimes, this may involve simply being with others.

The person with social phobia believes that being judged negatively may result from being seen to be anxious (e.g., blushing, sweating, trembling, or shaking), from saying or doing something they think is embarrassing, appearing awkward or making a mistake. Some also believe that there is some aspect of their appearance or behavior that may attract criticism.

Feared situations include public speaking (including tutorials and presentations), parties, writing or signing one’s name under scrutiny, standing in a line, using the phone with others around, eating or drinking in public, using public toilets, and public transportation. Some individuals fear that embarrassing bodily functions will occur inappropriately, e.g., losing control of bowel or bladder, passing flatus, vomiting, stomach noises.

The main fears in social phobia may relate more to performance situations or more to social interaction. There may be great anxiety about looking anxious or even having a panic attack in these situations. The individual may believe that this anxiety will be obvious and will lead others to evaluate them negatively. When social interaction is the main fear, the individual often worries about having nothing to say, being boring, saying something inappropriate or being judged as inadequate in some way. In any case, social situations are either endured with intense anxiety and discomfort (during which panic attacks may occur), or are avoided. Anxiety and avoidance may be linked to only one situation (circumscribed or nongeneralized social phobia), but commonly occur in many situations (generalized social phobia).

The fears in social phobia are excessive and unreasonable. While in the situation, feeling acutely anxious and convinced that things are going badly, it may not seem that the fear is unreasonable. However, most individuals with social phobia realize that their anxiety in social situations is much greater than for those who do not suffer from the disorder. Thinking about things more calmly once out of the situation it is usually possible to accept that the anxiety triggered by the actual circumstances was excessive. More about this later.

How does social phobia differ from shyness and normal social anxiety?

Many people describe themselves as shy, although there is no clear definition of what this means! Shyness with others, or increased self-consciousness, occurs in phases through childhood. It is common in the teenage years as an individual starts to think about how others might see them. For most people, this type of social anxiety decreases with age.

Some social situations continue to cause a degree of anxiety for most people. Good examples are public speaking, or arriving alone at a social gathering of unfamiliar people. Normal social anxiety is not disabling, it settles quickly during or after the event, and it does not begin weeks before the event. There is less expectation of negative evaluation. Things are different for the person with social phobia. They tend to start worrying a long way in advance, the discomfort may well get worse as they stay in the situation, and next time they may be even more worried. Afterwards they may go over and over aspects of their performance with which they were unhappy. The reasons for this will be discussed in detail in later sections. Severe shyness that causes significant avoidance of social interaction or distressing anxiety in social situations is probably social phobia.

What is avoidant personality disorder?

Individuals with avoidant personality disorder are anxious in almost all types of social interaction. They fear, and expect, not only negative evaluation, but also rejection or humiliation. There is often a sense of inferiority to others, low self-esteem, and considerable avoidance of social interaction. Interestingly, looking anxious is often not the greatest concern of those with the avoidant personality style. These individuals may be far more anxious about how they are relating to others, and fearful that in some way they will be found inadequate or worthless and be rejected. The problem has usually been present since early childhood, and involves deeply ingrained patterns of thinking. Estimates vary greatly as to how common this problem is, but at least a quarter of those with social phobia will also have the avoidant personality style. Avoidant personality styles can be helped by the social phobia program because there is so much overlap between the two disorders.

If you have an avoidant personality, you must be prepared for the fact that it will probably take some time to overcome your problems to a satisfactory degree because they have been present for so long, and to such an extent. In many cases, you will find it helpful to seek ongoing help with your problems after this program finishes. You can discuss this matter further with your therapist.

How common is social phobia?

Social phobia has been documented across a range of cultures. It is estimated that between 1.5% and 4.5% of the population have social phobia at any time. Slightly more women are affected than men. However, probably more men are affected by avoidant personality disorder. Social phobia usually starts in the teenage years and tends to be a chronic disorder that does not go away spontaneously. Studies consistently indicate that most people have suffered with social phobia for many years before they seek or find appropriate treatment.

What causes social phobia?

We still don’t know for sure what causes social phobia. It seems that the most important factor related to the development of social phobia is a genetic vulnerability to anxiety in general. This is probably largely due to greater sensitivity and reactivity of the nervous system. Some people tend to react more, often with anxiety or nervousness, when faced with any type of external event. These people seem to be more vulnerable to developing anxiety problems. There is also an increased risk of developing social phobia if a close relative has the disorder. It is unusual for social phobia to develop from a specific incident, although this may happen more often in “circumscribed” social phobia (where only one or a few situations cause anxiety). The nature of the family environment of itself does not appear to be an important causative factor in many cases. However, it is possible that aspects of the family environment might influence an underlying sensitivity or shyness in either a helpful way, to enhance confidence and make it easier to socialize, or by reinforcing these concerns.

The effect of personality

Personality refers to habitual ways of thinking about ourselves, our relationships with others and our environment, and the coping strategies we use in these situations. Individuals with social phobia tend to describe themselves as sensitive, emotional, and prone to worry. As we have seen, this does tend to run in families. People who are very sensitive to criticism, or overly concerned about creating a good impression may be more susceptible to social phobia. Some of these attitudes are learned in childhood, but genetic and temperamental factors also influence personality development in ways we do not fully understand.

Hypersensitivity, emotionality, and proneness to worry can be a handicap. You can’t radically alter your personality – but nor should you want to! There are advantages to being sensitive: sensitive individuals care about others and can empathize readily, which are valuable characteristics. We can teach people to be less sensitive but it is very hard to teach someone to be more sensitive! Those with social phobia are “people people”. What you can change about your personality is the degree to which you show various traits. This course aims to help you to learn to be less sensitive and less worried about what others think.

Treatment of social phobia

Cognitive behavior therapy has been shown to result in long-term improvement. It is based on the principle that how we feel about a situation is determined by how we think about it, and the work of Aaron Beck and Albert Ellis. These principles will be discussed in detail later in the Manual. The components of a cognitive behavioral program for social phobia include:

•  Knowledge about anxiety and social phobia.

•  Control of anxiety and panic.

•  Changing unhelpful thinking patterns.

•  Involvement in social interaction.

Drug treatments are also available in social phobia but many people will not need medication. When medication is necessary, it is still important to learn cognitive behavioral techniques for managing social phobia, since this appears to give the best long-term result. Your doctor can give you more information.

The aims of this program

What you can expect by the end of this program is for your symptoms to have shown a noticeable degree of improvement. You should have a good understanding of what is required to treat social phobia and be confident that you can continue to apply the principles you have learned with a good expectation of further success. Your therapist can discuss this with you in more detail.

Summary

Social phobia is an excessive, distressing, and often disabling fear of social situations in which a person fears they may say or do something which may lead to embarrassment, humiliation or rejection. Many types of social situations may be feared or avoided. Social phobia is common among both men and women. Cognitive behavior therapy is an effective treatment for social phobia.

The Nature of Anxiety

Anxiety-Management Strategies

Cognitive Therapy for Social Phobia

Graded Exposure

Assertiveness

Coping with setbacks and difficulties

Setbacks are inevitable. They happen to everyone. When it happens, people often become alarmed or despondent, fearing they have gone back to their very worst. The setback is often viewed as devastating because it has a lot of emotional meaning for the person who has put considerable effort into recovering. No matter how badly you feel during a setback, no-one ever seems to go all the way back to their worst level of incapacitation or to totally lose their new skills.

Setbacks often occur at times when you face additional stresses in your life, such as job, family, or money worries, or ill health, or when facing some particularly challenging situation. For most people, the apparent setback is only a passing phase. After the stressors pass, you will find it easier to get yourself out and about again. You can help this process by actively working to resolve the problems that face you so that you can once again devote your energy to facing your fears. While you feel stressed, don’t let your program go completely, but try to maintain the gains you have already made. However, even if you slip back a little, it is not a catastrophe: you moved forward before and you can do it again. Ups and downs in the recovery process are the rule rather than the exception. A typical pattern is illustrated in the diagram overleaf. Coping successfully with setbacks actually builds your confidence, and you are less likely to stumble over the same problem in the future.

Prolonged setbacks

Prolonged setbacks or difficulties in making progress are generally the consequence of not practicing your new skills! You will not get better just by thinking about it and hoping your anxiety will just go away. If you are experiencing difficulties, carefully read your Manual again (from the beginning) and follow the recommendations. Go back to basics with your anxiety-management strategies: practice the hyperventilation control and relaxation exercises – every day. Review your cognitive challenging skills and check for “cognitive errors”. Be alert for “shoulds” and unhelpful expectations of yourself. Be honest about avoidances and safety behaviors: these stop you from really confronting and therefore mastering your anxiety. Set yourself realistic goals of graded exposure and give yourself plenty of support and encouragement.

Checklist

I am doing the following:

Using hyperventilation control at the first sign of anxiety.

Exercising four times per week.

Getting up at the same time every day.

Keeping my nicotine, caffeine and alcohol intake nil or low.

