Social anxiety disorder can be defined as anxiety in social situations due to fear of evaluation (American Psychiatric Association, 2013). Essentially, this leaves an individual with social anxiety with two options: 1) Avoid social interactions all together; 2) Do so with anxiety and then engage in hours of what is referred to as post-event reprocessing. Post-event reprocessing entails revisiting social interactions and events mentally after they have taken place and critically evaluating your performance (Leigh & Clark, 2018). Ruminative thoughts about social errors may consume hours or even days after a social encounter for someone struggling with social anxiety disorder (Leigh & Clark, 2018). In addition, because social approval is never certain, uncertainty can fuel further rumination (Leigh & Clark, 2018). For instance, you may start to ask “did I really say that or did it come out incorrectly?” which further fuels uncertainty and an endless spiral of anxiety. Furthermore, because social anxiety tends to create internal focus (what should I say next, are they looking at me?, etc.), it can be very difficult to objectively evaluate social performance and therefore the cycle of post-event rumination can persist for extended periods of time, without factual data that one performed well (Leigh & Clark, 2018). It makes a lot of sense that many of my socially anxious patients come to me exhausted and disinterested in engaging socially with the world, as this process can be incredibly exhausting both during social encounters and after they are over. 

In Cognitive-Behavioral Therapy for social anxiety disorder, we will help you learn many strategies for combating social anxiety, including how to challenge your thoughts before, during, and after social events and how to “sit with” the anxiety during and after interactions. When “sitting with” anxiety, you learn that anxiety does not last forever and that what you are afraid of may not be as frightening or catastrophic as it feels.

Here, I will describe a “sit with it” tool I have entitled “so what” ing your social anxiety. Applying this tool involves starting to accept social mistakes. Many of my patients will ask the following types of questions after a stressful social encounter: 
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• Did I sound incompetent? 
• Did I have something in my teeth? 
• Did I say the wrong thing? 
• Did I offend someone? 
• Maybe I should apologize for that thing I said? 
• Will they still want to talk to me after this? 
• Will this have a catastrophic impact on my life? What if it does? I wish I had said that differently…
• Are they upset with me now? 
• Etc. 

The “so what” approach involves saying to yourself, “so what if I sounded incompetent in that one conversation? What happens then? Hmm. I guess nothing.” We evaluate others based on data patterns. One slightly ignorant comment or error typically does not completely change our perspective on someone. If it does, the other person should likely engage in some cognitive therapy so that they can stop thinking so extremely and inaccurately about the world and other people. One data point does not create a line. Similarly, one error does not completely alter our social image. 

We can say, “so what, I made a mistake,” and move on. Alternatively, we can ruminate for days about the one part of a conversation we could have engaged in better and change absolutely nothing about the past or the way it may impact our social image. Typically,  “so what” ing honest mistakes is more helpful and less exhausting. 

If “so what” leads to more catastrophic thinking, we can keep “so what” ing until we get to a resolution. For instance, “so what if I sounded incompetent in that conversation with my boss?” may lead to “what if I get fired?” We can “so what” the next thought too. “If I get fired, I will collect unemployment until I can find a new job. Would that be miserable? Of course. Would I survive it? Yes.” This technique is sometimes referred to as decatastrophizing (Zinbarg et al., 2006). 

If we can start to “so what” social fears, it becomes possible to recognize that we all make social mistakes and most of them are not at all catastrophic. Generally, we are all doing our best to make a good impressions but no one will do so perfectly. Social errors are a part of our social existence. “So what” the social errors so that you can start to “sit with” your reality: You are a human being, an imperfect social creature like the rest of us. 


References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
 
Hope, D. A., Heimberg, R. G., & Turk, C. L. (2019). Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach: Therapist Guide (3rd ed.). Oxford University Press.

Leigh, E., & Clark, D. M. (2018). Understanding social anxiety disorder in adolescents and improving treatment outcomes: Applying the cognitive model of Clark and Wells (1995). Clinical Child and Family Psychology Review, 21(1), 388-414. https://doi.org/10.1007/s10567-018-0258-5


Zinbarg, R. E., Craske, M. G., & Barlow, D. H. (2006). Mastery of Your Anxiety and Worry: Therapist Guide (2nd ed.). Oxford University Press.

