CBT Tools For Rapid Recovery From Social Anxiety: Expert Tips, Guidance, and Q and A
Angela Krumm, Ph.D. presents CBT Tools For Rapid Recovery From Social Anxiety: Expert Tips, Guidance, and Q and A
IN THIS VIDEO:
Jill Levitt: Welcome everyone to Feeling Good Institute's CBT Tools for Rapid Recovery from Social Anxiety, Expert Tips, Guidance, and Q&A. We are really happy to have you with us here today. And some of you were with us a month ago when we covered a similar topic and we had so many questions, so many important questions that were asked and submitted to us during that webinar.
And we didn't have a chance to answer all of them. And so we thought it would be most helpful to people to do sort of a part two. If you weren't there for our previous webinar, not to fear at all, because we will still be presenting some didactic information first and doing some teaching and training.
And then kind of the Q&A will stem from that. So you won't feel that you've really missed anything. But we're also going to include the recording of the previous webinar on the workshop page from today.
So if you'd like to watch that webinar, if you missed it, you'd be welcome to. Next slide. So I'm going to share with you guys our featured presenters today.
Angela Krumm is a licensed counseling psychologist and the global clinical director at the Feeling Good Institute. She's a certified level five master therapist and trainer in Team CBT. With nearly two decades of unwavering commitment to the field, Dr. Krumm has cultivated a wealth of expertise in the application of CBT with a particular emphasis on addressing anxiety disorders and a special focus on enhancing social skills.
She's been featured alongside Dr. David Burns, covering many topics, including curing social anxiety with flirting training, and Dr. Krumm's dedication extends beyond clinical practice as she imparts her knowledge to therapists locally and internationally doing these kinds of trainings. Our next featured panelist, LJ Davis, is a licensed professional counselor serving clients online and in person in Carlton, Georgia. He's a level four Team CBT trainer and has been treating clients for 15 years.
LJ was named FGI's up-and-coming trainer of the year for 2023. He leads our core skills practice group that accompanies our core skills of effective therapy course and he assists with our comprehensive online CBT training for therapists. LJ has experienced social anxiety himself and loves helping others to overcome this challenge and is looking forward to sharing his knowledge with you here today.
And I won't be introducing myself, but I'm Jill Levitt, and I'm a clinical psychologist and also the director of training at the Feeling Good Institute. I guess I am introducing myself. I wasn't planning to.
And I have, I think, over 20 years of doing cognitive behavioral therapy and have been training and teaching therapists for many years and really love treating anxiety disorders and helping therapists to get better at treating anxiety disorders. And especially love the topics that we're going to be covering today. I will just tell you a little bit about Feeling Good Institute, and then I'll turn it over to Angela and LJ.
The mission of the Feeling Good Institute is to alleviate suffering by elevating the practice of therapy. So we hope to help patients by helping therapists. We were started by a group of therapists, Angela, myself, and Maor Katz, mentored by Dr. David Burns at Stanford University.
We train and certify therapists in processes of evidence-based CBT, which are known to be the most effective, the most important processes, which includes using measurement, teaching therapists to have really excellent empathy skills, working with therapists on developing skills to increase patient motivation and reduce resistance, and lots and lots of CBT methods. The Feeling Good Institute therapists are all highly skilled and vetted. We all engage in a weekly system of continuous improvement.
We do case consultation. We use the deliberate practice model to practice very specific skills and improve them kind of week over week. And we have flexible services to meet the needs of clients.
So we have video-based therapy across the US and Canada, and then we have treatment centers in New York, Silicon Valley, Canada, and Israel. And we offer both weekly, traditional sort of outpatient counseling, as well as intensive therapy, where people will come in from out of town and receive many hours of therapy, many days a week to do sort of a more efficient, high-impact, short-term course of therapy. And we do have low-fee options as well.
And one more slide for me, which is how are you going to get your CE credit today? So make sure you are here and you stay until 1 p.m. At the end of the webinar today, just five of one, we will put the link in the chat box. So don't leave today without filling out your CE survey. Look in your chat box a little before 1. The link will be there.
You'll complete the survey. And within a week, not automatically, but within a week, your survey will be processed and we will email you your CE certificate of attendance. Awesome.
Angela Krumm: Thank you, Jill, for all the background and setup there, as well as the important info on CEs. And thank you for that generous introduction. I always feel a bit awkward and like I want to blush when you're saying those nice things about me.
It's good to have you all here today. I love just scrolling through seen faces and names. Some are familiar folks I've known for years to the Team CBT community and others who look brand new to me and you're all welcome.
