Conversation has been lightly edited for clarity

Jessica Risker:

Hey, everybody, welcome to Music Therapy! So many of my friends and therapy clients have been feeling anxious about returning to social situations after living for so long in lockdown.

But what exactly is social anxiety? And what's the difference between social anxiety and social anxiety disorder?  What can you do to make social situations easier for you and what coping mechanisms should you avoid? That's coming up on today's Music Therapy.

I'm Jessica Risker and I'm a musician based here in Chicago, Illinois. I'm also a licensed clinical professional counselor. Music Therapy is a show where I dive deep into the psyche of musicians. Today we're going to focus on a mental health issue. I want to talk about social anxiety because lately I've been hearing so many people express anxiety about returning to social situations after lockdown. And so I wanted to offer you some information about social anxiety, what you can do to address social anxiety and what you should not do to cope with social anxiety.

To help us understand all this today, I'm going to talk with Dr. Lauren Neaman. Dr. Neaman is a clinical psychologist and a chief clinical officer at the Depression and Anxiety Specialty Clinic of Chicago. She specializes in treating anxiety disorders, using cognitive behavioral therapy and exposure with response prevention. Dr. Neiman has presented at national conferences on topics related to social anxiety and is the current co-chair and a board member of the national social anxiety center.

First, here's a quick song from me. This is “How’ve You Been”.

Jessica Risker:

Okay. Let's turn to my conversation with Dr. Lauren Neiman about social anxiety.

Jessica Risker:

Thank you so much for being here today.

Dr. Lauren Neaman:

You're welcome. Thanks for having me.

Jessica Risker:

I've had a lot of friends and clients and other musicians talk to me about feeling really nervous or anxious about returning to social engagements after being at home so much and what that's going to look like.  On one hand, sometimes they're excited, but they're also feeling quite anxious about it. And I wanted to learn a little bit more today about social anxiety in general, and also social anxiety as it pertains to returning to a post lockdown world.

So I was hoping you could maybe start out by giving us a definition of what social anxiety is?

Dr. Lauren Neaman:

Yeah, definitely we are seeing a lot of this reopening anxiety, you know, in particular in relation to social anxiety. So I think this is an important topic. But social anxiety at the core  is really just a fear of negative evaluation from other people, quite simply.

And so that could be in any context, like it could be at a party, it could be a performance. Or it could be in an interview or a first date. And those are times where most people feel socially anxious, they're sort of evaluative situations. And most people have some levels of social anxiety, just like most people have certain levels of anxiety. Generally. It can be really useful. If we had no social anxiety, then we would just be doing our own thing, not caring, all that anybody thought, and that would sort of be problematic, right? No one would be polite, no one would probably take showers or be on time or do things, you know, calling on sort of social rules. So to some extent, social anxiety can be useful for us. But the problem is when it really crosses that line into being the primary way in which people are seeing things and that really is almost a phobia.

Social anxiety disorder is also called social phobia and people are really, really scared and feel a lot of anxiety about this potential of negative judgment or negative evaluation by other people. So when we're talking about social anxiety disorder, then there's some sort of functional impairment. Whether that's a business person who is not able to speak up at meetings, and so then doesn't get that promotion and can't advocate for himself or herself and that's now crossing over the line. It's no longer helpful. Now it's actually getting in someone's way. Maybe someone who won’t go on dates because they're too scared of that potential rejection, and then don't end up finding a partner and maybe they want one..

Jessica Risker:

Would you, what would be some examples you could imagine for a musician or performer with social anxiety impairing their functioning?

Dr. Lauren Neaman:

I mean the most obvious one would just be avoidance of saying, you know what, I've played the guitar for 15 years and I'm really, really good.

And I'm just too terrified to get on the stage. I guess I just won't do it, I guess I'll get someone else or do something else. I've definitely had clients who have music backgrounds and work office jobs because they were just too scared to get up there. So that would be like the biggest one. I'm just not doing it. Other ways that might be functionally impairing, you know, it could be that they they try, they go for it, but, but maybe the anxiety is too impairing and gets in the way and it impacts their performance and maybe they don't like get that gig or, or they're not able to make that band they were trying out for, or they aren't able to to record something because maybe the anxiety really is interfering with their performance.

Jessica Risker:

And what would you say the difference is between what we refer to as stage fright versus social anxiety?

Dr. Lauren Neaman:

Yeah, I think that's an important distinction. Just like we would talk about someone, maybe who's shy versus someone who has  a social anxiety disorder. It's really the level of impairment, right? Most people have some fear of public speaking. That's very normal. It's always in the top three of phobias. And you know, in the literature it's flying, dentists, and and public speaking, those are the top three. And so most people have anxiety getting up in front of a stage performing. You're going to feel something - they're gonna get the jitters or maybe have stage  fright. But they're able to continue on and do it. So I would, I would sort of characterize that stage fight of like, Ooh, this is fun. I like this. I've got the butterflies.

