Jess and David are joined by Professor Peter McEvoy to discuss what's being done to help sufferers address their social anxiety now and in the future.
Many of us are fearful of being judged by others. But, for those with social anxiety disorder, the associated negative thoughts and physical sensations – a racing heartbeat, irregular breathing and tense muscles – can be crippling.
In this episode, professor of clinical psychology Peter McEvoy discusses what's being done to help sufferers address their social anxiety now and in the future.
Have you been feeling anxious? You may want to contact Beyond Blue.
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You can read the full transcript for the episode here.
Jess: This is The Future Of, where experts share their vision of the future and how they work is helping shape it for the better. I'm Jessica Morrison ...
David: ... and I'm David Blaney. Many of us are nervous about being judged by others, but for those with social anxiety disorder, the fear of being in a social situation can lead to excessive sweating, trembling, and heart palpitations.
To discuss this topic further with us today is Peter McEvoy, a professor of clinical psychology at Curtin University. Thanks for joining us, Peter.
Professor Peter McEvoy: My pleasure.
David: What is social anxiety disorder?
Professor Peter McEvoy: We all probably admit to experiencing some social anxiety, some discomfort in social situations at some times, in some contexts. So, sitting job interviews, for example.
David: Recording podcasts ...
Professor Peter McEvoy: Exactly, recording podcasts. Being at parties sometimes, when we don't really know many people. There may be some mild social awkwardness, but that tends to be transitory – it passes quickly.
When we're talking about social anxiety disorder, we're talking about a level of social anxiety and panic – the symptoms of which you were just discussing – really start to become debilitating in some important way in the person's life. They report to us that it really affects their ability to even apply for a promotion, for example. They find it very difficult to interact with people at work or socially, and they really can feel very socially isolated in their lives.
So, the anxiety is dictating what they're able to do or not do in their life. So that's when we start to think about a social anxiety disorder.
Jess: How many people have this disorder?
Professor Peter McEvoy: Well, as I say, it exists on a continuum, so we all experience it to one degree or another. But when people start to say, this is actually severely affecting my life, and we're talking about social anxiety disorder, the best evidence we have suggests that about eight percent of us in our lifetime will meet all the diagnostic criteria.
So that's about 1.3 million adult Australians in their lifetime can expect to meet criteria. But most people will meet the criteria quite early in life. Half the people who do meet criteria will have already met it by the age of about 13, and half will meet it after that. Very few people will develop it after about their mid-twenties, so usually it's present quite early.
Jess: What would you say to someone if they said, socially anxious people are just being shy?
Professor Peter McEvoy: Well, certainly that's an element of it, shyness, but that's the milder end of the continuum. There's sort of cases I was talking about before when people tend to find themselves being a bit reticent to speak in social situations, but they're still able to go to those social situations, they're still able to sit the job interviews, they’re still able to establish and maintain conversations and relationships.
But when we're talking about social anxiety disorder, it actually debilitates them in all of those ways. So they're not able to meet their potential in all those important life domains. It also makes them miserable.
Jess: And also physical symptoms as well, as we covered at the start.
Professor Peter McEvoy: Yeah, exactly. So David, if I was to dangle you off the Narrows Bridge by your feet, your heart would be racing, you'd be sweating ...
David: Yes, I guess it would be!
Professor Peter McEvoy: Yeah, you'd have the urge to get the hell out of there. And they're all the same symptoms that people with social anxiety disorder have in what most people would consider fairly mundane social interactions. So, people with phobias of heights or snakes – imagine how you feel in the face of that object or that thing that you are terrified of. Well, that happens for people with social anxiety disorder in social situations.
David: In the past couple of decades, it's now become much easier for us to communicate with one another instead of sending letters and using carrier pigeons and using hand radios and semaphores. We're now using mobile phones and computers over the internet, social networking sites and the like. How is this feeding into this?
Professor Peter McEvoy: I think it can be a bit of a double-edged sword in terms of social anxiety. On the one hand, it's great at facilitating avoidance of real-world contact, and avoidance is one of the most critical maintaining factors for significant social anxiety.
So if I feel negative evaluation and I never actually confront that situation, I never actually have the opportunity to learn a) that it's far less likely that people are going to judge me than I think it is; b) Even on the occasion that that does occur, it's not a catastrophe – it doesn't really need to make a huge difference to my life; and c) I can cope with that level of anxiety. I never have the opportunity to learn those things, so my social anxiety, my social fears are going to maintain indefinitely.
The issue with online communication is that it gives people a sense of safety, and we can think about it as a bit of a safety behaviour or a subtle avoidance behaviour, which can maintain their fears of actual face-to-face social contact.
Now the other side of the coin is that people with severe social anxiety aren't going to be interacting with people that often anyway, so at least it provides them with some social contact – some opportunity to experiment with sharing some of their ideas with other people and not getting negative feedback as a consequence.
And also, the online space cause people to learn that they're not alone – there are other people who are suffering from similar problems – and also to access online treatments which are now available and can be a really important first step to helping people better manage their anxiety.
David: We’re social beings, or so we're told by other people, ironically; do we get the same benefits with social interaction online and digitally that we do face-to-face?