We have this amazing community of people who like to learn and grow together. So I hope if you're new, you feel welcome today and you find something useful and you come on back if you want to learn more and hang out with us more in the future. So we have two main learning objectives today.
We're going to keep the didactic pretty short. And then really, this is supposed to be a time to ask your questions. The LJ and I have the hard job of containing ourselves.
So two main goals. We're going to make sure that you can describe at least two interpersonal exposure methods and then also know how to set up shame attacking exercises. Specifically, I'll spend a couple minutes on the purpose of interpersonal exposure.
We'll talk about techniques like smile and hello, self-disclosure, the survey method and this one, shame attacking. And then we'll turn to questions. So we're excited to jump in.
So what is the purpose overall of interpersonal exposure? Well, the main concept here is that we want to banish avoidance. Let me let that sink in for a minute. What does she mean by a banish avoidance? Well, when folks are suffering from anxiety, social anxiety or other types, the tendency is to try to protect ourselves, right? So we try to avoid situations that create anxiety.
And it's wise and that we're wanting to stay safe, it feels safe. So folks with social anxiety may restrict their life or their social life might become smaller and smaller over time as they try to avoid becoming anxious. And we know that with exposure, we have to turn around and face that anxiety, right? This monster we've been running from, we have to turn around and face it to find out, is it really as bad as we think? Can we stand up to the monster? Will it crush us? Usually it won't crush us.
Anxiety is treatable and we can get through it. So what you see on the slide here is for potential learning points that can happen through exposure. And so these are ones I always talk with clients about when we're preparing to do the exposure work as we think about possible outcomes of exposure.
So let's take an example, anxious thought that's common with social anxiety, some version of if I say or do something awkward, people will reject me or judge me, right? So if I make a mistake, put mistake in finger quotes, it's, you know, the client's perception of something awkward or their perception of mistake, people will reject or judge me. So the first item we see here is it gives us an opportunity to test the anxious thought and find out if it's really true. Do people judge as harshly as we anticipate? Does something bad actually happen? The second point you see here is that exposure gives us an opportunity to just build tolerance for anxiety, okay? So to do this, we have to do some measurement while we're doing exposure.
So most therapists will use either a subjective units of distress, right, the sun scale, or another simple anxiety measure, maybe a one to 10 scale of anxiety. And we help clients by measuring anxiety throughout the exposure as a way to help them learn that the anxiety will wax and wane and will likely come down with longer and repeated exposures, right? So it's another main learning point. We can tolerate the anxiety, it will come down over time.
The third one is my favorite, maybe because it feels like the most important point to me, feels really key. It's this idea that we can build tolerance for actual mistakes, right? So most of my clients who come in for social anxiety secretly wish that I can just make them super skilled so they'll never do anything awkward. Do you have clients who wish that as well, right? So what they're really wanting is to somehow be this like social superpower who always gets it right.
More finger quotes here because I'm not sure what it means to get it right socially. But that's what many of them are craving. So in exposure, we actually have to confront this idea that we won't always get it right.
Socializing is by nature an awkward process that involves millions of little mistakes because everyone's perceiving things differently. So we need to build our tolerance for allowing awkwardness to occur and even invite it in exposure. We'll talk about that more in a little bit here.
Lastly, a possible learning is it does give us opportunity to practice some social skills. For example, we can practice opportunities of how to name awkwardness when it's occurring. How to end conversation when the flow of the conversation is kind of wrapping up.
How to deepen conversations to make them more intimate or vulnerable or even how to turn the attention to someone else as a way to take the spotlight off ourselves. So some of these will be things we touch on as we move through the slides today. There'll be four that we talked about.
LJ is going to talk with you about the first three years. Smile and hello, self-disclosure, and the survey technique. And then I'll jump back in to talk with you a little bit more about this cool thing we call shame attacking.
LJ, why don't you take it from here?
LJ Davis: All right. Thank you, Angela. And I would share too that I also was glad to see many faces there, people I know and people who I would hope to get to know more in the future.
Smile and hello, I think, is a really great starting place for an exposure technique. And you can see here that the technique is really pretty much all there in the name, but some of the details are really what makes it most powerful. And Angela used the phrase earlier that we want to banish anxiety.
And so the steps you see on the slide are ways that we can do that. And so we want to make sure that when we go out to do smile and hello practice, and what we'll do is we'll just go with our clients out of the office and we'll go around and smile and say hello to people. And it's usually a lot of fun.
And we may practice in the office before you go. And I'll just also add a little reminder here that, as we said earlier, we're trying to move through these quickly. And so if you want more detail on any of these, we did go into a little bit more detail when we did the previous CE workshop.