Maybe I'm, you know, not feeling so great, but I really want to do this and I'm going to find a way to make it work. As opposed to social anxiety disorder, if it's really that impairing, maybe they don't have the tools and the skills to be able to do that or to tolerate that level of anxiety.

Jessica Risker:

Okay. That's helpful. So you're making a distinction  between social anxiety and social anxiety disorder. Can you know, can you clarify that distinction?

Dr. Lauren Neaman:

Yeah. Like I was saying before, most people have some extent of social anxiety. And that just means in some situations,  it's more likely that people might be concerned about being negatively evaluated. So if someone's giving a talk or if someone's on a first date, like those are times that we might be more likely to be negatively evaluated and that might push us to maybe try to perform a little better.

But social anxiety disorder, is when it's impairing or social situations are inured with great amount of distress or they're avoided altogether.

Another thing that people who have developed  diagnostically social anxiety disorder tend to do is engage in a lot of what we call safety behaviors. And a huge part of the treatment is addressing these safety behaviors. Because what they end up doing in the long run is reinforcing the anxiety, even though people are trying to use them as ways to cope.

So some really common examples would be like, oh, I'll go to this party, but I'm kind of going to stand in the corner and play on my phone a lot.

Jessica Risker:

Right.

Dr. Lauren Neaman:

Phones are great safety behaviors for people these days, or maybe I'll have an extra drink or two before I go.

Or maybe I'll take a Xanax. That’s very popular these days, like, oh, I'm feeling anxious, I'll take a Xanax or something like that. Or I'll mentally rehearse what I'm going to say. So while someone else is talking, I'm going to mentally rehearse what I'm going to say. And the problem with all of these things I mentioned, and there's hundreds of others is, that they sort of work in the moment. They're great. Band-Aids like Xanax will calm me down. If you rehearse what you are going to say, and then you say it well, well that just reinforced you should probably keep doing that.

But the problem is that none of these safety behaviors or tools actually teach people that I can tolerate this. I can just do this on my own. Then we get really reliant on these other things.

And it actually makes the fear greater in the long run. Andthe safety behaviors and people engaging in the safety behaviors is also a good sort of marker of, when does this become more problematic? Cause you'll meet folks and they'll say, no, I can do all that. I just need to make sure that I have my safe person with me, I have my phone and I’ve taken my Xanax or  I prepared my script in my head, I’m good.  But then you're not really good because then you have all of these crutches that are not actually helping you in the long run to bolster your sense of ability to cope.

Jessica Risker:

So what you do when you work with clients is help them to actually tolerate that sense of anxiety?

Dr. Lauren Neaman:

Yeah. I think there's such a misunderstanding in just our culture and our society that anxiety is bad and that if I feel it, I must do anything I can to get rid of it. I can't tolerate it. We talk a lot about just the intolerance of anxiety. And so if we can really shift that and reframe that for folks, that anxiety isn't a bad thing. It's really helpful in a lot of situations. Thinking back to caveman days or whatever, if there's a tiger chasing you, you need that anxiety to run. That's a really useful emotion.  We get to decide now, when is this useful for me? And when is it not?  Going to a party is not the same as being chased by a tiger. And so we might be feeling those same feelings cause there's a misfire going on in our nervous system.

And that's okay. I can feel that and I can stay in this situation. So the more people are able to sort of make that shift from “ anxiety is bad”.  Sometimes anxiety is helpful.  But it's not here. I don't need to listen to those signals. And if I can feel that and stay in the situation, that's a really, really powerful thing for people to learn and experience because then we're opening doors like, oh, I can do these things.

Jessica Risker:

Right. Do you make a distinction between the word nervous and anxiety? If someone says I'm nervous or I'm anxious, would you say that's the same word or would you think that is there's two different meanings there?

Dr. Lauren Neaman:

Yeah. I mean, I tend to think of that sort of on a continuum.  I would consider nervous to be just anxiety. It's just maybe lower, but that's  just my conceptualization of it. I think a lot of those words can be interchangeable. You know, when people talk about being scared, being nervous, having anxiety or having a fear, they’re sort of all similar at the end of the day.

Jessica Risker:

They're fear based.  When you defined social anxiety, you pointed to a fear of judgment of others. Do you find that there is a common category of judgments that people tend to experience that they're worried about? Or is it very scattered and varied?

Dr. Lauren Neaman:

No, that's a great question because there are a few that tend to come up most often. And so typically that's the question I always want to know from people:  what is the worst thing that someone could think about?   What do you really not want?  How do you not want to be thought of?

