Use this 14-step, therapist-backed framework to build a CBT case formulation of social anxiety that targets the maintaining mechanisms (safety behaviors, self-focused attention, anticipatory worry, and post-event processing). You’ll leave with a mechanism map, example experiments, and a checklist you can copy into notes or supervision.
Who this helps: clinicians, trainees, and serious self-learners.
Use cases: intake, treatment planning, case reviews, and progress checks.
Safety note: Educational content only; not medical advice or a substitute for therapy.
- Treat the process, not just the content of thoughts.
- Identify safety behaviors and attention style; these are the fuel.
- Convert fears into testable predictions and run behavioral experiments.
- Track SUDS and “expectancy of catastrophe” weekly; revise the map every 4–6 sessions.
Read more: Is it Time to Consult an Anxiety Therapist? Signs You Shouldn’t Ignore
What is a CBT case formulation for social anxiety?
A CBT case formulation is a personalized map of how the problem operates: trigger → appraisal (“I’ll look foolish”) → self-focused attention → physiological arousal → safety behavior (avoid/escape/camouflage) → short-term relief → long-term maintenance. The goal isn’t a perfect narrative—it’s to locate levers you can pull in treatment.
Read more: How to Help Someone with Anxiety: 5 Compassionate Techniques
The 14-Step Therapist-Backed Method
1) Define the presenting problem & functional impact
Pin the problem in the client’s words and quantify impact: missed opportunities, calls avoided, meetings skipped, social events declined. Establish a baseline using quick measures (e.g., LSAS/SIAS/SPIN examples), daily avoidance counts, and SUDS for key situations.
Deliverable: 2–3 measurable targets (e.g., “initiate one conversation/day,” “speak in weekly stand-up”).
2) Differential and rule-outs (tight, targeted)
Screen for panic disorder, major depression, ADHD/ASD traits affecting social functioning, substance effects, and relevant medical conditions (e.g., hyperthyroidism). Note comorbidities that can shift mechanism focus (e.g., OCD contamination vs. social evaluation).
Deliverable: 3–5 differential bullets; note any medication/sleep/caffeine factors.
3) Build the individual CBT chain
Walk through a recent episode to identify the chain:
Trigger → Appraisal → Self-focused attention → Arousal → Behavior → Consequence.
Map 2–3 common triggers (meetings, introductions, eating in public) and the specific appraisals (“They’ll notice my voice shaking”).
Deliverable: One simple diagram you can redraw in 30 seconds.
4) Write the feared outcomes & rate Probability × Cost
Elicit the catastrophe script. Rate expected likelihood (0–100%) and cost/impact (0–10). You’ll use these as your hypotheses for experiments.
Deliverable: “If I speak up, ___ will happen (est. ___%). Cost: ___/10.”
5) Identify safety behaviors (the fuel source)
List overt (avoiding eye contact, leaving early, camera-off) and covert actions (over-rehearsal, mental “blanking” checks, perfection scripts). Label S/M/W (strong/moderate/weak) by situation.
Deliverable: Top 3 safety behaviors to drop or thin first.
6) Assess self-focused attention
Notice the shift from the task (“what I’m saying”) to the body/monitor (“is my face red?”). Self-focus amplifies perceived threat and degrades performance.
Deliverable: Three external focus cues (e.g., “count blue objects,” “summarize the other person’s last sentence,” “note 3 facts about the room”).
7) Tackle anticipatory worry & post-event processing (PEP)
Anticipatory phase: cap prep at 10–15 minutes; avoid script-memorizing.
Post-event: run a 5-minute PEP ledger: evidence for/against feared outcomes; what you’d repeat vs. change.
Deliverable: Two rules—“Prep cap” and “PEP window”—written on a card.
8) Identify core beliefs, rules, and assumptions
Uncover deeper drivers: core beliefs (“I’m unlikeable”), conditional rules (“If I don’t sound polished, I’ll be rejected”), and assumptions (“People are harsh judges”). Select one belief to test explicitly during experiments.