Abstaining from illicit drugs.

Regularly writing down anxious thoughts and challenging them.

Working to eliminate cognitive distortions and “shoulds”.

Setting realistic goals.

Giving myself praise and encouragement.

Confronting feared situations daily.

Using graded exposure.

Remaining alert for subtle avoidance and safety behaviors.

Working to eliminate avoidance.

Really confronting my fears.

Learn to be your own best friend

Many sufferers of social phobia have low self-esteem. They are highly critical of themselves when they fail to meet their own expectations. It is essential to learn how to give yourself support and encouragement – it means more when it comes from within. Be kind to yourself when you don’t do as well as you’d have liked -how would you respond to someone else, or, especially, a child? Congratulate yourself on your effort as well as your successes. Consider setting yourself small rewards for meeting goals. Set your goals at realistic levels and learn to appreciate small successes. It may be only a small step, but if you keep taking small steps you will eventually reach your goals.

Mastering anxiety is going to take time. It is challenging and tiring and difficult, and no-one else really knows what it’s like. Learn to be kind to yourself and you’ll not only last the distance, but you’ll find it a whole lot easier to challenge unhelpful beliefs about how much the opinions of others really need to matter.

If you are still having trouble, seek advice from your therapist.

Summary

Setbacks are inevitable. They can be a learning experience and result in greater confidence. Don’t panic, but go back to basics – revise the work you have done in this Manual. The techniques work, but only if you use them. Get help if you need it. Learn to be kind to yourself.

Anxiety is part of an automatic response to threat that all animals share. It is known as the flight or fight response. A series of physiological changes is triggered that is designed to give the animal extra strength and speed in order to successfully escape from the threat, or, if trapped, to fight it.

Changes triggered by the flight or fight response

•   Increase in alertness.

•   Increase in heart rate and blood pressure, to pump extra blood to the muscles.

•  Extra blood goes to the skin and sweating increases to help to cool the body.

•  Muscles tense ready for action.

•   Blood is diverted away from the gastrointestinal system and digestion of recent meals slows down. Any waste products already in the bowel are hurried along.

•  Saliva production decreases, causing a dry mouth.

•   Breathing rate speeds up. Nostrils and air passages in lungs open wider to get in air more quickly.

•   Liver releases sugar to provide quick energy.

•  Sphincter muscles contract to close the openings of the bowel and bladder.

This response is produced by the release of various stress hormones, most notably epinephrine (adrenaline), which occurs instantaneously once a threat is perceived. It is designed as an immediate and brief response. Once out of danger the hormones that were released are rapidly metabolized (destroyed) by the body and the flight or fight response ceases. Think about the last time you narrowly avoided a collision on the road … what happened once you knew you were safe? You probably felt pretty shaky for 10 minutes or so, but then almost back to normal.

In animals the flight or fight response is largely instinctual. Humans may also have instinctive fears, e.g., of snakes, heights, or storms. However, animals and humans also learn to fear situations. When an individual feels threatened they will become anxious. This anxiety often becomes linked in the individual’s mind with the situation in which it occurred.

The flight or fight response is designed to help us to escape from physically threatening situations. The key point, though, is that it is triggered by perceived threat. Whilst this threat maybe physical (e.g., a near-miss traffic accident or being followed down a dark alley), it can also be more abstract in nature. We may become anxious when we feel the threat of a loss of some type. In social phobia, the threat is the loss of the approval or acceptance of others, or of the individual’s social standing. The actual likelihood of being disapproved of or rejected may be small. It is the individual’s perception of being under threat of negative evaluation that is the key. To some extent the strength of the anxiety response will relate to the perceived likelihood of the consequences that are felt to threaten the individual, and how catastrophic the individual believes these consequences would be.

An anxiety disorder arises when the flight or fight response is being repeatedly triggered at too low a threshold, or by situations that do not actually represent a threat to survival. The flight or fight response occurs as an automatic reaction to perceived threat. It cannot be eliminated. What needs to change is the individual’s tendency to interpret situations as threatening.

What is a panic attack?

Panic means a sudden spell or attack of feeling frightened, anxious or very uneasy. Typically symptoms come on suddenly and escalate in severity over the next 5 to 10 minutes. A panic attack is essentially a severe flight or fight reaction. During a panic attack the following symptoms may occur:

•  Feeling short of breath

•  Pounding heart

•  Sweating

•  Trembling or shaking

•  Blushing

•  Trembling or croaking voice

•  Nausea or a fear of vomiting

•  Dizziness or light-headedness

•  Tingling fingers or feet

•  Tightness or pain in the chest

•  A choking or smothering feeling

•  Hot or cold flushes

•  Feelings of unreality

•  A feeling that you cannot get your thoughts together or speak

•  An urge to flee

•  A fear that you might die

•  A fear that you might act in a crazy way

Any or all of these symptoms may occur. Not everyone with social phobia gets panic attacks. Individuals tend to have their own pattern of symptoms in response to anxiety and find some symptoms more distressing or unpleasant than others. In social phobia, blushing, sweating and shaking are often seen as the most troubling symptoms.

When anxiety becomes severe, most people try to escape the situation in order to prevent the feared consequences (the “flight” aspect of the flight or fight response). In other words, if an individual fears that their anxiety will cause them to look odd or say something inappropriate, they will try to escape the situation before this can happen. Once out of the situation, the anxiety usually settles quickly.

Most people rapidly learn to predict the situations in which the anxiety or panic is likely to occur. Some people quickly begin to avoid such situations altogether. Anticipatory anxiety can be a severe problem. Sometimes an individual really intends to go through with a social outing or performance situation but avoids it at the last minute because their anxiety has escalated to the point where they feel totally unable to manage the situation. Avoiding situations that cause anxiety may seem the only alternative to the negative evaluation that it is feared may result if social performance is adversely affected by anxiety.

But what if your performance wasn’t as badly affected as you thought? You would lose the opportunity to learn this. Your anxiety would probably start spreading to other types of social situation. Meanwhile, your level of confidence and self-esteem would drop as you found yourself more and more restricted in what you felt you could cope with. Hence, you would become even more anxious about the situations you feared. When social phobia has been present for a long time the individual often structures his or her life around the need to avoid certain situations or expends considerable effort and anxiety planning what to do in case a panic should occur.

This program will teach you how to control your anxiety and panic and how to cope with situations in which anxiety is likely to occur.

The role of hyperventilation

We now turn our attention to one particular aspect of the flight or fight response, namely the increase in rate of respiration, or overbreathing.

Efficient control of the body’s energy reactions depends on the maintenance of a specific balance between oxygen and carbon dioxide. This balance can be maintained through an appropriate rate and depth of breathing. The flight or fight response triggers an increase in the rate of breathing in preparation for taking flight. When this response is triggered by a social situation, you are unlikely to respond by running away – at least, not literally! The increase in oxygen intake is not matched by an increase in carbon dioxide production and an imbalance results.

Hyperventilation is defined as a rate and depth of breathing that is too much for the body’s needs at a particular point in time. The imbalance that results can cause many physical symptoms, including:

•  Dizziness

•  Light-headedness

•  Confusion

•  Breathlessness

•  Blurred vision

•  Feelings of unreality

•  Numbness and tingling in the extremities

•  Cold, clammy hands

•  Stiffness in the muscles (including the muscles of the chest, which can lead to a sensation of chest pain or tightness)

Hyperventilation also causes a heightened sense of anxiety, which in turn makes it increasingly difficult to think objectively. It may also be a factor in the experience of constant anxiety and edginess that some people describe.

You can demonstrate for yourself how an increase in breathing can affect the way you feel by deliberately overbreathing until you experience symptoms of overbreathing such as feeling dizzy and light-headed. Note that symptoms rapidly settle once you allow your breathing to return to normal.

Recognizing hyperventilation

One way to determine whether you are overbreathing is to count the number of breaths you take in a minute.

Exercise: Try monitoring your breathing rate now

For one minute (timed), count one breath in and out as 1, the next breath in and out as 2, and so on. It may be difficult at first, but don’t try to change your breathing rate.

If your rate was over 12 breaths per minute then you are probably hyperventilating.

What other factors contribute to anxiety?

Many individuals report an almost constant sense of anxiety, edginess or dread.

There can be several reasons for this. One is chronic overbreathing as mentioned above. But many lifestyle factors also contribute to high levels of tension and anxiety.

Consider the following:

•  Are you feeling stressed or worried about something? Are there situations in your life that are causing chronic unhappiness or anxiety? Can anything be done to improve the situation? If you don’t know where to start, talk to your therapist about a structured problem solving approach.

•  Are you smoking too much or drinking too much tea or coffee? Tobacco, tea, and coffee are all stimulants that increase your basic level of tension or arousal and accelerate the flight or fight response. Some individuals are particularly sensitive to caffeine.

