Interview with Dr. Richard Heimberg
| February 2000
Dr. Heimberg received his Ph.D. from Florida State University in 1977 and joined the faculty of Temple University in the fall of 1996, after 18 years on the faculty of the University at Albany, State University of New York. He has written over 175 articles and books on social anxiety, generalized anxiety, depression, and related topics. He is widely recognized for his work on the development of cognitive-behavioral treatments for anxiety and is a frequent speaker on the topic at professional meetings. |
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Joffe: Can you tell me a little about your background, childhood, education? Why did you become interested in Social Phobia? |
| Heimberg: I was born in 1950 in Durham, NC and went to college in Nashville, TN. I grew up a shy and anxious child. Social phobia was not officially recognized until 1980, so if I had been born later, I would probably have fit the diagnosis. I did well in school, didn't have a whole lot of friends, and had public speaking anxiety. There's where my interest in SP came from -- trying to understand some things that were true for myself. I have since found out that exposing yourself to feared situations works, and I have made so many talks....it's not that hard anymore. I have dedicated a large part of my professional life to researching, understanding and developing treatments for people who have social anxiety. |
| What do you do today? |
| I am a professor at Temple University in my forth year after having been at the State University of New York at Albany for 18 years before that. I also went to graduate school at FSU before that. Today, I work in the clinical psychology doctoral training program. I run the adult anxiety clinic at Temple, where we have programs for people with SP and generalized anxiety disorder. |
| How would you define SP? |
| The fear of what other people think about you that is severe enough to really disrupt your life....Fear of humiliation, embarrassment, fear of negative evaluation -- it's all the same thing. It's concern that people will look at you and find you either unacceptable or incompetent....and those are heavy crosses to bear. |
| Where do you feel SP comes from? |
| 27,000 different places. Partly from genetics, but not mostly. Some from the messages we get from our parents. It comes from parents who are themselves anxious and don't allow us to experience life openly and freely because their anxiety gets in the way and they have to protect themselves. It comes from parents who are harsh and critical and whatever you do is never good enough -- these can be parents who deeply and truly love their kids. It comes from being teased when you're a kid and taking it to heart. It comes from somehow or another incorporating into your own self the messages you hear from other people, whether your peers, parents or the world at large....messages that say you've got to be some way in order to be OK, and then the worry that we might not be OK in that way. |
| When and why did you write Social Phobia: Diagnosis, Assessment and Treatment? |
| It was published in 1995, but was basically put together a couple of years before then. That's an edited book that's sort of 'everything you ever wanted to know about SP and a ton more'. It's intended mostly for professional audiences, from a cognitive-behavioral/pharmaco-therapy point of view. At the time, professional awareness was going up, but professional knowledge was not. There had not been any place where the stuff had really been pulled together. There were a lot of ideas that people had about SP that were really off-base. For example, the DSM-III said that SP is a fear of 1 or 2 specific situations, that people rarely have more than one and that they are not impairing. I've been seeing people with SP for quite some time and their lives were turned upside down by it, and as we did more work in that way, we were more and more right and the other people were more and more wrong. My hope is that it's raised professional consciousness about SP, and there has been a lot of increase in attention in SP since. |
| Could you discuss the relationship between thoughts and feelings? |
| Basically when you speak of SP, it's having learned that the world is a bit of a dangerous place in terms of social outcomes. If you have parents who always expect too much or if you learn from your parents who themselves are anxious that the world is potentially a dangerous place, then you will be in a situation where you are always going to be scanning the world for that danger. It's just a basic truth, that if there's danger out there, we need to pay attention to it. The problem that happens with social phobics is that it turns into social outcomes, rejection, non-acceptance, humiliation, embarrassment, negative evaluation -- all those things that hurt, and we tend to think that they're everywhere. We find them everywhere because we're looking for them all the time. And we confirm to ourselves how dangerous the world is. The thoughts determine the threat in the world. What could happen that's bad in the world? That's thinking. When we determine that there's something that's dangerous out there, then our feelings and physiology act naturally to get ready for the bad thing that's coming. The thing is that we're not always right. It's like getting dressed up with no place to go. |
| What do you mean by getting dressed up with no place to go? |
| Let's talk about public speaking. I have to give a talk next week at a psychology meeting. The night before, I'm all worried about it, so when I get ready to go and do it, I get all tanked up because I worry about something, I'm telling myself all of the things that could go wrong that I ought to be watching out for. Now, what does that have to do with reality? Reality hasn't happened yet. I've been on all this stuff in advance, but I'm nonetheless more anxious than I would have been if I had a glass of wine, watched TV and relaxed myself to sleep. So I go in and I have an attitude that is 'hypervigilant'; I'm worried about what's going to be happening, I'm convinced that it's going to go wrong. Because of this, I'm watching everyone like a hawk to see what they think of what I'm doing. What I would find out from that, if I was balanced, is that some people like what I do and some people don't. The ones who like it are wonderful and the others can go take a hike. But what I do instead is I focus on those people who are showing me any sign that they are disinterested, and there are 100 people in the audience -- 5 who are disinterested, and I see those 5 and I can tell you everything that they thought during that period of time; I can tell you every move they made. I have created a different situation by virtue of my thinking about it and I've made my feelings just go nuts on it. So what we do with social phobics is we take the situation as it really is, whatever that may be. Social phobics focus on the negative part of it, capture it, and let the other part of it go. And of course, it's the other part that would give us self-confidence. |