Deliverable: Belief-to-test + a disconfirmation plan.
9) Functional analysis (ABC) across contexts
Use A–B–C (Antecedent–Behavior–Consequence) to see function, not form. The same behavior (asking questions only) can be adaptive with new contacts but avoidant with peers.
Deliverable: One ABC table per high-value context (work meeting, dates, presentations).
10) Select mechanisms to target (2–3 max)
Prioritize safety behaviors, self-focused attention, and post-event processing. Add situation-specific drivers (e.g., fears of blushing/voice, intolerance of uncertainty) only if they maintain avoidance.
Deliverable: A one-line treatment aim per mechanism (e.g., “reduce self-focus via task-attention drills”).
11) Clarify exposure vs. behavioral experiments
Exposure reduces avoidance through repeated contact.
Behavioral experiments test a prediction (“They’ll judge me as incompetent”) and measure outcomes. Most effective plans combine both.
Deliverable: For each task, write the prediction and the data you’ll collect.
12) Build a hierarchy & experiment matrix
Draft 10–15 tasks spanning SUDS 30 → 80 and varying uncertainty, visibility, and stakes. Example ladder:
30 — ask a cashier for a recommendation →
45 — make a small talk comment in elevator →
60 — join a meeting with camera on and ask 1 question →
70 — share a dissenting opinion in a group →
80 — give a 3-minute extemporaneous update with one planned mistake.
Deliverable: A table with task, SUDS, prediction, safety behavior to drop, data to count.
13) Add brief, mechanism-matched skills
Use small skills that enable learning: attention training, decatastrophizing (estimate/observe gap), compassionate imagery for shame spikes, assertive micro-scripts (“I’ll start—two points”). Avoid over-investing in generic thought-challenging that displaces exposure/experiments.
Deliverable: Pick two skills only; tie each to a specific task.
14) Measurement, review, and relapse plan
Track SUDS, expectancy ratings, and safety-behavior counts each week. Re-formulate at sessions 4–6 to reflect learning. Create a relapse plan with if–then cards (e.g., “If I skip two exposures, then schedule a booster experiment by Friday”) and tie to values (connection, leadership, creativity).
Deliverable: One-page scorecard + quarterly “booster” experiment.
Read more: Managing Anxiety: Therapeutic Techniques for Success
14-Step Checklist (copy/paste into notes)
| Step | Purpose | Therapist Cue | Client Prompt |
| 1 Presenting problem | Anchor goals & impact | “Where does this hurt most?” | “List 3 roles anxiety disrupts.” |
| 2 Rule-outs | Avoid mis-targets | “Any panic/substances/medical?” | “Note meds, sleep, caffeine.” |
| 3 CBT chain | See maintenance | “Walk me through last event.” | “What changed right before?” |
| 4 Fear script | Make testable | “What’s the catastrophe?” | “Write worst prediction + %.” |
| 5 Safety behaviors | Find the fuel | “What do you do to feel safe?” | “Circle 3 to drop/thin.” |
| 6 Self-focus | Redirect attention | “Where was your focus?” | “List 3 task cues.” |
| 7 Anticip/PEP | Bracket loops | “How long planning/ruminating?” | “Set prep/PEP timers.” |
| 8 Beliefs/rules | Target schema | “What must be true?” | “If…then… rules.” |
| 9 ABC analysis | Fit by context | “What kept it going?” | “Antecedents/Consequences.” |
| 10 Mechanisms | Pick levers | “Top 2–3 maintainers?” | “Circle 2 to hit first.” |
| 11 Exposures vs BE | Clarify aim | “Reduce avoidance or test?” | “Write the hypothesis.” |
| 12 Hierarchy | Dose the work | “30→80 SUDS ladder.” | “Draft 10 tasks.” |
| 13 Skills | Support learning | “Only mechanism-matched.” | “Pick 2 micro-skills.” |
| 14 Metrics/relapse | Sustain change | “When do we review?” | “If–then relapse plan.” |
Two mini-cases (for supervision & teaching)
Case A — Performance fears
Prediction: “If I present, people will notice my shaking voice and think I’m incompetent (80%).”