So to banish avoidance, we're going to attempt with everybody we see so that we're not being selective about what this person looks friendly or this person doesn't because then we might not believe that we're really able to talk with anybody. We'll also make eye contact and be sure to speak in an audible voice so that we're making as full contact with people as we can. And then we can also add gestures, like waving or things like that.
And I know that I've always really enjoyed doing this. I used to work on a college campus and going out and really making the gestures. It can be a great way to break the ice a little bit too with the client.
And when we're doing this, we also want to help the client prepare for the outcomes. And the way I see it, there are three possible outcomes with each encounter. My experience is that most people respond one of two ways.
They're either friendly or maybe a little bit quizzical about a stranger coming up and saying hello, just depending on the context and that particular person's mood. There's also a fair number of people now who will be involved with their phone or have their earbuds in and may not even notice. And then very rarely there might be people who will be grumpy.
And all of those are good opportunities for our clients to learn. Either they will learn, oh, it is actually much easier to do this than I thought and people tend to be friendly or ignore me and I can tolerate that. Or if somebody is grumpy, we can also learn that that's something we can tolerate and we can keep moving and it doesn't have to ruin our day or wreck our experience.
And something I did want to add too is I think it is important, Angela mentioned earlier, measuring anxiety throughout. And so if I was going out with somebody to do this, I would like before and after each encounter be asking them what their anxiety level is because there tends to be a real spike right before. And then once we faced the scary situation, oftentimes we'll see the anxiety starting to come down and then hopefully cumulatively over the experience, we'll also see the anxiety come down.
If we want to, we can go on to the next one. And so then the next one is self-disclosure. And I think this one is also really powerful.
And in my introduction, Jill mentioned that I've had some social anxiety myself and this has actually been the one that's been really powerful for me as well. And that's to let people know that you're feeling anxious because a lot of us who do have some social anxiety or some shyness, we feel like, oh, if people knew I was shy or people knew how anxious I felt, then they would reject me or they wouldn't want to talk to me. And that's actually the problem.
You see that on the side. The problem is not the shyness, but that we feel ashamed about the shyness. And so just imagine if you were at a gathering of people or even I've done this in a park and somebody walked up to you and said, oh, hi there, my name is LJ.
And I've spent years being shy and feeling ashamed of that. And today I've decided to stop hiding my shyness and let people know. And that's why I'm talking to you right now.
Just imagine how that would feel to you if somebody came up and said that to you. I think very few of us would feel inclined to reject somebody like that. And so it creates this openness and connection.
And we'll use the phrase a minute ago about deepening relationships and self-disclosure can be a way to deepen our interactions with people as well. And of course, again, we would want to prepare our clients that in my ideal world, if a client goes out to do this, I would ask them to talk with 10 people at least so that they will get a variety of experiences. And my hope is that seven of those 10 people would be really friendly and open.
And that's certainly probably about the experience I had when I did it. I had some incredible moments of strangers wanting to give me hugs and telling me about their life and all sorts of incredible things. And I have one person who's confused and maybe even a little judgmental.
And that was also an important experience for me to see that I could have this kind of interaction with somebody and feel like it hadn't gone the way that I wanted to. And it didn't destroy me. I was able to keep moving forward.
We can go on to the next slide. And then the last one that I'm going to talk about is called the survey technique. And so this is a way that we can test some of our negative thoughts.
And this is an interesting one because it has both the exposure technique and it also has some cognitive helpfulness for you. You can go out and talk to people, and it can be included with self disclosure where you can let people know that you're shy. It can even be tagged on to the end of the thing I said a second ago.
And at the end of that, you could say, have you ever felt shy and wanted to hide it? And then you can find out that lots of other people have this sort of feeling, too, if maybe you're feeling or if your client is believing nobody else ever feels this way. Or the client could also ask people, do you think shyness is something to be ashamed of? And then they could find out whether other people do, in fact, judge people who are shy. But you can also do the survey technique, not necessarily with self disclosure.
I've had clients who would go out and I mean, they would say they're taking a survey. And so they take a survey and say, I just wanted to know if you knew somebody who was shy or anxious, or if you found out one of your friends was shy or anxious, would you reject that person? And then they can collect the results and start to get more and more interactions with people, but also get more information so they can reevaluate some of the thoughts they have about how people would interact with somebody who does feel shy sometimes, which I think the truth is, almost all of us feel shy or awkward sometimes. And once we learn that, it can be a very freeing experience.
I'll hand it back to you, Angela.
Angela Krumm: Yes, that's good. So let's talk about shame attacking.
What is shame attacking, right? Well, it's this idea that we're going to actually invite the very things that folks who are socially anxious are afraid of, which is creating these socially awkward moments or doing things that are purposely outrageous or goofy and public. You might be wondering why we do that. We'll make sure to answer that in a minute.