•  Are you drinking too much alcohol? Although alcohol has immediate anxiety-relieving properties that can make it seem attractive, when consumed in excess it has toxic effects on many organs, including the liver, heart, stomach, nerves and brain. Under the influence of alcohol you won’t be yourself. You also won’t be learning anything that will help you manage better in the future or to cope in situations where you can’t drink. You will also tend to feel even more sensitive and prone to anxiety “the day after”.

•  Are you using marijuana? Many people believe that marijuana helps them relax. However, many also find that after the acute relaxation stage they find themselves feeling more sensitive than usual to others, and hence their anxiety levels rise. Again, you’re not yourself, and you’re not learning anything.

•  Are you getting insufficient sleep? Excessive tiredness can reduce your coping reserves and predispose you to anxiety.

•  Do you have trouble being assertive? Many people with social phobia have trouble getting their own needs met. Many have difficulty saying “No” to the requests and demands of others. This may leave the person feeling stressed and out of time for their own needs as well as resentful towards others for making these demands. Learning to be assertive will help to reduce your tension. This topic will be looked at in more detail later in the program.

•  Are you overly conscientious, working too hard or too fast, or trying to be perfect? You will achieve more by staying calm and working at a reasonable pace. Have fair and reasonable expectations of yourself.

•  Are you getting regular exercise? Exercise helps anxiety in several ways. In addition to its well-known physical benefits it also leads to better-quality sleep so you feel more rested. It improves mood and outlook. It also helps to reduce levels of tension and anxiety. You probably need to exercise at least every other day in sessions lasting 30 minutes or more in order to get most benefit.

It is impossible to eliminate stress altogether. Rather, the aim is to develop the best possible coping strategies and the confidence to use them in order to minimize the amount of stress and anxiety triggered by demanding situations. It is also important to reduce hypersensitivity and the tendency to misinterpret situations as more threatening than they really are.

Anxiety reduction will be most successful when an attempt is made to address all sources of stress and anxiety and introduce effective anxiety management strategies as a way of life.

The relationship of anxiety to performance

People who fear the consequences of anxiety become afraid of even small amounts of anxiety in case it escalates out of control. But anxiety can be useful. In the event of real danger the flight or fight response may save your life one day. The relationship between anxiety and performance is surprising. What would you predict it would be?

When this was first studied in a research experiment the researchers did not expect the results they found. In fact, the relationship between anxiety and performance was found to be as shown in the diagram.

Several important points arise from studying this diagram. First, it can be seen that an average performance can be obtained at two different levels of anxiety. A person who is reasonably calm will perform averagely well, as will a person who is very tense. However, should extra demands be placed on the reasonably calm person, there is a wide margin for anxiety to increase without performance deteriorating. On the other hand, for the person who is already very tense, a further increase in anxiety is likely to result in deterioration of performance. But note that such deterioration does not occur until very high anxiety levels have been reached.

Ideally, then, we should aim for calmness as we go about our daily business. In this way, we will have larger coping reserves for times when we have to face stressful situations. Regular practice of a relaxation technique can help to achieve this.

Remember, however, that without some increase in tension or anxiety you will not do your best. Note, from the diagram, that the best performances come at higher levels of anxiety than those that produce average performances. The increase in mental alertness and ability to focus that anxiety produces is actually essential to achieving our best level of performance. You can probably think back to some situations in your own life where this was the case… Would you have done so well in a certain interview or in examination situations, for example, if you had not been more anxious than usual? This program does not aim to eliminate anxiety from your life. Rather, the aim is to learn to control unwarranted anxiety, and not get worried about appropriate and reasonable levels of anxiety.

Summary

Anxiety results when the flight or fight response is triggered by feeling threatened in some way. In social phobia, anxiety results when the fear of being negatively evaluated in a social situation triggers the flight or fight response. Hyperventilation occurring as part of the response can make symptoms worse but responds readily to controlled breathing. Moderate levels of anxiety actually enhance performance. It is probably best to aim to keep everyday levels of anxiety low by paying attention to lifestyle factors so that when faced with a demanding situation the resulting increase in anxiety will not be overwhelming.

By paying attention to these factors you can help to reduce your level of arousal - the degree of tension and alertness you feel – when this is excessive for your needs and your health.

Specific anxiety management strategies include:

•  Hyperventilation control.

•  Relaxation training.

Slow-breathing technique

It is known that even a slightly elevated rate or depth of breathing beyond what is required in the circumstances can contribute to feelings of anxiety. Many individuals do not have obvious hyperventilation, and currently it is not thought to play a major role in the anxiety experienced by most people with social phobia. It is more likely to be of importance if you noted an elevated breathing rate in the exercise above, or if you do actually suffer panic attacks.

The slow-breathing technique can be used as the foundation of your anxiety-management strategies, helping to calm you down so that you can think more clearly and apply the “straight thinking” strategies you will learn in the next part of the program. It can also be a useful strategy to shift your focus away from your anxious concerns, and many people over the years have found the technique helpful for these reasons. The best approach is to use the technique at the first signs of anxiety.

The slow-breathing technique will give you a breathing rate of 10 breaths per minute. It is best to use a watch in practice sessions initially to make sure that you get the feel for the right timing – when we feel anxious there is a tendency for us to feel a bit “speedy” and want to do everything too fast! Concentrate on making your breaths smooth and light. Breathe through your nose to help limit the amount of air you take in and thus prevent overbreathing. It should feel as though the air is just drifting lightly past your nostrils. Relax your stomach muscles. The breathing movement is so light that it is unnoticeable from normal breathing to anyone who may be watching. Ready? Now do the following:

Slow-breathing technique

1.  Take a medium sized breath in, hold it and count to 6 (timing 6 seconds with your watch).

2.  When you get to 6, think “relax” and breathe out. Try and feel as though you are releasing tension as you breathe out.

3.  Next breathe in for 3 seconds and out for 3 seconds, in a smooth and light way.

4.  At the end of each minute (after 10 breaths) hold your breath again for 6 seconds, think “relax”, breathe out, and then continue breathing in the 6-second cycle for another minute.

Continue breathing in this way until you are feeling calmer. Sometimes, you will notice that symptoms of anxiety return after a short while. That’s okay, just do your controlled breathing again for as long as it takes to settle. It is probably because you are still having anxious thoughts about the situation. As you develop your straight-thinking skills this should become less of a problem.

If you find it hard to do this in the anxiety-provoking situation, consider the possibility of taking “time out” to calm yourself. For example, at a party you might slip out to a quiet spot for a short time and do your breathing, then return to the party. With practice, you will find it easier to control breathing while you are actually in the situation.

Daily record of breathing rate

Choose four convenient times spread through the day to monitor your breathing and do the practice. Wait for 20 minutes or so after any strenuous activity. Time yourself for a minute before you do your practice, without trying to modify your breathing rate. Then do your practice. After your practice, time your breathing rate for a minute, again without consciously trying to change your breathing. Your therapist will be able to use your records to monitor your progress. You may also learn more about your own patterns of anxiety and overbreathing from studying your chart.

Some people worry about the fact that counting their breathing rate makes them too conscious of it, and alters it somehow. This is probably true to a small extent, but not enough to really matter.

Problems with breathing control: troubleshooting

A small number of individuals report that they get symptoms of anxiety when they first start breathing retraining. This may happen as you become more aware of times when you are anxious as part of this program, which requires you to confront your anxiety rather than trying to avoid it. Most people find that if they persevere with the breathing practice it does begin to have a calming influence.

Other people report that when they first begin to practice this slow-breathing technique it feels unnatural. This is only to be expected if you have been habitually breathing at a higher rate, too deeply or too shallowly, or in some irregular fashion. As you practice the slow-breathing technique it will come to feel not only more natural, but also more comfortable.

Don’t become too focused on your breathing. It’s just one of the building blocks in your anxiety-management program. Do your practices, use it when you’re anxious, and forget about it the rest of the time!

Relaxation training – progressive muscular relaxation

Progressive muscular relaxation is a specific technique for releasing tension from muscles. It is best seen as a skill which requires practice to master. The potential benefits include reduced feelings of overall tension, as well as the ability to better control acute rises in anxiety, especially with the technique of “applied relaxation”. Applied relaxation is a follow-on skill to progressive muscular relaxation, which aims to provide a portable strategy that can be used in any situation to quickly reduce feelings of tension and anxiety. It has been shown to be useful in a number of anxiety disorders.  It may also be possible to purchase audio tapes containing instructions for progressive muscular relaxation, and this is often a good way to start learning the technique.

Summary

The slow-breathing technique and the skill of applied relaxation can help to reduce acute symptoms of anxiety. Progressive muscular relaxation can help to reduce the overall level of arousal with frequent practice. Other strategies to help to reduce arousal levels include regular exercise, sufficient sleep, and reducing sources of stress and anxiety in the work and home environment.