Safety behaviors: over-script, camera off, avoiding Q&A.
Experiment: give a 3-minute update with one planned pause; keep camera on; ask for one question. Data: count overt negative reactions, self-rated performance, and follow-up invitations.
Learning target: expectation drops from 80% → observed 10–20%; self-focus replaced by task cues.
Case B — Conversation fears
Prediction: “If I share an opinion, others will judge me as boring (70%).”
Safety behavior: ask questions only, zero self-disclosure.
Experiment: at a meetup, share a two-sentence opinion in 3 chats; track number of neutral/positive responses and conversation length.
Learning target: PEP ledger shows no catastrophic outcomes; next step increases stakes (small dissent in a team chat).
Read more: Navigating Entrepreneurial Anxiety: Therapy Solutions
Exposure vs. Behavioral Experiments: what’s the difference?
- Exposure: repeated, planned contact with a feared cue to reduce avoidance and allow corrective learning.
- Behavioral experiment: a structured hypothesis test that measures whether predictions come true (e.g., “People notice my tremor and mock me”).
Best practice: embed experiments inside exposures—write the prediction, specify the safety behavior you’ll drop, and state what you’ll count.
Measurement plan that actually changes treatment
- Before task: SUDS (0–100), expectancy of feared outcome (0–100), safety behavior planned to drop.
- During: brief attention cue (“What color are their eyes?”).
- After (5 minutes max): count objective data (interruptions, questions asked, visible negative signals); complete PEP ledger.
- Weekly: safety-behavior tally; one brief scale; one functional KPI (calls made, meetings led, invites accepted).
Read more: Cultivating Success: Anxiety Therapy for High Achievers
Glossary (fast scanning)
- Safety behaviors: Actions that reduce short-term distress (rehearsal, avoidance, alcohol) but maintain fear long-term.
- Self-focused attention: Monitoring internal sensations (blushing, shaking) instead of the task; amplifies perceived threat.
- PEP (post-event processing): Biased rumination after social events that cements anxious narratives.
- SUDS: Subjective Units of Distress (0–100).
- Expectancy violation: Observing a feared prediction not occur (or occur but with lower cost than predicted).
Read more: Balancing Brilliance: Anxiety Therapy for High Achievers
FAQs
What keeps social anxiety going?
- A loop of safety behaviors, self-focused attention, anticipatory worry, and post-event processing that trades short-term relief for long-term avoidance.
Is exposure enough, or do I need cognitive work too?
- Use brief cognitive tools (decatastrophizing, compassionate reframe) to support exposures/experiments—don’t let thinking work displace doing.
How do I know when to move up the hierarchy?
- Advance when expectancy drops and SUDS recover predictably—not when you feel perfectly comfortable.
What do I measure each week?
- SUDS, expectancy ratings, safety-behavior counts, and at least one functional KPI (e.g., meetings led). Add a brief scale (e.g., LSAS/SIAS/SPIN examples) for trend.
What if my belief feels obviously true?
- Treat it as a testable hypothesis. Run small, high-information experiments to gather disconfirming data; aim to reduce certainty, not force positivity.
How do I handle setbacks or spikes?
- Use your if–then relapse card (e.g., “If I cancel two exposures, then I schedule a 30-minute booster by Friday”), and reconnect tasks to values (leadership, connection).
Can I do this on video calls?
- Yes—video adds unique tasks (camera on, speak early, volunteer a question). Still drop safety behaviors (mute-lurking, script reading) and run experiments.
How long until progress shows up?
- Often within 4–6 sessions when experiments are frequent and safety behaviors are reduced. Expect uneven gains; learning beats comfort.