And some of you may have heard of something called the comfort crusher movement, which is just like a popularized version of shame attacking where there's this trend online for people to do goofy, awkward things in public. You might see YouTube videos of people holding up a sign, offering free hugs or, you know, dancing on the street corner and seeing if they can get other people to dance with that. So the idea with shame attacking the why we do it is that we're going to purposefully confront the fear instead of trying to avoid things that could be goofy, awkward or uncomfortable.
We're going to do them on purpose so that we can have that experience I talked about earlier where we find out if people judge and if they do, we practice tolerating that. Right. We practice letting people see us doing things that are imperfect or awkward or goofy and realizing that we can survive that and that we can actually if we do it enough that we can do those things without the anxiety staying so high.
So we can keep doing good things and the anxiety can come down over time. There's if you're interested in more research on this. So we call this shame attacking in the team CBT community burns has popularized it with that language in the research literature.
They'll more often refer to it as social mishaps. So if you want to dig up the research on it, that's how you'll find it referred to. And so let me give you some examples of it to bring this to life.
So lots of ways you can do shame attacking. It really is only limited by the creativity of yourself and the client that you're doing this with in our community. We do believe that you should try things yourself before you ask your clients to do it.
And so most of the therapists who are have been part of the team CBT community have done these things either together or on their own as part of their learning and growing. One example I'll give you today is about Arne Olivera, who I think is here with us today. He's one of our therapists in Florida.
Awesome, awesome, dear, dear guy. And he was out in California with us for a retreat we had for our therapists this past year. And we all went out in this little beach town and we're doing shame attacking.
And Arne decided he would stand at the edge of the beach and find one of those warning signs that has all the rules of the beach. And then his loudest voice and was full as if he was on a stage in a theater full volume, read the warning signs to the entire beach. Large waves will create destruction.
Do not open beer bottles. And just announcing his passerby's or just kind of having to like wonder why is he reading things aloud and he had a big smile on his face and did it. Did it draw attention? Absolutely.
Did it make him uncomfortable? Probably, although Arne's pretty low anxiety on these things, I think. But he definitely was inviting the shame, having to tolerate people's reactions, whether they were judging or not. The second example I have here is a fake name, but a very real client who's been near and dear to my heart.
And this is someone I spoke about in the CE last month. And so if you decide to go back and watch that, you can hear more about Kia's story. And Kia, I'm referring to her as the reluctant dancer because she was terrified of doing shame attacking.
And it took lots of sessions of cognitive work before we were ready to have her do shame attacking. And we had to start with many of the things LJ described to build up. Right.
We just had to start with trying to say hello and smiling at strangers. And we had to we moved on to something that was a bit harder where she had to ask. She had to ask questions in stores of customer service folks, because even that felt like awkward and a burdensome to her to ask questions of people who worked in stores.
And as we built up in our hierarchy, we eventually got to doing what we call silly walking, which I think that's like an old Seinfeld term that something Elaine used to do on Seinfeld. But the idea is like, can you walk down the street and as goofy as a way of possible that could look like anything you might be doing high knees, you might be twirling, your arms might be swirling. It could start to feel like dancing, depending on what what feels right for the client.
So Kia was doing some combo of squat, high step, back, turn around, you know, and we finally got to the straight corner and she just started dancing, full arms flowing, you know, no music around making it up. And so Kia was a very reluctant dancer. It took us a long time to get there, but really powerful shame attacking for her.
And so to bring to life the why we do these goofy things in public. Let me tell you some of the examples of what Kia learned from from this shame attacking exposure. And, you know, lots of learning for her came from a few highlights for that most people weren't as judgmental as she expected.
She actually noticed some people appeared to have almost admiration, as they noticed her right you think you see someone dancing on a straight corner. Maybe there's a combo of curiosity judgment, but also some, some kind of admiration and who thinks that's kind of brave right you kind of think there's something cool about it. And she learned she could tolerate if people did judge right if she got some kind of side eyes my 11 year old calls this the bombastic side eyes when you give someone like the look so a couple of these looks she got.
She could tolerate it. And she learned that her anxiety did in fact come down over time the longer she did it, she'd get a huge spike each time we'd take the next step of the hierarchy. And then it would come down every time, and importantly, she learned that if she kept doing it over time we'll talk about that more of the fact that you have to keep doing it.