People with social phobia experience anxiety in the company of others. However, there are marked variations between individuals in terms of the degree of anxiety that is experienced, and the number and types of situations that provoke anxiety. In order to overcome social phobia it is important to develop an understanding of the general sorts of underlying thoughts and anxieties in this condition, and your specific thoughts and fears in particular. It will then become clearer to you why you are anxious in particular situations, and how you can begin to overcome your fears. We refer to these underlying thoughts as “cognitions”, and learning to deal with them constructively is the “cognitive” part of the program, often referred to as “cognitive restructuring”.

Cognitive therapy: the importance of the way you think

It may seem surprising, but no outside situation or event can directly cause feelings of distress. What does cause us to become upset? The answer is: it’s our point of view!

Consider the following example. Three people are waiting at a bus stop. They see the bus approaching, hail the bus, and the bus just drives straight past without stopping. The first person in line begins to jump up and down waving her fists in the air and shouting: she seems angry. The second person in line bursts into tears, appearing distressed. The third person in line begins to laugh very heartily, seeming amused. Now, the same thing has happened to all of them, yet there were three different reactions. Clearly, it is not the event that caused the reactions. So what was it? To know why each person reacted as they did, we have to know what they were thinking. It turns out that the first person was thinking to herself, “How dare the driver go right past! I’m going to be late for an important meeting.” Hence, she feels angry. The second person woke up feeling a bit blue that morning. When the bus goes past he thinks, “Oh no. Nothing is going to go right today, I feel so miserable.” The third person thinks, “Hooray! The next bus is not for half an hour. I have a completely legitimate excuse to be late. I think I’ll go have a cup of coffee.”

A basic principle of cognitive therapy is that it is the interpretations we make of situations that determine our emotional response. These interpretations are influenced by our previous experiences of similar situations and by aspects of personality, including our general sensitivity, our feelings about ourselves and our relationships with others, and our worldview. Of course, some events may realistically be unpleasant, or situations uncomfortable, but they are rarely, of themselves, capable of causing us to feel extreme levels of anxiety, fear, depression, worthlessness, inferiority, anger, etc.

Hence, if you find yourself frequently feeling very anxious, angry or unhappy, it is likely that you may be making unhelpful or unrealistic interpretations of events or situations in which you find yourself. People tend to develop patterns of thinking about particular types of situation. One of the aims of cognitive therapy is to examine the ways in which we are thinking about ourselves and our world. If we identify some habitual unhelpful or unrealistic patterns of thinking about certain types of situations, the next goal is to identify more helpful ways of thinking about such situations. The ultimate goal is to create new habits of appraising situations that make our lives easier and happier. This will take a great deal of active practice.

Specific anxieties in social phobia

The predominant emotion in social phobia is anxiety. As we have seen, anxiety occurs in response to a perceived threat through activation of the flight or fight response. While this response developed in animals as an emergency response to physical danger, in humans it can also be triggered by the threat of some type of loss. It maybe that a fear of losing our social standing with others may trigger the anxiety of social phobia. It may also relate to some deep-seated need to be accepted by others that could date from prehistoric times when an individual’s survival in a harsh and dangerous environment depended on acceptance by the tribe. In any case, it is now clear that the anxiety in social phobia is triggered by a fear of being negatively evaluated. Underlying this is an excessive concern about the opinions of others.

You can compare your degree of concern about what others may think of you with the general population by completing the following questionnaire, developed by Watson and Friend.

FNE scales

In each case indicate whether or not the statement applies to you by writing either T for true or F for false. Please be sure to answer all the statements.

1.	I rarely worry about seeming foolish to others.
2.	I worry about what people will think of me even when I know it doesn’t make any difference
3.	I become tense and jittery if I know someone is sizing me up.
4.	I am unconcerned even if I know people are forming an unfavorable impression of me.
5.	I feel very upset when I commit some social error.
6.	The opinions that important people have of me cause me little concern.
7.	I am often afraid that I may look ridiculous or make a fool of myself.
8.	I react very little when other people disapprove of me.
9.	I am frequently afraid of other people noticing my shortcomings.
10.	The disapproval of others would have little effect on me.
11.	If someone is evaluating me, I tend to expect the worst.
12.	I rarely worry about what kind of impression I am making on someone.
13.	I am afraid that others will not approve of me.
14.	I am afraid that people will find fault with me.
15.	Other people’s opinions of me do not bother me.
16.	I am not necessarily upset if I do not please someone.
17.	When I am talking to someone, I worry about what they may be thinking about me.
18.	I feel that you cannot help making social errors sometimes, so why worry about it.
19.	I am usually worried about what kind of impression I make.
20.	I worry a lot about what my superiors think of me.
21.	If I know someone is judging me, it has little effect on me.
22.	I worry that others will think I am not worthwhile.
23.	I worry very little about what others may think of me.
24.	Sometimes I think I am too concerned with what other people think of me.
25.	I often worry that I will say or do the wrong things.
26.	I am often indifferent to the opinion others have of me.
27.	I am usually confident that others will have a favorable impression of me.
28.	I often worry that people who are important to me will not think very much of me.
29.	I brood about the opinions my friends have about me.
30.	I become tense and jittery if I know I am being judged by my superiors.

Score this questionnaire by giving yourself one point if you said “True” to numbers 2, 3, 5, 7, 9, 11, 13, 14, 17, 19, 20, 22, 24, 25, 28, 29, 30. Score one point if you said “False” to 1, 4, 6, 8, 10, 12, 15, 16, 18, 21, 23, 26, 27. Your score gives an indication of how concerned you are to get the approval of others in your life. Approximately 75% of people in the general population score less than 19 on this scale. Scores higher than this indicate a level of over concern about others’ opinions of you that is likely to cause distress – and result in anxiety in social situations.

That’s not to say that others don’t get any social anxiety. They do. Everyone would like to think that they are accepted and approved of by others they come in contact with. We all know the feeling of embarrassment when we make a silly mistake, say something inappropriate or draw attention to ourselves in an unflattering, and usually accidental, way. However, there are several differences between normal social anxiety and social phobia.

Normal social anxiety	Social phobia
Moderate desire for approval	Strong desire or perceived need for approval
Expectation of approval	Expectation of negataive evaluation
Reasonable tolerance for disapproval	Extremely distressed by disapproval
Easily forgets about social mistakes	Dwells on social mistakes, very upset by them
When in doubt interprets response as positive	When in doubt interprets reaction as critical

So, it is the fear of negative evaluation that is the core of the problem, but it is compounded by unrealistic beliefs about:

•  How bad you think negative evaluation is, and what you believe the consequences will be for you.

•  How likely you think it is that you will be evaluated negatively.

This explains why some people who show the apparent signs of anxiety that worry you – who blush or tremble, sweat or shake, appear lost for words or stumble over what they are saying – do «of appear to worry about it. Indeed, many of the people we have treated in the past have commented that they have encountered people who did what they themselves feared without worrying about it, e.g., the person who shook when writing, yet seemed unconcerned, and certainly had not developed a fear of writing. Furthermore, most of our program participants report that they do not think any less of the person for showing these “embarrassing” behaviors. Nor do they feel that other observers at the time were critical of the person. It often seems that individuals with social phobia have one set of “rules” or standards for themselves – a very harsh and strict set – that they don’t apply to others in their lives. This is despite the fact that they expect others to apply these rules to them.

Sometimes, though, people with social phobia apply the same unreasonable standards they have for themselves to everyone. Thus you may find yourself feeling sorry for someone who looks anxious or makes a mistake, or you may even judge them critically. It can come as a surprise to learn that others don’t care nearly as much as you do about what others think of them, and probably wouldn’t be overconcerned even if they knew you were critical of them! (But don’t worry, they can’t read your mind!) The range of behavior that is seen as acceptable and normal in social situations is almost certainly broader than you currently believe.

Common personal beliefs in social phobia	Common beliefs about what others think
“I have to appear competent!”	“What a fool.”
“That person seems inept or silly.”	“I must be entertaining or I’ll be seen as a failure.”
“If they see my anxiety, they will think me weak.”	“What’s wrong with them?”
“If I have nothing to say it will be a catastrophe.”	“She seems a bit odd.”
“They will start to dislike me.”	“He can’t control himself.”

How does all this tie together with the material we have covered in previous sections, including your individual symptoms of anxiety and your own experience of what situations seem to trigger your symptoms? The diagram opposite is one model of social phobia that links all these elements.

As part of this program, we are going to examine the way you think about yourself and others. It is likely that you have some unrealistic and therefore unhelpful beliefs, and we now know that these are especially likely to revolve around the theme of negative evaluation from others. The aim of the program will be to reshape these views; to make them realistic and helpful to you in your daily life. We call this “cognitive restructuring” – or learning how to think realistically. Remember, however, that we are not aiming to eliminate all anxiety from your life, since there are times when such a reaction is perfectly reasonable, and helpful. Rather, we are aiming to reduce as much as possible unnecessary or extreme degrees of anxiety. We are also aiming to help you to learn to feel more comfortable with normal social anxiety.

The following sections will take you through a step-by-step, practical approach to making this happen.

The ABCs of realistic thinking

The following boxes summarize what has been discussed previously.

