DB 2 Psyc 620

Learning to Overcome Automatic Negative Thoughts

1: Opening the Session

0 seconds DR. ANNE MARIE ALBANO

[00:00] DR. ANNE MARIE ALBANOSo Nicole, what we’re going to do today is I want to find out about the way social anxiety is sort of, impacting and interfering with your life and your goals and enjoying yourself and doing things you want to do. Now, once we get that out, I guess an agenda for the session is to understand, you know, where you are with this and then I’ll do a little bit of education about why this is, as best as we understand it and understanding the way that you can address it and then we’re going to get into, then, the next aspect would be how to coach yourself, the way you talk to yourself to see if we can adjust some of the things there to make it more helpful for you and proactive and then finally, I want to end with a key component of the way that we work with this issue and that is telling you how to expose yourself to the challenges that you have. Okay? I might take notes, if you don’t mind, so, so just, you know, in general, or specific even, if you could tell me how social anxiety, what are the main challenges for you with this issue? NICOLE: Well, the first one is

1 minute 12 seconds NICOLE

[01:12] NICOLEI get invited out to friends’ houses or bar or whatever and I just go by myself and I know where the bar is, I know how to get there, their house and I just get there and I’m driving around the place a few times and I just park, and I sit in the parking lot for a few minutes, half hour sometimes, and I just can’t bring myself to get out of the car and just to walk in. DR. ANNE MARIE ALBANO: Okay. NICOLE: There’s just this overwhelming nervous feeling, fear that I walk in the door and all the eyes are going to be on me. DR. ANNE MARIE ALBANO: Okay. So that’s one of the things you think, all

1 minute 52 seconds DR. ANNE MARIE ALBANO

[01:52] DR. ANNE MARIE ALBANOeyes will be on me. NICOLE: Yeah. DR. ANNE MARIE ALBANO: Okay. Other situations – NICOLE: I have a lot of trouble doing things that I’ve never actually

2 minutes 2 seconds NICOLE

[02:02] NICOLEdone before. I remember when I was 18 and I got my first checking and savings account and I’d been in the car with my parents, I (inaudible) drive to the bank thing, and the teller and I’ve never done that. DR. ANNE MARIE ALBANO: Okay. Alright. NICOLE: It’s just doing things that are new, by myself, it just, I get this block and I just can’t go in and just do it and enjoy myself. It’s, even in high school, when school would start, the first day at school, I was just nervous, I’m going to get lost and embarrass myself and – DR. ANNE MARIE ALBANO: Okay. NICOLE: And, my first year here at GSU, I remember coming a day before classes starting and finding all the classrooms and everything and, I always show up early to classes that way. DR. ANNE MARIE ALBANO: To avoid all eyes being on you

2 minutes 57 seconds DR. ANNE MARIE ALBANO

[02:57] DR. ANNE MARIE ALBANOif you walk in late, okay. NICOLE: Exactly. DR. ANNE MARIE ALBANO: So, new situations that are social in nature or interactive are difficult and so you tend to avoid

2: Reviewing situations that elicit social anxiety

3 minutes 7 seconds DR. ANNE MARIE ALBANO

[03:07] DR. ANNE MARIE ALBANOthose, okay. Let me go through some common situations first. Someone of your age, who has social anxiety, and let me just see if any of these others are difficult for you. And if you could think about a zero to 10 scale, zero being you’re fine, no problem and 10 is the worst anxiety you experienced. What about asserting yourself. That is, asking someone to stop doing something that bothers you or saying no to something you think is unreasonable or you don’t want to do.

3 minutes 42 seconds NICOLE

[03:42] NICOLEIt’s kind of odd. As far as asserting myself, if someone in class is annoying me or whatever, I let it get pretty bad and I get pretty upset before I actually say anything but the odd thing is I was trying the EMTI for a little while and in emergency situations it just, I take charge and react and everything’s under control, it’s just when little people at the theater won’t be quiet or something, it’s just, it just gets under my skin, it’s like I want to say something but I just can’t. DR. ANNE MARIE ALBANO: Well, you know, you just bring up a

4 minutes 22 seconds DR. ANNE MARIE ALBANO

[04:22] DR. ANNE MARIE ALBANOvery important and interesting fact about anxiety. It’s discreet and specific, given the situation. So, from one situation to the next, you could find yourself more or less assertive, as you just identified and another thing about anxiety is, typically people feel they can’t cope, they can’t handle, but in crisis and in the clutch, they’re fine, they’re on target, they’re managing and they’re taking control, but afterwards, sometimes, they fall apart and they think they didn’t do as well as they could.

4 minutes 57 seconds DR. ANNE MARIE ALBANO

[04:57] DR. ANNE MARIE ALBANOBut that discreet nature of anxiety and the way that there’re very specific thoughts associated with each situation, you’re showing, in the way that you change from one situation to the next then. What about entering, what about like if, there’s people gathered in school and you know them and stuff, just entering into a conversation that’s going on. Can you walk up to a group? NICOLE: Sometimes, if it’s something I know a little bit about I’ll

5 minutes 27 seconds NICOLE

[05:27] NICOLEthrow in a little bit but not unless it’s somebody I really know pretty well. If it’s just fellow classmates or whatever and they’re talking about something I pretty much don’t. DR. ANNE MARIE ALBANO: So how anxious would you get with fellow classmates like

5 minutes 42 seconds DR. ANNE MARIE ALBANO

[05:42] DR. ANNE MARIE ALBANOthat from zero to 10? NICOLE: About a six or a

5 minutes 47 seconds NICOLE

[05:47] NICOLEseven. DR. ANNE MARIE ALBANO: Okay. And I should have asked how anxious do you get in those assertiveness

5 minutes 52 seconds DR. ANNE MARIE ALBANO

[05:52] DR. ANNE MARIE ALBANOsituations like at the movies or something. NICOLE: Usually about a 9.

5 minutes 57 seconds NICOLE

[05:57] NICOLE. DR. ANNE MARIE ALBANO: Okay, so assertiveness is one of the big ones then.

6 minutes 2 seconds DR. ANNE MARIE ALBANO

[06:02] DR. ANNE MARIE ALBANOPersons of authority and interacting with them, professors, again, like, I guess we could even say bank tellers, store clerks. NICOLE: Depends on the situation.