That the application to the real world was huge for her, she was able to start doing more things outside of therapy with her family with her friends take more risks socially the more present and free because remembering that she did the stuff that felt really extreme in the therapy room. Other brief examples of shame attacking examples again the, the world is your oyster you can be as creative as you can with your client, and we have asked questions that feel goofy like maybe we convey some naiveness for example, standing right in front of an ice cream store and asking people where you can get ice cream. David Burns is notorious for asking people if he can take a bite of their food, walk up to people in restaurants and compliment the dish and ask if they'd be willing to share and this is part of his name attacking.
I'm a big fan of tree hugging and public I think there's something fun and goofy about it to like hug and adamant objects trees are particularly fun and connecting I think to hug. Dancing, dancing provocatively if that feels fun for a client or feels appropriate depending on the contact lots of lots of that can be done. So let's talk about briefly some shame attacking do's and don'ts and then as we promised we're going to turn to questions and really just get into the nuance of this stuff today.
So, some important things to keep in mind so the slide of shame attacking dues, followed by some don'ts, which will come in a minute. We do want to explain the rationale, get consent and prepare with the client, right we don't want to just do this on the drop of a dime, we want to help them understand why we're doing it. There are some great books that can explain the rationale and help you I mean really any guided treatment manual for social anxiety exposure will likely have a whole chapter you can have them read on the wise in the house.
My favorite is the treatments that work series Timberg and Turk and hope are the three authors, Timberg, Turk and hope not in that order can't remember the order. There are treatments that work series for social anxiety disorder. And so, part of the preparation is having at least a loose hierarchy I think with with with this type of shame attacking there should be some flexibility built in but we want to start with at least some ideas of the exercises we're going to try and guessing at the anxiety and advance and then that will motivate them to record it as they go.
We also want to make some decisions in advance about the logistics. So, many of you may only do video based therapy now many of you may have in office practices that you need to first decide, are you someone who is willing and able to go out of the office with the client and do these activities. I highly recommend that if you're able to do that.
It's your client can just make so much more progress with your support. And then if you're not in a circumstance where you can do that for any reason, whether it's video therapy or other limitations you have that you want to plan in advance. Is the client going to do it on their own.
Do they want to start with a practice study. You can always involve a support person of practice study as part of the hierarchy, right that maybe they're going to first do things with a partner and then over time take that partner out of the hierarchy to keep doing exercises on their own, but you want to have thought about this and decided with the client. Lastly, you want to think about how do you handle it if a client freezes, meaning the phrase word here I used to refer to this very common experience and any exposure exercises where clients really are wanting to do it and have, you know, taken this huge step to be willing to do these hard things and then in real time they get a bit flooded or they the resistance pops up and they freeze and don't feel able to move forward and you need to have a plan with your client.
Usually the plan is simple. It's something like you're going to gently coach them to try it anyway. Maybe you're going to take a small step down on the hierarchy and then jump right back into the activities so that we don't end the client with a learning that they can't handle it or that it's too hard for them.
So we want to have that plan in the family. Other do's here, try to have fun with it. Practice on your own before asking a patient to do it.
I wouldn't ask my client to dance on a street corner if I haven't done it myself. And they're much more likely to trust you if you've done these things yourself. And I mentioned this idea of doing it with the patient or assigning a practice study if they aren't ready to do it on their own and then be creative.
Let's talk about some don'ts. Really, item one and three here are very similar. We want to figure out where's the line when we're making others uncomfortable or mocking others.
And once in a while when I've heard therapists or clients start to brainstorm ideas for shame attacking that I feel in my heart there's something that starts to feel worrisome about it. Some examples of that would be I had a teenager one time who wanted to act like an old person as part of shame attacking. And it was it was an example that they wanted to dress in a certain way and walk in a certain way.
And it started to feel like this kind of age stuff that was being played out. And so we talked about how could we do shame attacking that doesn't involve any mocking of other identities, right? We also want to be respectful about the way we do it, right? Places of worship, hospitals. Let's just be thoughtful about the impact.
And that's actually these are harder decisions to make than they might seem because if you're nervous about doing shame attacking, everything might feel inappropriate to you. You might think too far to say, well, if we if we dance on the street corner, someone might walk by and be uncomfortable, right? And then I'd say we're probably going too far. We're giving in to our own fears.
So get some consultation if these things aren't clear to you. There's plenty of therapists and trainers who've had enough experience with this to help if it's not clear to you. But mostly if you follow these rules that we're just going to be respectful, the client needs to get uncomfortable, but we don't want to harm psychologically or of course physically anyone else.
I always tease my clients that as long as we know we won't get arrested, we're probably okay, right? I've had clients say, well, what if someone thinks I'm having a heart attack and they call an ambulance? I say, well, we'll tell them they don't need to call the ambulance. You know, we'll speak up and let them know we're okay. So sometimes we just have to reassure our clients that we'll get through it.