A		С
The Activating event or Action	is presumed to lead to	The Consequences: your feelings and behavior
The bus not stopping for you	is presumed to lead to	feeling angry, depressed, anxious or happy

But thoughts intervene between A and С and thus the true association is:

A The Activating event or Action	leads to	В Your Beliefs, thoughts or interpretations	which results in	С The Consequences: your feelings and behavior
The bus not stopping for you	leads to	“I’ll he late for an important meeting” or “Nothing goes right for me” or “This is a good thing to happen”	which results in	Feeling angry, or depressed or happy

If you habitually tend to expect the worst, overreact when things don’t go well, and worry too much about what others think, you will start to feel better if you can change these patterns!

Cognitive restructuring: changing the way you think

This will take some practice. It is best approached in a series of steps.

Changing the way you think

1.  Learning to identify the thoughts that go through your head in response to events, and the interpretations you make of events and situations.

2.  Learning how to look at each of these thoughts objectively, and decide whether they represent reasonable assessments of the situation (challenge them).

3.  Restating any unrealistic or unhelpful thoughts in a way that better reflects the reality of the situation and is more helpful to you.

4.  Putting the more helpful beliefs into practice by basing your behavior on them.

Step 1: Identify your thoughts

It is not easy at first to determine what you are thinking about any given situation. One reason for this is that many of our thoughts occur almost automatically in response to frequently encountered situations. For this reason they are sometimes referred to as “automatic” thoughts. Anxious individuals also develop habitual ways of thinking about the situations that worry them.

The following features are characteristic of habitual unrealistic thoughts. They are:

Automatic: They just pop into your head without any effort on your part.

Distorted: They do not fit all of the facts.

Unhelpful: They keep you anxious, make it difficult to change, and stop you from getting what you want out of life. Involuntary: You do not choose to have them, and they can be very difficult to switch off.

Our appraisals of events and situations are made at lightning speed, and this is another reason why we are usually unaware of them and why, initially, they can be difficult to track down. But many people using these methods have demonstrated that it can be done. With sufficient practice it will begin to come naturally to you.

One way to get started is to use any feelings of anxiety, fear, or discomfort and work backwards. That is, if you feel uncomfortable, then there must be some underlying thought that caused the feeling. In any situation or interaction in which you find yourself unhappy with your feelings or actions, ask yourself:

•  How do I feel?

•  What has been happening recently?

•  What do I think about myself?

•  What do I think about the other person?

•  What do I think about the situation?

To help you determine what you were thinking, you can also try asking yourself, “What could I just hear?” or “What might I have been worrying about?”. With time, you will probably find that you have a small collection of particularly troublesome thoughts that occur in many situations. Once you know about these, you can have a high index of suspicion that they are also causing trouble in your current situation, and be sure to listen for them.

To practice this first step, think about a recent situation where you found yourself feeling more anxious or upset than you think was reasonable. In your workbook write down the situation which triggered the anxiety, think back to how you felt emotionally, then see whether you can work back to identify what might have gone through your head at the time. An example looks something like this.

A Activating event or situation	В Beliefs/interpretations	С Consequences: Emotional state and Subjective units of distress rating
Running into a colleague from work in the street at the weekend	I have to say something I don’t know what to say I’ll look awkward and uncomfortable They will wonder why I am looking so strange and … They will think less of me and might tell others at work who will laugh at me	Anxiety 80 (Ducked quickly into a shop to escape)

The “Subjective units of distress” rating is a way for you to estimate how strong or unpleasant the emotions that you experienced felt to you. “Subjective units of distress” stands for Subjective Units of Distress. You estimate the strength of the emotion according to the following scale:

X	x	x	X	X
0	30	50	80	100
Nil	Mild	Moderate	Severe	Worst ever

Keeping a diary in your workbook can help you to become aware of thoughts, or cognitions, that you get in particular situations, so that you can begin to see patterns emerging in the types of thought that are causing you to feel anxious and uncomfortable. It is important to record your challenges to these cognitions in your diary or workbook, too.

Step 2: Challenge your thoughts

You will now challenge your thoughts to meet the requirements of being helpful and realistic. In this step it is important to subject the beliefs and interpretations that you identified above to critical examination. Are your interpretations logical? Are they supported by the facts? If not, then you should not accept them as a true and accurate representation of the situation. You can ask yourself the following questions to help you challenge your thoughts:

•   What is the evidence? Do the facts of the situation back up what you think, or do they contradict it? Imagine that you are presenting this evidence in a court of law: would it stand up to cross-examination? Would others probably make the same interpretation? It is important to be realistic about whether people really are looking at you, talking about you, judging what you do. You may be so anxious that you do not correctly interpret what is happening around you. Hence it takes a conscious effort to make interpretations of the environment, and your own performance, that are as objective as possible.

•   What alternative views are there? There are many different ways to look at any experience. How else could you interpret what has happened? Think of as many alternatives as you can, and review the evidence for and against them. When you consider it objectively, which alternative is most likely to be correct?

•  How likely is it? How likely is it really that what you fear will happen?

•  How much would it really matter? If the thing you fear did happen, how much would it really matter in your life? Would it really be the worst thing you could ever imagine happening? Would it have to affect the rest of your life? Could you live with it? Be objective and realistic.

• Are you making “errors” of thinking? People with social phobia typically develop habitual patterns of interpreting information about their social environment. They may distort how they see their experiences in systematic ways. We call these “cognitive errors” or “cognitive biases”. We now believe that these are very important in maintaining anxieties in social phobia. We also believe that they explain why, despite showing great courage and perseverance in “forcing” themselves to confront feared situations, many people only find things getting harder.

Some of these types of cognitive biases have been given names to help you to remember them so that you can check for them in your own thinking. Particularly prominent are “mind reading”, “fortune telling”, “mental filtering”, and “discounting”. Which of these errors can you find in your own thinking?

Cognitive “errors” All-or-none thinking

You see things in black-and-white categories. For example, because you felt uncomfortable at one stage during a dinner party you decide that the whole experience was a bad one. Or you think, “I made a mistake on that… the whole job is ruined”.

Overgeneralization

You see a single event as a never-ending pattern. For example, “I didn’t handle that meeting very well… I never cope in meetings”.

Mental filter (focusing on the negative)

You pick out a single detail and dwell on it exclusively, or make unwarranted conclusions. For example, while talking to someone, you are momentarily at a loss for words at one point. Looking back on the whole experience, you think “I had nothing to say”.

Discounting or disqualifying the positive

You reject successful experiences by insisting they don’t count for some reason or another. In this way, you can maintain a negative belief that is contradicted by your everyday experiences. For example, you manage to take the bus all the way to work, but discount it by saying “It wasn’t really full today, so it doesn’t really count”. Or you discount your achievements by saying something like “Even a baby could do that”.

Jumping to conclusions

You make a negative interpretation even though there are no definite facts that convincingly support your conclusion. For example, after not receiving a promised phone call from a friend, you conclude “They don’t really care about me”.

Mind reading

You automatically assume that you know that someone is thinking negatively about you and you don’t bother to check this out with them. “They thought I was boring … I could just tell.”

The fortune teller error

You anticipate that things will turn out badly, and you feel convinced that your prediction is an already established fact. For example, you worry about a presentation you have to give and think “I know I will make a fool of myself and they all will laugh”.

Catastrophizing

You exaggerate the importance of your mistakes or someone else’s achievements. You expect the very worst and tell yourself that things are extremely bad. “It was awful.” “I can’t stand it.”

Emotional reasoning

You assume that your negative emotions necessarily reflect the way things really are: “I feel bad, so things must be going badly”; “I feel anxious so it must be obvious to others.”

“Should” statements

You try to motivate yourself with shoulds, musts, and oughts. If you find yourself unable to do something, you then feel guilty and demoralized; for example, “I should be able to understand this the first time that I read it”. If you direct these should statements towards others you feel anger, resentment, and frustration; for example, “They should have known how I was feeling”.

Personalization and “omnipotence”

You see yourself as the cause of some negative external event, or as the center of attention. For example, you think “I always bring bad luck”, or “Everyone was looking at me”, or “I made them uncomfortable”. Remember that just as you are responsible for your own thoughts and feelings, so are others responsible for themselves. You can’t make anyone think or feel anything.

It is important to be realistic about how much attention people are paying to you, and how likely it is that you will be judged harshly. By and large, people who don’t know you don’t care about you and don’t think about your behavior. They are much more interested in their own lives – the fight they had last night, the new car they just bought.

People who do know you would have already made up their minds about you. They are not going to make the extreme shifts in their opinions of you that you expect them to. They might think that you seem a bit stressed today. They might think of you as being a tense person, or even a nervous type, maybe even that you’re shy – but that is about all they are going to think, and does it really matter? What things are most important to you in how you would like others to think of you? It is also important to be realistic about how much you need to have the approval of others.

