CNS762 Special Topics

Introduction and Rationale: Social Anxiety

Cognitive Behavioral Interventions have been found to be helpful for treating Social

Phobia, in fact, it has one of the highest efficacy rates according to a large majority of research.

Many individuals with social anxiety have such an intense fear of negative evaluation that they

do not seek treatment until ten or more years after the onset of the symptoms (adaa.org). Better

outcomes are associated with preventative care and early identification, therefore, it is imperative

for the population at large to better understand the development of social anxiety disorder, so that

young individuals suffering from it may be better understood and receive the corrective

interventions that are necessary.

Review of Literature
According to the Anxiety and Depression Association of America, 6.3 percent or nearly

15 million Americans suffer from Social Phobia, more commonly known as Social Anxiety

Disorder (SAD) in the Diagnostic and Statistical Manual 5th Edition (DSM-5). Their intense

anxiety stems from their fear that peers will judge them or evaluate them negatively. Symptoms

include sweating, flushing of the face, rapid heartbeat, trembling, nausea, and/or inability to

recall thoughts (i.e. blank mind) (NIMH, 2021). Stein (2015) offered a physiological

understanding of SAD through the utilization of Functional Magnetic Resonance Imaging

(fMRI), which revealed that hyperactivity of various brain systems, such as the Amygdala,

Insula, and Prefrontal Cortex.

Most often, these individuals are highly concerned with how other view them and will

most often avoid drawing attention to themselves, though there has been research to indicate that
some individual presenting with both Social Anxiety and impulsivity issues may have symptoms

that are slightly different than the typical. Kashdan and McKnight (2010) discussed how

impulsivity can shape socially anxious individuals to be less likely to received positive treatment

outcomes due to their greater functional impairment. This is why they push for greater

investigation of self-regulatory styles and behaviors. One of the most effective treatment

modalities for SAD is Cognitive Behavioral Therapy (CBT), as it utilizes multiple interventions

that evaluate cognitions, behaviors, and emotions. Priyamvada, Kumari, Prakash, & Chaudhury

(2009) found that SAD affects individuals across all age ranges ethnicities, and genders, though

the average onset is around thirteen years of age.

Case Study: Geralt of Rivia

Geralt of Rivia is a 38-year-old Human pale skin male. He has been classically trained in

Kaer Morhen to be a Witcher or monster hunter for hire. His physical appearance matches his

age, he is muscular, approximately 5’10, has golden feline eyes, and long white-silver hair.

Geralt states that part of his vocational training required him to undergo a process of genetic

mutation, which resulted in an increase in strength, agility, and intelligence. Despite no college

education, Geralt claims that he is akin to an expert detective and can readily solve mysteries

through his skills of deduction and with aid of his ‘Witcher sight.’ Geralt has few friends, often

seen as an ‘outcast’ or ‘freak’ to other townsfolk as he travels, this in combination with his

secluded upbringing has coalesced into a reserved and quiet interpersonal style; Geralt indicates

that through his travels he has fought many monsters and sometimes finds it easiest to avoid

others, use magic to suggest they leave, or to respond aggressively if provoked.

 Geralt states that he does not know much about his parents, as they gave him up at a

young age in order for him to begin his training as a ‘Witcher.’ He also notes that he has had a

girlfriend, Yennefer, though their relationship has been on and off due to her dissatisfaction of

Geralt’s working conditions. When discussing trauma, Geralt reveals that the process to become

a Witcher was very painful and traumatic and that he has not forgotten it yet. He also describes

that due to the nature of his job, he is often injured, though he recovers much more quickly than

typical humans. Geralt claims that he is in good physical health, as the mutations have helped

him remain physically fit despite the trials he has faced, though claims that his mental and social

health has suffered.

Geralt is seeking help now due to job and interpersonal difficulties, as they have become

difficult to navigate. Aggression has become his automatic response when interacting with

others, regardless of the demeanor of others. This has made it difficult to claim the rewards for

monster bounties, which has resulted in Geralt avoiding all others if possible. He worries that he

will begin to see his coffers dwindle due to his inability to claim work rewards. Yennefer has

also expressed dissatisfaction with Geralt’s avoidance and/or aggression, as it often causes issues

when they are together. She is an important and well-known individual of her kingdom, so

interpersonal interactions are unavoidable, therefore she has asked Geralt to attend counseling

sessions so that he may retrain this behavior after a recent scuffle with a visiting noble. When

further discussing the issue, Geralt states that it is a cycle, where he feels extremely anxious

around others and believes that they will react negatively to him. These thoughts build up to an

extreme where he lashes out to protect himself, which causes them to react negatively and

confirm his fear in the first place.