6 minutes 17 seconds NICOLE

[06:17] NICOLEIf something’s really wrong, I usually have no problem with it but as far as being in class and not understanding a concept, I will never raise my hand. DR. ANNE MARIE ALBANO: How anxious do you get?

6 minutes 32 seconds DR. ANNE MARIE ALBANO

[06:32] DR. ANNE MARIE ALBANO. NICOLE: It’s quite about a nine – DR. ANNE MARIE ALBANO: Okay. NICOLE: 10, it’s pretty bad because I’m just

6 minutes 37 seconds NICOLE

[06:37] NICOLEso afraid of raising my hand and saying I don’t understand this and the class goes duh. DR. ANNE MARIE ALBANO: You think the class goes duh. NICOLE: Yeah. DR. ANNE MARIE ALBANO: Okay.

6 minutes 47 seconds DR. ANNE MARIE ALBANO

[06:47] DR. ANNE MARIE ALBANOInteracting with someone that you’re attracted to. . NICOLE: Well, I’ve not had a whole lot of problems or any experience with –

6 minutes 57 seconds DR. ANNE MARIE ALBANO

[06:57] DR. ANNE MARIE ALBANOAnd is the lack of experience because you shy away from those situations?

7 minutes 2 seconds NICOLE

[07:02] NICOLETypically, I always have. DR. ANNE MARIE ALBANO: Okay. NICOLE: But my current boyfriend, we work together and we became friends and then he just said he wanted to go to dinner one night and it was just, because we were friends first – DR. ANNE MARIE ALBANO: Okay. NICOLE: It was a lot easier. DR. ANNE MARIE ALBANO: You’re right, but you’re in a

7 minutes 17 seconds DR. ANNE MARIE ALBANO

[07:17] DR. ANNE MARIE ALBANOrelationship so it’s not something that’s challenging you at the moment then. NICOLE: No. DR. ANNE MARIE ALBANO: Okay. And it’s also an example of if you get used to something, it’s easier for you as time goes on. NICOLE: Yes. DR. ANNE MARIE ALBANO: Okay. And then, what about if we think of situations where you’re the focus of attention. So let’s say one of your professors calls on you or you have to do an oral presentation? NICOLE:

7 minutes 42 seconds NICOLE

[07:42] NICOLEIf I get picked on in class or have to answer questions, I just, I really hope I know the answer because if I don’t I just feel terrible afterwards. As far as public speaking goes, at my previous university I did take a speech class and I managed through it. I just, I had to pick topics that I knew through and through and it wasn’t that bad. DR. ANNE MARIE ALBANO: So what we’re talking about is the difference between being unprepared and

8 minutes 17 seconds DR. ANNE MARIE ALBANO

[08:17] DR. ANNE MARIE ALBANOcalled on, how would rate your anxiety there? NICOLE: Being called on,

8 minutes 22 seconds NICOLE

[08:22] NICOLEseven or eight. DR. ANNE MARIE ALBANO: Okay. And then how about then,

8 minutes 27 seconds DR. ANNE MARIE ALBANO

[08:27] DR. ANNE MARIE ALBANObeing able to prepare something and doing a report? NICOLE: Probably about a four.

8 minutes 32 seconds DR. ANNE MARIE ALBANO

[08:32] DR. ANNE MARIE ALBANOOkay, so that’s a little easier if you have the time. NICOLE: Yeah. DR. ANNE MARIE ALBANO: Okay. Which is, again, another interesting thing is, you mentioned to me a little bit before we started this session, you play in a band. You perform on stage. NICOLE:

8 minutes 47 seconds NICOLE

[08:47] NICOLEYeah, sort of. DR. ANNE MARIE ALBANO: Okay. But you enjoy the performing aspects with playing your

8 minutes 52 seconds DR. ANNE MARIE ALBANO

[08:52] DR. ANNE MARIE ALBANOguitar and such. So again, there’s something that you’ve mastered and you feel good about and you’re able to perform, which is, and actually, probably feel in more control.

9 minutes 2 seconds NICOLE

[09:02] NICOLEI do. DR. ANNE MARIE ALBANO: Yeah. NICOLE: I do. DR. ANNE MARIE ALBANO: Okay. So, so that,

9 minutes 7 seconds DR. ANNE MARIE ALBANO

[09:07] DR. ANNE MARIE ALBANOhow much anxiety do you get when you’re playing? NICOLE: Well, typically we play in

9 minutes 12 seconds NICOLE

[09:12] NICOLEthe garage and friends come over, kids from neighbor come over and I play lead guitar and I sing as well and the music, it just kind of encompasses me and I just, it just feels so natural, I don’t even think about it. DR. ANNE MARIE ALBANO: So there’s zero to anxiety?

9 minutes 32 seconds NICOLE

[09:32] NICOLEWhen I first started doing it, there was, because I was just, you know, how do I sound on the microphone and, but just over the years, just practicing, getting used to my band mates and everything, it’s just, it’s gotten a lot easier. DR. ANNE MARIE ALBANO: Okay. NICOLE: We’ve not done, you know, stage production or any parties or anything, it’s just kind of what we do in the garage. DR. ANNE MARIE ALBANO: Okay.

9 minutes 52 seconds NICOLE

[09:52] NICOLEBut if we did do a stage production, I’m sure I would be, you know, a 12. DR. ANNE MARIE ALBANO: Okay.

9 minutes 57 seconds DR. ANNE MARIE ALBANO

[09:57] DR. ANNE MARIE ALBANOAnd so what, you know, when you first get out there, so, things like, there’s assertiveness, there’s unstructured social conversations. The social gatherings, like going out with your friends, I mean, going to someone’s house or a bar or something, and you avoid those totally.

10 minutes 17 seconds NICOLE

[10:17] NICOLEPretty much unless someone is with me, where we walk in together. DR. ANNE MARIE ALBANO:

10 minutes 22 seconds DR. ANNE MARIE ALBANO

[10:22] DR. ANNE MARIE ALBANOSo, it’s easier if you’re accompanied. NICOLE: Yeah. Typically, if someone

10 minutes 27 seconds NICOLE

[10:27] NICOLEwants to go out for, you know, a drink for their birthday or something, I say, you know, can I pick you up, can you pick me up, can we walk in together and I’m a lot more relaxed. DR. ANNE MARIE ALBANO:

10 minutes 37 seconds DR. ANNE MARIE ALBANO

[10:37] DR. ANNE MARIE ALBANOSo you found a way to make the situation manageable then, okay. NICOLE: Yeah. DR. ANNE MARIE ALBANO: And so I would assume that without someone there, a 10; but with someone, how anxious are you? NICOLE: With someone, if I’ve been to the place before, it’s relatively

10 minutes 52 seconds NICOLE

[10:52] NICOLElow at three or four. DR. ANNE MARIE ALBANO: Okay. NICOLE: But if it’s a new bar, a club or something, or an area I’m not familiar with, it’s more of a six.