А	В	С	D
Activating event or situation	Beliefs and interpretations	Consequences	Dispute (challenge) beliefs: record realistic thoughts
Drinking coffee in front of people at the railway cafe	Oh no! What if I shake and spill the coffee They will see me shaking and… They will think I am mad or crazy They won’t like me and… They’ll move or turn away They might even talk about me That would be awful because I can’t stand to appear conspicuous, or tense, or nervous, because that means that I’m a failure as a person		I probably won’t, as I usually cope okay They may, but they probably won’t even notice me They probably wouldn’t think anything of it Even if they did, it would probably be that I’m a bit tense They probably won’t think that I’m mad or crazy – they might think I’m upset or physically ill They probably won’t talk about me as they have much more interesting things on their minds
		Sadness 60/100	Sadness 0/100
		Anxiety 80/100	Anxiety 45/100

Practice example

Write down an example of a situation where you may have overreacted. Choose some situation in which you recently felt panicky or uncomfortable. To begin with, choose a situation that was only mildly upsetting. As you become more familiar with the technique, you can work on situations that cause high anxiety. Record the details of this situation in the “A” column. It can be helpful to go next to the “C” column and write down how you felt about this situation at the time. For example, you may have felt anxious. You may also have felt disappointed, frustrated or angry. Write down all the emotions you can recall, and then give each emotion a Subjective units of distress rating to reflect how strongly you experienced it at the time. Next, try to recall what you were thinking, or would probably have been thinking, in that situation, and record these thoughts in the “B” column. Try to be as inclusive as you can – that is, try to catch everything that might have gone through your mind about the situation. If you are successful you will find that there is at least one thought that matches each emotion in an understandable way. In the fourth column, write down your realistic challenges to each thought. Rate the amount of anxiety you would experience if you were thinking in this more helpful and realistic way about the situation. Re-rate any other emotions you identified, too.

Realistic thinking does not reject all negative thoughts and it is not simply positive thinking. It is looking at yourself and your environment in a realistic way, a way that maximizes the chances of successful coping. It is important to distinguish realistic thinking from irrationally positive, or wishful, thinking.

Some examples of the difference between unrealistic, wishful, and realistic thinking are shown below. In each case, try to identify the type of cognitive distortion involved in the irrational thoughts.

Unrealistic thinking

“I didn’t get the job, which proves that I am a failure. I’ll never get a job or have things go right for me.”

Wishful thinking

“I didn’t want the job anyway.”

Realistic thinking

“I am disappointed I didn’t get that job, but I can cope.”

Unrealistic thinking

“What if I can’t cope with this? It will be absolutely disastrous.”

Wishful thinking

“It’ll be easy.”

Realistic thinking

“I’ll probably be able to cope. It doesn’t have to be perfect: I’ll give it my best shot.”

It is often difficult to tell the difference between various forms of thinking. Here are some clues to what you might be saying:

Unhelpful or unrealistic thinking:

“I must…”

“I’ve got to …”

“What if… that would be awful/unbearable.”

“I couldn’t stand it if…”

Wishful thinking:

“It’ll work out…”

“I don’t care that…”

“It wouldn’t have done any good anyway.”

“I’ll will it to happen.”

Realistic and helpful thinking (“straight thinking”):

“I would like very much to…”

“I’d prefer not to…”

“I will do everything I can to…”

“If things don’t go the way I want, I might be disappointed but I don’t have to become overanxious or depressed.”

Common problems challenging negative thoughts: troubleshooting

•   “I don’t seem to have any thoughts.” If at first you find it difficult to pin down what you are thinking, ask yourself “What might I have been thinking about a situation like this?”, “What would I be worried about?”. If you can’t identify your thoughts while you are in the situation, think about it immediately afterwards, once you are calmer. With practice, you will be able to identify and challenge your thoughts even when you are in a difficult situation.

•   “I can’t think of any alternatives.” Standing back, questioning, evaluating, and challenging our thoughts is not something we normally do. You may well find it difficult at first to be objective and to find answers that affect your feelings to any great extent. Do not be discouraged if at first you cannot always find effective challenges. Would you expect to win the Wimbledon tournament after six tennis lessons?

•   “I don’t really believe the realistic thought.” You don’t have to be convinced. Treat the realistic thought as a hypothesis to be tested. Then act as if‘it’s true, and see what happens. For example, to test the hypothesis that you are always the center of attention, try going for a walk down a busy street. As you pass people, glance at them to briefly make eye contact. What do you notice?

•   “I still feel anxious.” This feeling relates to the problem above. Since you don’t yet fully believe that nothing terrible is likely to happen, you will not be free from anxiety. However, you know that you can cope despite feeling anxious, you know that some anxiety is a normal part of life, and as you collect evidence to support your rational views of social interaction you will believe these more and therefore gradually feel less anxious. Your graded exposure program is particularly helpful in this regard.

Do not get discouraged if you find the same thoughts occurring again and again. If you have been anxious for some time, these thought patterns have become a well-established habit. It will take time to break it. The more often a particular thought occurs, the more opportunity you will have to challenge and change it.

“Ten irrational ideas”

The following is based on Albert Ellis’ work on rational emotive therapy and his book, A New Guide to Rational Living 1979.

It is irrational to think that:

•  You must have love or approval from all the people you find significant.

•  You must prove yourself thoroughly competent and have talent at something important.

•  You have to view life as awful, catastrophic, or depressing when things don’t go the way that you want.

•  People who harm you or do misdeeds are bad or villains and you should blame, damn, and punish them.

•  If something makes you anxious, you should become terribly preoccupied with it and upset about it.

•  People and things should turn out better than they do – if they don’t, you have to view it as awful.

•  Emotional misery comes from outside conditions and you have little ability to control your feelings and get rid of anxiety, hostility, and depression.

•  You will find it easier to avoid facing difficulties and situations than to undertake rewarding forms of behavior that involve self-discipline.

•  Your past is all-important, and because something affected you once it has to keep on determining your feelings and behavior.

•  You can achieve happiness by being passive and uncommitted.

You may feel as though you disagree with some of these statements – it is often very helpful to discuss them with your therapist.

Do not expect your belief in the negative thoughts to disappear completely, all at once. They have probably been around for a long time, whereas the alternative thoughts may be quite new to you. It will take time and practice to build up belief in them, and you will need to test them out in action.

Summary:

Identifying and challenging unrealistic thoughts about situations and events is a key element in overcoming social phobia. By consistently challenging unrealistic beliefs and testing realistic beliefs in real life situations (through graded exposure), you will gradually develop habitually realistic and helpful ways of thinking about things.

Ultimately, a phobia can be overcome only when an individual confronts his or her fears. This is called “exposure” to the feared situation. The most commonly used technique is to start by confronting the least anxiety-provoking situations. As confidence grows, increasingly more difficult situations are tackled. This process is known as “graded exposure” and research has shown that it is a powerfully effective technique in overcoming phobias. The aim of this section is to help you to formulate a plan for confronting your fears that will be both tolerable in terms of the anxiety it causes you and effective in helping you to overcome your social phobia.

Why is exposure necessary?

In the section 2 of this Manual we discussed the development of situational fears; that is, fears of certain situations that the individual has learned to associate with anxiety or even panic. Being in such situations, or even thinking about being in such situations, triggers anxiety as part of the flight or fight response. The natural impulse is to escape or avoid the situation. This effectively reduces the anxiety.

Unfortunately, this natural tendency to avoid situations that provoke distress or uncomfortable degrees of fear or anxiety is one of the key factors which contribute to the development of a phobia in the first place, and then help to maintain it. For example, let’s say you are asked to “say a few words” at a gathering of coworkers to say goodbye to a friend and colleague of yours who is leaving. You may immediately think “Oh no. There’s no way I could do that. I wouldn’t know what to say.

What if my mind went totally blank?”.

This makes you feel so anxious that you devise some excuse so as to avoid having to make the speech. You then feel much calmer. You may be thinking something like “Phew! That was a lucky escape. I would have made a fool of myself.” However, you probably also feel disappointed in yourself and perhaps even quite critical of yourself. This pushes your self-confidence even lower. You also lose the opportunity to discover that maybe you actually could have managed to say a few words that were well received by your audience and appreciated by your friend.

Several important consequences of avoidance are:

1.  The original fear is strengthened or reinforced (that is, you strongly believe that had you not avoided the situation you would surely have embarrassed yourself because of your incompetence as a public speaker).

2.  You miss the opportunity to have an experience that might disprove or disconfirm your negative beliefs about yourself and start to build some confidence.

3.  You miss the opportunity to practice a social skill: most people only develop confidence in their social skills because of frequent practice, including learning from their mistakes.

Note, of course, the importance of what you think about these situations in determining your behavior and emotions. To mount a successful graded exposure program in social phobia it is essential to apply your cognitive challenging, or “straight-thinking”, skills in every situation.

