Adult Treatment Planner

Objectives and Interventions

• Describe the history and nature of social fears and avoidance.
  • Establish rapport with the client toward building a therapeutic alliance.
  • Assess the client's frequency, intensity, duration, and history of panic symptoms, fear, and avoidance (e.g., The Anxiety Disorders Interview Schedule for the DSM-IV by DiNardo, Brown, and Barlow).
  • Assess the nature of any stimulus, thoughts, or situations that precipitate the client's social fear and/or avoidance.
• Complete psychological tests designed to assess the nature and severity of social anxiety and avoidance.
  • Administer a measure of social anxiety to further assess the depth and breadth of social fears and avoidance (e.g., The Social Interaction Anxiety Scale and/or Social Phobia Scale by Mattick and Clarke).
• Cooperate with an evaluation by a physician for psychotropic medication.
  • Arrange for an evaluation for a prescription of psychotropic medications.
  • Monitor the client for prescription compliance, side effects, and overall effectiveness of the medication; consult with the prescribing physician at regular intervals.
• Participate in a small group therapy for social anxiety.
  • Enroll clients in a small (closed enrollment) group for social anxiety (see "Shyness" in The Group Therapy Treatment Planner, 2nd ed. by Paleg and Jongsma; "Social Anxiety Disorder" by Turk, Heimberg, and Hope in Clinical Handbook of Psychological Disorders by Barlow [Ed.]).
• Verbalize an accurate understanding of the vicious cycle of social anxiety and avoidance.
  • Discuss how social anxiety derives from cognitive biases that overestimate negative evaluation by others, undervalue the self, distress, and often lead to unnecessary avoidance.
  • Assign the client to read psychoeducational chapters of books or treatment manuals on social anxiety that explain the cycle of social anxiety and avoidance and the rationale for treatment (e.g., Overcoming Shyness and Social Phobia by Rapee; Overcoming Social Anxiety and Shyness by Butler; The Shyness and Social Anxiety Workbook by Antony and Swinson).
• Verbalize an understanding of the rationale for treatment of panic.
  • Discuss how cognitive restructuring and exposure serve as an arena to desensitize learned fear, build social skills and confidence, and reality test biased thoughts.
• Learn and implement calming and coping strategies to manage anxiety symptoms during moments of social anxiety.
  • Teach the client relaxation and attentional focusing skills (e.g., staying focused externally and on behavioral goals, muscular relaxation, evenly paced diaphragmatic breathing, ride the wave of anxiety) to manage social anxiety symptoms.
• Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk.
  • Explore the client's schema and self-talk that mediate his/her social fear response, challenge the biases (or assign "Journal and Replace Self-Defeating Thoughts" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma); assist him/her in generating appraisals that correct for the biases and build confidence.
  • Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure (see "Restoring Socialization Comfort" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma; The Shyness and Social Anxiety Workbook by Antony and Swinson; Overcoming Shyness and Social Phobia by Rapee).
• Undergo gradual repeated exposure to feared social situations within therapy.
  • Direct and assist the client in construction of a hierarchy of anxiety-producing situations associated with the phobic response.
  • Select initial in vivo or role-played exposures that have a high likelihood of being a successful experience for the client; do cognitive restructuring within and after the exposure, use behavioral strategies (e.g., modeling, rehearsal, social reinforcement) to facilitate the exposure (see "Social Anxiety Disorder" by Turk, Heimberg, and Hope in Clinical Handbook of Psychological Disorders by Barlow [Ed.]).
• Undergo gradual repeated exposure to feared social situations in daily life.
  • Direct and assist the client in construction of a hierarchy of anxiety-producing situations associated with the phobic response.
  • Select initial in vivo or role-played exposures that have a high likelihood of being a successful experience for the client; do cognitive restructuring within and after the exposure, use behavioral strategies (e.g., modeling, rehearsal, social reinforcement) to facilitate the exposure (see "Social Anxiety Disorder" by Turk, Heimberg, and Hope in Clinical Handbook of Psychological Disorders by Barlow [Ed.]).
  • Assign the client a homework exercise in which he/she does an exposure exercise and records responses (or assign "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma; also see The Shyness and Social Anxiety Workbook by Antony and Swinson; Overcoming Shyness and Social Phobia by Rapee); review and reinforce success, providing corrective feedback toward improvement.
• Learn and implement social skills to reduce anxiety and build confidence in social interactions.
  • Use instruction, modeling, and role-playing to build the client's general social and/or communication skills (see Social Effectiveness Therapy by Turner, Beidel, and Cooley).
  • Assign the client to read about general social and/or communication skills in books or treatment manuals on building social skills (e.g., Your Perfect Right by Alberti and Emmons; Conversationally Speaking by Garner).
• Implement relapse prevention strategies for managing possible future anxiety symptoms.
  • Discuss with the client the distinction between a lapse and relapse, associating a lapse with an initial and reversible return of symptoms, fear, or urges to avoid and relapse with the decision to return to fearful and avoidant patterns.
  • Identify and rehearse with the client the management of future situations or circumstances in which lapses could occur.
  • Instruct the client to routinely use strategies learned in therapy (e.g., using cognitive restructuring, social skills, and exposure) while building social interactions and relationships.
  • Develop a "coping card" on which coping strategies and other important information (e.g., "Pace your breathing," "Focus on the task at hand," "You can manage it," and "It will go away") are written for the client's later use.
• Explore past experiences that may be the source of low self-esteem and social anxiety currently.
  • Probe childhood experiences of criticism, abandonment, or abuse that would foster low self-esteem and shame, process these.
  • Assign the client to read the books Healing the Shame That Binds You (Bradshaw) and Facing Shame (Fossum and Mason), and process key ideas.
• Verbally describe the defense mechanisms used to avoid close relationships.
  • Assist the client in identifying defense mechanisms that that keep others at a distance and prevent him/her from developing trusting relationships; identify ways to minimize defensiveness.
• Explore beliefs and communication patterns that cause social anxiety and isolation.
  • Utilize a transactional analysis (TA) approach to undercover and identify the client's beliefs and fears. Then use the TA approach to alter beliefs and actions.
  • Assign the client to read a book on improving social relationships using transactional analysis (e.g., Achieving Emotional Literacy by Steiner).
• Return for a follow-up session to track progress, reinforce gains, and problem-solve barriers.
  • Schedule a follow-up or "booster session" for the client for 1 to 3 months after therapy ends.