Approximately 1 in 100 adults (and about half that number of children) are thought to have Obsessive-Compulsive Disorder (OCD).  OCD can cause a great deal of suffering and impairment.  Usually, OCD presents obsessional content in themes, and there is significant diversity in the content areas.  Some of the more common content areas or themes of OCD include, but are not limited to, obsessions related to contamination, harm, perfectionism/just-right, religion and morality (often called scrupulosity), identity, relationships, and so on.

Obsessions are defined as persistent unwanted thoughts, images, impulses, or intrusive doubts that cause significant distress.  People with OCD tend to interpret these obsessions as being dangerous, shameful, or meaning something sinister or concerning, and therefore want to avoid them and try to push them away.  These obsessions can cause many emotions, such as anxiety, fear, doubt, guilt, disgust, uncertainty, and frustration.  Obsessions are repetitive, and attempts to suppress the thoughts often only worsen them.  For example, what is the first thing you think of if I tell you not to think of a polar bear?  That is right.  No matter how much you attempt to avoid the thought of a polar bear, it continues to show up in your thoughts.  It is not a big deal when we are talking about a polar bear that is relatively meaningless, but what about when the thought is disturbing or upsetting?  

Compulsions are strong urges to engage in a behavior and/or mental act to reduce the obsessions and/or to keep the obsessions' feared outcome(s) from happening.  Although compulsions are technically purposeful behaviors or mental acts, many individuals with OCD describe compulsions as feeling automatic, especially those that occur mentally.  When people engage in compulsions, they become reinforced by a short-term sense of relief.  However, compulsions tend to strengthen the danger signal of the obsessions long-term.  

Exposure and Response Prevention (ERP) is a form of Cognitive Behavioral Therapy.  While ERP is usually associated with treatment for OCD specifically, the foundations of the treatment itself can apply to several other disorders, including other anxiety disorders and eating disorders.  ERP is considered a gold-standard treatment for OCD.  It involves asking clients to either trigger or allow obsessions to exist (this part is called exposure).  During the exposure, clients are directed to resist pushing the obsessions away and are discouraged from engaging in compulsions or other forms of avoidance (this part is called response prevention).  I am sure this sounds hard and scary, and for someone with OCD, it really can be. For this reason, therapists and clients work collaboratively in a safe environment to develop a gradual, systematic approach. Working together helps to increase the chance that clients are successful and have the best chance at learning safety.  

Learning safety is a critical component of treatment. OCD convinces client's that their thoughts, images, impulses, or doubts are dangerous, and if compulsions are not utilized, something dangerous or bad will happen.  Ideally, ERP will teach clients that they can handle distress and uncertainty.  As a result, many clients build self-efficacy and learn to trust their ability to face complex thoughts and internal experiences. Additionally, clients get the opportunity to learn that compulsions are not helpful or necessary (and, in fact, perpetuate the cycle of anxiety).  I often tell clients that compulsions get all the credit for safety, but they rarely measure up when put to the test.  Clients will likely learn that what they are afraid of is unlikely to occur and that thoughts/images/impulses are not necessarily meaningful and essential.  

Once safety is learned, and clients consistently manage their intrusive thoughts without pushing them away or seeking safety through compulsions, clients enter into the relapse prevention phase of treatment.  Relapse prevention is a critically important part of therapy.  Relapse prevention aims at reviewing the skills developed, processing the evidence obtained, identifying how the client can generalize the skills moving forward, and developing plans to address any symptoms of lapses or relapses in the future.  In some instances, clients may request to return to therapy for booster sessions to ensure they stay on track and do not fall into old OCD habits.  

For more information, blogs, and resources on OCD and ERP, please visit OakHeart's Obsessive-Compulsive Disorder specialty page: https://www.oakheartcenter.com/obsessive-compulsive-disorder-ocd.html