And actually one of the top ones is just anxious. Like I don't want people to see that I'm anxious. So people are really worried about whetherI'm blushing, or what if I'm sweating or what if I kind of stammer over my words and then they'll know I'm anxious and then they've sort of figured me out. So appearing anxious is a really big one, as is incompetence. I don't ever want to seem incompetent. And and then there's sort of a third one, which is just sort of like being found weird or boring, just sort of  vague, like generally not someone people want to be around. But those are, those are the big ones that we hear the most here at this clinic.

And I know that a lot of the exposure, which is part of that treatment plan is a lot of  exposing people to appearing anxious or to appearing incompetent. And how can we get you better at being incompetent and having people think that about you and being okay with that?

Jessica Risker:

Interesting. That's helpful. So obviously we have been through an extended period of forced isolation, whether it's just with ourselves or with a family or a roommate or something like that, but we weren't able really to be social in the way that we were used to, or maybe even had to before. And how do you feel the lockdown for the pandemic may have contributed to social anxiety or social anxiety disorder?

Dr. Lauren Neaman:

Yeah. Well, so in order to answer this, let me give a little more background on just the concept of avoidance when we talk about anxiety disorders.

Cause I think that will make it a lot clearer. So when we think about social anxiety or general anxiety, any kind of anxiety, what maintains the anxiety?  What keeps the anxiety going or makes it worse? It’s avoidance in a very general way and avoidance can look like lots of different things and lots of different disorders. But generally we know that avoidance makes it worse.

So let me give an example unrelated to social anxiety, just to make it really clear. So this is an example I use with all my clients. Let's say that I'm afraid of dogs and I'm walking down the street and there's a woman coming with a big dog. She's got a Rottweiler or something. So, you know, here they're coming towards me.

And of course, since I'm afraid of dogs, I'm going to have some negative assumptions about what's about to happen, right? I'm going to think, oh no, this dog, this is a big, scary dog stops and attacks me. It's not going to kill me. I'm going to have these thoughts. My anxiety physically is going to, you know, ramp up. I'm going to feel my heart race, I’m sweaty, I'm uncomfortable. I don't like the situation. And so what am I likely to do? Well, I'm likely to turn around. I'm likely to cross the street and I'm likely to get out of there. Right? I'm likely to escape that fight or flight response.

So let's say,I cross the street and then the dog's over there and I'm here and my anxiety comes down and I'm feeling all better. And so most people in this scenario I would say, okay, no problem.

So the problem here is that I did nothing to teach myself that maybe that dog might've  not attacked me, maybe that would have been okay. I didn't get to learn that. So by running away, I just reinforced my fear. Now dogs just got a little bit scarier for me by creating all that distance.

But more importantly, from an anxiety perspective, I also learned that I can not tolerate anxiety.  I just learned that I must do anything I can do to get rid of this experience. And so that was actually really problematic that I ran away, even though it seemed like what's the big deal, actually, it wasn't a big deal. So when we think about social anxiety and all the ways people can avoid - and the list goes on and on whether it's, you know, just not going somewhere, whether it's choosing to text someone instead of calling them or choosing to text someone, instead of seeing someone face-to-face, there's all sorts of subtle ways that we can avoid social interaction, even if it seems like we’re being social.

So pandemic lockdown, this couldn't have been any more avoidant. Whether or not people had a preexisting social anxiety disorder, maybe just were on the shyer side, or maybe didn't really struggle that much socially -  we were all engaging in avoidance. Some of us didn't really want to, some of us loved it. A lot of my clients were like, well, this is great. In a nutshell, we avoided for over a year, most people anyways, so then coming back to it, well, now we're really out of practice and we've reinforced that fear so much every day. And we were sort of encouraged to do that, right? We were to stay home, stay away from people. And while there are ways to stay connected, whether it was zoom, phone calls, texts, there were ways. But those are all a little bit inherently avoidant. And so folks that maybe wanted to avoid already were able to do that for a really extended period. Yeah. Really given permission, in fact, encouraged to.

Jessica Risker:

When you're talking about the example of avoiding the dog, crossing the street or turning around and saying, this reinforces the anxiety. Do you feel that that kind of holds the same amount of anxiety in place? Or does that build the anxiety? Does it make the anxiety worse over time?

Dr. Lauren Neaman:

It actually does make it worse over time, because every time people engage in some sort of avoidance, it reinforces this idea that I can't tolerate this feeling, and it's bad and I must get rid of it. And so our ability to tolerate anxiety goes down and down and keeps going down every time we do that.  Because we're never having the experience of “hmm...I'm sort of anxious. Let me see if I can just  sit with this. Let me see if I stayed in this situation if that doesn't happen.”

