Counselling Case Study: Social Anxiety
Sasha is a 60 year old woman who has recently retired from a career in teaching. Working for many years in a secondary school environment, Sasha was confident, motivated and dedicated to her work, but at the same time looking forward to retirement so she and her husband could travel and spend more time with their adult children who lived nearby.
However upon finishing work, Sasha found herself experiencing severe anxiety, particularly when around other people, and began not wanting to leave the house or invite people into the house. She also experienced bouts of crying when attempting to complete tasks such as housework and using the sewing machine. Sasha found her symptoms eased when she and her husband went on camping trips in national parks where they often did not see other people for days.
While working with Sasha, the Professional Counsellor adopts strategies from Cognitive Behavioural Therapy and Gestalt frameworks in order to address any irrational thoughts and behaviours which may be maintaining Sasha’s anxiety, and to complete any unfinished business which may have led to the development of her anxieties in the first place. For ease of writing, the Professional Counsellor is abbreviated to “C”.
Sasha was an unplanned baby, born after her older brother. Her parents did not want a second child but when they realised another was on the way, they hoped for another boy. As a child Sasha remembers always being in the background and her brother and father being the ‘important’ ones.
Sasha reported a vivid memory of coming home from school one day and finding no-one home. Sasha sat on the front porch and cried until her mother eventually came home and told her to stop being so silly. She described her mother as being more concerned with the state of the house than with her young daughter.
Sasha’s father died when she was very young, and she remembers her mother not coping well for a long time. During this time she (but not her brother) was often sent to her grandparents’ farm to give her mother a break. Here Sasha spent most days on her own. However she remembers these visits fondly, like ‘a lull in the storm’.
When her mother died, she left everything to Sasha’s brother, who was by then a well- paid solicitor with a young family. Sasha also had a young family but did not question her mother’s decision as she had been conditioned from childhood to believe males were more important.
Sasha’s symptoms appeared to be those of social anxiety disorder. They included:
- An extreme fear of situations where she may have to meet new people or be scrutinized by others.
- Social situations were either experienced with intense anxiety or avoided altogether.
When she did face these situations, she experienced physical symptoms such as sweating, shaking, tension, shaky voice, dry mouth and a pounding heart. The main symptom of this disorder involves feeling extreme anxiety in the presence of others. Sufferers often believe other people are very confident in public and that they are the only ones who aren’t.
Almost everyone experiences some social anxiety now and then; however social anxiety disorder severely limits the lifestyle of the sufferer, causing them to avoid making friends or miss important opportunities at work.
In the first session, Sasha described her current physical symptoms and her feelings of hopelessness that she would never have the lifestyle she had dreamed of having in retirement. She was very tearful and her voice was quite high and shaky. She stuttered occasionally and her hands moved constantly, tearing the tissue she was holding to pieces.
She described trying to sew curtains and being overtaken by an uncontrollable fit of crying. She could not explain why this had made her so upset. She had also avoided inviting former work colleagues to her house for fear it would not be ‘good enough’. Her main concern was her daughter’s wedding, coming up in three months. She became more tearful talking about this, saying she did not know how the bride’s mother was supposed to look or act.
C then took a history of Sasha’s family background and noted that she had always been relegated to the background, leading to the core belief that she was unimportant. Sasha then described her work history which seemed to be in sharp contrast to her family experiences. C took some time to explore this with Sasha.
Sasha described being in the classroom as ‘being in control’. She felt that she had a good rapport with students and was good at her job. She often took on more than she could handle at work but somehow managed to get through it and was praised by her colleagues when she did this. It appeared that the only time Sasha had ever felt important was in the workplace.
However while she got along with other staff, she had made no real friends and had never had any friends throughout her life. C asked her why this was. Sasha became tearful again and said that she just wanted to go and live somewhere she wouldn’t have to see anyone except her husband and her children. She described her camping trips with her husband as being relaxed because she didn’t have to talk to other people. She experienced particular anxiety when her husband’s family visited as she felt pressure to be a perfect wife and housekeeper in their eyes.
Sasha mentioned that while she was working in the Education Department, she had been given a personality test to complete which had told her she was an extrovert. She was puzzled by this because she did not like people and clearly stated that it was not her goal in counselling to change this.
At this stage, C shared with Sasha her impression that Sasha appeared to have developed the belief that her authentic self was unacceptable and had created a false self to present to the world. This created intense anxiety because she was never quite sure who people wanted her to be from one situation to the next, requiring her to constantly scan her environment for clues as to how to feel and behave. Consequently it was easier to think about going away to a place where she would not have to see anyone, as she had done as a child at her grandparents’ farm. Only when she was away from people was she able to relax and feel in control.
Also, because she had married an introverted man who indulged her need to avoid social situations, she had learned to suppress her extroverted nature still further. It was no surprise that retirement was causing her such distress, since the only time she had ever felt important and comfortable around people had been in the work environment.
C decided to explore the unexpressed extroverted side of Sasha’s personality first. She asked Sasha what she did that was fun. Sasha could only list one item, the morning walk she took with her husband in the hills. Even this caused her concern however, because she felt she should be walking faster and further than she was.
