What to expect in therapy for social anxiety

In CBT for social anxiety, you and the therapist work as a team. The first session is mostly about understanding your fears. After that, you test those fears in small, planned experiments, in the session and in everyday life. A typical course lasts about three to four months. It is hard work at times, but you go at a pace you agree on.

Before the first session

Many people dread the first session more than anything that follows. It helps to know that:

• the therapist expects you to be nervous. Social anxiety is their job. Freezing, blushing or not knowing what to say will not surprise them;
• you don’t have to tell everything at once. You can say “I find this hard to talk about”;
• you can write things down and bring the notes, or send them by email first;
• you may be asked to fill in questionnaires about how anxious you feel in different situations. These help track progress over time. There are no right answers.

If the waiting room worries you, you can ask to arrive just on time, or to wait somewhere quieter. If getting there at all is the hard part, see when booking is hard.

The first session or two

The therapist will ask about:

• which situations you fear and avoid;
• what you fear might happen (for example, “they’ll see me blush and think I’m weird”);
• what you do to protect yourself, such as rehearsing, avoiding eye contact or holding your glass tightly. These are called safety behaviours;
• what you think about before and after social events;
• your mood, sleep, alcohol use and any medication.

Together you will draw a picture of the loop that keeps your anxiety going. You will also agree on goals, such as “speak up once in each team meeting”.

What happens week by week

In cognitive therapy for social anxiety (CT-SAD), the best-tested form, sessions often include:

• Experiments with safety behaviours. You have a short conversation twice, once using your safety behaviours and once without, and compare how it felt and how it went.
• Video feedback. You watch a recording of yourself. Most people look far less anxious than they felt.
• Shifting attention outward. You practise focusing on the other person and the conversation instead of on yourself.
• Behavioural experiments. You test a feared prediction in real life. For example, you ask a shop worker a “silly” question and see what really happens.
• Dealing with the replay. You learn to notice when you start going over a conversation afterwards, and to stop.
• Old memories. Some people work on painful memories, such as being bullied, that still shape how they see themselves.

UK guidelines (NICE) describe CT-SAD as up to 14 sessions of 90 minutes over about four months. Another well-tested CBT model uses 15 sessions of 60 minutes plus a longer exposure session.

Homework is part of it

Most of the change happens between sessions. You will usually agree on a task for the week, such as making one phone call without a script. This is not a test you can fail. If it doesn’t go to plan, that is useful information to bring back.

Other forms of therapy

• Online CBT with a therapist. You work through modules at home and message your therapist. In a trial of 102 people in England, the online version of CT-SAD worked as well as face-to-face therapy. See internet CBT.
• Group CBT. You practise with others who have social anxiety. It helps, but individual CBT showed a bigger effect in a large comparison of trials. See group CBT.
• VR exposure. Some therapists use a headset so you can practise a meeting, a talk or a party in a virtual room. Inside therapy it works about as well as real-life practice, and it lets you start small and repeat a moment many times. See VR exposure therapy.

Will it work?

For many people, yes. In one trial, 84% of people who had cognitive therapy for social anxiety no longer had the disorder at the end. It still did better than the comparison treatment a year later.

Gains often last. In a five-year follow-up of 80 people who had internet CBT in Sweden, most of the improvement was still there.

Therapy does not make you a different person or remove all nerves. The aim is that fear no longer decides what you do.

Getting the most from it

• Tell the therapist what is really happening, including what you avoid in sessions. They can only work with what they know.
• Say if something isn’t working or feels too fast.
• Do the homework, even a small version of it.
• Expect ups and downs. A bad week is normal and does not mean you are going backwards.
• Plan for the end. Near the end you will make a plan for keeping up the practice and handling setbacks.

If you start feeling much worse, very low or have thoughts of harming yourself, tell your therapist or doctor. If you need help right now, see crisis lines.