11 minutes 2 seconds DR. ANNE MARIE ALBANO

[11:02] DR. ANNE MARIE ALBANOOkay. And let me ask you one other thing. Interviews? And I assume as you’re going through school and you want to go to grad school and such, you may have to interview and finding work eventually interviews. How are you with interviewing?

11 minutes 17 seconds NICOLE

[11:17] NICOLEI’ve got a few jobs and when I first started getting, you know, a lot of high school jobs, I was nervous as could be and didn’t know what to say or how ot act or what to do but it’s gotten a little better now that I have experience and training and a few things, I can talk about my skills, instead of just focusing on, well, I like to read and, so it’s capabilities and things like that. So it’s still nerve wracking because I go in a cold sweat and I come out and I feel like, you know, I just climbed Mount Everest. DR. ANNE MARIE ALBANO: Okay. NICOLE: But it’s not that terrible. DR. ANNE MARIE ALBANO: So you see your anxiety’s

11 minutes 57 seconds DR. ANNE MARIE ALBANO

[11:57] DR. ANNE MARIE ALBANOhigh going in, you get into the situation, does it come down any, when you’re in it? NICOLE:

12 minutes 2 seconds NICOLE

[12:02] NICOLEIt depends on what type of questions I’m being asked. If I’m being asked about my skills or given a situation, how would you handle this, if I can answer the questions, then I don’t feel too bad but if they throw something in there that I’m not prepared for, it just kind of shakes everything up. DR. ANNE MARIE ALBANO: Okay, and then afterwards,

12 minutes 22 seconds DR. ANNE MARIE ALBANO

[12:22] DR. ANNE MARIE ALBANOyou do the post mortem. NICOLE: Yeah. DR. ANNE MARIE ALBANO: And the post mortem brings back anxiety or – NICOLE: Kind of, I’m glad

12 minutes 32 seconds NICOLE

[12:32] NICOLEthat was over and I hope I get the job but then it’s kind of like a critical analysis, you know, did I say the right thing, did I make eye contact, you know, did I smile; it’s just kind of, I judge what I’ve just done and beat myself up over it until they call. DR. ANNE MARIE ALBANO: Okay. Okay. Any other situations that are particularly

12 minutes 52 seconds DR. ANNE MARIE ALBANO

[12:52] DR. ANNE MARIE ALBANOtroubling or difficult for you, that we didn’t just touch on? NICOLE: No. Those are the major ones. DR. ANNE MARIE ALBANO: Okay. What,

3: Psychoeducation on anxiety

13 minutes 2 seconds DR. ANNE MARIE ALBANO

[13:02] DR. ANNE MARIE ALBANOyou know, with your social anxiety, because it covers unstructured social situations like, you know, casual situations, and then this, the more formal situations like answering a question in class, some of the interview things, it’s what we call generalized social anxiety. You’re not focused in on public speaking only, and everywhere else you’re okay.

13 minutes 27 seconds DR. ANNE MARIE ALBANO

[13:27] DR. ANNE MARIE ALBANOSo it’s generalized, and it’s the most common social anxiety, actually. This is the kind that starts early and stays and hangs with you until you, you know, get a handle on it. So, let me ask, how long has this been going on in terms of how far back do you remember yourself being anxious in these kinds of situations? NICOLE: I

13 minutes 52 seconds NICOLE

[13:52] NICOLEpretty much remember, I’d have to say about seventh or eighth grade, when school started because I moved to a new town, it was a new school, and I’d never been terrified, and from then on, I think it just gradually got worse as I got older. DR. ANNE MARIE ALBANO: Okay.

14 minutes 12 seconds DR. ANNE MARIE ALBANO

[14:12] DR. ANNE MARIE ALBANOSo what this leads into now is the second sort of, part of what we’re doing. First we understand you and where you’re at with the anxiety and then, you know, now to understand how it starts or where it comes from and, you know, anxiety itself, is a normal, natural emotion and it’s meant to be there to protect us and motivate us. It had a greater use when, you know, we were in primitive ways. Now that we have streetlights and doors with locks on them and stuff, we don’t need it the way that we used to need it, so to speak, but it sticks with us and arises from a part of our nervous system that, it’s biologically based and there’s actually a part of the nervous system that we call the fight or flight response, it alerts us to danger and it sends off hormonal responses and all kinds of different physiological changes to help us focus in on the danger and either fight it or flee from it. Now the thing when you’re sitting in a classroom, and the teacher is, you know, lecturing and then starts the Q&A period, what are you focusing in on, right? You’re, you know, all of a sudden, you know, the teacher looks like a tyrannosaurus rex, you know, and you feel completely bare and unable to deal. What happens is, for whatever reason, people, you know, have maybe a biological predisposition to be more anxious, family history, genetics, who knows?

15 minutes 47 seconds DR. ANNE MARIE ALBANO

[15:47] DR. ANNE MARIE ALBANOBut over time, as your system, your biology, interacts with the environment, from the time you’re little, for whatever reason, your mind and your psychological being, has learned to focus in on things that are innocuous even, or ambiguous, and misinterpret threat, and in fact, over interpret threat. Maybe you’ve had some experiences, some people with social anxiety have been teased or they’ve had embarrassing moments that they felt really overwhelming, or maybe you’ve observed others or you know, you just, for whatever reason, become afraid in these types of situations. So, over time, you were shaped in the way you think, to anticipate rejection, humiliation, worry about that and then that leads into either escape or avoid, or, as you’ve learned to do, bring someone with you, you know, to sort of, keep you covered, in a way, okay? The great thing about this is whatever you learn, you can unlearn, and new adaptive ways can be taught, of managing these situations. Does this make sense in any way to you? NICOLE: Yeah, it does. DR. ANNE MARIE ALBANO: Okay. And, you know, the other thing is that, I don’t know if you’ve tried to tell yourself or if you heard from others, just relax.

