An astute clinician strongly encouraged our team to explore anxiety as part of our social thinking treatments for higher-functioning autism spectrum disorders, ADHD and similar diagnoses. While we had all come to realize we had been teaching strategies to reduce anxiety, we were not talking about “anxiety” and really starting at its impact on Social Thinking/social learning because, quite frankly, we are mostly a group of speech-language pathologists and that seemed to be crossing into the domain of mental health. However, the more we reviewed the materials for anxiety, the more we began to focus on how strong a role anxiety plays in the hearts and minds of our higher level students and how this affects their abilities to demonstrate their own improved social thinking to others. For those of you familiar with my work, you know that I encourage a very interdisciplinary approach with our students. Meaning, we all have to learn about social pragmatics, sensory systems, emotional regulation, counseling, behaviorism, educational demands, etc., to work with our students. As much as we try to uniquely assess a student using these different disciplines, they learn as whole people!
The more I explored anxiety treatments, the more I realized that different types of anxiety require different types of treatment. For example, there are “phobic anxieties” where students refuse to engage in a particular behavior due to irrational fear of a specific event (e.g., won’t flush a toilet; won’t go in an elevator, etc.). This type of anxiety is managed well with a cognitive-behavioral technique that works at recognizing when fear is healthy or reasonable and when it is unjustified (e.g., flushing a toilet). There are good programs that work on slowly desensitizing the client to their specific fear, exploring why it is irrational and developing a step-by-step plan to overcome their fear.
Another type of anxiety is social anxiety. However, this is not as simple as addressing the irrational fear and desensitizing oneself to the situation. Social situations, unlike specific events, are much more dynamic and synergistic involving nonverbal, verbal, situational and perspective-taking cues. In a nutshell, there is far more that can go wrong in social situations and simply trying to desensitize a person to an irrational fear of relating to others is likely going to miss the point. This is not a linear skill but a complex concept that requires a number of perceived, synchronized social competencies in order for one to approach social interaction with a successful mindset. Therefore, students with social anxiety MUST be taught to increase or at the very least recognize their social competencies before any reduction in social anxiety is going to take place.
I have developed a tool to help students deal with the complexity of learning about their own social anxiety and how to help take control over it. It was developed in large part from lessons learned from our students over the years as well as from the study of techniques and teachings offered by a team in Australia who have created some very cool curriculum addressing the issue of social anxiety. In this blog and the next, we will review of concepts that led me to create what my students now call, The Spirals (i.e., Spiral of Social Success and Spiral of Social Failure).
Basics in Learning about Anxiety
A book published in the US to teach core concepts related to anxiety that we feel everyone should read (parents and professionals who do not have mental health training in their background) is Helping Your Anxious Child 2nd Edition (Rapee, Wignall, Spence, Cobham & Lyneham, 2008)
Assessing Anxiety and Levels of the Social Mind
An “aha” moment I had after using this curriculum with our students is that if you are born to a social learning disability, then you are born to the fact that you have fewer social competencies. For these students the evidence for anxiety is that they truly don’t have the skills or competencies to be anything less than anxious when relating to others. This is particularly true for the group of students we refer to as Nuance Challenged Social Communicators (NCSC). This group of students is highly aware of how they are perceived by others and know they haven't learned some of the needed social competencies. Those whom we refer to as Emerging Social Communicators (ESC), are less likely to have strong social anxieties given they are more aloof or unaware of how people around them perceive their behaviors. This latter group still has a lot of anxiety, but it appears more related to "world-based" anxiety such as living in an unpredictability where schedules change, people get their hair cut, environments are loud, rules change when they were told rules don’t change, etc.
Because this tool is focusing on more social types of anxiety, Spirals below are more for students with characteristics of the NCSC rather than the ESC. For more information on NCSCs and ESCs, please read our article on this website about different Levels of the Social Mind (The Social Thinking-Social Communication Profile).
Strategies must belong to the Individual - Not us
Our students (adolescents) often don’t know how to use the strategies we generate or take ownership and accountability, unless we literally teach them to do this. After many years of working with adolescents, I realized that as long as I had to prompt them to use their strategies - I was the one taking ownership of their problems. Now I realize that they have to realize these strategies are theirs and not ours (the teachers and parents). We also need to help them learn that using strategies may not necessarily make their life feel more comfortable or easy; in fact, they may even feel more stress, as they have to take on the work of learning and using Social Thinking. So, as adults we need to assure them it's OK to feel some stress - we all do at times. Lastly, we need to help them to feel proud of themselves for their progress. Instead of earning points towards a token economy, they can earn “proud points” for doing things about their own social learning and anxiety management (some individuals don't need either type of points to help motivate learning).
Most of us rely on an inner coach or private voice in our heads to encourage us to do things that are uncomfortable or remind us that we know how to do this (competencies to get through the social demand or task we are stressing over).
