Dr. Matthew May was our speaker at our March luncheon in Mountain View. Dr. May kindly submitted this article outlining his presentation.

This is a story about “Wendy,” a young woman from rural Virginia who sought treatment for Social Phobia the year after she graduated from college. Wendy’s problems began in middle school, when the “mean girls” would make fun of her and call her “fatty.”

In retrospect, Wendy believes that her response to the bullies at school played almost as much a role as the bullies, themselves, in creating her problems. Afraid of being teased, she would call her mother from school every day rather than going to recess and facing her tormentors. Her fears increased such that it became emotionally challenging to be in any social setting. She never attended any dances or social functions during high school and felt lonely, isolated and terrified she would never meet anyone to date or marry.

In college she developed an infatuation with one of her classmates and experienced a devastating breakup. She moved home after this and with- drew even more. She was convinced that the few friends she had left would look down on her, judge her, and reject her because she had failed to succeed in her relationships. She was fearful of job interviews and remained unemployed, worsening her shame and sense of hopelessness.

Noticing her depression, a family member recommended the book, Feeling Good, by Dr. David Burns. After reading this, she began to feel better and develop more hope for her future. She reached out to Dr. Burns, who spoke with her and empathized with her experience. Through him, she was referred to my practice in Menlo Park, California. She came to therapy every day, two hours per day, for five days.

Wendy and I worked together, using the methods described by Burns in his books, Feeling Good, Intimate Connections and When Panic Attacks. At the time she began treatment, she was dressed in dark, baggy clothing, avoided eye contact, spoke haltingly and, as the title suggests, appeared
to be hiding behind her hair. By the end of therapy she had a new look, a new wardrobe, a new hairstyle and had the confidence and social skills to go out in public, talk with strangers, eat meals, even to act in silly and spontaneous ways. On her last day, she noticed an attractive man in a pet store working behind the counter. She approached him and asked for his phone number, leading to a wonderful romantic date and a lasting friendship.

Social Phobia (SP) is the third most prevalent psychiatric diagnosis, with around 15 million suffering from this disorder in the United States. Individuals with SP worry about social situations, such as public speaking, entering a crowded room, or talking with strangers. The symptoms interfere with activities of daily living and with the attainment of those things we

hold most dear: meaningful relation- ships, gainful employment, pleasurable recreation, creative play, and the ability to feel good about ourselves in public and in private. Individuals with SP have worse medical outcomes and are more likely to have legal difficulties or to commit suicide.

Therapy that includes social exposure and response-prevention has robust evidence supporting its efficacy in treating individuals with SP. Despite the effectiveness of available treatments, several barriers prevent care from reaching those in need. These include feelings of shame and avoidance behaviors characteristic of individuals with SP and the reality that many therapists lack familiarity, practice and skill in utilizing the methods that are required for successful treatment of SP.

Dr. David Burns has spent a large part of his career addressing these problems. A wide array of materials and information is available for therapists through his website www. FeelingGood.com. Additionally, there are training opportunities at the Feeling Good Institute in Mountain View, California: www.FeelingGoodInstitute.com. The model developed by Dr. Burns is based on tenets of Cognitive Behavioral Therapy (CBT) but goes beyond typical CBT paradigms. It is called TEAM therapy, which stands for Testing, Empathy, Agenda Setting, and Methods.

CBT proposes that one way to understand our emotions, including anxiety, is the cognitive model, which states that our feelings are caused by automatic negative thoughts (ANTs). According to the cognitive model, we ‘feel the way we think’ and the thoughts which create our suffering are distorted and can therefore be refuted, leading to improvement in mood. Just as importantly, the behavioral model states that we must change what we do in order to change how we feel and includes exercises that boost motivation and eliminate our fears.

TEAM therapy incorporates sever- al other models, in addition to those of CBT. The author believes that the most important of these, and what accounts for the profound and rapid responses seen in patients treated with TEAM, is ‘Paradoxical Agenda Setting’ (PAS). PAS acknowledges that therapists are powerless to overcome both types of therapeutic resistance:

Outcome Resistance: Not wanting change, even if it were as easy as pressing a button.

Process Resistance: Being unwilling to do what is required to recover.