Cognitive-Behavioral Case Formulation

Geralt is presenting with a severe increase of social avoidance and interpersonal

aggression (Presentation), which has led to repeated aggressive explosions when he perceives

that escape from social criticism is unavoidable or when he is directly challenged or confronted,

as exampled by the recent fight with the visiting noble (Current Precipitant) and the unprovoked

reactions towards him due to his class and profession (Continuing Precipitant). He self isolates

when not contractually hired and lashes out aggressively when provoked or overwhelmed with

anxiety (Pattern-Maladaptive). Geralt is predisposed to maladaptive cognitions that have led him

to adopt maladaptive behaviors that serve to reinforce and exacerbate his presenting symptoms.

He possessed a range of cognitions that automatically cycle when in the presence of others,

which stem from being negatively evaluated. His sense of displacement is already heightened;

therefore, he perceives his every move as being scrutinized. He believes that everyone will react

to him the way they react to the monsters and beasts that he slays, as some have already

indicated as he travels past their villages. Maladaptive behaviors are seen to reinforce the

cognitions, as he self isolates and avoids contact whenever possible, even to the detriment of his

profession. This avoidance originates from others perceiving him as lesser status or a social

outcast. When he perceives that escape is impossible and that he is being threatened, he retreats

back to his survival instincts and lashes out aggressively at others (Predisposition). Geralt’s

cognitions and behaviors are maintained by his continued avoidance of others at all costs, as well

as his tendency to lash out when he feels that he cannot escape from perceived criticism

(Perpetuants). He has shown to be quite resilient in his tactics to overcome the monstrosities that

he faces and has strong mental fortitude. While his relationship has been on and off with

Yennefer, she seems to be a stable social support in Geralt’s life (Protective factors/strengths).
 Geralt identifies as a Human pale skin Witcher, who is seen as lower class, despite his

apparent monetary savings (Cultural identity). Due to the nature of Geralt’s job and the political

climate at large in The Continent, Geralt travels across various kingdoms with different political

and religious values. As a Witcher, he is seen as lower class by many in the larger kingdoms,

who dismiss the importance of his profession (Acculturation and cultural stress). His presenting

anxiety and aggression are a result of a long history of harsh interpersonal interactions with

others, which has taught Geralt that his options are limited to Avoidance or Fighting (Cultural

explanation). While there are components of culture that conflict when Geralt is present in

culturally diverging kingdoms, personality seems to be the predominant dynamic that best

explains his current issues (Culture/personality).

Geralt has difficulty functioning in social situations that cause anxiety and stress, often

relying on aggression to escape (Treatment pattern). Treatment goals for Geralt reducing anxiety

stemming from thoughts, increasing his ability to relate with others through modifying

behaviors, and identifying alternatives to aggression in personal interactions (Treatment Goals).

The focus will center on the interaction between Geralt’s maladaptive beliefs and the situations

that reinforce his prior maladaptive behaviors (Treatment focus). This will be done by focusing

on identifying maladaptive beliefs, thoughts, and behaviors that perpetuate his current actions,

and modifying them through the use of cognitive restructuring, exposure, and skills training

(Treatment strategy). Various treatment interventions will be implemented with Geralt to help

him overcome his maladaptive beliefs and behaviors. To address his anxious thoughts, they will

be addressed through guided discovery. He will use exercises of thought challenging to engage

with thoughts that are automatic and may be irrational or based on no evidence. Mindfulness

techniques will also be utilized to help Geralt control his emotions and prevention impulsive
reactions when overwhelmed. To address his maladaptive behavioral modes, we will utilize

roleplay or rehearsal and enactment to allow him to identify how to interact with a range of

individuals with varying beliefs towards Geralt. This will help him understand that aggression is

not always the best tactic and that others may not be automatically hostile towards him. If Geralt

is open to the suggestion, group psychotherapy may help him get a sense of how to better relate