The other major problem with using avoidance to try to control anxiety is that fears often seem to spread or generalize across situations. For example, you might start out being anxious about speaking on the telephone only when someone who makes you nervous is close enough to overhear. You might then try to avoid that situation, but gradually you find that you’re not really comfortable using the phone when anyone is nearby … with time you find that you worry a lot about what the person on the other end might be thinking about what you have to say, too … eventually you find yourself trying to avoid all phone conversations… you don’t make calls and you won’t answer the phone… To relate this to the discussion above, about the importance of how you think about situations, it is likely that way back with that first element of avoidance the message you were unconsciously giving yourself was: “X might think what I have to say is foolish … that would be awful … I will make sure I don’t say anything when he’s/she’s around”. In other words “I can’t trust myself” and “it is essential that others have a good opinion of me” or even “the opinions of others determine my worth as a person”.

So, confronting feared situations is an absolutely essential part of the program.

What will make it bearable is taking a graded approach and applying your cognitive challenging skills to keep you realistic about the actual degree of risk.

Principles of graded exposure

There are several key features to a successful graded exposure program.

A moderate level of anxiety

Anxiety-provoking situations are listed, and the level of anxiety each might be expected to cause rated so that the situations can be ranked in order from least to most anxiety provoking, thus creating the exposure hierarchy. The individual chooses to confront a situation that is moderately anxiety provoking. It is better to err on the side of choosing a situation that is easier than expected, rather than choosing something daunting and feeling unable to proceed, or feeling overwhelmed. Fears can be made worse if a person suddenly forces himself or herself, without sufficient preparation, to confront something that has been avoided for years, or which is perceived as extremely threatening. In this situation, the anxiety produced by a sudden and overwhelming exposure can actually strengthen the association between the situation and the fear. This is known as sensitization and is the opposite of what we are trying to achieve!

Repeated exposure

Just confronting a situation once will not be enough. It takes many repetitions, in conjunction with consistent application of straight thinking techniques, to “wear down” the anxiety associated with a given situation. This is the process of desensitization, the desired outcome of a graded exposure program.

Frequent exposure

The more frequently a situation is confronted the sooner the degree of anxiety it is capable of provoking will begin to decrease.

No escape

It is very important to remain in the situation until the anxiety provoked by it begins to diminish. Many people initially feel anxious about this. “How bad could the anxiety get? What if I lost control?” are fears that many people report. First, remember that you are deliberately going to choose to tackle only those situations that are moderately anxiety provoking. Second, research has shown that anxiety increases only to a certain level – you have probably already had the worst panic or anxiety attack you will ever have, particularly now that you have already been practicing some anxiety-management strategies. Such research has shown that, even if an individual did not apply any breathing control or cognitive challenging strategies but simply stayed put in the situation, their anxiety would spontaneously diminish over the next 30 to 90 minutes. This makes physiological sense, since the flight or fight response is designed to be used as an emergency response. Anything that doesn’t kill you within a half hour or so is reclassified by the automatic parts of our brains as not being a true emergency… and the response is switched off.

It is true that many individuals report experiences of anxiety that seem to last for hours at a time. However, in most instances the flight or fight response is waxing and waning in intensity in response to recurrent anxious thoughts about the situation. It’s rarely maintained at a “full-blown” level for long. Once again, this illustrates the necessity of actively applying straight thinking techniques while in the anxiety-provoking situation. If our thoughts about a situation remain realistic and helpful, we will of suffer extremes of anxiety.

“No escape” also means not using alcohol or sedatives to control or avoid anxiety. Instead, choose a level of anxiety that you can manage without these unhealthy aids.

Planning your program

Step 1: Identify your problem situations and choose your goals to create your exposure hierarchy

Add to this list any other goals of social interaction or performance that you would like to be able to achieve. At this stage it would be most helpful to identify very specific goals, such as the following examples:

To be able to eat a meal with a couple of close friends at the local restaurant.

To be able to sign credit card vouchers.

To make a short announcement in front of 10 people at work.

It is helpful to have a range of goals that vary from relatively easy to very difficult. The more specific your goals are, the easier it is to formulate a program to achieve them. For example, “to enjoy going to parties” as compared to “to be able to go to Jane’s party this Saturday night, stay for at least 20 minutes, and talk to two people for about 5 minutes each”. Being specific also helps you to more accurately gauge the level of anxiety you feel and identify and challenge any unrealistic or unhelpful thoughts about the task.

Include both long-term and short-term goals. Some of your long-term goals may well be described in fairly broad terms, e.g., “to feel more comfortable socially”. You will find it helpful to consider how you are actually going to achieve these goals, and devise some steps toward them. For example, if you chose “to be

comfortable in social situations” you would have to decide how to define “comfortable”, you would have to decide which social situations you want to be comfortable in, and then you would have to begin to practice exposure to each of these social situations, or groups of similar situations.

Do not aim to eliminate anxiety. For example, the goal “to go to Paul’s dinner party and not feel anxious” will be very hard to achieve, since some anxiety in this situation is quite reasonable. A further problem with this approach is that the focus continues to be on the anxiety. The more you worry about trying not to get anxious, the more likely you are to actually get anxious. If you were told not to think about a pink elephant, how would you go about it? The goals “to go to Paul’s dinner party” or “to go to Paul’s dinner party and manage my anxiety” are much more reasonable.

Key points about setting social goals

•  Make your goals realistic.

•   Break difficult, broadly focused or long-term goals into specific steps.

•   Do not aim to eliminate anxiety.

In the space below we would like you to work out five goals of your own choosing. These goals should vary in difficulty from those things that you hope to achieve in the next few weeks, to those that may take 6 months to attain.

Step 2: “Subjective units of distress”ratings

Use the Subjective units of distress scale to estimate the degree of anxiety each goal might cause. In this case, a Subjective units of distress rating of 100 represents the worst anxiety you have ever experienced, and 0 is no anxiety. We will also use Subjective units of distress ratings to monitor your progress.

Step 3: Breaking down your goals into steps

Any goal with a Subjective units of distress rating of more than 30 to 40 will need to be broken down into smaller steps to enable you to work up to the goal a little at a time. Take the example of the goal “to be able to eat a meal in the local restaurant”. This comes from an individual with a fear of eating in public. In order to be able to work towards eliminating this fear you might start with (1) small amounts of food and (2) uncrowded restaurants. Then, gradually, you would increase the amount of food and the number of people.

Coal: To be able to eat a meal in the local restaurant

This goal could be broken down into the following steps:

	Subjective units of distress
Have a soft drink at the restaurant early in the morning	30
Have a soft drink at lunch time	45
Have a cup of coffee and a sandwich early in the morning	50
Have a cup of coffee and a sandwich at lunch time	65
Order a soup at dinner; stay at least 20 minutes then may leave even if not finished	75
Order a full meal at dinner and stay until it is all eaten
With friend aware of problem	90
With friends not aware of problem	100

The task in planning steps to achieve an exposure goal is to think of ways in which you could do something similar to, but easier than, your goal task. Took at the example above and notice what changed at each step. The following are aspects of tasks or activities that can commonly be modified (you may think of others):

Who	is present when you are working towards your goal
What	behavior you set as your goal – exactly specified
When	you carry out the task
Where	you carry out the task
For how long (duration)	you perform the task or stay in the situation

The number of steps involved depends upon the level of difficulty of the task involved. Using the example above, for some people, some of these steps might be too easy. In that case, you would eliminate those that are too easy.

Be realistic in your rating – it’s better to overestimate than underestimate the anxiety a given step might cause and work on tasks where you feel you have a reasonably good chance of being successful. Some people use the “75% rule”. That is, you only set goals that you are about 75% certain you can achieve. If you use this rule you can determine whether you are going from one step to another with too big a jump; that is, attempting a level that you are not ready for. If you feel less than 75% certain of success, make that step easier so as to increase your confidence. But don’t use the 75% rule as a reason for avoiding activities – you can always modify the activity in some way.

Subjective units of distress or confidence ratings can also be used to determine when you are ready to progress to the next step. Basically, you stay at a given level until either you are about 75% sure of being able to achieve the next step, or your anxiety ratings have fallen to 30/100 or less on the current step.

If anxiety becomes severe, don’t panic or run away. If circumstances allow it, stop your activity temporarily. Find a place to sit down or rest, control your breathing and any unrealistic thinking, and wait for the fear to diminish, as it will within a few minutes. If circumstances prevent you from stopping an activity, consider allowing yourself to continue the activity with no pressure to perform. For example, if there are silences in the conversation, let them happen. It is not your responsibility to fill every gap.

Aim never to leave a situation out of fear: take time out if you need it, control your breathing, stay focused on the task at hand – not on yourself! Stay at least until you feel your anxiety level starting to decrease. Best of all is to remain for a time in the situation even after your anxiety has settled. If you do not stay until your anxiety has lessened, you will see it as a failure, lose confidence and your fear is reinforced.

