Richard Heimberg and the treatment of social anxiety

I suffered from social anxiety for a few years in my late teens and early twenties, and managed to overcome it thanks to Cognitive Behavioural Therapy (CBT). I then researched and wrote a long and rather crazy book, looking at the relationship between western culture and social anxiety. The book, which was called The Wild Man, suggested there was a link between liberalism and social anxiety, because in liberalism we replace the gods with other people as the ultimate judge of our worth. So anxiety about divine judgement is replaced by anxiety about the judgement of the public. I still like the theory, though the book needs a lot of work.

As part of my research, I interviewed a few CBT experts to ask them what they thought was the relationship between culture and social anxiety. Here's one of the interviews, with the great cognitive therapist Richard G. Heimberg, perhaps the world's expert on social anxiety. He was kind enough to give me an interview, in 2007. Here it is.

What is the prevalence of social anxiety?

Around 12% are affected by it at some point in their lives. That's an awful lot. It makes it the second most common emotional disorder after depression, and the odds of developing co-morbid depression with social anxiety are high.

Is there some opposition to defining it as a mental illness?

Yes. People with social anxiety tend to be thought of as simply being shy, as if it's a personality characteristic that doesn't require treatment. [See, for example, Christopher Lane's Shyness: How Normal Behaviour Became A Sickness (2007).] That's very wrong. It's very impairing. You can't get much nastier than it. Anything that cuts people off from being able to bond to others can only lead to a very unsatisfying existence. Social support is really, really important to overcoming the stresses of life. When you don't do well in an exam, for example, or there is a death in the family, and you don't have a shoulder to cry on, that's really hard.

How severe can it be?

We have people in the clinic who can't even eat dinner with their families - they're too anxious even to do that. It can be an extremely impairing condition. They end up like vampires, only able to come out at night when no one is around.

Could some cultures be more conducive to social anxiety than others?

First of all, it seems that if you're living somewhere other than your native country, the less acculturated you are, the more vulnerable you are to developing social anxiety. There have been studies of people who've emigrated to the US, for example, which shows a higher incidence of social anxiety among immigrants than among the resident population. At our clinic, we work with people from around the world who have moved to the US and developed social anxiety. It's because the cultures are very different - either the US is more socially demanding or it's simply different, but it's pretty stimulating of anxiety. Especially if the country you're immigrating into is economically superior, so you want to stay in it long-term, which means you put a high value on fitting in. The more that fitting in is a high cost game, the more likely you are to be anxious.

[I can personally attest to this. I overcame a lot of my social anxiety, in fact, living as an expat in Russia. The difference between an expat and an immigrant is an immigrant, typically, has traveled to an economically superior country to make a living, and so, as Heimberg says, there is a pressure to fit in with that country's cultural demands. An expat, by contrast, has gone to a less developed economy to make a living, and feels less anxiety about fitting in. If anything, they feel more relaxed and less self-critical, because they are outside their own culture and peer group.]

Do you think western culture is particularly conducive to social anxiety?

Ours is a social anxiety-provoking society, in the sense that people in western societies by and large believe that people are looking at them, evaluating them and being highly critical of them. And they're right - we are very critical of others in this culture, and would do well to be less so. There are differences from culture to culture in terms of how important these things are, and you should see a difference in prevalence. For example, a professor in Australia talked about the 'tall poppy' phenomenon in Australian culture - that you don't want to be a tall poppy in its culture, otherwise someone or something will whack you off.

In Sweden, to take another example, it's a very social country. and there's a habit in the workplace of taking a mid-morning coffee break. So, by institutional demand, everyone in the office gets together for a mid-morning coffee. There's so much that's healthy in that. But many more Swedes than other cultures come to our clinic with anxiety about drinking in front of other people.People in Asia, in general, are more afraid of doing something that will bring shame onto their family rather than themselves. For example, it's not always considered bad to be shy and quiet, but it might be considered shameful to fail at school.

But there are alternate views, like the evolutionary psychologist Paul Gilbert, who argues that social anxiety is in our nature, that it's an evolutionary adaptation in primates to prevent group conflict. It makes primates defer to the dominant male, avoids fights, and lets the primate who feels the social anxiety stay in the group. It's an interesting theory.

What about the psychiatric theory of social anxiety, that it's a biomedical condition that you should treat with medication?

When I first started working on social anxiety, in the 1970s [before it was introduced into the DSM-III in 1980], I became friendly with the psychiatrist Michael Liebowitz [who went on to develop the Liebowitz social anxiety scale]. We always shared the notion that our goal was to help clients do as well as possible. It doesn't matter how. The literature and science is divided by a turf war in a very un-scientific way. Psychologists read psychology journals, psychiatrists read psychiatry journals. They're far more different worlds than you'd imagine. But Liebowitz and I wanted to help people from both sides.

We carried out one of the first large scale comparisons of CBT with the drug of the day, which was monoaximine inhibitors. We found that both of them worked well - the drug treatment worked a little bit faster, while CBT worked better after the treatment was over. There have been studies since that look at what happens when you combine CBT and medication, for example by Isaac Marks at Kings College in London. There's some evidence that those people who give more credit to their medication for the recovery are more likely relapse after treatment ends. So we try and tell clients that the drug may help you open the door but you have to go through it yourself, and take the credit for it.

What's the relationship between CBT and ancient Greek philosophy?

If you want to ask about the roots of CBT, you need to go back to ancient Greece. The best summary of CBT is the Stoic line: 'It's not events, but our opinions about them, that cause us suffering.' Stoicism is absolutely a direct influence on CBT, though of course, there's a few thousand years in between. The philosophy itself is informing the theory, while the therapy adds the procedure and activities that are necessary to move from the Greek philosophy to understanding how that shows up in our lives.

Thanks very much.

By the way, anyone reading this with social anxiety - an audio course that I found very helpful in getting over it is Dr Thomas Richards' series, Overcoming Anxiety Step-By-Step. I hope you get better soon, Jules.