The opposite is having a self-defeater or inner critic voice in our heads. This voice, rather than encouraging us to push through something or recognize we have the competencies to do it, it says, “you suck at this” or “you have never been able to do this, so you won’t be able to do it now.” Those who have a powerful self-defeater voice will default to avoiding the uncomfortable task at hand while those with strong inner coach have a far better chance of pushing themselves through the uncomfortable task.
Those with strong self-defeater voices also tend to find a lot of benign excuses for avoiding the task at hand. Many of our students don’t recognize that what they are saying is in fact making excuses for not pushing themselves through an uncomfortable moment. Instead, they default to their excuses. We explore what excuses look like, and they are not as explicit as the classic student’s excuse of “the dog ate my homework.” Instead their excuses look more sophisticated. Here are some of the many excuses we hear for not making phone calls (or even texting) friends even after they had proven in the clinic they had developed the social competencies.
- I was busy.
- I had too much homework to call someone on the phone.
- I will do it tomorrow, I promise.
- I will do it next year when I am in a new school.
- I got mad at my mom.
- I could not find my cell phone.
- I had to study for a test (we had calculated the phone call homework would take no more 1.0-1.5 minutes per call and they only each had to make three calls).
Train the Brain
Our groups then discussed how our brains are always learning, all the time, and that anytime we are awake we are learning from our experiences. If we default to what we are used to then we constantly teach our brains we can only do what we are used to doing. So if students are used to not being able to feel like they can use a cell phone to call others, the only thing they have taught their brain (related to this set of competencies) is that they simply cannot do it. We study our default patterns (what our brain is the most comfortable doing) and then study what our brain has learned by repeatedly attempting the stressful task over and over again. Students explore that their brain has literally learned they cannot do it! To teach their brain they can do it now means they have to push themselves to use different strategies. These strategies must be part of the repertoire they have developed and proven to themselves that they have the competency by practicing in the clinic successfully. Then, they can practice these strategies outside of the clinic - with a push.
We have also learned that anxiety, once attached to a person, has really deep roots does not want to go away easily! This means that as our students prove to themselves they have increased competencies (from years of learning social thinking strategies, etc.), their anxiety still may not allow them to use strategies until they minimize the anxiety. In other words, anxiety is not going to go away without a fight. As our students learn strategies, we then work with them on making a choice: are you going to default to anxiety or strategies?
The Spiral of Social Success
A social situation happens...
The opposite approach usually results in "The Spiral of Social Failure".
Here's how this looks:
These Spirals have helped tremendously by:
After creating the Spirals with academically solid adolescents who wanted to help themselves get through some of their more anxiety evoking situations, we entered into some different conversations:
- My students teased me that I was nagging them, so I replied, " no need for me to nag you anymore. You can see so clearly when the other members of the group are making excuses and not helping themselves. Therefore, from now on when you see someone in the group engaging in a self-defeater behavior, you can tell them that it sounds like an excuse and then ask, 'what are you teaching your brain?'" As we shifted to having them point out to one another the pretty obvious maneuvers each was using to default anxiety, they each took their own learning more seriously.
- One individual was refusing to do the work she had just done at the clinic at home (not doing her homework). She was encouraged to explore why she was avoiding using her newly recognized competencies? Was it because that getting upset and arguing was getting more recognition and attention than if she just did what she new she was supposed to do. Although she said, "that's creepy," she later reported that she did get a lot of attention for being less than competent. This helped to motivate her to find new positive ways to get attention and helped her parents shift into giving her more positive attention for when she did things "expected" rather than "unexpected." *She was 20 years old and saying she wanted to be perceived as more independent.
- A student I had worked with for over seven years had learned many strategies, but was still not using them. I pointed out to her one day that I thought her anxiety was her "best friend." She stated that I was wrong and she hated her anxiety, but then she asked why I would say that? I explained that now that she had many social competencies and ways to think socially about situations, her default continued to be her anxiety rather than to her strategies. Again, this changed the focal point away from her anxiety towards focusing on her competencies.
On a final note: What about those who may truly have social anxiety and many social competencies?
Based on our growing experience, it appears that some of our students have high levels of anxiety, but also have solid social knowledge. For these students, we still find that helping them through their anxiety has a lot to do with helping them explore and practice their social competencies. The Social Thinking teachings helped to put this all into context. Thus, these same lessons have shown to be helpful to them as well.
It is always a good idea to have a mental health professional on your team to help figure out the complexities of anxiety. It's also important for our mental health professionals (counselors/social workers/psychologists, etc.) to become familiar with how to teach Social Thinking and related social competencies/skills!
Our book for high-level teens and young adults to read themselves to help them learn about the intricacies of the social mind and social competencies is entitled Socially Curious and Curiously Social: A Social Thinking Guidebook for Teens and Young Adults (Winner and Crooke). However, we have also learned from many professionals that this book was helpful for them to read, as it teaches directly how we address various topics with our older kids, young adults and in fact our adult population. As Pam and I completed writing this book, we decided not to put in a chapter on anxiety since the book was already longer than we had hoped (we added the chapter on the difference between being friendly and making friends in the 11th hour!), so the above summarizes what we would have written.