Monitor your progress by keeping a diary of your exposure work that includes both the predicted and actual Subjective units of distress experienced. You may have to make running adjustments as you discover in the middle of a program that the next step is too easy or too hard. Your diary can include goals, steps and achievements, together with comments about how you felt and how you dealt with particular situations (coping strategies). This will help you to structure your progress and give you feedback as to how you are doing. You can learn as much from your difficulties as from your successes. Continued use of a diary is highly recommended.

Try to work on at least three goals at any one time. When you have achieved one step or goal, move on to a more difficult goal. It can be helpful to work on both short- and long-term goals at the same time. Remember that your long-term goals may require many steps.

Aim to do something every day.

Getting the most from your exposure program

Several thinking patterns that seem to develop commonly in those with social phobia can stop you from getting the benefit you deserve from all the hard work you put into exposure practice. These habits may be summarized as follows.

“Discounting” or minimizing

For example, “So I managed to ask a question in class. That’s pathetic compared to what all the others can do.” Or, “Yes, I caught the bus, but it wasn’t very crowded and I only went a couple of stops so it hardly even counts. I should be able to catch the express at peak hour but I can’t…”

Take one step at a time and give yourself credit! More is achieved by positive encouragement than by criticism. If you can be patient and keep taking the small steps you’ll eventually reach your goal!

The video replay

Recent research has suggested that individuals with social phobia have quite a different perspective of social situations than those with only normal levels of social anxiety. When someone without social phobia attends a party or social gathering, they may be a little nervous and self-conscious initially, but after a few minutes their attention is focused firmly on what is happening around them -particularly other people with whom they are interacting, listening closely to what they say, and making eye contact. Their recollections will be as though they are watching a video that they themselves made.

In social phobia it is quite different. The anxiety and self-consciousness are probably worse to start with, particularly if there has been a lot of worry about the occasion in advance (we call this anticipatory anxiety). Unfortunately, it only gets worse for many. We now know that this is because their attention stays focused on themselves. It is as if they are watching a video of themselves taken by someone else. This is sometimes referred to as “self-focused attention” or as taking “the observer perspective”. The person suffering with social phobia tries to imagine the image that others are getting of them – “Do I look relaxed? Do I sound anxious? Oh no, I can feel my face going red!” etc. Naturally, this constant monitoring is also very distracting, and sooner or later the person will miss some part of the conversation and possibly truly be at a loss as to an appropriate reply.

As if all this isn’t bad enough, once safely home the “video replay” starts. As if watching a video of themselves the person replays every awkward moment, every sign of anxiety they felt they displayed – over and over. The video replay is often combined with “focusing on the negative” – positive achievements are overlooked. The net result can be that a person takes what was in fact a positive achievement of a planned goal and ends up interpreting it as a failure. This is the main reason why so many individuals who report having pushed themselves to do things describe it as having had a demoralizing effect rather than building their confidence.

Focusing on the negative

All positive elements are ignored and the person focuses only on perceived mistakes, the net result being a perception of failure.

Unrealistic expectations

Many people expect too much of themselves in too short a time. It takes time to overcome what may be close to a lifetime of anxiety. Additionally, it’s important to know that improvement doesn’t happen in a straight line. It’s absolutely typical to find that something you did with relative ease last week causes unexpected difficulty this week, and to experience real setbacks from time to time. We devote a special section to this at the end of the Manual.

Imaginal desensitization

In a few instances, it may be difficult to approach your goal in a series of real-life steps. In such cases, some steps can be practiced in imagination. This type of desensitization is less powerful than real life exposure, but it does provide a way of adding in-between steps in some all-or-none or one-time-only activities. Imaginal desensitization is best limited to situations where you are unable to perform a step in real life. It should be used in combination with real life exposure to feared situations. Imaginal desensitization alone will not cure social phobia.

The following method can be used for imaginal practice:

•  Specify in detail the situation to which you want to desensitize yourself.

•   List all the steps involved in performing this activity, or devise versions of this activity that gradually increase in difficulty.

•   Record these details on a card, or series of cards, that you will use to script your imagination sessions.

•   Rank the examples in order of difficulty or anxiety that they provoke.

•   Imagine each scene following a relaxation session. Do not imagine the scene when you feel tense or fearful: stop and relax.

For example, suppose that you wish to rehearse a job interview. This is a normal fear, but the person with social phobia may become so preoccupied about it that they are a nervous wreck by the time of the interview and thus more fearful about saying or doing something stupid, or being badly judged. Of course, you can always practice one or two of the steps associated with interviews in real life, e.g., getting a friend to be the interviewer, or actually visiting the interview building the day before the interview. However, there may be other factors that make it difficult for you to practice the situation.

You could proceed through the following in your imagination: You arrive at the reception desk, and give your name. You are seated waiting for the interview in a quiet room. You are seated waiting in a room with three other candidates. You are seated with three other candidates and about 10 office staff. Your name is called and you have to stand up.

You are introduced to someone who gives his name. You enter the interview room. There is one person to interview you. You enter the interview room. There are three people to interview you… and so on.

Begin by imagining yourself in these scenes operating in a competent manner. If you begin to feel anxious, don’t go further until you have controlled your anxiety. In this way, you can rehearse competent behavior at the same time as desensitizing yourself to the fear. Only imagine one scene at a time. Move on to the next when you can imagine any given scene with little anxiety. Once you have mastered all your steps you can add some challenges to desensitize to. For example, if you have fears of particular things going wrong (e.g., your prepared speech blowing off the lectern if your feared situation is public speaking) imagine yourself coping with the challenge in a calm and competent way.

Achieving your own personal goals

From your list of five goals, select two that you would like to begin to work on first, and write these below. To get started, choose either something low on your anxiety hierarchy or else something that is a priority for you. Set out beneath each goal the steps you intend to take in order to achieve it.

Implementing your program

Use your diary to plan a week or so ahead. Even if you are having a bad day, try always to do something, but you need only go over the steps that you have already mastered. Confront a situation frequently and regularly until you overcome the fear. Many fears need to be confronted frequently (that is, three to four times a week) at first, otherwise your fear will rise again by the time you do it next. The general rule is: the more you fear it, the more frequently you need to confront it.

Repeat each step over and over until the Subjective units of distress it generates have dropped to 30 or less consistently (i.e., a few times in a row). An example of a diary is shown below.

Confront your previously feared situation regularly, even after you no longer fear it. This will make sure it stays under your control.

Practicing the steps

Use the standard relaxation and breathing control exercises before you go out. Think realistically and helpfully about the task you plan. Get yourself as calm as possible – but you don’t have to be completely calm to cope.

Use your anxiety-management techniques while in the situation.

Concentrate on the task at hand, not on how you are feeling, how you look, or what others might be thinking about you.

Give yourself recognition for your efforts and plan rewards for achievements. Learn to congratulate yourself when things go well, and be supportive of yourself when you don’t do as well as you’d have liked – learn to be a good friend to yourself.

Example of diary

This person is fearful of scrutiny and of interacting with others.

	Task	Subjective units of distress		Comments
Date		Predicted	Actual
19 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	40	50	It was more crowded than I expected; just kept my head down and tried to concentrate on magazine
20 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	50	Quite difficult to walk in; reminded myself no-one pays much attention, really
21 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	40	Seemed a bit easier today
22 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	35	No-one really pays much attention
23 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	30	Not as many people here on a Friday, maybe; looking forward to a break from this!
24 Mar	Go to movie with Sally at morning session; sit near exit	40	30	It was easier than I thought -cinema VERY quiet; Sally is really supportive; I actually enjoyed the movie! Will go more often.
25 Mar	Bus to local shops	40	40	Not busy on the weekend
	Try on 4 pairs of shoes at the shoe store where they have the assistants	60	80->50	Nearly couldn’t go through with it as store was quite busy- felt sorry for assistant – but a few people left and assistant was very cheerful
26 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	50	Just as hard as last week – very disappointing; did straight thinking – just hard coming back after a break + canteen busy; reminded myself: no-one cares
27 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	30	Much more settled today
28 Mar	Sit with magazine in staff canteen for cup of coffee towards end of lunch (10 minutes)	50	30	No real problem: time to try the next step
29 Mar	Take late lunch & eat in staff canteen: join Trish if she’s there or else sit with magazine (30 min)	60	40	Not much harder than the last step, really. Trish not there – read magazine. Will try this one a few more times to be sure
30 Mar	Take late lunch & eat in staff canteen: join Trish if she’s there or else sit with magazine (30 min)	60	35	Feeling more confident. Looked up a few times and no-one was looking my way at all

Summary

An excessive fear of negative evaluation gives rise to anxiety in a range of social situations. The natural tendency is to avoid situations that make us anxious. Unfortunately, avoidance and escape only strengthen the underlying fears, and contribute to the spread of fear across more and more situations. In order to overcome anxiety it is necessary to confront feared situations. This can be done in a planned and graded way that builds confidence gradually without provoking extreme levels of anxiety. Anxiety-management skills and cognitive challenging techniques help to control the anxiety generated by confronting feared situations and help to reduce future anxiety. Success requires frequent and repeated exposure to feared situations.