And so our perceived ability to cope plummets.  Anxiety from a cognitive perspective is an overestimation of bad things happening. So like “this dog will attack me”, when that problem is probably low in reality, but  high estimated risk pairs with underestimation of one's ability to cope. And that's a very scary place to feel, right? Like all these bad things are gonna happen and I'm not gonna be able to handle it. And so every time we avoid that gap getsbigger and bigger.

Jessica Risker:

Yeah. Like not using a muscle, it atrophies.

Dr. Lauren Neaman:

Exactly. Yeah.

Jessica Risker:

When I work with clients who have anxiety, you're talking a lot about the cognitions or the thoughts that are happening with the anxiety  -  for example “this dog's going to attack me”. But some of my clients don't know the thoughts they're having.

They just feel anxious. And when I try to explore with them, what that's about, it can be really, really hard to connect with that. What are your thoughts to help somebody connect with the cognitions or the thoughts behind their anxiety?

Dr. Lauren Neaman:

Hmm. That's a good question. I feel like this comes up sometimes, sometimes it's hard to access exactly what the fear is. Sometimes I might have folks ask themselves, like, if I were to stay in this situation, what do I think will happen? Or like a prediction as opposed to what is the anticipatory thought that led to the anxiety? But, now that I'm anxious, what do I think might happen if I stayed here? I find often times it is more physical, people having panic attacks in social situations.

So sometimes it is that just overwhelming physical panicky experience of like, if I stay in this, I'm going to somehow lose my mind or I'm going to lose control, or I'm going to have a heart attack. It's not so much like I'm worried this person won't like me, but more like now I'm here and now my body is doing this thing where I'm feeling really panicky and now what's going to happen.

Jessica Risker:

This is kind of a branch-off question, but I would be really interested in hearing your thoughts on this, because it feels like your level of expertise and the work that you do, you would have ideas about this. I'm thinking of a client in particular who doesn't have social anxiety, but he does have a lot of anxiety, obsessive thoughts about illness or getting sick. And he has really struggled with his anxiety in the time of COVID . What he tries to do to calm his body down is to do deep breathing. But then if he feels he can't catch a deep breath, he wonders, what's going on, do I have COVID?

It's just a really terrible place to be, but I'm curious if you have any thoughts on that?  How would you work with somebody who is struggling with that in the world of COVID?

Dr. Lauren Neaman:

Health anxiety is a tricky one, for sure, because we do want to be healthy and take care of our bodies and if something is not feeling right or not sitting right, it is important to go to a doctor.

But when it crosses that line into hypochondria or health anxiety, or OCD with the health anxiety bent, they all sort of function the same way. Then it gets problematic because then doctor seeking is actually that safety behavior or avoidance behavior or compulsion. And so we don't want people to do that or to be really somatically focused and monitoring their experience constantly.  Because then that can be compulsive. So it is really like finding that balance of how can we try to enact that value of physical health without it being an anxiety cycle?

And your point about breathing is a really good one because there are some people, the research is showing - you know, deep breathing used to be like, our go-to like for physical anxiety is deep breathing and it still is probably our best tool - but there are some folks that actually the focusing on the breath increases their anxiety.

They get really focused on that feeling and “am I getting a full breath?” So for some people breathing is actually not the most useful strategy and doing more like relaxation, you know, like PMR, you know, tensing and releasing the muscles might be more helpful or doing like an external focused, mindful exercise, mindfulness exercise, something more physically grounding as opposed to deep breathing.

It's not the norm, but it does happen when they say that breathing thing just really stresses me out. And especially now with COVID people may be obsessively monitoring if they're able to get a full breath. Am I not? And what does that mean? And so that's it’s better to refocus away from ourselves and see what's in their room, notice our surroundings and not get so focused on the breathing.

Jessica Risker:

Yeah, that makes sense. And when you say PMR, you're referring to progressive muscle relaxation.  Just to our listeners, there are tons of YouTube videos out there for guided relaxation, progressive muscle relaxation. That can be a good resource. They're very easy to find.

If somebody is listening and they're wondering if their level of anxiety is  clinically significant? Is it a disorder? When should I seek help? What would you have them look at or ask themselves to help them? You know, they may not be able to make that  diagnosis on their own, but what might be some signs that you would have them look for to see if it's crossing that line?

Dr. Lauren Neaman:

Yeah. I mean, I think behaviourally, the hallmark would be “am I avoiding things that I normally would want to do?” Like I would like to go to this party, or I would like to go to this work happy hour, but I just feel too anxious. That's a really good indicator of your anxiety  getting in the way of things that are important to you, that you want to do. People are usually pretty insightful, like, no, I do all the things. I just do them with my tools. Again, going back to that idea of safety behaviors. If it feels like, well, if someone asks you to go to that party, but you couldn't have a drink before, what would happen? Oh, well then it wouldn't go, well then maybe that's an indicator that's reaching a level that is more diagnostic.