| Is that the basis of CBT? |
| It is largely the basis of CBT. CBT involves teaching people to monitor their thoughts, to really become aware of what the content of them is. To become scientific about their thoughts, looking at their thoughts as hypotheses, like 'That person doesn't like me' is not a fact, it's a hypothesis that actually has an answer that can be checked out. You can ask them, start a conversation and see if they're interested in continuing it. We take ourselves out of the game before we have a chance to play -- so we don't get the evidence that the world is actually not a bad, awful place. |
| Is there group work in CBT? |
| Yes, mostly group work, with some individual work. We'll help some people to understand what their thought process is, we'll ask them to cast them as hypotheses, we'll ask them how it is that they can gather data about that, we'll create situations in the group so they can face those situations they fear, we'll do role-playing, and it's all very personalized. It's all designed to help each person gather new information that can help them change their ideas about how much danger their really is so they can come back down to it and reassess that the danger is not as extreme. I don't mean to say that there is not social danger or no risk -- there is. But if you focus your life on that, all you do is kill the joy. If you are able to focus otherwise and say, 'Ok, there's some risk but I can tolerate that level of risk', then you learn to go out there and take a chance and find out that there's some reward for you in this world. |
| It's it 2 different things for some people to say, 'Ok, I can deal with it,' and then to bring their body along as well? |
| Yes and no. think about why their body reacts. If there's torqued up and anxious because they have a genetically overactive nervous system that's overactive every moment of their waking day, I'd be doing relaxation training with them in a heart beat. But if they are physiologically aroused because they are perceiving something to be dangerous that's not, then I'd much rather have them see that there's no need for a coping technique. |
| So in your treatment, you gather information on both the psychological and physiological components of SP? |
| Yes, for sure. The physiological is very much involved, although we're not doing a lot of active physiological treatment. We do more risk reassessment. |
| How successful is CBT? |
| It depends on how you define success. If you define success as the eradication of social anxiety, then it is not successful. If you define it as the reduction in anxiety enough that a person can get on with their life and learn techniques to endure situations that they're afraid of so that they can go forward and accomplish things in their life, it's very successful. The statistics of our program will say that of patients that go through our program just for 12 weeks, at the end of it, they have not confronted every situation that's a problem for them but they have learned the skills that they need to know, and they're doing lots of things they weren't doing before and have started the process of building their life up in a positive direction. They still may have some social anxiety, even for a long time. But there's a lot of difference between some, a little and a lot of social anxiety. If you see yourself as somebody who is really socially anxious, or SP, enough to spend the immense about of effort to put this newsletter together, you understand the difference between overwhelming anxiety versus being uncomfortable. |
| One you can deal with and one you feel like you can't.... |
| Yes, exactly. And, if I can get you down to uncomfortable, then you do the rest and you can live with uncomfortable the rest of your days and be damned happy with it. Some people go on and have basically reinvented themselves. I'm one of the very fortunate ones; the amount of time I spend being socially anxious these days is trivial. Today, I find myself doing things everyday that I never thought when I was younger that I could do. I've now given 20,000 classroom lectures and over 200 professional talks. Things change. |
| If CBT doesn't work for an SP, would you tell them it is their fault? |
| Never. Sometimes any treatment works for some and not others. If CBT doesn't work for somebody, sometimes it's because the person is not ready to do it. But it's often that the CBT therapist has not conceptualized things right, or has pushed too fast too far, or it may be that the person's anxiety is just such that it is very hard for them to be willing to take the risks they need to take. If that happens, it's the therapist's job to find a different way. A lot can be done within CBT by trying to understand what comes in the way, but when it comes down to it, if any particular approach to treatment doesn't work, it's never ultimately anyone's fault, it's just not a right match. This is a very important concept for us SP's who tend to blame ourselves when things don't go right. |
| Many SP's have a hard time finding a doctor/therapist they like. Many say they want someone who knows more about SP and is more compassionate. What can we do to get more doctors like this? |
| Well, you're talking about a problem that is very serious and real. You should always be a consumer in picking out a therapist/doctor. If you don't like the way that they treat you, then show them the street. That's an act of assertiveness that's good for SP's to do anyway. There are more and more resources that are available that are educational about SP, and a large part of what needs to happen is professional education. One of the best ways is to give your doctor stuff to read, give them resources to go to. Send them to my web-site (www.temple.edu/phobia). Send them to www.socialphobia.org. send them to NIMH or ADAA or to paxil.com. |
| Is there anything you'd like to say to people with social phobia who are reading this? |
| Hang in there. Something I think is true in life...the people who end up succeeding in the end are the people who persist. Try and try and try, and when something doesn't work, try again. There are more things that are happening, more medications coming on line, more interest in CBT, there's a future here. Take a risk, try things, try something each day that's one iota beyond where you went yesterday. Say hi to one more person. One step at a time ends up taking you across the country before too long. |
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