“I’m not going to teach you how to pick up women,”

 she mutters in a dour Scottish accent. I can feel her eyes judging me, but I gather that’s why she is being paid.

“Well fuck this shit then!” I think to myself. Luckily, there’s no Freudian slip, my cynicism veiled by a mere sheepish nod.

Why they hell have I even come to see this woman? I know precisely what is responsible for my chronic decrement in mood and I know precisely how to assuage the problem. Well, at least I thought so.

 “Everywhere around me, I see couples, Hermes and Aphrodite; sexually fulfilled beings rejoicing in mutual affection. My Facebook newsfeed is littered with people getting engaged, getting married, having babies. There seems to be mass celebration of human fecundity, yet I’m not invited.”

There is silence, but it is a sympathetic silence. I continue my self-indulgent rant:

“ Perhaps it’s my own naivety, but I was raised with the notion that you can accomplish anything with hard work. If you want to get good at running, you train hard. If you want to pass an exam, you revise a lot. I even developed social skills through hard work: forcing myself to make eye contact and then small talk with strangers.”

Maybe this last part is the key to finding a partner: by trying harder. Some people may pin their involuntarily prolonged singledom on bad luck, bad people or bad looks (which is, in turn, surely some sort of genetic bad luck?). For me, I acknowledged that my inability to meet a girl was largely due to a wider fear of people, of social situations. It was a species of social anxiety, albeit mild, that was keeping me imprisoned. DSM-V, the latest diagnostic manual used by US psychiatrists, describes social anxiety disorder (or social phobia) as “a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.”

The cruel irony of social phobia is; that which one fears is the very thing one craves. Friendships, relationships, the need to love and be loved: these are all contingent upon the very social interactions that we are afraid of making. Yet, as I mentioned, I took steps to vanquish this phobia. Essentially, what I undertook independently was a form of exposure therapy. Post-25, my life became one long spell of systematic desensitisation towards these feared social situations.

It started off small, forcing myself to sustain a few seconds of eye contact with checkout staff at supermarkets. Of course, this was terrifying, but each time I tried it, it got slightly easier. I was then able to progress to the next step: asking random strangers around London banal, impersonal questions such as, “Do you have the time?” or “How do I get to Fenchurch Street Station?”

Again, this got easier, but physical touch was still beyond my comfort zone. Accordingly, I started to chip away at that barrier. My tools consisted of a platonic pat on the shoulder when asking a colleague how their day was, or an innocent hug when bidding goodbye to a friend.

The denouement of this incremental exposure to feared situations was my initial foray into paid online dating. I actually was able to meet complete strangers and forge meaningful conversation with them. Alas, conversation that was papered over with feigned opinion, feigned confidence and a feigned hinterland of romantic experience.

Ah, but the point remains that things progressed swimmingly with a bit of effort? Well, if that was so, then why am I here emptying the contents of my consciousness to a therapist?

“ The trouble with the social world is that you can’t just simply try harder. Showing effort when socialising, somewhat perversely, penalises you. People shun others for ‘trying too hard.’ You end up like David Brent in The Office, reeking of desperation.”

While I have definitely made improvements in my social confidence, there prevails a core problem in making and sustaining relationships, especially romantic ones. Despite my efforts, my perennial singledom persists.

The therapist probes deeper. We discuss my childhood, my relationships with my family, my experiences at school. This is the essence of psychodynamic psychotherapy. The aim is to identify those unconscious processes that govern my, presumably maladaptive, behaviour today. My past has apparently shaped my present mental complexion.

Errrr isn’t that obvious? Of course past experiences will shape who I am today. How is that going to get me a girlfriend? Surely the answer to my relationship woes is also obvious: put myself out there more and meet more people. It’ll gradually get easier and eventually I’ll strike lucky. Yes?

Well, not necessarily. In graded exposure therapy, patients make a hierarchy of the social situations they fear, with a rating of 0-100% for anticipated anxiety. The patients are then repeatedly exposed to the lowest rung of this hierarchy until they habituate and no longer feel fear. They then progress onto the next feared situation.

Unfortunately, studies show that exposure alone fails to fully treat social phobia. Exposing oneself to a feared situation is bloody hard. Many patients either fail to engage with or drop out of exposure therapy. According to Veale (2003), only 50% of those completing the full course of exposure therapy will be successfully treated, with those suffering from depressed mood, avoidant personality type or an “intolerance of (strong) emotions” more likely to fail.