17 minutes 22 seconds DR. ANNE MARIE ALBANO

[17:22] DR. ANNE MARIE ALBANOHow does that feel? NICOLE: It depends. Sometimes

17 minutes 27 seconds NICOLE

[17:27] NICOLEI’m just so uptight, I just, it doesn’t work. DR. ANNE MARIE ALBANO: No, it doesn’t work,

17 minutes 32 seconds DR. ANNE MARIE ALBANO

[17:32] DR. ANNE MARIE ALBANOand it doesn’t work because you know, just relax doesn’t give you any hint of what to do to manage the situation. But if we think about, from our perspective, and when I say our, it’s the cognitive behavioral perspective, whatever brought you to this point, you’re here. We focus on the here and now, your history is important, because it shaped you, but what is getting in the way of you moving forward is important at the moment and the idea of just saying relax doesn’t give you any way to deal with the anxiety. We break the anxiety into three components; the cognitive, which is what you think, so your cognitions, your beliefs, ideas, images that you have, I mean, when you are sitting out in that car in front of a party that’s going on in your friend’s house, you’ve got in your mind specific, like, it’s like a movie flashing and images flashing of what could happen, and you are running a dialog in your mind as you say, you know, should I, shouldn’t I, should I, shouldn’t, and you know, and so forth. So there’s the cognitive aspect. The second part is the physiological somatic aspect. Anxiety is typically accompanied by sensations; what are your physical sensations when you’re anticipating? NICOLE: Trying to go over to a party or something,

18 minutes 57 seconds NICOLE

[18:57] NICOLEI just, I get nauseous, my stomach tightens up, and other situations it’s gotten to the point where I’m just physically tense everywhere and I start getting cold and it’s just, I just want to go home and just forget the whole thing. DR. ANNE MARIE ALBANO: Right. And those are classic autonomic

19 minutes 17 seconds DR. ANNE MARIE ALBANO

[19:17] DR. ANNE MARIE ALBANOnervous system driven anxiety reactions. So there’s the cognitive, then there’s the physiological, and they kind of feed off of each other because the more you feel nauseous, the more you say, oh my gosh, I might vomit, I can’t go in there, that’ll even be worse, and like, you’re right, and then, the third component is the behavioral, what you actually do. When you are in front of a house or a bar and you are having that, you know, go in, don’t go in, go in, don’t go in struggle, and your anxiety’s running, when you turn on the car and back out and drive away, what happens to your anxiety?

19 minutes 57 seconds NICOLE

[19:57] NICOLEFor the most part, just slowly diminishes and then I get home and then there’s the whole regret thing, it’s just I missed a great party, I should have been there, no one’s calling where are you, and it’s just – DR. ANNE MARIE ALBANO: Right. So you see, what happens is the behavioral

20 minutes 12 seconds DR. ANNE MARIE ALBANO

[20:12] DR. ANNE MARIE ALBANOpart is the escape or the avoidance or bearing it with distress, alright? But mainly escape and avoidance and it feeds back into the cognitive because the moment you’ve an initial release, but then you start beating yourself up which makes, again, a whole cycle happening, okay? So understanding that, this cognitive behavioral therapy is geared towards teaching you certain ways of coaching yourself in a realistic, coping, focused way. The stuff you do in an emergency, okay? So that’s the kind of thing we’re going to go for with the cognitive. Physiological, we may or may not touch, with social anxiety because for us, for you to get into a situation and coach yourself in the situation, to focus on the situation, deal with it, will take care of those symptoms, they’ll go away, it’s habituation, they extinguish themselves over time, as you get used to the situation, and then that leads to the third aspect of CBT, which is exposure.

21 minutes 22 seconds DR. ANNE MARIE ALBANO

[21:22] DR. ANNE MARIE ALBANOBecause you’ve been escaping or avoiding so much, you haven’t given yourself the opportunity to challenge and refute the thinking you have about things, right? But you’re an interesting study because you said to me, in two different places, how putting yourself into situations like playing your guitar with a band, you dealt, over time, it got easier and easier and you actually enjoy it. NICOLE: I do. DR. ANNE MARIE ALBANO: This is the model for you to go forward with in understanding how to manage the social anxiety for all these other situations.

22 minutes 2 seconds DR. ANNE MARIE ALBANO

[22:02] DR. ANNE MARIE ALBANOIt is like learning to play the guitar, over time, you get better, but if I ask you this, when did you pick up the guitar for the first time?

22 minutes 12 seconds NICOLE

[22:12] NICOLEOh shoot, I was 16. DR. ANNE MARIE ALBANO: 16

22 minutes 17 seconds DR. ANNE MARIE ALBANO

[22:17] DR. ANNE MARIE ALBANOyears old, okay. What was it like the first time you played for someone or someone listened to you? NICOLE: Terrible. I

22 minutes 27 seconds NICOLE

[22:27] NICOLEreally hadn’t taken official lessons and another person was teaching me to play lead, it was his guitar and I wasn’t good at it at all, didn’t think I’d ever take it up. DR. ANNE MARIE ALBANO: Okay. NICOLE: But I just, something in me always said, you know, you can do this and I’ve just kept with it and I ended up getting a nice guitar and some setup and it’s one of my favorite hobbies. DR. ANNE MARIE ALBANO: Well, let me ask you

22 minutes 52 seconds DR. ANNE MARIE ALBANO

[22:52] DR. ANNE MARIE ALBANOthis. What if you just put it down and quit? NICOLE:

22 minutes 57 seconds NICOLE

[22:57] NICOLEI don’t think I could, not for very long. DR. ANNE MARIE ALBANO: Okay. But if

23 minutes 2 seconds DR. ANNE MARIE ALBANO

[23:02] DR. ANNE MARIE ALBANOyou had, look at what you wouldn’t have learned. One, about the anxiety of playing in front of people, and two, about the joy that you brought to your life. And you see, that’s the thing with social anxiety, is that when you escape the situation, you don’t allow yourself the opportunity to mess up, strike a bad chord, right? And do it again and again, until it feels comfortable to you and even the missed chords or whatever, the missed notes, at this point, so what?