Another thing though that I would encourage people to think maybe, I mean, there's the behavioral piece, but also just how they feel, right? Like, gosh, I'm noticing that I'm feeling really anxious when I'm even just talking to my friends or even talking with coworkers, like my heart's racing, I'm feeling flushed. I feel like it's out of context, right? People are usually able to logically say, I feel like I'm being threatened, but I'm not. Am I feeling anxious in this situation? I'll have a lot of clients say, there's no reason to be anxious. I'm just out to lunch with my coworkers, but I'm really feeling anxious.  If it feels out of proportion to the situation, that could be another indicator that maybe it might be a good idea to be professionally evaluated.

But I would encourage anyone if there's even a thought, huh? Is this what's going on? Is this something I should seek out for them? Yeah, sure. Go get an evaluation.

I think there's a misconception about if I go see a therapist that I have to go see a therapist every week for five years, which no, you might just go and say, Hey, I'm kind of wondering about what's going on. Maybe get evaluated. And maybe the conclusion is, I don't need to see a therapist or a psychiatrist, whatever it is, but I would encourage people if they even wonder at all, then get an evaluation, chat with someone. Maybe there are things you can do to improve the quality of your life that you weren't aware of.

Jessica Risker:

Absolutely. One of the things that keeps coming up when you're talking just now is that with this experience, people are generally aware of an inner conflict.

So I want to do this thing, but I can't, or I should be able to talk to my friends,  but it's really, really hard for me.  They are very cognizant of that experience rather than fully believing, you know, I just can't go, that's bad.  It feels like there is a level of awareness, and the struggle is the conflict that I would like to, but I can't.

Dr. Lauren Neaman:

Yeah, yeah, definitely. Yeah. Yeah.  But absolutely to your point, it usually feels like they're sort of conflicting with what they value and what they find important. And they're not able to do those things or they feel like they're not able to do those things.

Jessica Risker:

So can you share with us what people can do? What kind of work do you do with people who have social anxiety or social anxiety disorder?  How do you work with somebody struggling with that?

Dr. Lauren Neaman:

Sure. So yeah, I use primarily cognitive behavioral strategies (CBT) and then also acceptance and commitment therapy, which is called ACT for people that are familiar with different treatment modalities. But primarily we're looking at the thinking patterns that I referenced.   We really want to get a good sense of what are these predictions that people are making about what the experience will be like?

We got, you know, the anticipatory anxiety when they're actually in this situation, what kinds of thoughts are they having? Because we know that there's a tendency for folks with social anxiety to be really internally focused because they're also evaluating themselves in their performance. And that really backfires because if I'm talking to you and the whole time I'm thinking about how dumb I sound, how dumb I look, how much you must dislike me, then I must be sort of detached because I'm preoccupied, preoccupied with myself. And then I do come across as a little bit aloof and distracted, and I can't really maintain a conversation because I'm distracted by all the ways that I'm beating myself up. And so then it sort of does perpetuate this, this loop of, well, then that person didn’t seem as interested in me. It's like, well, you probably seem disinterested in that because you were thinking about how poorly you were performing in this social situation.

So we'll look at those kinds of thoughts, and talk about strategies to get back to the external focus. Like let's focus on that other person, not so much on how you're performing. And then the act afterwards, right. Then there's thoughts about how it went afterwards, which we call post-event rumination, which is just a fancy way of saying, like, I think about that thing after it happened and how I feel I did. So those are all sort of the self-talk or cognitive components that we try to  help folks reframe or create different relationships with those thoughts. So before, during and after there's all sorts of unhelpful thoughts going on that reinforce the anxiety. And then from the behavioral standpoint, it's a lot of exposure work and this is the stuff that people hear about and they think it's not really scary and you don't want to go in and do it.

But it's done in a very thoughtful graduated way. So we start with  easier situations and then we build our way up into the more challenging scenarios.

But you know, some examples of exposures depending on what the fear is. Let's say the fear is when I'm going back to the idea of, I'm so scared that someone will think I look anxious. Okay. So what we actually want to do, as odd as it sounds, is we want to expose people to situations where it's really likely people are going to perceive them as anxious so that they get better at tolerating that experience. So it doesn't feel like they have to try to live their lives in a way to avoid it. So, you know, simple ways that you can do that.

These might not be starter exposures, but just as an example, like we might have people blot their forehead with some water. So it looks like they're sweating or maybe get water under their shirts. It looks like they're sweating and just go out in public and have people see them appear sweaty. And maybe that person thinks you're nervous. And what is that like to tolerate that? Or having people get really hot and run around a bit. So they are sort of flushed and then maybe going to a store and talking to an employee at the store while appearing anxious, or having people intentionally stammer over their words or something like that.