I think we're ready to do some of our questions, Jill. Does it feel like a good time to turn to them? Is there anything you wanted to add before we do that?
Jill: That sounds great. Sorry, I realized I had to unmute myself. And will you move to the next slide?
Angela: Yeah. Yeah.
Jill: Wonderful. So we collected questions from the last webinar that we did. We answered some of them live, but we had too many questions to answer live.
So we're going to start with the questions that you already submitted during the last webinar, and then we'll move on to the questions that you've been submitting to me throughout. And I've already gotten many, many, many more questions. So we'll do the best that we can to address as many as we can until the end of the hour.
So let's start with the first one. And the question is, what if your patient is more afraid of their own anxiety slash shame slash overwhelmed than the actual reaction of others? Meaning even if others reacted well, the patient still judges themselves. And how can they work on that self judgment? And I'll turn to LJ to answer that first question.
LJ Davis: Thank you, Jill. And I think it's an excellent question. I think it's a little bit complex and it shows some of the complexity of the kind of work we're wanting to do, because it sounds like there are two parts there.
One part it mentions where the patient is judging themselves. And I think in that case, we would probably want to do some cognitive work and find out what are the thoughts they're thinking about themselves and then use any of a large number of different techniques to help them lessen or maybe even eliminate that self judgment that's there that may be really having an effect on them. So the other part is it says, what if they're afraid of their own anxiety and overwhelm? And in that case, if it's not about the self judgment, if it's that they're afraid of their own anxiety, that may be an indication that we may need to keep doing exposure and do more exposures or try some different ones because that's part of the point is for us to get over the fear of our anxiety or trying to avoid things that make us anxious.
And it may also be a sign that we want to reconsider our hierarchy and start a little bit lower on the hierarchy and then work back up to the thing that they're feeling overwhelmed by. So there's a few different ways I think we could address that problem. Wonderful.
Jill: And I'll move on to the second question. Well, so any tips on how to do some of the exposure exercises, if I myself as a therapist, I'm 100 percent virtual and I did see a couple of people sent me the same question in the chat box today. So that's a common one.
And I'll let you do that one, too, LJ.
LJ: OK, yeah, I think that one's a great question, too. And I think it is with these.
It is really nice to be able to go with our clients out into the world and do them, but I don't think it is 100 percent a requirement either. And there are a few different things we can do. I know I've talked to some therapists who will say, hey, why don't you put the Zoom meeting on your phone next time and then maybe you could put in one of your bud.
We'll have the other one open so you could interact with people. But then we can go out in the world and we can do exposure exercises and I'll be right there in your pocket and in your ear and I'll still be there to support you. Another option would be to give them the exposure exercises for homework.
And again, if we think about our hierarchy, maybe they would want to choose a support person to take with them, which would probably be a starting point and then eventually for them to move on, to be able to do them on their own, because doing the exposure exercises on their own without us would also be a homework, even if they were coming into our office. So we still want to be building up to that, being able to do it without a support person there as well.
Jill: Great. And if Angela, of course, if I'm directing toward LJ, you have anything to add. But let's let's move on to the next question. Is the standard practice that we have clients do exposure outside of the therapy session? So that kind of overlapped a little bit, but Angela, do you have anything to add about that?
Angela: Yeah, I do have a couple of comments because I think what it speaks to me or makes me want to share is this idea that in general with exposure, we want to do as much as is needed as often as possible for longer with shorter durations in between until the anxiety has come down.
So when someone asks me, am I supposed to do it during session or out of session? Am I supposed to do it in between session? Do I need to be with them or not? The answer is just do more until they feel less anxious. So I do think starting with opportunities in session is an awesome way to start. It will support your client.
Some might argue that I'm being a little bit too hand holding in that and that would be fine to just assign it and let them go do it. And my guess is it depends on the client, your relationship and their readiness. So in session, even without leaving or seeing other people, you can do role play practice, which is really important, important and is part of exposure work, right, is to practice fear and situations and to confront them.
You might be very surprised your clients who are highly socially anxious will still have a very high anxiety just having to do pretend conversations with you. So you imagine a scenario that's real in their world and they have to start a conversation or sustain a conversation or end a conversation. They will feel so much anxiety just even pretending, right? So that is exposure starting in session.
Then they need to practice out of session between sessions with other people, all right? So build, build, build. But there's a lot you can do even in real time in session. Yeah.
