For adults
Social anxiety
Social anxiety is a well-understood pattern in which fear of being judged is kept going by watching yourself and avoiding situations. It is different from shyness, and it responds to a specific form of CBT.
What social anxiety is
Social anxiety is the fear of being judged and found wanting, of doing something that shows you to be awkward, boring or visibly anxious. Many people with it are not shy at all and come across as confident while finding the effort exhausting. In a feared situation you turn your attention inwards and monitor how you are coming across, which takes your attention away from the conversation and gives you a vivid, usually wrong, impression of how badly it is going. If the evening goes acceptably, you conclude that it did so because you rehearsed and said little, so the fear is never tested. Afterwards you may lie awake replaying one clumsy sentence, and that review is based on how anxious you felt rather than on anything anyone saw.
What social anxiety looks like, at work and socially
- Scripting what you will say in a meeting, then not saying it.
- Letting a call go to voicemail and texting instead.
- Not eating in front of colleagues, in case your hands shake.
- Spending most of the party in the kitchen or with the one person you know.
- Turning down a promotion because it involves presenting.
- Blushing, sweating or shaking, and then worrying about whether it showed.
Why the things you do to get through keep it going
Most people with social anxiety have ways of getting through, such as a drink before going out, a script, looking at their phone, avoiding eye contact or standing near the door. They feel like coping, but they also keep the fear going, because when the evening goes well you put it down to them and never learn that you could have got through it without them, anxious but managing. Alcohol is a common example, and reducing it is often a useful early change.
- Situation: Walking into a meeting, or starting a phone call
- Prediction: They’ll see I’m anxious and think I’m odd
- Attention turns inwards: Watching yourself, a hot face, a shaky voice
- What you do to get through: Rehearsing, saying little, avoiding eye contact
- Afterwards: Relief, the prediction goes untested, and you replay the worst moments
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: Ordering in a café, eating in front of others, video calls, small talk at the school gate.
Where treatment steps in. You go into the situation, drop the rehearsing and the other ways of getting through, and move your attention onto the conversation. You learn that you can be there while anxious, and you get real information about how you came across.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
What treatment involves
NICE recommends cognitive behavioural therapy based on the Clark and Wells model (guideline CG159) as a first-line psychological treatment for social anxiety disorder. We start by drawing out your own version of the loop above, from a recent situation, so that we both know what keeps it going for you. The main thing you learn in treatment is that you can be in a social situation while anxious, without the rehearsing, the self-monitoring and the other ways of getting through, and that the anxiety becomes easier to manage the more often you do that. An early exercise makes the point directly: you have a short conversation while watching yourself and using your usual habits, then the same conversation with your attention on the other person and the habits dropped, and you compare how each felt and how you think you came across. Most people find the second version less anxious and think they came across better. You then practise moving your attention outwards, onto the other person and the room, which gives you real information in place of your own impression, and feedback on how you actually came across, which is usually better than how it felt from the inside.
Alongside that, we plan experiments. We state precisely what you predict will happen: “it will go badly” cannot be tested, whereas “I will go blank for ten seconds and they will look at each other” can. You go into a situation you would normally find hard, drop one of the things you do to get through, keep your attention outwards, and notice what actually happens. Later you may do the feared thing on purpose, such as asking an obvious question or letting a silence run, and find that even if it goes less well than you would like, it is something you can handle. The behavioural experiment sheet is the one we use to write down each prediction and what happened. Later in treatment we also work on the replaying afterwards, and on the memories of earlier social experiences that the fear often draws on.
Social anxiety in teenagers
Social anxiety usually starts in adolescence, and it is easy to miss, because a quiet teenager who causes no trouble at school is often not referred. Signs include refusing to order food or ask a teacher a question, stomach aches on days with presentations or PE, friendship groups that shrink, contact that stays online, and missed lessons, which can become school refusal. Treatment is the same therapy adapted for adolescents, with shorter pieces of work, more concrete experiments and parents involved, usually for the last few minutes of a session. Parents often help by ordering for their teenager, making calls or accepting invitations on their behalf, which spares real distress but also removes the chance to find out they can manage. Where a young person will not attend, SPACE (Supportive Parenting for Anxious Childhood Emotions) is a treatment for parents alone that helps them change those responses.
What recovery looks like
Recovery does not mean becoming an extrovert, and if you are naturally quiet you can stay quiet. What changes is that anxiety no longer makes the decision, so you go because you want to, you speak when you have something to say, and the replaying afterwards stops.
Sources
- Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). Guilford Press.
- National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. Clinical guideline CG159 (2013). nice.org.uk/guidance/cg159 (opens in a new tab)
Common questions
Will therapy make me do public speaking?
Only if that is one of your goals, and only at a point you have chosen. Treatment works from a list you build, starting with situations that feel manageable and moving on as your confidence grows. Some people want to give a best man’s speech. Others want to eat lunch with colleagues or make a phone call without rehearsing it. The steps are planned with you in advance, and they come from your life rather than a standard set of challenges.
How long does treatment usually take?
There is no fixed number. NICE guidance (CG159) describes this form of CBT as up to 14 sessions over about four months. Many people date their social anxiety to childhood or early adolescence, but a long history does not have to mean slow treatment. Progress depends mostly on the practice between sessions, particularly going into situations without the rehearsing, drinking or avoiding you have relied on, which becomes easier the more you do it. I give you an estimate by the end of the first session, and sometimes further assessment is needed before I can.
My teenager will not talk to me about it. What can I do?
There is a route that does not depend on your teenager talking. In parent-based treatment such as SPACE, parents attend and the young person does not, and the focus is on changing how the family responds rather than persuading a reluctant teenager into therapy. Ordering for them, making their calls or letting them skip the party are understandable ways of helping, but they can keep the fear in place. Changing those responses can reduce anxiety even when the young person never takes part.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.