4: Cognitive restructuring

23 minutes 42 seconds NICOLE

[23:42] NICOLEJust keep going and play good. DR. ANNE MARIE ALBANO: Yeah, okay? So it’s that model,

23 minutes 47 seconds DR. ANNE MARIE ALBANO

[23:47] DR. ANNE MARIE ALBANOexactly the model you had in your life so we have to apply to very specific situations that you’ve identified as we move forward, okay? First thing that we’re going to start with though, is the inner coach or the, you know, what goes on in that head? NICOLE: It’s

24 minutes 7 seconds NICOLE

[24:07] NICOLEconfusing sometimes, it’s just, when I’m really comfortable playing with my band it’s just, I don’t hear anything, I don’t, I just do it, it’s just so natural. But going to a friend’s house for parties, it’s just, you know, go in, go in, go in. DR. ANNE MARIE ALBANO: Don’t go. NICOLE: And then it’s just, you know, you’re going to embarrass yourself, it’s just, it’s overwhelming sometimes.

24 minutes 32 seconds DR. ANNE MARIE ALBANO

[24:32] DR. ANNE MARIE ALBANOOkay. So you’re sitting outside and you are, you have very specific thoughts, quite, you know, take me through, you know, a couple of thoughts that you have sitting outside.

24 minutes 47 seconds NICOLE

[24:47] NICOLEOne of my friends, she had a birthday, she turned 23 and we were supposed to go to a pub down the street from where I live and I’d been there several times and I was supposed to meet in and I got to the parking lot and walked around my car a few times, I’m just thinking, you know, just walk in and just go in and find them and you’ll be fine and, but it’s – DR. ANNE MARIE ALBANO: Why not walk in? What was the flip side of that?

25 minutes 12 seconds NICOLE

[25:12] NICOLEIt’s just, every time I go anywhere like that, I walk in and it just, you know, I know it’s not happening, I just feel it, everything kind of gets quieter and they’re looking at the door and they’re like, oh, who’s here and I remember when I turned 21, at first I’d go into a bar, you know, when you do walk in, a lot of people look to see if you’re who they’re waiting for but it’s just, get in through the door, have them check your ID and then just going in and relaxing, it’s just getting through that first part. DR. ANNE MARIE ALBANO: Because

25 minutes 47 seconds DR. ANNE MARIE ALBANO

[25:47] DR. ANNE MARIE ALBANOyou think what will happen at the door? Everyone will look. NICOLE: Yeah,

25 minutes 52 seconds NICOLE

[25:52] NICOLEand just – DR. ANNE MARIE ALBANO: And what? NICOLE: I’m just afraid of, like, ridicule or – DR. ANNE MARIE ALBANO: Okay. NICOLE: You know, I just, someone said, oh, she’s here. DR. ANNE MARIE ALBANO: Okay. Did that ever happen?

26 minutes 2 seconds NICOLE

[26:02] NICOLENot since high school and grade school. DR. ANNE MARIE ALBANO: Okay. When people are cool

26 minutes 7 seconds DR. ANNE MARIE ALBANO

[26:07] DR. ANNE MARIE ALBANOand immature. NICOLE: Yeah. DR. ANNE MARIE ALBANO: Right. So in your adult life, when you have the freedom to choose the friends that you want to be with and you’re not stuck with, you know, the 25 kids in the class that, you know, you’re stuck with. But you have freedom to choose, you’ve been solid with your friends, your band? Okay. But what’s lingering is, what if someone ridicules me. NICOLE: Pretty

26 minutes 32 seconds NICOLE

[26:32] NICOLEmuch. DR. ANNE MARIE ALBANO: Okay. So the thing to know about this

26 minutes 37 seconds DR. ANNE MARIE ALBANO

[26:37] DR. ANNE MARIE ALBANOway of thinking is that what we identify are distortions or errors in thinking, that the past is the present. You’re haunted by some memories and some bad feelings that are not today, they’re not the peer group you have now. There may be some people who are iffy, I mean, that happens, you know, but you’re able to choose who you want to be around and when you go into a bar, that mean there’s going to be your friends and there are nobody, other people. You associate with who you want to and you don’t have to associate with people who aren’t friendly. But you’re haunted, and those memories keep driving you into thinking but it’s going to happen again, you know, in some way. I mean, it’s over generalizing this but, you know, that sort of thing. These thoughts are real discreet, so if I walk in, everybody’s going to look, somebody’s going to say, oh, there she is, you know, and then what?

27 minutes 37 seconds DR. ANNE MARIE ALBANO

[27:37] DR. ANNE MARIE ALBANOWhat next? NICOLE: It just depends, I mean, sometimes I

27 minutes 42 seconds NICOLE

[27:42] NICOLEcan walk right up to the door and I’m going to walk in and I turn around and don’t do it. DR. ANNE MARIE ALBANO: But

27 minutes 47 seconds DR. ANNE MARIE ALBANO

[27:47] DR. ANNE MARIE ALBANOwhat do you think would happen next? Your friends are there, someone says, here she is again, or whatever, what would happen next? If that really happened? NICOLE: Well, probably I’d just start

28 minutes 2 seconds NICOLE

[28:02] NICOLElooking the other way and just start looking for whoever I’m supposed to be hanging out with. DR. ANNE MARIE ALBANO:

28 minutes 7 seconds DR. ANNE MARIE ALBANO

[28:07] DR. ANNE MARIE ALBANOOkay, alright. But the discomfort would be there. NICOLE: Oh yeah. Until I found my

28 minutes 12 seconds NICOLE

[28:12] NICOLEfriends, it’s definitely there, it’s like, you smile fairly here. DR. ANNE MARIE ALBANO: What’s guiding you here, what we call what if statements.

28 minutes 22 seconds DR. ANNE MARIE ALBANO

[28:22] DR. ANNE MARIE ALBANOWhat if this happens? What if that happens? And you’ve got negative consequences associated with that, you know, or ideas. And so, you know, the idea is though, to really examine the evidence for each thought, each individual thought. What is the evidence today, that if you walked into a bar or party situation, and you pull out your ID and somebody says, oh, it’s just her. Okay, how many times has that happened in the last year? NICOLE: I’d have to say almost never. DR. ANNE MARIE ALBANO: Okay. This is what you have to say to yourself. You have to take those, what we call automatic thoughts, which were the negative thoughts, and subject them to an analysis, don’t treat it as a fact, I’m going to walk in and someone’s going to reject me, you treat it as a guess, one of the alternatives is, I could walk in and I could hear something negative, but, in the face of the reality and evidence, this hasn’t happen to me in my adult life in this way?

