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Dr. Albano's approach to the treatment of social anxiety disorder is steeped in the cognitive–behavioral model. In effect, nonclinical social anxiety is viewed as a normal, developmentally appropriate reaction to social or evaluative situations. It is expected to occur periodically in response to certain developmental stages (e.g., ages 4–6, upon starting school; ages 12–17, when social-evaluative demands increase for the adolescent) and to certain environmental stressors (e.g., being evaluated, interviewed, or entering new situations with unfamiliar people). For most individuals, these social anxiety reactions are mild to moderate in intensity and they decrease in their frequency over time, given experience with the situation and habituation to the anxiety response. However, some individuals are more prone to experiencing social anxiety and to becoming overly anxious in anticipation of, or when confronted by, social-evaluative situations. If the anxiety interferes in functioning (school, social relationships, family, work), and the anxiety is experienced as distressing or debilitating, the individual likely has an anxiety disorder. Anxiety disorders may result from a number of converging factors, including genetics, temperament, learning experiences, cognitive style, parental rearing practices and attitudes, and other psychological vulnerabilities (e.g., anxiety sensitivity). Whatever the cause of social anxiety disorder, the focus in treatment is on what the person thinks, feels, and does in response to social-anxiety-provoking situations in the present day. Hence, CBT is focused on the here and now, on changing patterns of behavior (including verbal behavior as well as overt actions) to become more proactive and prosocial. CBT involves education about the nature of anxiety and the ways that pathological anxiety is maintained, somatic management techniques such as relaxation to dampen arousal, cognitive restructuring to address anxiety-focused thinking and to develop realistic, coping-focused thinking styles, and behavioral exposure to practice dealing with anxiety-provoking situations and allowing habituation to occur. Specific skills are taught to address any deficits in problem-solving skills, social skills, or assertiveness. Parent involvement depends on the age of the child and the degree of impairment in functioning, with younger children potentially having more parental involvement in the treatment than adolescents. Relapse prevention strategies are to maintain the gains made in therapy and promote generalization to a wider range of situations. CBT is flexibly applied to meet the needs of individual patients, given patient characteristics such as age, cognitive-developmental level, severity of illness, access to social support, and comorbidity. Hence, specific cognitive–behavioral treatment protocols have been developed and tested for the range of disorders affecting children, adolescents, and adults, with the goal of using these manuals as guides to developing individual treatment plans for assisting the patient. A typical patient in Dr. Albano's social anxiety program is an adolescent around 15 years of age, enrolled and attending 10th grade, and progressing through school with average to above-average grades. The adolescent is liked by teachers and other adults and viewed as a quiet or shy individual who is no problem in the classroom and usually "a pleasure to teach" but "not very involved" in class activities or discussions. Siblings of the adolescent are viewed as much more social and outgoing, and typically are involved in extracurricular school events and attend social outings such as parties; these are things that the socially phobic adolescent has stopped doing altogether by the age of 15. Whereas he or she used to attend parties and school events when younger, this was usually at the parents' insistence and encouragement, and also with the parent's assistance; as an older adolescent, he or she no longer engages in these activities. By the age of 15, the adolescent has convinced him- or herself that "I'm not interested in these sorts of things" and "I'm fine being alone and by myself, because going out takes too much energy and it's no fun, anyway." A solitary activity or hobby may be in place, such as spending hours on a certain computer game, art project, or watching videos. The adolescent also does not like to engage in socializing with extended family members, so he or she retreats to the bedroom when aunts, uncles, and cousins come to visit. If asked, the adolescent may say that these relatives are "too loud" or "boring." Struggles may occur with the parents when the adolescent refuses to engage in these activities and retreats from taking responsibility for him- or herself in contacting peers for missed assignments when out sick, ordering food in a restaurant, or answering the phone at home. The adolescent with social phobia dreads social and evaluative situations, so that the school day is one big ball of nerves. He or she arrives just on time, to avoid "hanging out" with peers. Such unstructured time is overwhelming for the adolescent, because these are the times that peers plan social events, talk about past events and what happened, and engage in joking and teasing with one another. The adolescent will worry about being called on in class and will rarely volunteer an answer for fear of looking foolish or saying the wrong thing. Lunch period may be spent eating in a bathroom stall or staying in the library, because of the social nature of the cafeteria. Oral reports can be overwhelmingly upsetting, as the adolescent recognizes that blushing, sweating, and shaking can be noticed by others and will cause embarrassment. The adolescent cannot discuss any questions or concerns with teachers, for fear of being yelled at or viewed as stupid, so he or she will sit with uncertainty and not ask for clarification on things misunderstood. The end of the day is a relief for the adolescent, so he or she goes directly home to where they feel safe. Of note, some teens will not use the bathroom in school ("shy bladder" is the fear of others hearing you in the bathroom and judging one negatively) and may not eat during school, so they may run into the house in discomfort. Adolescents have some degree of insight into their anxiety because they realize they are uncomfortable in these situations and would rather avoid them. The idea of wanting to make friends and be around people is scary to the adolescent, so this may not be something the adolescent can admit to. The adolescent will come to treatment, with hesitation, and usually at the insistence of the parent. It is important to note that this approach is appropriate for most teens but with caveats. Dr. Albano would not use a straight CBT approach for youth with psychosis or prodromal symptoms, as medication and family intervention is warranted as first-line treatments. Youth with Asperger's disorder or pervasive developmental disorders may not be appropriate for CBT but do benefit from more straightforward behavioral techniques such as social skills training and applied behavioral analysis. Teens with comorbid conditions, such as selective mutism or other anxiety disorders such as obsessive–compulsive disorder, require evaluation by a therapist who then develops a thoughtful and pragmatic treatment plan that addresses the most interfering symptoms first. |
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