My personal experience has borne this out. In spite of my efforts, I still get flustered at the prospect of a “date” or even just introducing myself to stranger. Moreover, my desired outcome – to meet a girl and get into a relationship, remains unfulfilled. So why is it that repeated exposure to social situations fails to abrogate the fear response: the sweating, the tremors and the racing heart rate? The fear remains even when most of these social situations didn’t go catastrophically badly.

According to Professor David Clark, Chair of Experimental Psychology at Oxford University, socially anxious individuals enter social situations with certain maladaptive beliefs and assumptions. For example, someone may enter a date with the unwavering and unconditional belief that “ No one will ever love me.” They may make the assumption that a potential partner will expose them as the angsty, inexperienced fraud once they get to know them. They may even concoct certain rules to which they feel they should strictly adhere – always appear to be a confident, alpha-male type, for example.

These assumptions, beliefs and rules then lead the person to perceive themselves in social danger. This causes them to shift attention to themselves. They think, incorrectly, that every cell of their body is being scrutinised by the other person. Such an attentional shift means that internal information is used to formulate what the other person is probably thinking. My heart is racing, the other person can probably see me shaking. “God, what a pathetic, socially awkward loser!” she must be thinking. “Probably never had a girlfriend in his life.” Images of her going back to laugh with her mates about a pathetic date start to surface. They probably stem from childhood experiences of groups of teenage girls laughing at me.

These beliefs serve to perpetuate social anxiety. Augmenting this, social phobics are said to engage in “safety behaviours.” Drinking alcohol, avoiding eye contact, asking barrages of questions – these are all mobilised in an effort to thwart a social catastrophe. In reality, all they serve to do is reinforce the notion that the social situation should indeed be feared and that social catastrophe, embarrassment etc. are just around the corner.

So, how does one overcome this? What is the best way to rid of social anxiety?

Cognitive and Behavioural Therapy (CBT) aims to identify and challenge some of these negative automatic thoughts and beliefs. Patients are also taught to shift their attention outwards, rather than inwards. Therapists may even employ videos of patients in social situations to show them that they didn’t come across as awkward as they thought at all.

Published studies attest to the efficacy of CBT. A good way of determining the effectiveness of a certain treatment is to collate all the Randomised Controlled Trials that compare that treatment to a placebo or some other form of control. This is known as a meta-analysis.

Powers et al (2008) conducted a meta-analysis of 9 RCTs and found CBT therapies to be significantly effective. Canton et al (2012) conducted a meta-analysis of 30 trials of psychological therapy for social anxiety disorder. One study in the meta-analysis showed that CBT had better outcomes when compared to mindfulness-based techniques. Another study, showed CBT to be more effective than interpersonal therapy (a therapy that focuses on understanding social roles and interactions with other people). It should also be noted that medication (particularly SSRI medication) also plays a fundamental role in the treatment of social anxiety.

“So I’ll see you next week, at the same time?”

 the therapist ends.

“Ermm, yeah. I guess so.”

The trouble is, I’m not receiving CBT; I’m receiving psychodynamic psychotherapy. I won’t be videoed in a social situation and given feedback, nor will I be given exercises to try and shift my attentional focus outwards. But hopefully, an exploration of my childhood and my life to date can impart some clarity over why I think the way I do, why I’ve formed these unjustifiable beliefs in the first place.

Whether altering these beliefs will make a girl fancy me remains unanswered. Yet, in terms of efficacy of treatment, truth be told; this is the only outcome I really care about.

References:

Canton, J., Scott, K. M., & Glue, P. (2012). Optimal treatment of social phobia: systematic review and meta-analysis. Neuropsychiatric disease and treatment, 8, 203.

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. Social phobia: Diagnosis, assessment, and treatment, 41(68), 00022-3.

Powers, M. B., Sigmarsson, S. R., & Emmelkamp, P. M. (2008). A meta-analytic review of psychological treatments for social anxiety disorder. International Journal of Cognitive Therapy, 1(2), 94-113.

Veale, D. (2003). Treatment of social phobia. Advances in psychiatric treatment, 9(4), 258-264.