Morgan Hagner, PsyD, Post-Doctoral Fellow

Harper* is a 32-year-old woman who works remotely doing data entry. She has dealt with episodes of anxiety since her teenage years, but she recently started treatment after her symptoms worsened. Because of her anxiety, Harper tends to avoid social interactions. Despite feeling anxious in social settings, Harper hopes to build skills and reduce her anxiety so she can engage with others and participate in activities that used to bring her pleasure. 

Understanding the Cycle of Social Anxiety and Avoidance

During a recent session, Harper discussed a trip to the movies with close friends during which her anxiety became intense. She reported that she became quite uncomfortable on her drive there and she was unable to enjoy the experience. While with her friends, all she could think about was wanting to leave so she wouldn’t feel anxious anymore. On her way home, she told herself, “It wasn’t worth it” and decided that she wouldn’t go to the movies again. 

I asked Harper, “Are there any other places that you’ve already decided you’d never return to? Or any other activity that you’ve decided you won’t do again?” Although she didn’t actually get sick, Harper said she felt so horrible at a local coffee shop a few months before that she’d never make a repeat visit there. Likewise, she said she wouldn’t go bowling again or to a concert.  

A woman shaking hands at a networking event.

I noticed that Harper believed that if she had a negative experience, she could never go to the specific location or engage in the activity again. I conceptualized that this pattern puts enormous pressure on her to control her behavior, her physiological symptoms, and her anxiety, at the risk of narrowing her life even more. I decided to help Harper identify and vividly describe her worst fear and assess whether it was the most realistic outcome—and explore how she could cope if it actually happened. 

Identifying Worst-Case Fears Through Imagery

In our next session, I asked Harper to picture herself driving to the movie theatre and asked her what was going through her mind. She said that she was afraid she would get sick. I asked her to imagine her worst fear coming true and to tell it to me in great detail. Harper vividly described driving to the movie theater, becoming anxious, feeling nauseated, questioning whether she should pull over, and ultimately, arriving and throwing in the crowded theater lobby while she was looking for her friends. At the end of the exercise, she repeated that she would not go to the movies again in the future. 

I asked Harper to imagine another scene in detail, one that was very frightening to her. Harper described having an in-person interview for a potential job. She feared that car trouble would make her late. Then she would be so anxious and disoriented and nauseated when she got to the office that she would ruin the interview. She believed that her anxiety would decrease only after she arrived home and was lying in bed. 

CBT Strategies to Cope With Anxiety

This made me wonder: What is causing her to think she needs to escape to the safety of home and avoid a situation like this in the future? What was happening in the moment? What was she thinking, doing, and feeling, and how was her body reacting? I asked Harper to imagine the interview again, but this time, to let her anxiety become very intense. I asked questions to intensify the image even further. When she was about to head home in the image, she had her typical automatic thought: “That was so horrible, I need to go home!”  

I suggested that she imagine responding to that thought, saying to herself: “Wow, that was really intense. But I lived through it! This shows me that I can handle it when I’m really, really anxious.” We also discussed coping strategies, for example, doing deep breathing, engaging in progressive muscle relaxation, listening to a podcast, taking a walk, or calling a friend before a feared situation (and after, if she is worried or upset about the experience).   

From Negative Predictions to Realistic Predictions

Harper was able to recognize that her prediction, “I’ll get sick” increased her anxiety and made it difficult for her to enjoy time with friends and stay present in social interactions. And it hadn’t actually ever come true! She also learned to respond to negative thoughts she has after an anxiety-provoking experience.  

Harper started to make more realistic predictions about upcoming experiences and to draw more adaptive conclusions when she participated in social events. Other standard CBT and ACT interventions such as exposure, cognitive diffusion, acceptance of negative emotion, using her senses to ground herself in the present, shifting her attention to the present when she’s worrying about the future, and taking committed action in alignment with her values helped her overcome her social anxiety and re-engage in activities she once enjoyed.   

*The client’s name and identifying details have been changed to protect confidentiality.

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