So there's an exposure component and we call those social mishaps because we're actually trying to elicit if those responses within those are tougher.

But lower-level ones may be just, let's just go into a store and ask the cashier for help, or let's go to this party. And this is your goal for the party. You're going to introduce yourself to three people - it's very structured. And did you meet your goal and what was that like? As opposed to just go to the party and see how that goes, cause that's what people are doing on their own, and that can be really frustrating and actually reinforce the anxiety.

So we do a lot of exposure work and a lot of cognitive reframing and having people really pay more attention to the utility or helpfulness of their thoughts and how their thoughts are. You know, in most cases really moving them further from the life that they want to be living.

Jessica Risker:

So would you pair an activity like going to the party and saying hi to one person, would you do that the night before a therapy appointment so that you can really be there with your therapist to review the feelings instead of giving it a few days?

Dr. Lauren Neaman:

Not necessarily we could. But we have people do tracking and there's logs. They have a really structured way of really evaluating what happened. And so there's a form we use in particular, it's called the record of social situations and they do a really nice job.  Beforehand you would fill out, like, what do you predict will happen? How likely is that thing to happen? How bad would it be if it did happen? And how long would those consequences persist?

Something I haven't mentioned yet as part of social anxiety is there tends to be an overestimation of the social costs. Like, if someone doesn't like my joke that I will never have a friend in my entire life, as opposed to that person just didn't like my joke.

And that's all that means. So people will kind of create these predictions before they go to whatever the event is, whether it's a work happy hour or the first date or whatever it is. And then afterwards there's a structured set of questions. Like, well, let's check in on that to start challenging. Some of those  overestimated probability, there's really bad things happening or how bad it would be if I did, because typically what happens is people cope better than they give themselves credit for. But if they never reflect back on it, they can't learn. They just say, well, that was, that was terrible. So then being able to evaluate, well, did my prediction come true? And even if it did, how bad was it really? And how long are those consequences going to last? So whether or not I would necessarily see someone right after they would fill this out.

Dr. Lauren Neaman:

So they feel like they have a way to really process that in a more useful way, as opposed to just engaging in that post event. Rumination of, I can't believe I said that they thought I was anxious. I'm never going to see those people again. I'm never going out again, let's get out of that and actually break down what happened in a more sort of useful way. And that's great because if they can get in the practice or habit of that, then they can carry that, those exercises with them to lots of situations and how to do that for somebody who struggles with social anxiety, would you, and how does it look for you?

There's a lot of teletherapy going on right now, not coming into the office. We all understand why, but a lot of people are continuing with that. Is that something that if you were working with a client who has social anxiety, would you want them to come in to see you in person?

Dr. Lauren Neaman:

You know, it's interesting. The research really does support teletherapy for social anxiety. I think the difference though is tele-health as a modality for one-on-one individual therapy, is just as effective. However, during a pandemic folks couldn't do the exposures that we were having them do because they can’t just go to stores or talk to strangers. So it's not necessarily the tele-health, it was more of the shut down. And it was hard, we had to get really, really creative with the exposures we were having people doing when we couldn't actually have contact with people. But I think as a modality, it's, it's perfectly good. As long as people are able to get that practice outside of session, I personally really liked doing exposures with clients.

We actually have a social anxiety group we run that is very exposure based and we're on a pretty busy street here in the city. And so we would go out together and do these exposures and it's I think useful for clients to see I'm willing to make a joke of myself too, and that's okay. I can tolerate it too.

So we all would do them together and I think there's a lot of power in that. So that is the one major challenge that teletherapy has. We can't really go down together.

Jessica Risker:

Yeah. Yeah. When we had checked in beforehand, you had mentioned social media and the way that people might use it socially or as a substitute. Would you mind talking a little bit about how social media can impact our social lives and the anxiety that could be part of that?

Dr. Lauren Neaman:

Yeah. I mean the two things that come to mind for me regarding social media is again that safety behavior,  sort of an avoidance strategy of like, well, I talked to people on Facebook, or Twitter or whatever. And so I'm connected. But maybe using that as  a crutch or instead of having in-person interaction.

But the second one, which I think probably is equally, if not more powerful as you know, outside of just social anxiety, but just generally though, like social comparisons and people obviously curating what they're posting and like a lot of, you know, people with social anxiety and say, well, it looks like that person is really competent or it has a really active social life, but they probably never feel nervous. Look at all the fun things they do and all the friends they have which can sort of contribute to the distorted thinking of assuming everyone else has got this down.