Jill: So yes, again, as with actually all the work that we do with all of our patients, we're always saying that outside of session work is, you know, probably the most important ingredient in people overcoming whatever depression, anxiety, habits, addictions. If we only see them for one hour once a week, of course, everything they're doing from week to week is going to be, you know, way more impactful actually than that one hour once a week, right? So yeah, therapy session, meaning homework is always going to be important. Yeah.
Angela: Can I add just one piece because you said something so important there, which is that that's why at FGI and really within the larger team, CBT community, we love this model of what we call intensive therapy, which Jill spoke to earlier, which says, let's let's let go of this need for 50 minutes once a week, which is a really hard way to do exposure therapy, right? And if you have flexibility in your practice to do longer or more frequent sessions with exposure work, the impact can be so much more profound and obviously not every client can afford that or not every therapist can provide it. But in the circumstances where it's feasible, it's really powerful. And so when we have clients either fly in or local clients who work with us in intensive therapy, we'll do hours of exposure, of course, with breaks and really make tremendous progress over the course of just a couple of days.
Jill, do you want to take number four?
Jill: Sure. And I'll just, I'm getting a lot of notes. I'm trying to multitask here.
I just wanted to share that just this is like supporting what we're talking about today. But Andrew just sent me a note saying from the the FANG article, that's one of the references we talked about with social mishap, which is what they call shame attacking in the literature. Andrew sharing with me to share with all of you, early data suggests that treatment protocols that incorporate the social mishap exposures, which is shame attacking, show considerably greater efficacy than traditional CBT protocols, which are typically associated with only moderate effect sizes.
And exactly, I think what we're saying, there's no one size fits all, but certainly in the in the literature and in our clinical experience, cognitive therapy is very useful and very helpful. But typically you need to be doing exposure in order to help your patients get over their anxiety and exposure that specifically kind of targets that fear of messing up can be so liberating and helpful for patients for a variety of reasons, kind of those four reasons that Angela gave on that earlier side. The fourth question here, I'm happy to answer that is any specific regulation techniques you would suggest to use with clients during the initial exposure exercises if they feel high levels of distress.
So I'll share my own training and the way that I do it with patients, which may be controversial, although all the people I've trained with support this idea, which is when we're doing exposure therapy, our goal actually is to have our patients face their fears without any kind of avoidance or distraction. And so I don't teach patients any kind of emotion regulation strategies to use while they're doing exposure. I really want them to learn that they can actually handle the experience.
They can handle the anxiety. They can handle the mild embarrassment, these kinds of things. And so what I would do instead of teaching them a regulation strategy, if they feel high levels of distress, is I would more turn to your hierarchy.
I would say you need to find a way to make the experience that they go into feel tolerable, if that's the right word, but to basically create a hierarchy. Right. We're not going into the hardest situation first.
We're going to start with something that's going to be anxiety producing, right? It has to be anxiety producing for it to be exposure, but where they're going to be willing to do it. So if we have a hierarchy of zero to ten or one to ten, maybe you start with a three and they kind of build their tolerance and their acceptance of mistakes and things like that. And then we move up the hierarchy because I find that if a patient goes into an exposure with an intention to control their anxiety, which is generally the idea of a regulation strategy, I'm going to try to make myself feel better.
It's kind of counterintuitive to what we're actually trying to help them to accomplish. Should we move to the next one? We have a few more questions and then I can turn to some questions that we have to this number five. Let's see.
So how do you modify exposure techniques for middle schoolers? I worry because the response of peers can sometimes be so mean. Do you want to take that one, Angela?
Angela: Sure. Happy to. Yeah, I mean, my heart goes out to any child being treated meanly by peers. And I do think we want to always be sensitive to the individual client in front of you and what's what's their circumstances. What are the real barriers they're up against? And that might make situations less safe very last time in the C.E. We talked a little bit about prejudice and bullying and these situations where we want to have done a really good assessment to understand the factors that someone's facing with social anxiety and what's like legitimate, unfair, unfair situations in their life that we want to be thoughtful around.
Broadly, though, with with middle schoolers, I with with younger kids, you know, we want to remember, as Jill just said, that we're not trying to make it super comfortable where there's no judgment. The idea with interpersonal exposures, they have to get used to making mistakes and being OK with those mistakes happening and tolerating the anxiety of engaging, even if it's imperfect and their engagement. And so, again, we'd want to have a hierarchy that really respects where they're at and what they're willing to try with.
And maybe a lower items on the hierarchy will keep them far away from known peers, right? Maybe they're going to first do shame attacking around folks that are very different age group or away from their peer group and kind of take steps on the hierarchy closer and closer to their their peer group where they're afraid of reactions. They also might benefit from having some social skills training of how to handle it if there are negative reactions. So let's say that a child maybe isn't even doing shame attacking, but is trying to just engage more people on campus with smiling hello or maybe doing some self-disclosure just starting more conversations.
