In many ways, relationships are at the heart of social anxiety disorder. People with this disorder find it difficult to establish new relationships, and their avoidance of other people puts them at risk for feeling lonely, having fewer friendships, and being unable to take advantage of the enjoyment of being with people who share their hobbies and interests. If they should become involved in a long-term, committed relationship, individuals with social anxiety disorder are less likely to be able to express their emotions. As a result, any relationships they do manage to forge will be less satisfying, both to themselves and their partners.
Research on social anxiety disorder tends to approach the understanding of its causes and treatments from the standpoint of the individual’s extreme aversion to other people. However, as pointed out by University of British Columbia’s Lynn Alden and colleagues (2018), there is not enough attention paid in the literature to the ability to function in close relationships as a component of this disorder. The authors note that “the importance of addressing this issue is underscored by work indicating that social avoidance and social approach behavior are guided by partially independent neurocircuits.” In other words, it’s not just social avoidance that contributes to the disorder. This is because “adaptive relational functioning depends in large part on the social approach system” (p. 506). Treating the avoidance isn’t sufficient to helping people with this disorder improve because, in this view, individuals with this disorder need to learn how to interpret social cues from others and to be able to derive joy from their interactions with other people.
This intriguing perspective suggests, then, that social anxiety disorder needs to be understood in a relational context. Alden et al. note that people with this disorder find it difficult, in their intimate relationships, to be able to self-disclose, to reciprocate the affection others show toward them, and even to be able to smile back when people smile at them. Imagine yourself trying to get close to a person who never shares positive emotions, who rarely displays intimacy, and who seems to rebuff your attempts to establish a deep connection. After a while you’d just give up and find someone else who will return your feelings. The Canadian researchers propose that treatment for people with this order should zero in not only from the avoidance behaviors but should also address those deficits in positive approach behaviors.
According to this new approach to social anxiety disorder, the traditional cognitive-behavioral therapy (CBT) that attempts only to reduce the individual’s avoidance behaviors would benefit from addressing more specifically the relational deficits that such people experience. A previous study on this method, known as CBT-R (the “R” is for relationships) established the efficacy of this approach compared to a no-treatment control condition. In the present study, the authors compared CBT-R with another form of psychotherapy oriented toward reducing only the avoidance behaviors in social anxiety disorder. By being able to show that CBT-R has a unique benefit above and beyond traditional fear-based approaches, the Canadian study therefore was intended to test whether addressing the relationship deficits associated with social anxiety disorder could boost further the effects of treatment based on the more traditional behavioral approach.
To test their model, Alden et al. recruited a sample of 100 adults (50 males and 50 females, 18-65 years old) who all were diagnosed with social anxiety disorder and were not currently in psychotherapy. The participants were randomly assigned to CBT-R, a more traditional behavioral therapy, or a waiting list control condition. All treatments were administered in group therapy format, with treatment consisting of 14 2-hour sessions led by cotherapists.
Therapists began the CBT-R therapy protocol with an explanation of the treatment along with education in the disorder itself. Participants were instructed to keep records of their daily social situations, and they were assigned homework so that they could practice the methods they learned in therapy. In the first segment of treatment, participants were encouraged to identify their “safety behaviors” in which they protect themselves from getting too close to other people. Treatment in this phase encouraged participants to evaluate the impact of these safety behaviors on their interactions. In the second phase, therapists led discussions about the principles of close relationships (e.g. expressing feelings); participants were then asked to evaluate these principles in their social interactions. Finally, participants engaged in exercises intended to help them understand the origins of their negative beliefs about relationships, understand their own patterns of interactions with others, and then re-evaluate the accuracy of those negative beliefs about relationships.
At the end of therapy, and then 6 and 12 months later, participants rated the frequency with which they engaged in actions involving social initiation (e.g. inviting someone out for coffee) and their relationship satisfaction. Additionally, their social anxiety symptoms were evaluated via questionnaire and interview. The researchers also believed that frequency of engaging in social safety behaviors would be affected by therapy and that these, in turn, would affect social initiation and relationship satisfaction. They measured social safety behavior by asking participants to rate themselves on items such as the frequency with which they would pretend that they’re not interested in someone else. Participants also rated an additional possible influence on treatment outcome, which the the researchers call “social judgment biases.” For example, participants rated whether they thought they would react poorly in a social situation and then to evaluate “how bad” it would be if they did so.
As predicted, CBT-R had a positive and lasting (12-month) effect on satisfaction with social relationships. Both CBT-R and the more traditional fear reduction form of therapy had positive effects on the tendency of people with the disorder to initiate social interactions. However, CBT-R’s effect on relationship satisfaction showed the importance of helping people with the disorder to open up and disclose to others in close relationships. Indeed, CBT-R alone reduced the tendency of participants to engage in those social safety behaviors that can keep them isolated and lonely.
These findings provide important insights into the relationship deficits experienced by people with social anxiety disorder. It’s not only that these individuals fear closeness, but that they don’t understand how to establish affectional bonds with the people they actually want to have relationships with. Treating social anxiety disorder only from the standpoint of “fear,” then, misses out on this key interpersonal component.
To sum up, fulfillment in close relationships involves being able to share intimate details with the people you care about the most. Learning how to overcome the barriers that keep you from these deep connections will only help to ensure that your intimacy continues to flourish.