And actually that's something else that I didn't mention, but there is that misconception of well, no one else ever seems anxious with these things. Everyone else just speaks up at meetings when, you know, we don't know how other people are feeling. And most people feel some level, like I said before, of social anxiety, but there is an assumption that it's just so easy for everyone else.

Jessica Risker:

Yes. That's great. I think you had mentioned to me earlier, too, that you have found some people are struggling more with reopening than the initial shutdown.

Dr. Lauren Neaman:

Yeah, I did. I definitely have noticed that. And I think there's a few things that contribute to that, but I think the primary contributing factor to that is the shutdown is very clear. Like that was a rule, right? Like everything is shut down. There's no gray area. We don't go anywhere. Restaurants are closed, everything non essential is closed. So that was very easy for people to understand and follow the rules. And people who tend to be more anxious,  social anxiety, or otherwise tend to be more black and white thinkers, like all-or-nothingness and like lots of rules. And it's like, just tell me what to do and give me a structure. And so that was very clear.

However, the reopening is much less clear.  There's so much more gray. People's tolerances are much different. There's the CDC guidelines, but a lot of people are still not comfortable, you know, going inside somewhere without a mask or traveling or getting on an airplane. And so there's a lot more gray. And so I think that that reopening especially depending on people's own levels of comfort, and then we're talking about assertiveness and having to advocate for oneself, which is very, very hard for people, especially with social anxiety. So that's a whole other sort of category there work to be done.  I'm inside and someone's not wearing a mask and I don't feel safe, but I couldn't possibly say anything. So I think that reopening, just the grayness of it, has been really hard for people to know how to navigate it.

Jessica Risker:

Absolutely. do you feel that a feeling of distrust about, I mean, it's been really unfortunate how the past year has really fostered a sense of distrust in our own country. And is that a factor that you see with anybody's anxiety? You know, I don't trust other people, so I don't want to go out, is that playing in?

Dr. Lauren Neaman:

Yeah, I think that comes back to that concept of control and folks with anxiety tend to really want a lot of control or they sort of under the illusion that they have a lot of control. And so now when we're talking about other people's behavior and what are other people doing in their free time? And now I need, you know, now I'm expected to go to this, you know, dinner or party or whatever it is with all these folks that I don't know what they've been doing.

And so I think, yeah, I mean, I think it can, it can look and feel and sound a lot, like you're saying like distust and I would conceptualize that coming from like, well, I don't control other people and that's really hard for me. And so unless I know what everyone else has been doing and everyone they've been into contact with,  I'm not going, and people have to sort of navigate those lines differently. And so I think, yeah, that idea of choosing to trust others or choosing to live with some amount of uncertainty is really hard when you're working with people and using this type of therapy to help them with anxiety.

Jessica Risker:

I know this is a really big question and I'm sure it's really different from person to person, but how does treatment generally go?  How long does it take? Is there an average for how long it takes for somebody to build up their tolerance for anxiety or even be more comfortable or even just not feel it as much? What does that tend to look like?

Dr. Lauren Neaman:

Yeah, that's a good question. And one that people ask all the time, like how many sessions will this take. And you're right. I mean, you know, being in the field too, it varies so much from person to person and sort of what else might be going on in their lives or how long the anxiety has been reinforced, how severe it is. And also how willing they are to really kind of dive in and do the work. Cause it is challenging. It's hard. But I mean, if we look at the research, right, like the research for an evidence-based protocol for social anxiety disorder, assuming that's just the focus of the treatment would suggest somewhere in the neighborhood of like 15 to 20 sessions. And again, that can vary a lot.

Jessica Risker:

Yeah. Why is it important to be social?

Dr. Lauren Neaman:

Well,  we're social beings. We've depended on each other for always for survival, for connection. There is a lot of research, it's just sort of being disseminated more now and I'm guessing you've probably heard about it, but it's sort of in that under-controlled, over-controlled spectrum, with folks with social anxiety tending to be more on that overcontrolled end of things. And folks with chronic depression, folks on the spectrum, on the autism spectrum. And what we know is that like at the heart of it now with this newer research is that they're really conditions of social isolation and loneliness. And without that genuine feeling connected to others, it can come out in different ways. So social anxiety is diagnostically different than then chronic depression then obsessive compulsive personality disorder, CPD those are different disorders, but that's sort of like temperament, underpinning, they're all disorders of social isolation and not feeling connected to people or part of, they use the term “tribe”.

And I know some people don't like that, but that's what the researchers  use. Like not feeling a part of the tribe. And so it's, yeah, it's so important for our emotional wellbeing, for our physical wellbeing. And even if not everyone wants to have 1500 best friends and that's okay. But the research really shows it is important to have at least a couple of people in your life that you really feel close to, that you can trust and feel.

