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We explore the complexities of social anxiety with renowned psychotherapist Jonathan Berent. We delve into two contrasting cases: a high-achieving physician facing performance anxiety and a young adult paralyzed by avoidance. Jonathan shares insights on how trauma, perfectionism, and family dynamics contribute to social anxiety and discusses practical treatment strategies that integrate both technique and core emotional work. Join us as we uncover the critical elements for understanding and overcoming social anxiety.
Jonathan Berent is a psychotherapist.
He discusses the KevinMD article, “When high achievers and isolated adults share a common enemy: social anxiety.”
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome Jonathan Berent. He’s a psychotherapist. Today’s KevinMD article is “When High Achievers and Isolated Adults Share a Common Enemy, Social Anxiety.” Jonathan, welcome to the show.
Jonathan Berent: Thank you for having me.
Kevin Pho: So let’s start by briefly sharing your story and journey.
Jonathan Berent: Here’s my story. When I got out of graduate school in 1975, I was working as a youth worker in a community center in the North Shore of Long Island, and one of my associates who was doing special education for the Girl Scouts had an idea. She said, “Let’s start a socialization program for teenagers with learning disabilities.”
I had no idea what she was talking about. That said, we did interviews for the group, and an interesting thing happened. Many of the kids did not come to the group itself. Welcome to social anxiety. So here I am, 50,000 plus clinical hours on the front line later. And while the title of the article, your article was “High Achievers and Lonely Adults Share Something in Common: Social Anxiety,” the original title was “Social Anxiety: The Real and Untold Story.”
And that’s what this is about. And at the risk of sounding a little ridiculous, I’m the only one who can tell the real story for many reasons. The real story of social anxiety remains untold. While it is basically the biggest anxiety disorder in the world because it’s based on performance, and let’s face it, we live in an age of technology and high performance, it’s the classic disease of resistance.
Now, there are many examples of social anxiety: public speaking anxiety, fear of being noticeably nervous, as in erythrophobia, fear of blushing, hyperhidrosis, sweating, selective mutism, voice phobia, school phobia, pervasive social avoidance, selective mutism, which is an insidious, complex example—a manifestation of obsessive-compulsive disorder—where the primary symptom is the person does not speak.
That said, there are two basic types of individuals with this problem. One is the person with initiative for their mental health, and the other are those without initiative. For example, two of the patients that I referenced in the article: one whose name was Karen is a world-renowned physician. She had public speaking anxiety.
She was speaking around the world, and all of a sudden this panic disorder developed, and she was confused. She didn’t know where it came from, but she had initiative. She was highly motivated to fix the problem. That contrasts, and this is an example of how this is a spectrum disorder. We have patient Michael, age 26.
He graduated from college with good grades and spends the next few years in his room, a hundred plus hours of video games a week, has no initiative for his mental health, doesn’t work, has no social life. And his parents are working on eggshells as they are totally confused as to what to do.
Talking about initiative and the lack of initiative.
Kevin Pho: So tell us the common traits or underlying mechanisms that connect those two experiences from Karen and Mike despite their varied levels of functionality. What are some common traits?
Jonathan Berent: That’s a good question. First of all, both have what I reference as too high an internal critical script.
The critical script is one mind state. The doctor’s critical script went, “You’ve got to be perfect at all times.” And she grew up with something she referenced as Palo Alto syndrome. This is perfectionism. Now, in this case, her perfectionism—the development of her internal script—she didn’t know it, but that was trauma.
The intensity of the development of the critical script meets OCPD, which in essence is perfectionism. That’s the perfect cocktail for performance anxiety. Michael’s critical script went something like, “You’re just not okay as a person, and you need to avoid at all costs to be safe.” Both people have what’s called dissociation, and this is the essence of the pathology, meaning that as a safety device and a defense mechanism over time, people with social anxiety become experts at dissociating or disconnecting from going inside. Again, social anxiety is the classic disease of resistance, and when people listen to a lot of the interviews on my homepage with real patients, a lot of them who have done well in the program have said about the program, which I often reference as CrossFit, “It’s the hardest thing I’ve ever done in my life.”
And what they’re specifically referencing is the process of going inside: introspection, emotional awareness, and interoception, which is your seventh sense—internal awareness, awareness of physiological cues. But going back to the example of Michael, who is pathologically avoidant, this is a very important story because this is the kind of thing that holds the psychotherapy profession helpless.