Paradoxically, when therapists ac- knowledge that they are powerless to make the patient’s decisions for them, and let go of the need to convince and change their patients, is when they are most effective.

The magic of therapy is not in the therapist. It is within the individual who is seeking help. For example, in the initial phone call with Wendy, I allowed her to decide whether she wanted the type of help I was offering:

“I’m very optimistic that you can recover using some combination of these methods. However, I’m not sure you would want to work with me. Some of the required methods for overcoming anxiety involve facing one’s fears. I would be willing to face them with you. However, there would be a temporary increase in anxiety while we did this. I would understand if that is too high of a price for you to pay. At the same time, I would be very eager and willing to work with you.”

On the phone, Wendy was able to convince me that she wanted change and that she was willing to pay the ‘price’, including feeling more afraid before she felt relief. However, when I met her, I realized there was another problem that was going to defeat our work.

Question: Based on what you know, why would Wendy NOT benefit from social exposure?

The clue is in the title of the talk, “The Girl Who Hid Behind Her Hair”. When individuals have anxiety, it is natural for them to respond by avoiding their fears and protecting them- selves in a variety of different ways. A patient with a phobia of germs and contamination will ‘respond’ by washing his or her hands excessively. Those with a fear of losing control will count their steps and engage in repetitive checking behavior. For Wendy, she tended to hide herself by covering her face with her hair and wearing baggy clothes. This ‘response’ was in- tended as protection and was a reflection of her belief, common to those with SP, that people are judgmental and critical. Someone who engages in exposure exercises without letting go of their ‘protective’ responses and self-defeating beliefs will not benefit. They often will continue to think “yes, but if I hadn’t protected myself by [washing my hands/counting and checking/concealing my appearance], then I would have [become sick/lost control/been judged and rejected].” In this way, the thoughts that cause the fear are not defeated and the fears persist.

What this meant, for Wendy, was that her recovery depended on not only facing her fears, using social exposure exercises, but also giving up her protections and preventing her natural ‘responses’ to anxiety (response prevention). Giving up these safeguards increases anxiety, how- ever, so there is usually an element of ‘process resistance’ when asking whether patients are willing to do this (see above).

As soon as I told Wendy that this would be an additional price for her to pay, she became extremely fearful and refused to agree to this approach. After empathizing with her new anxiety and the unfairness of this previously unmentioned ‘cost’, I utilized a PAS method, ‘open hands’: “You don’t have to continue further in our work if you don’t want to. I am curious, however, what you would be afraid of if you were to wear a nice dress, makeup and pull your hair back?”

The patient was horrified by this idea and said, ‘I couldn’t dress that way. People would think I’m a prostitute!’

Realizing that this belief was holding back the therapy, I suggested we address it through a safer form of exposure called the ‘Feared Fantasy’. She accepted and we took turns practicing responses to a judgmental and critical stranger:

Critic: ‘Eww, what are you doing? I can’t believe you’re out in public!’

Patient: ‘Wow, I’m a little hurt and angry you would say that. You’re definitely a straight shooter, though. Perhaps you have some good fashion tips for me? After all, you do look fantastic in that outfit.’

Critic: ‘No way! You look like a prostitute! I’d never be seen talking to a tramp like you!’

Patient: ‘It’s true; I’ve been dressing more adventurously, to help overcome my shyness. That has been a thrill and I’m much more confident about myself. To be honest, your feedback is a tad hurtful and I’m a bit wary of you. Have I done something to offend you?’

Critic: ‘You’ve offended my senses with that terrible outfit. You need to get away from me as soon as humanly possible’.

Patient: ‘I’m waiting to meet someone, actually. I see an exit sign in that direction, though, if you need to get going. I’m still confused, though. What part of my outfit is most off-put- ting to you?’

Critic: ‘Everything about it is gross and weird’

Patient: ‘Yikes! I suppose I am in need of an urgent fashion consultation. I’m glad someone as sophisticated and savvy as you was around to make me aware. Is there anything else you wanted to add?’

Critic: I reject you! Patient: Rejection accepted!

Practicing like this led to laughter as Wendy realized that the ‘critic’ was ridiculous and just a figment of her imagination. Even if someone were to respond like the ‘critic’ of her ‘feared fantasy’, they would be the one with the problems.