29 minutes 32 seconds DR. ANNE MARIE ALBANO

[29:32] DR. ANNE MARIE ALBANOI’m going to meet my friends. I mean, when you say that to yourself, you get a different feeling then, what if this thing happens? NICOLE: I think I would, actually. DR. ANNE MARIE ALBANO: And you really have to look at, wait a minute, you know, at my age and what I’ve been doing in the last several years, the friends I have, what’s the realistic likelihood that something like that would happen? What do you think it is, from zero to 100% sure it’s going to happen? NICOLE: Probably about a 1% chance.

30 minutes 7 seconds DR. ANNE MARIE ALBANO

[30:07] DR. ANNE MARIE ALBANOOkay. That’s the way to talk and focus your mind is on the realistic probabilities of what can happen in a situation. Not on the guesses, old history, memory stuff, on the reality of what you’ve been experiencing and what is around you. And the truth is, if somebody look, you know, if people turn and look, I mean, you actually are loaded with what we call rational responses. I know people are looking at the door to see if their friends are coming in, and it’s true, that is, when I walk in, I mean, this is one of the number one things people with social anxiety say, I don’t want to walk in because everybody will look. And what I try to coach them to is yeah, people look to see if they know the person, their friends are there, or whatever, and then what? NICOLE: I go back to what they’re doing if you’re not them.

31 minutes 2 seconds DR. ANNE MARIE ALBANO

[31:02] DR. ANNE MARIE ALBANORight, right. And so that’s the way is, you know, yeah, people are going to look to see, and you know what? So will my friends, and they’ll say, hey, we’re over here.

5: Behavioral coping through exposure

31 minutes 12 seconds DR. ANNE MARIE ALBANO

[31:12] DR. ANNE MARIE ALBANOThat’s the focus for you, okay? That’s the cognitive aspect, the cognitive restructuring is thinking realistically and you know, challenging each specific thought with realistic evidence; people look, so are my friends going to be looking, and I’m going to find them, okay? And then the next aspect though, is the behavioral and this is what we call exposures.

31 minutes 37 seconds DR. ANNE MARIE ALBANO

[31:37] DR. ANNE MARIE ALBANOHave you heard of exposures? NICOLE:

31 minutes 42 seconds NICOLE

[31:42] NICOLEProbably somewhere. DR. ANNE MARIE ALBANO: This is what people kind of get a little,

31 minutes 47 seconds DR. ANNE MARIE ALBANO

[31:47] DR. ANNE MARIE ALBANOwhat do you mean? It’s because they know it’s in order to learn how to cope with something, you’ve got to get to dealing with it. So you do have to set up situations for yourself where you enter these situations while you’re challenging your thoughts and you have, in the beginning, you need to have realistic, simple goals for yourself because the idea of, I’m going to go to the party, I’m going to walk in, I’m going to have a great time, you know, that’s an overwhelming goal for someone who’s been anxious about going into these situation.

32 minutes 27 seconds DR. ANNE MARIE ALBANO

[32:27] DR. ANNE MARIE ALBANOBut let’s be specific and let’s make some, you know, really simple goals to work towards. Do you have a situation coming up in the next week, let’s say, that you have to go to that might be challenging in terms of social anxiety? A class that you’re going to be in or

32 minutes 52 seconds NICOLE

[32:52] NICOLEI do have a, it’s a weekend class coming up, it’s going to be, I believe, eight hours – DR. ANNE MARIE ALBANO: eight-hour class?

33 minutes 2 seconds NICOLE

[33:02] NICOLEYeah, Saturday and Sunday and it’s four hours and the previous Friday and then that’s it. DR. ANNE MARIE ALBANO: Okay. What kind of anxiety do you have around the

33 minutes 12 seconds DR. ANNE MARIE ALBANO

[33:12] DR. ANNE MARIE ALBANOclass?

33 minutes 17 seconds NICOLE

[33:17] NICOLEI’m not sure. It’s, this will be the second time I’ve done a class like that and I remember the first time was pretty bad. DR. ANNE MARIE ALBANO: Why? Tell me why.

33 minutes 27 seconds NICOLE

[33:27] NICOLEBecause that particular professor is very much, you know, open, share your feelings, everyone’s safe here and it’s just, you know, it’s difficult for me to, you know, walk in and say, hey, you know, – DR. ANNE MARIE ALBANO: Okay. NICOLE: And I was really rigid and anxious and, till about the first three hours and then I losen up a little bit and – DR. ANNE MARIE ALBANO: But it’s the idea that you know, going in, that this professor wants you talking,

33 minutes 57 seconds DR. ANNE MARIE ALBANO

[33:57] DR. ANNE MARIE ALBANOwants you sharing, wants you putting stuff out there, right? So what are your thoughts as we think about this situation that’s coming up? What if, what? NICOLE: Just trying to walk

34 minutes 12 seconds NICOLE

[34:12] NICOLEinto the class and sit down and know that I’m in the right room. DR. ANNE MARIE ALBANO: Okay. So what if I get lost?

34 minutes 17 seconds NICOLE

[34:17] NICOLEYeah. DR. ANNE MARIE ALBANO: Okay, that’s one. What else? What if I enter late?

34 minutes 22 seconds NICOLE

[34:22] NICOLEYeah, that’s another problem. DR. ANNE MARIE ALBANO: Okay. Because if I come in the classroom

34 minutes 27 seconds DR. ANNE MARIE ALBANO

[34:27] DR. ANNE MARIE ALBANOlate, what’s going to happen? NICOLE: Everyone looks and then you don’t know if you’re

34 minutes 32 seconds NICOLE

[34:32] NICOLEin the right place and it kind of throws a monkey wrench into the whole system of the class and – DR. ANNE MARIE ALBANO: Let me focus on, everyone looks. If I walk in late and everyone

34 minutes 42 seconds DR. ANNE MARIE ALBANO

[34:42] DR. ANNE MARIE ALBANOlooks, then what?

34 minutes 47 seconds NICOLE

[34:47] NICOLEI’m just going to say I’m here and I’m late. DR. ANNE MARIE ALBANO: Okay,

34 minutes 52 seconds DR. ANNE MARIE ALBANO

[34:52] DR. ANNE MARIE ALBANOwhat’s anxiety provoking about that?

34 minutes 57 seconds NICOLE

[34:57] NICOLESomehow, I just don’t like to disrupt things, I don’t – DR. ANNE MARIE ALBANO: Because if I

35 minutes 2 seconds DR. ANNE MARIE ALBANO

[35:02] DR. ANNE MARIE ALBANOdisrupt things, what?