They might need a little social skills training of how do you respond to a critic for someone who does tease them or is unkind? And luckily, there's great, great literature out there about that. One of my favorite books for younger kids is around this topic is Stand Tall, Molly Lou Mellon. It comes from ABC Reader Project Cornerstone Project, which is an initiative of the YWCA that's an anti-bullying project.
And both the child in this book just models shame attacking and self-disclosure with tremendous self-acceptance and even models in the book how to respond to the critics. And so I think those types of books can be helpful for the younger kids to kind of see an example of someone who's putting her true authentic self out there doing things that might be perceived as awkward by others and really kind of owning herself and feeling good about it. So let's play with those things.
Jill: OK, great. So how do you address when patients say that the exposure practices are not generalizing to their real lives? Like, it's easier to do silly things in session, but in real life, it's still quite difficult to push past the shame. Angela, do you want to start us on that one?
Angela: Yeah, I'll take this one. First of all, I'll say it's it's very commonly a concern of clients before they try the exposure. They'll say, how will this apply? And that's that's true for a lot of exposure situations, even outside of social anxiety, that it takes clients a bit to kind of buy into the approach that if I do these silly things with strangers in in therapy, how will it actually make me feel better? Often the learning, you know, again, remember the goals for them to face the fear, tolerate anxiety. The anxiety will come down and that learning does stick.
Our brain really does start to understand that we can tolerate more than we think we can and that the feared outcomes are things they can manage. And so almost always it does generalize. One example of generalizing is clients will put it in their own words and say things like, man, if I could do that really intense thing I did, even if it was in therapy, then man, this everyday stuff starts to feel pretty easy.
You know, chit chatting with someone at the work water cooler isn't merely as hard as it was dancing in public or disclosing my shame to all these strangers. I could surely do a little shame disclosure in my workplace and get closer to people. And so sometimes the fact that we push them to the extreme is what really helps that generalizing to the real world happen.
LJ, Jill, any other thoughts you had on that?
LJ Davis: There's probably lots of ways to think about this one. One thought I just had was it can be surprising sometimes how things generalize. And I was just thinking about my son, actually, who's got various things that come up as anxieties.
And one of them was a fear of heights. And we went and went to some high places. And that was enough to build his confidence.
But then he was also able to be more social. And there's no obvious connection between going to high places and being able to be social. But I think his his confidence that he could feel anxious and do something then translated even into other spheres that weren't connected to the fear of heights.
Jill: Yeah, I love both of your answers and I think quite the simplest answer is if a patient is saying something isn't generalizing, then find stuff that does, right? Like, what is it that is scaring them in their life? And let's work on that, right? So if it's that they're worried about what their friends will think of them rather than what the person on the street will think of them, then we need to be starting to do some exposure stuff with friends or we need to do survey technique with friends or things like that. So if you think about it, the sort of exposure and shame attacking is a large category of ideas and you need to be creative with them and always tailoring any method, really, to the needs of your patient, to the specific fears of your patient. If a patient doesn't get what you want out of exposure, you need to be asking them, what are you most afraid of happening? And then we need to make sure we're targeting that in both cognitive work and exposure work.
Let's do this last one on the screen, and then I've got plenty more. This one is, how can you incorporate shame attacking in a support group or a group therapy setting? And I got a couple of questions that touch on that in the chat box, too. So I think this is a good one.
LJ Davis: Yeah, I'll get us started, then we'll see how those other questions roll into it. I think a group therapy setting is actually a really exciting or really potentially powerful place to be working on shame attacking because we talked about how you would practice in sessions.
So with shame attacking, you have a group of people there. You could practice doing some social mishaps there in the group itself, and that could be part of your hierarchy. And then not too long ago, one of FGI's therapists, Craig Gilkey, posted about with a group of college students then going out and doing some shame attacking on the college campus.
And so, you know, depends on the setup of your group and how you could discuss that and set that up with people. But I think that would also be a really powerful opportunity and would be a way, again, to help people launch into it and maybe make it a little bit more comfortable to get started because if we're out doing something with the group, it can lower the anxiety a little bit. And then they may still want to go on and do some solo practice as well.
But I think having a group would be a really powerful way to get things started with shame attacking. Typically, we think of... I'm not currently running any kind of social anxiety groups, but I always would... I would love someone to do that at Feeling Good Institute. We oftentimes find that groups are really powerful places to be practicing exposure and you kind of have the audience built right in and you can do survey techniques and all of that.
So, yeah, I think that's great. So I'll turn to some questions, some more questions that we've had.
QnA Session