with others (Treatment Interventions). There are some treatment obstacles and challenges that

many be anticipated given Geralt’s reputation across The Continent. This may be at the forefront

of his mind during the session, which may add to his anxious thoughts. Since he mentioned that

they eventually compound into aggression, it would be recommended for the counselor to keep a

constant check on the thoughts he is experiencing. These thoughts should be diffused,

normalized, and positively reframed to transform central maladaptive schemas into constructive

ones. He seems forthcoming at current, though it is anticipated that through the course of work,

he may experience resistance at the crossroads of behavior change, as much of it has been

informed through trauma and survival. This sensitivity may provoke painful memory and tug on

his instinctual aggression response, it would be wise to proceed cautiously by being open,

honest, and disarmed. Avoidance is common for Geralt when he perceives interactions are

unsafe, therefore, if he feels as though the therapist is a threat, he may withdraw from therapy

interactions ranging from being less forthcoming and talkative to outright refusing to come to

sessions. If he skips sessions, it would be important to approach him with sensitivity to his

perception, as a contrary approach may only serve to reinforce his maladaptive schemas

(Treatment obstacles). Geralt understands that there are some cultural components at play,

though he does not believe that they need to be of primary consideration, as his profession will

require him to communicate with various other cultures. It is worth noting that while he does not
consider cultural interactions paramount, the perceptions of others regarding his own culture as a

Witcher may prove to persist outside therapy. It would be important to spend time discussing

how these views of others may be positively dealt with (Cultural treatment). If Geralt is able to

successfully challenges his anxious thoughts, implement relaxations, and determine successful

alternatives to aggression through the use of activities and exercises inside and outside of

therapy, his prognosis should be good, otherwise, it would be determined to be guarded

(Treatment prognosis).

(Sperry & Sperry, 2020)

Advocacy and Legal/Ethical Considerations

There exist many advocacy opportunities for promoting awareness of social anxiety.

Many confuse social anxiety with shyness, but this simply is not the same thing and spreading

awareness of this would provide a bevy of benefits from parental advisory to program

development in schools. Psychoeducation is the best way to spread awareness, as it is the most

accessible method, examples of this include Workshops, Seminars, and Special Events. There is

such an emphasis on extraversion, that introverts, shy individuals, or those with social anxiety

are often seen negatively, or not provided the attention that they require, especially in learning

environments with a large student-to-teacher ratio. The hope is that these interventions will allow

for socially anxious individuals to be better taken care of to help them get over their fears when

they are first identified, instead of allowing them to go unnoticed (NIMH, 2021).

Ethical consideration with regard to Geralt’s case or any case that includes individuals

from various differing cultural backgrounds, include abiding by the American Counseling

Association Code of Ethics (2014). Counselors are called to avoid imposing their own values
(A.4.b.) on clients with varying backgrounds from their own. This is important, as imposing

values strays over ethical lines and can damage the therapeutic relationship and prevent the client

from making decisions that best represent their best interests. Additionally, this steps over the

core principle of autonomy, where we respect the client’s ability to make their own decisions

(ACA, 2014).
 References

Adaa.org. (2021). Social Anxiety Disorder | Anxiety and Depression Association of America,

ADAA. Retrieved 19 June 2021, from https://adaa.org/understanding-anxiety/social-

anxiety-disorder.

American Counseling Association. (2014). 2014 ACA code of

ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-

code-of-ethics-finaladdress.pdf

Kashdan, T. B., & McKnight, P. E. (2010). The Darker Side of Social Anxiety: When

Aggressive Impulsivity Prevails Over Shy Inhibition. Current Directions in

Psychological Science, 19(1), 47–50.

NIMH: Social Anxiety Disorder: More Than Just Shyness. (2021). Retrieved 19 June 2021, from

https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-

shyness.

Priyamvada, R., Kumari, S., Prakash, J., & Chaudhury, S. (2009). Cognitive behavioral therapy

in the treatment of social phobia. Industrial psychiatry journal, 18(1), 60–63.

Sperry, L., & Sperry, J. (2020). Case conceptualization: Mastering this competency with ease

and confidence. 2 ed. Routledge/Taylor & Francis Group.

Stein, D. J. (2015). Social anxiety disorder and the psychobiology of self-

consciousness. Frontiers in Human Neuroscience, 9, 89-92.