CBT with Fear of Public Speaking

Fear of public speaking is quite common and usually can be treated quite effectively with CBT. The treatment approach is based on the same principles as our approach to all of the anxiety disorders. It differs in important ways from our approach to treating depression. I'll try to summarize the main points.

Many therapists think of Cognitive Therapy as consisting primarily of the therapist identifying dysfunctional thoughts and then helping the client to generate "rational responses." While this is a gross oversimplification of CT, when we are treating depression this type of intervention can be quite effective. However, "rational responses" and similar interventions are not very effective in treating anxiety disorders unless they are coupled with exposure-based interventions, preferrable in-vivo exposure.

A central principle to keep in mind when treating anxiety is that, in order to gradually decrease the intensity of the client's anxiety, we will need to induce them to face the situation they fear despite their anxiety. If they face the situation on a regular basis and tolerate the anxiety for long enough, the intensity of their anxiety will steadily decrease. Cognitive interventions can be very useful in getting the client to the point where they are willing to face their fears and can help maximize the impact of exposure sessions, but they are rarely effective if they are not coupled with exposure-based interventions.

First, we do a good assessment and try to understand just what it is that the client fears, what cognitions they experience when facing phobic situations (and when anticipating them), the extent of their avoidance behavior, and the extent to which they are able to cope effectively with anxiety. Many individuals who fear public speaking are afraid that they will make a mistake or "say something dumb." Others fear that they will become so anxious that their anxiety is apparent to others. Yet others simply fear and avoid anxiety itself.

Often clients report experiencing thoughts which greatly exaggerate the risks they face in public speaking (such as "I'll make a total fool of myself.", "I'll never live it down.", or "I could blow my whole career."). When this is the case, de-catastrophising can be quite useful. However, it is important to remember that we are trying to look realistically at the risks they face, not trying to convince them that the situation is risk-free, and that we are not attempting to eliminate their fear through decastrophisizing.

The most important component of treatment is exposure. Our preference is to use in-vivo exposure (i.e. exposure to real-life stimuli) rather than relying on imagery, role-play, video, etc. unless there are reasons that in-vivo exposure is impractical. We typically plan the exposure as a series of manageable steps rather than starting with the situations the individual fears most intensely. Either approach can be effective but it is usually much easier to get the client to follow through on graduated exposure. When the client understands the rationale for the exposure, understands that by tolerating anxiety in the short-run they are likely to gain lasting improvement, and when the exposure is planned in manageable steps, we don't have too much trouble with non-compliance.

The timing can be important on exposure sessions since frequent brief exposures can actually make anxiety worse. Our goal is for the individual to face the situation until their anxiety peaks and starts to subside. The amount of time this requires can vary from person to person and from situation to situation.

It can be important to attend to the client's interpretations of their experiences in exposure sessions. Sometimes their cognitions can undercut the impact of the exposure sessions (i.e. "I got away with it that time but next time I'll really be in trouble!").

Relaxation exercises and other techniques for coping with anxiety can often be useful as a way to help the individual cope more effectively while we work to eliminate their fears. They also can increase the individual's confidence that they can cope with anxiety when necessary and increase their willingness to follow through on in-vivo exposure. However, coping techniques alone are not likely to eliminate phobic anxiety and avoidance.

When we are treating fear of public speaking, exposure often consists simply of the client going ahead and speaking in public, starting with situations which are not too uncomfortable and building up to the situations the client fears intensely. It is important to remember that the idea is for the client to face the feared situations, not avoid them. If the client fears making mistakes, it is important for them to face situations where there is a risk of their making mistakes and to face occasions where they actually make mistakes and cope with the consequences. If the client fears that others will notice that they are anxious, it is important for them to face situations where there is a risk that others will notice that they are anxious and to face occasions where others notice that they are anxious and they cope with the consequences.

One question which often comes up is "What about people who speak in public on a regular basis yet continue to fear public speaking? Doesn't this show that exposure doesn't eliminate the fear?" Remember that a person who speaks in public on a regular basis may be trying very hard to avoid making mistakes or to make sure that others don't notice his anxiety. This avoidance can maintain phobic anxiety even though, at first glance, the individual appears to be facing their fears on a regular basis.

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