35 minutes 7 seconds NICOLE

[35:07] NICOLEI don’t know how to explain that, it’s just (inaudible) way feels. DR. ANNE MARIE ALBANO: Okay. My guess,

35 minutes 17 seconds DR. ANNE MARIE ALBANO

[35:17] DR. ANNE MARIE ALBANOand I’d like to use the iceberg analogy, is what if I walk in late and everyone looks and I’m disrupting things, that’s above the water. It’s what’s under the water that you have to work on, you know, exposing, or you hit the Titanic, you know, right? What’s under the water is, if everyone looks at me and I’ve caused the professor to miss a beat or disrupt the class, then people will think badly of me, the professor will have a black mark against me, that’s the thing that drives this kind of anxiety and it’s those thoughts that we have to uncover because we have to challenge them, right? And we challenge them in a couple of ways.

36 minutes 7 seconds DR. ANNE MARIE ALBANO

[36:07] DR. ANNE MARIE ALBANOHave other students walked in late to classes? NICOLE: Many times.

36 minutes 12 seconds DR. ANNE MARIE ALBANO

[36:12] DR. ANNE MARIE ALBANOOkay. Are they still students or did they get kicked out? NICOLE: Oh, they’re still here.

36 minutes 17 seconds DR. ANNE MARIE ALBANO

[36:17] DR. ANNE MARIE ALBANOOkay. And you know, you have to think about situations like that. Again, if someone walks in the door, people are going to look, right? Somehow you’re thinking, you’re associating catastrophic ideas with, if you’re a little late or if you get lost or whatever, you’re associating some catastrophe with that, right? And you’ve got to challenge that. Other people have walked in late. Actually, I’m rarely late, from what my guess is, right? And as you say, you even scout out some of these places so you get there on time and you know where to go.

36 minutes 52 seconds DR. ANNE MARIE ALBANO

[36:52] DR. ANNE MARIE ALBANOSo one of the things, you know, about this is, if I walk in, you know, I’m usually prepared and if I’m late, it’s not going to have an impact on things because that happens, people wander in for the first 20 minutes of these kinds of classes, half hour late, with their Starbucks in hand, and maybe a professor will say, oh, too bad you didn’t get some coffee for the rest of us, but it’s not a big deal, okay? That changes the valence of the thoughts, they make it more neutral, not anxiety provoking. And then the other thing is, this professor’s going to want you to talk. NICOLE:

37 minutes 27 seconds NICOLE

[37:27] NICOLEYeah, she does. DR. ANNE MARIE ALBANO: What about that? And if I

37 minutes 32 seconds DR. ANNE MARIE ALBANO

[37:32] DR. ANNE MARIE ALBANOopen up, what?” NICOLE: It’s just, I feel like I’m

37 minutes 37 seconds NICOLE

[37:37] NICOLEexposing myself to people that I don’t know, who don’t know anything about me and it’s like, you know, if I say something really personal, can I trust that they won’t run around the school and you know, I’ll seem him next week and oh, that’s, she said, it’s just, it’s more of a trust issue and it’s like, how far am I going to take something and expose myself. DR. ANNE MARIE ALBANO: Okay. Is everyone in this class

38 minutes 2 seconds DR. ANNE MARIE ALBANO

[38:02] DR. ANNE MARIE ALBANOdoing the same thing? NICOLE: We’re supposed to all be doing it. DR. ANNE MARIE ALBANO: Right. So, the expectation is people talk more than they don’t and the expectation is that there’s a confidentiality agreement? Okay. The other thing is, are you in control of what you said? So you can choose to get more or less personal. NICOLE: Yeah. DR. ANNE MARIE ALBANO: Okay, and that’s something to bear in mind. Some people like to come into these classes, they take these classes regularly, they love to, like, bare it all, but the reality is, it’s up to you, okay?

38 minutes 37 seconds DR. ANNE MARIE ALBANO

[38:37] DR. ANNE MARIE ALBANOSo that’s something else. I will, this is what we call rational response, I will say what I want to say. I will gauge what I say by how I feel about the people around me, okay? But I don’t have to say nothing, okay? So that’s again, a rational response to the automatic thought that if I expose myself then people are going to use it against me later, okay? The rational response is, I can say things and I can have control over what that is, alright? Now, for when

6: Closing the session

39 minutes 17 seconds DR. ANNE MARIE ALBANO

[39:17] DR. ANNE MARIE ALBANOyou go into this class, let’s have some goals for what you would like to accomplish that’s reasonable. What do you think?

39 minutes 27 seconds NICOLE

[39:27] NICOLEIt’s just go into the class and sit down and just chit chat with everybody until the class starts. I’m usually not one for doing that sometimes if I don’t know anybody in the room. DR. ANNE MARIE ALBANO: So, what is your

39 minutes 42 seconds DR. ANNE MARIE ALBANO

[39:42] DR. ANNE MARIE ALBANOusual mode of entering the class? NICOLE: Usually I’m the first one there

39 minutes 47 seconds NICOLE

[39:47] NICOLEor first few and take a seat and just sit there pretty much. DR. ANNE MARIE ALBANO: Put your head in a book, so no one talks to you? NICOLE: Well, sometimes. DR. ANNE MARIE ALBANO: Okay.

39 minutes 57 seconds DR. ANNE MARIE ALBANO

[39:57] DR. ANNE MARIE ALBANOHow about a goal of going to class closer to on time, as opposed to getting there real early, so closer to on time. So, a goal of going in, sitting down, and just sitting up, okay? So, and as people walk in, just being available. If someone says hello, you say hello, okay? So a goal would be, and this is a very focused goal because we don’t have a goal, we don’t want the goal, I’m going to go in and become people and talk to people, no, no, no. NICOLE: Yeah. DR. ANNE MARIE ALBANO: I’m going to go in and I’m going to sit up and be available, not be in the books, right?

40 minutes 47 seconds DR. ANNE MARIE ALBANO

[40:47] DR. ANNE MARIE ALBANOAnd the second thing is, reciprocate a hello, right? What if somebody sits next to you and they don’t say anything but they kind of, look over? Could you say hi? NICOLE: Yeah, I’ve done that before,

41 minutes 7 seconds NICOLE

[41:07] NICOLEjust say hi and give my name and – DR. ANNE MARIE ALBANO: Good,

41 minutes 12 seconds DR. ANNE MARIE ALBANO

[41:12] DR. ANNE MARIE ALBANOthat’s excellent. Alright, so the third thing is, maybe initiate.