After this exercise, she did multiple social exposure exercises while wearing attractive outfits and makeup. She emerged from beneath her hair and eliminated her social anxiety. These exposure activities included ‘Smile and Say Hello’ practice and ‘David Letterman Technique’ (asking questions and paying compliments). After success with these, she tried more difficult exercises, like ‘Self Disclosure’ (sharing vulnerable feelings and truths about ourselves, like, saying, ‘I’m a shy person’ or ‘I feel a bit nervous’) and ‘Survey Method’ (asking what other people really think). Wendy even did the most difficult social exposure exercises, ‘Rejection Collection’ and ‘Shame Attacking’.

In Shame Attacking, the therapist and patient will intentionally do ridiculous (but safe) things in public, challenging the idea that people are judgmental and critical. Wendy, for example, went running around in circles in a crowded coffee shop, victoriously pumping her fists and whooping happily. This led to the realization that people were remarkably non-judgmental and frequently wanted to join in the fun! It also helped generate confidence that if she encountered judgmental people she could tolerate the judgment or even tease them back.

The results were impressive, as indicated on the measurement of the patient’s mood and feedback of therapy, where she stated that it was hard, now, for her to understand what she was afraid of in the first place!

Years later, the patient is now in great spirits. Shortly after the treatment she developed the urge to move out of her parent’s home and she now enjoys a vibrant social life and is successful in her work. She maintains her gains by continuing to socialize and engage in shame-attacking and rejection practice.

Other techniques discussed included common automatic negative thoughts in SP, tactics to “talk back” to these ANTs, use of the cost-benefit analysis tool, and uncovering techniques such as the “what-if” exercise to understand deeper fears, beliefs, and values that underlie a patient’s patterns of thinking and feeling.

Two other important aspects of TEAM therapy include Homework and Relapse Prevention. Homework is a requirement for patients in TEAM therapy to actively participate in their recovery by doing daily homework exercises. Research has shown that active participation and practice is required for recovery from depression and anxiety, just as it is required to learn a musical instrument, new language, or martial arts.

Relapse Prevention is a necessary part of psychotherapy because of the “inevitability of relapse.” When we feel better, it is tempting to imagine that a permanent state of enlightenment has been achieved. This unrealistic expectation is a ‘setup’ for prolonged and severe relapse, rather than brief, self-treatable relapses. Patients will think to themselves, when they relapse, ‘even that therapy didn’t work, I really am a hopeless case’ unless they are prepared for this eventuality and given the reminder, when they feel that way, to use the methods that worked for them. Just like our physical health, our mental health is a work-in-progress, requiring regular maintenance. Developing healthy mental habits is part of Relapse Prevention.

The remainder of the talk was focused on identifying problems and risks associated with exposure exercises for anxiety. The speaker noted that many therapists were understandably reluctant to use exposure methods and acknowledged that there were problems associated with these methods, including:

a. Forcing exposure on the un- willing patient, which is ineffective and damaging

b. Inadequate duration, frequency and intensity of exposure

c. Failure to address co-morbid problems like depression and sub- stance-abuse

d. Inappropriate use of ‘anti-anxiety’ medication, defeating the exposure work

e. Excessive focus on the expo- sure model when other models are more appropriate

f. Failure to include ‘response prevention’ as part of the ‘exposure’

g. Failure to include ‘relapse prevention’ to prepare the client for relapses

h. Exposure to the wrong stimulus, failing to address the appropriate fears

Also, many therapists, due to a lack of experience and training, feel uncomfortable using these methods despite the strong evidence for their efficacy. Therapists treating individuals with anxiety can increase their familiarity and skill with TEAM methods by participating in training and certification through the Feeling Good Institute in Mountain View, California (www.feelinggoodinstitute.com).

In conclusion, the speaker ex- pressed concern that Social Phobia (SP), like many psychiatric diseases, remained under-diagnosed and under-treated, with approximately 13 million un-treated cases in the United States. Fortunately, there are now powerful and rapidly-effective forms of treatment available to patients who are willing to participate in the type of treatment outlined and described by the author.

Dr. Matthew May is a board-certified psychiatrist and an adjunct clinical faculty member at Stanford’s Department of Psychiatry and Behavioral Sciences. He has a private practice in Menlo Park. He can be reached at matthewmaymd.com