Professor Peter McEvoy: It really is going to be individualised in that respect. Certainly we see clients who are terrified of interacting with social media. It's a very open forum in a lot of ways – not only does the person you're posting to see it, but all your friends might see it as well. So, there might be actually a lot more opportunity for judgement than just a one-on-one conversation. So that can actually lead to an increase in anxiety.
But on the other hand, it can help to facilitate some degree of contact and some normalisation and validation of our ideas as well. If we take a risk and post something and we don't get disapproval, then that may help us develop some confidence over time to do more of that, make more contributions, and then make the leap to face-to-face interactions.
Jess: Thinking of social media, I'm going to take it a little bit further. Dating apps, I have a whole friend-group now who don't meet people how I may have met my partner. Is that another facet that you're seeing?
Professor Peter McEvoy: I don’t necessarily see that as a problem. It's just another form of meeting people. As long as it makes it to that next step where you're meeting people face-to-face and they're able to have a real-world connection, then that might be fine.
Jess: Obviously the digital connectedness is helping but also causing some social anxiety issues. What are some new treatments that have been developed in this space?
Professor Peter McEvoy: The main target for treatment is really targeting that avoidance behaviour in whatever form it comes in and just about everyone we see has their own creative ways of avoiding their social fears from coming true or they think they're avoiding their social fears from coming true. Whether they would come true, whether there's likely as they think they are, is a very different kettle of fish.
Treatment really is about helping clients to engage with social context and directly test their fears. For some people who have a fear of digital social media, then it would be about confronting that situation, taking a risk and evaluating the results and the outcome. Just like a scientist, really: what's my prediction? what do I need to do to test that prediction? what evidence would I need to observe that would support or not support that prediction, and then go out and do it.
We can do what’s called behavioural experiments. They're a core technique in evidence-based treatments for social anxiety. Sometimes it's about the probability of my fears coming true. So, we might walk down the street and just see what proportion of people are looking at us, or staring at us, or completely ignoring us. Because people with such anxiety disorder often believe they're the centre of attention.
Or, we might assess, well what's the cost of drawing attention to ourselves? How much does it need to matter? In which case we have to draw attention to ourselves. So we'll go out in the street and do stupid things like run around like planes, or do cartwheels, or just collapse on the floor inexplicably, or take a banana for a walk down the street on the end of a piece of string, and see how hard it is to draw attention to ourself. And you might be surprised, but virtually no one pays attention to you – even when you do all those things.
We often do social anxiety treatment in groups and people come back and they’re almost disappointed at how hard it is to draw attention and other people it's like, Oh my gosh, I'm not really the centre of everyone's attention. Actually, if I wanted people's attention, it would be extremely hard to get. People caught up in their own lives and they're just walking to work or doing their own thing. And they’ll just walk around you or whatever you're doing and just continue on.
So, we can test the cost, how much it needs to matter if attention is drawn to us. And it certainly feels extremely threatening to draw that attention to oneself if you're meeting criteria for social anxiety disorder – or even if you're not – but when people learn that their social fears very rarely come true, and even if they do from time-to-time, we all do silly things or make faux pas and be laughed at. You know, that happens for all of us, but we need to assess, well how much does that really need to matter? Do the people who are laughing at us kind of get past that? Can we get past that? Can we tolerate the anxiety, and how much does it need to matter in a year’s time or five year’s time, what's just happened?
They’re all the things that we need to learn, and we can learn that in what we call in-vivo, like in the actual situations themselves, and we're testing that. Certainly there are a lot of online treatments now that help to guide people through that sort of process, but one of the downsides to o nline treatment is that we're relying a lot more on people doing those things without the face-to-face support, and often at the beginning of treatment this feels very threatening.
The client really needs to be sold that this is going to be really helpful for them, or why would they put themselves through that much anxiety at the outset? And I think face-to-face clinician can really help with that.
David: Well that brings me onto what I was about to ask. Traditionally, cognitive behavioural therapy, like you're describing, is typically done in a clinical environment, in an office somewhere. In the future are we going to have websites or mobile apps where this is all done, and does this produce the same results?
Professor Peter McEvoy: Great question. The first thing I like to say is actually the best therapy is done outside of the office. We will talk to the clients, set up something we think is important for them to do, but then we get out of the office and we actually do it. So the behavioural experiments, I'll go out with clients and I'll do them as well. I'll do those silly things and they can observe how they react to me, and then they’ll do them ...
David: Or don’t react.
Professor Peter McEvoy: Exactly. Then they'll do them, and we’ll just spend a lot of time doing these behavioural experiments, cause there's nothing like actually experiencing a lack of response from others, even when you do silly things. You can talk about it but it doesn't feel real until you actually observe it.
Jess: And do you find that the clients find it easier to do these things with you?
Professor Peter McEvoy: Initially, absolutely. And our aim is, as a therapist, to step back and let them take more control over that. And also between sessions we set a whole range of homework tasks that they can keep testing it without the therapist, because the therapist could become a bit of a safety behaviour as well, a safety signal and, “Oh it's okay because you were there, but if ...”