Jessica Risker:

This has been great. Where do you stand on using medication to manage anxiety and social anxiety?

Dr. Lauren Neaman:

Yeah, that's another really good question. Medication, you know, really depends on the class and the function of it can be very, very different.

And so I'll share with you my perspective based on my training. I'm not a prescriber and I don't have a medical degree. And so I want to just make clear, this is my opinion based on how I do treatment, how I understand anxiety to function.

So there's a difference betweensomething like an SSRI, so something like Prozac, Paxil, those are medications that people take once a day, at the same time, and they don't necessarily feel anything when they take it. It's just something that's helping to regulate the levels of serotonin in their brain, which can help them overall regulate their anxiety levels better and can help them make use of some of the skills we're doing in therapy. So those types of medications, I think, can be helpful for people, especially if people are feeling a lot of symptoms.

If someone has really severe social anxiety, and they can't even engage in treatment unless I kind of have something to help me take the edge off a little bit. Like, okay, I can fully understand that and support that. And a lot of the clients that I work with are on some, some sort of SSRI, I think, and this is where I'm saying my opinion, where it gets a little more problematic is when we're using what we refer to as like PRN medications or as-needed medications. And those tend to be the benzos, like, you know, Xanax, like I mentioned before, Ativan, lorazepam. I know a lot of people take these medications. I'm not trying to villainize them. The problem is when they're being used as a safety behavior, it inhibits someone's ability to learn that they can cope with anxiety. So if every time I, you know, have a social gathering, I take a Xanax.

You know, it will work, but I'm not learning anything about my ability to just socialize on my own. I'm just learning that I am dependent on something else to help me get through it. So in that way, I think it is problematic in terms of someone being able to actually learn to cope on their own. There are situations where, you know, okay, fine. You know, I've had clients say, I really, really am terrified of flying and I fly once a year. Okay. So if once a year you hop on a flight and you take a Xanax it that the end of the world? I suppose not, but that's very different than every single time I have to socialize. So that's just, again, based on my conceptualization of how people tend to use.

Jessica Risker:

Well, like you said, there are safety behaviors, but there's also risk of dependency if you're using frequently as well.

Dr. Lauren Neaman:

Yes. And all the research showing the very, very strong relationship between regular benzo use and dementia and Alzheimer's, and that's another concerning thing. So yeah,from an anxiety perspective, it's concerning and absolutely they're easy to build a dependence on, people tend to need more pretty quickly. It impacts sleep. It impacts brain and memory development. There's a, there's a lot of things, again, I don't want to get too outside of my expertise here, but there are definitely concerns. So if someone is thinking about using them or is taking them, I think it's important just to really have a good conversation with their prescriber.

Jessica Risker:

Yes, absolutely. Thank you so much, I really appreciate your time today.

Dr. Lauren Neaman:

Absolutely.

Jessica Risker:

if somebody wanted to work with you, is there a way they can get in touch with you or is that something that you're offering right now?

Dr. Lauren Neaman:

Yeah, I mean, I'm currently full, but given the nature of work that I do, I tend to wrap up with folks pretty regularly. I don't see people for long periods of time. But yeah, our clinic is The Depression and Anxiety Specialty Clinic of Chicago. So the website is just the acronym, which is desk D a S C and then Chicago. So two C’s, DASCchicago.com. And we're a large practice. There's 25 of us and we all do different sorts of evidence-based work. And a lot of us treat social anxiety. And like I said, we do have that social anxiety group, which is a good resource.

Jessica Risker:

Thank you so much for all this information. It's been really interesting and helpful. Is there anything else that we didn't cover that you want to make sure to share with the listeners about this?

Dr. Lauren Neaman:

You know, I did just want to maybe give a little bit of a plug for the National Social Anxiety Center, just because it's a great resource for people. So if anyone, you know, who's listening or knows of someone who might benefit from more information or how to find a therapist that specializes in social anxiety there's a network of regional clinics, my clinic being the Chicago clinic. But we're all over the country and it's called National Social Anxiety Center. And the website is just https://nationalsocialanxietycenter.com.  And it's a great place to read about social anxiety. There's also resources for clinicians.

If you have other clinicians that listen to this podcast, there's training videos that we've done at national conferences that we just posted on there, everything is free. We're just trying to disseminate information about social anxiety and there's regional clinics across the country. So if someone says, oh, I know if someone in Houston then okay, we have a Houston clinic. So we sort of serve as a hub. So people reach out to me through this organization and help them get connected with someone in the Chicago-land area, who I know is doing good work with social anxiety. So it's a good resource. I just wanted to let people know about that one.

Jessica Risker:

That was great. Thank you so much.

Dr. Lauren Neaman:

Thank you.