41 minutes 17 seconds NICOLE

[41:17] NICOLEYeah, I’m not one to initiate things all the time, you know.

41 minutes 22 seconds DR. ANNE MARIE ALBANO

[41:22] DR. ANNE MARIE ALBANOSo maybe this first time you go into class on Friday is the first wave, right? You reciprocate a hello, but on Saturday, because you’ve been in there, same group of people on Saturday? NICOLE: Yep. DR. ANNE MARIE ALBANO: Your goal will be to say hello to one person, okay? You see, these are stepwise goals, alright? And then on Sunday, you have it again on Sunday? NICOLE:

41 minutes 52 seconds NICOLE

[41:52] NICOLEYep, most for it is. DR. ANNE MARIE ALBANO: So then maybe on Sunday, you follow up

41 minutes 57 seconds DR. ANNE MARIE ALBANO

[41:57] DR. ANNE MARIE ALBANOthe hello with what he thinks, how you think the class has been going. More of a question on Sunday to maybe, start a conversation, okay? This is exposure, you don’t want to bite off the whole thing on the first day. NICOLE: No. DR. ANNE MARIE ALBANO: You’ve got to make it manageable and each day you add a little bit more, okay? So then it’s controllable for you and manageable for you and you know, you can stay focused on the situation, and it’s kind of like what I want you to keep in mind is the first day is the day you learned to play the guitar, the second day, you know, your first lesson, the second day is like, you know, down the road, when you first had to play your first song in front of your teacher, the third day, you’ve got some friends around and you’re jamming for the first time. You’re sort of, building it, alright? Does that make sense? NICOLE: Yeah, it does. DR. ANNE MARIE ALBANO: Okay, what do you think about as you approach things in that way with, like, a plan? NICOLE: I think I’ve got to use it just step by

43 minutes 7 seconds NICOLE

[43:07] NICOLEstep so I get comfortable with it enough. DR. ANNE MARIE ALBANO: Right. Now there’s another

43 minutes 12 seconds DR. ANNE MARIE ALBANO

[43:12] DR. ANNE MARIE ALBANOimportant part to this too, which is, again, if you learn to play that guitar and then, you know, didn’t rehearse and practice, what would happen? NICOLE: You don’t sound as good as you should. DR. ANNE MARIE ALBANO: Right. So part of, you know, there’s two aspects to practicing; one is being in the situation, putting yourself in the situation, that’s exposure practice, okay? The second part is the cognitive practice. So before you go to the class, or to a friend’s house, I want you to sit down with a piece of paper and first of all, write out what your goals are, what you might want to accomplish going to this party, going to this class, going, you know, and using the bank teller or something, okay? What do I want to accomplish and let me use the very discreet goals. The second part is getting out, for that situation, what am I saying to myself? Okay?

44 minutes 22 seconds DR. ANNE MARIE ALBANO

[44:22] DR. ANNE MARIE ALBANOListing those automatic thoughts, one at a time, list them. I won’t know what to say, what if somebody is looking at me weird, list those thoughts down and for each thought, I want you to evaluate the evidence for the thought. NICOLE: Okay.

44 minutes 42 seconds DR. ANNE MARIE ALBANO

[44:42] DR. ANNE MARIE ALBANOOkay, and then come up with a rational response. How can you challenge that thought? So an example, what, the next time you go to a friend’s house, and there’s people gathered, or a bar with the, you know, social outdoor gathering, and there’s people gathered and your thought is, as you’re walking up to the table with your friends, there are also people you don’t know. What is your thought? NICOLE: Just relax and

45 minutes 12 seconds NICOLE

[45:12] NICOLEhave a good time. DR. ANNE MARIE ALBANO: Oh, but you know what? That’s not a helpful thought.

45 minutes 17 seconds DR. ANNE MARIE ALBANO

[45:17] DR. ANNE MARIE ALBANOThat’s a positive thought and positive thinking actually gets in the way of dealing with anxiety because it doesn’t give you anything to really focus on behaviorally. More on the lines of, if I’m walking in there and there’s people I don’t know, your thought might be, -- NICOLE:

45 minutes 37 seconds NICOLE

[45:37] NICOLEYou know, I’m just carrying the look. DR. ANNE MARIE ALBANO: Okay. Right? Who are these

45 minutes 42 seconds DR. ANNE MARIE ALBANO

[45:42] DR. ANNE MARIE ALBANOpeople, what are they going to think of me? Now, the evidence in things to refute and challenge that thought are, what? Realistically, what’s going on? NICOLE: They’re just looking to see if they know who’s coming and – DR. ANNE MARIE ALBANO: And they’re with my friends, right? I’ve met people in the past, how did I make my friends? I met them. I kept light, so these are things then, to challenge your thoughts and then you put together a rational response. Oh there are new people sitting around with my friends, hmm, well, I’ve met people in the past, my friends are evidence for that, now let me see who these people are. That changes the way you feel about a situation. NICOLE: Yeah, it would. DR. ANNE MARIE ALBANO: Okay? And then, so that’s what you do with your practice before you get to the situation and then the thing is, afterwards, after you do these things and you try to meet your goals, I’ll introduce myself, let me ask questions of these people, afterwards, evaluate how you did, but don’t beat yourself up for things that didn’t go the way you want to because that happens. Instead, focus on what can you do differently and what do you think you did really well and also, if you focus on the situation, as you did, learning to play the guitar, you’ve already told yourself and shown yourself that the more experience you have, what happens? NICOLE: The better you get at it. DR. ANNE MARIE ALBANO: Right. It’s going to be the same thing with socializing.

47 minutes 12 seconds DR. ANNE MARIE ALBANO

[47:12] DR. ANNE MARIE ALBANOOkay? Take that with you then? NICOLE: Yeah.

47 minutes 17 seconds DR. ANNE MARIE ALBANO

[47:17] DR. ANNE MARIE ALBANOOkay. Alright, so do that for your first try at this is, you know, with the class this weekend, I think it’s a great, you know, progression of the three days, and then it’s kind of, that the kind of model for moving forward. Okay? NICOLE: It’s got to work. DR. ANNE MARIE ALBANO: Okay, great. Good luck.