In which case I say, “but what?” That's a really important ‘but’ – let's hear about that and then it's tested in that situation. And clients are then, “Oh, it doesn't actually matter what context I do it in or who’s around, same outcome. Really no one cares that much about evaluating me at all”.
There's a lot of evidence now that the online interventions can be as effective as face-to-face treatment for some people, not for everyone, but people who are able to stick with it and are really very self-motivated. Or people who can't access face-to-face treatments. So, people in rural and remote areas or people who work full-time don't have easy access to face-to-face clinicians, then sometimes online is the best option for them, and treatments can be very effective, but drop-out tends to be a lot higher because you don't have that accountability, if you like, and that person to check in and support you. But, you can get a lot of that with discussion groups and therapists’ guidance either via the internet or via the telephone. Services like MindSpot, which is a national online assessment and treatment service, can provide that and has had really good outcomes. Virtual reality is another future direction for this area. There's been some early research creating a lot of these contexts and situations we’ve been talking about – various social situations and, through virtual reality, receiving the intervention. So that would be very easy to disseminate quite widely as that technology becomes more widely used.
Jess: Tell us about that – very early days, is it?
Professor Peter McEvoy: It is quite early days with the virtual reality work. So, what they would do is ... you know, I was talking before about going out in the street and doing silly things, but in virtual reality you can create any context. So, a context where you're giving a presentation to just a small group or a large group and people are giving me negative feedback as well as positive feedback.
Jess: So, you can tailor the situation to what the client's fear is. Is that it?
David: Virtual Room 101.
Professor Peter McEvoy: Exactly right. So we can create any context and the clients can practise the skills with all that feedback, and then redirecting their attention back to the task at hand. Because often people with social anxiety, very self-focused, they're feeling so uncomfortable, so anxious that they're just so aware of their sweatiness and heart racing. And then they worry that people are noticing their anxiety and that feeds the threat of the situation. We can create all those situations and also teach them how to focus back on the task at hand – regardless of the context, regardless of the feedback they're getting back – and help them to manage their anxiety that way as well.
Jess: We've spoken about treatment. How can communities work together to help reduce the prevalence of social anxiety?
Professor Peter McEvoy: Look that's a great question. If we think about some of the risk factors for social anxiety, but also psychological problems more broadly, then certainly there's a genetic load. You know, we all are vulnerable to varying degrees based on our genes. If we have a close family member who suffers from social anxiety or an anxiety disorder, then we're more likely to have an anxiety disorder, but not necessarily, and that's a really important thing. A lot of parents feel a bit guilty if they notice their anxiety in their kids, but most anxious parents won't go on to have anxious kids. It's not a foregone conclusion by any means. That is an important factor. We're all born with our own temperaments as well. Any of us that have more than one child know same gene pool, same context, but very different personalities.
So we all have different personalities that are varying in terms of our vulnerability to anxiety. Those factors really aren't necessarily that changeable per se, but certainly contextual factors or environmental factors – you know, abuse of various kinds – are going to have an impact. So, how much do we focus as parents, um, blaming the parents on one, do we focus on the need for our kids to have external validation or approval from others? Not to say it isn't important and that we do need to get on with people, but the degree to which we believe our children must have approval of others is going to be important. The degree to which we criticise them ... that can turn into to a bit of a monologue in their own mind, that can then feed their expectations moving forward.
And I'm not saying this to make parents feel guilty because we've all criticised our kids, you know, we all criticise ourselves, but it's a matter of balance in that. And are we doing that to really help them, or is it from our own anxiety that we're doing too much of that? Encouraging our kids also to be prosocial and to interact with others; if we're not giving our kids the opportunities to develop those skills then might be more likely to develop social anxiety,
Jess: if there's someone listening who wants to address their social anxiety, it may not tick all the boxes to social anxiety disorder, but they may notice a few of these symptoms. What's the first step they should take?
Professor Peter McEvoy: if they did want to investigate treatment options and certainly a GP’s a great first start. Just have a chat about your experience, your symptoms and see what they offer. They might offer to refer to a psychologist that can help you work through this process. The treatment is going to involve identifying the thoughts and beliefs you have, and the predictions you’re making about social situations, and teach you skills for helping to challenge some of those; reducing the avoidance so that you can directly challenge those views; strategies for challenging this self-image that we had about how we think we coming across to others. It’s going to be training our attention to focus back on the task at hand, rather than being caught up with evaluation. And also some of the core beliefs about why are we assuming that we're likely to be criticised, or that others are going to be hostile and critical.
They're the sort of things that you might explore. The online options are a great option. I mentioned MindSpot before, but there are others as well that can provide some information and support. There's a lot of online materials. The Centre for Clinical Interventions is a local service that has a lot of online materials for a whole range of mental health issues, and social anxiety in particular. So there's lots of information that can help people learn about it, learn about the things that seem to maintain it, and also ways to manage it better.
David: Okay, and that brings us to the end of our discussion. Thank you very much Professor Peter McEvoy for sharing your expert knowledge.
And if you are concerned about anxiety, you may want to contact the Beyond Blue info line on 1300 224 636, or by doing an online search for Beyond Blue.
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