Using the Gestalt technique known as Empty Chair, C placed a chair opposite Sasha and asked her if she would speak to the extroverted side of herself. Sasha found it difficult to stay in the first person and avoided this by talking directly to C. C guided her attention back to the empty chair and suggested she ask this part of herself what it would do if it could take over for a day.
When Sasha had done this, C asked her to move to the empty chair and reply as her extroverted self. Once seated in the other chair, Sasha began to relax and freely spoke about wanting to go to Dreamworld and wanting to make a quilt. When she returned to her original seat, C asked Sasha how she felt about allowing this side of her to have some fun. Sasha appeared reluctant but agreed to ask her husband if he would go to Dreamworld with her.
In the following session, Sasha reported she had not only gone to Dreamworld, but that they had purchased season tickets. Throughout the course of the counselling sessions, Sasha and her husband began visiting the theme park for half a day every week. She also started several creative projects, including hand quilting and scrap booking. She found these activities extremely difficult at first, but utilising cognitive-behavioural strategies to challenge her core beliefs, she was able to continue to the point where she was able to enjoy herself for the first time in years.
Challenging and modifying a client’s faulty thought processes is the basis of Cognitive Behavioural Therapy (CBT). After Sasha had outlined several situations that were causing her anxiety, C helped her identify her beliefs about these situations. Sasha was shown that it was her beliefs about these situations which led to her bad feelings, and was encouraged to find more realistic alternative beliefs. Some of these processes included:
Activating event (A) = sewing
Belief (B) = I can’t do it well enough, I might as well give up
Consequence (C) = crying, giving up, bored and depressed
Dispute (D) = I’ll do my best and focus on enjoying myself rather than focusing on the outcome
A = husband’s family staying
B = they’ll see the state of my house and be horrified
C = panic
D = I’ve got better things to do than clean the house and if they don’t like it, it doesn’t mean I’m a bad wife
A = attending daughter’s wedding
B = I’ll let her down and embarrass the whole family by saying or doing something wrong
C = panic
D = people will be focusing on the bride, not me, so I’ll focus on her too
In this manner, Sasha was asked to practice disputing her thoughts for homework.
C then asked Sasha to use the Empty Chair technique to complete unfinished business with her mother, addressing her feelings about coming home to an empty house and then being told she was ‘silly’ for crying. Sasha had always believed her mother had treated her as insignificant because she had been such an inadequate child. Playing both roles, Sasha was able to see that her mother had her own agenda which made it difficult for her to have time for her daughter. After Sasha told her mother via the Empty Chair technique how she had felt in this situation, she realised the beliefs she had developed about herself were not necessarily accurate or helpful and could therefore be challenged.
Again reverting to CBT techniques, C asked Sasha to look for disconfirming evidence for the belief that she was inadequate. She was able to find many examples of this, chiefly in her work and as a mother to her own children. Sasha was asked to continue noticing examples like this on a daily basis. She was also asked to be aware of herself in the present moment as much as possible, rather than focusing on the past or the future. This allowed her to enjoy what she was doing, rather than focusing on previous failures and criticisms, or future ‘what ifs’.
Sasha’s counselling sessions focused on a number of issues:
- Integrating repressed parts of herself that were ‘unacceptable’
- Allowing her extroverted side to be expressed so she could take part in and enjoy pleasurable activities which lifted her depression
- Completing unfinished business with her mother
- Challenging her thoughts and behaviours – the belief that she was unimportant and the need to compensate by being perfect
- Learning to be present in the here and now, allowing her to focus on the activity at hand and enjoy it, rather than worrying about the outcome Experimenting with relaxing her perfectionist standards, which showed her that nobody else even noticed.
- Her daughter’s wedding – Sasha discovered that by distracting her thoughts about being around so many other people in such an important role at her daughter’s wedding, and instead focusing on the needs of her daughter and guests, her anxiety was no longer present.
Sasha’s experiments reinforced the fact that her thoughts were producing her anxiety, not other people. She realised that when she wasn’t focused on herself, her anxiety was no longer there. When she couldn’t distract her thoughts, she learned to modify them to something more realistic. By challenging her irrational belief that if she wasn’t perfect she was inadequate, she began to enjoy everyday activities and became much more relaxed. This was noticeable even in her voice, which lowered in tone, and in her generally more relaxed nonverbal behaviour.
As a result of implementing these strategies, Sasha found it a lot easier to be around other people. By learning to accept herself as she was, she no longer felt the need to guess what other people wanted from her, and began to feel comfortable presenting her authentic self to the world.
Author: Leanne Chapman is a Psychologist who has worked in community clinics and hospital settings with both children and adults. She has also conducted group therapy for patients with anxiety, depression and eating disorders at New Farm Clinic. In addition to her work with AIPC, Leanne operates a successful private practice.
I found this article useful especially as it illustrates how effective forms of CBT can be in regard to treating anxiety. I thought the model used (ABC of Emotional Disturbance) was Albert Ellis’ Rational Emotive Behaviour Therapy. I think CBT and the ABC of Emotional Disturbance is sometimes attributed to the work of Beck and others. I have always understood that this was Ellis’ creation.
Thanks again for a very helpful article.