We’ve got the over-18-year-old who doesn’t have initiative. They’re totally addicted to avoidance. The parents don’t know what to do. The parent calls for help. The therapist says, “We can’t. Why are you calling? Your son is an adult.” What, what’s happening here is that the psychotherapy profession—the mental health profession in general—does not understand the avoidant personality, as well as social anxiety in general.
Let’s face it: people who are perfectionists don’t want to admit they’re not perfect, and people who are avoidant are super excellent at avoiding.
Kevin Pho: So, in the case of Karen, can you draw the distinction between performance anxiety and broader, more pathological, perhaps social anxiety? How does one tell the difference between the two?
Jonathan Berent: The way that you measure the severity of social anxiety is by two things: how much does the person avoid what’s threatening and what is the degree of the pain of social anxiety. Now, the way I do my work, I reference social anxiety, worrying, obsessiveness. The obsessiveness is one of the keys here.
These are all interchangeable with the concept of pain. Now, the core work. There’s technique and there’s core work. Everybody wants technique: “What do you do?” OK, but the most important thing is core work. And the core work is based on the work of Dr. John Sarno, S-A-R-N-O, world-renowned doctor, famous for his work on back pain at NYU.
He died a few years ago. When people would go see him, he would take them through workshops based on the dynamic that repressed emotion is so powerful it inhibits the flow of oxygen, causing the physical symptoms. In essence, any physical symptom that does not have a biological etiology to it is a manifestation of TMS.
So social and performance anxiety is TMS. And the answer, the resolution for healing, is to be able to go inside. And people with this condition will do anything to not go inside because that’s where the pain is. So let’s say you have people like Karen and Mike, the people that you wrote about in your article, come into your office with this story.
Kevin Pho: So tell us about some of the techniques that you would use as a psychotherapist to approach this.
Jonathan Berent: OK, well look, this is very interesting. You see this bio card? This is a plastic card. OK. OK. And it measures skin temperature. It’s a biofeedback technique, and I put my thumb on it, and it measures skin temperature.
OK. And what it does is it’s showing that I’m cold, which is stress. OK. But there’s good stress, eustress—E-U-S-T-R-E-S-S—and there’s bad stress. OK. So technique-wise, what we’re doing is we’re teaching adrenaline acceptance because the person with anxiety views adrenaline as the enemy. OK. So, so the technique is surfing.
Step one: you’re going into a situation with realistic expectations. Your adrenaline is going to be there; don’t waste any time hoping it’s not. Step number two, which is the hardest, is accepting it with the interpretation that it’s power and your friend. Steps three and four together are the vision of the surfer on the wave going with it—the adrenaline is the wave—and one or two diaphragmatic breaths.
That’s an example of technique. OK. The core work involves getting to the repressed emotion and the trauma. That is involved. Now, trauma is an insidious thing here. There are two types. So, we have patient X, who’s a successful entrepreneur, but he’s got wicked performance anxiety. We’ll look into his past.
His parents were both drug addicts. There was no nurturing in the family. There was a lot of abuse. That’s easy trauma to identify. OK. The next patient, it’s a little more difficult. He grows up in a loving, supportive, wealthy, generous family. He’s the golden child. In this case, the trauma is the degree of the expectations of perfectionism and the development of the critical script.
This is where we’ve got to go to really solve the problem. And one very, very important concept that I try to teach my patients as well. There was an article in Harvard Business Review about emotional agility that said it’s important to label your emotions at work for productivity. We take it a step further in treatment.
The Latin word for emotion, emovere, literally emotere, is translated to mean energy in motion. So we’ve got to connect to the energy in order for the patient to be able to channel it.
Kevin Pho: And how successful are you using some of these techniques for patients who come in with varying degrees of social anxiety?
Jonathan Berent: Well, I’ve seen everything in my practice from a total cure to the problem being permanent and everything in between. There are many variables that go into the learning curve. This is not an easy thing to treat, and there’s a lot of misinformation. Primarily, what has happened over the last few decades is CBT—cognitive behavior therapy—has misled a lot of people with their research, really simplifying the situation.
The patient—the doctor—who resolved this problem. She used the word “cure.” That was her word. She, you know, cured herself with my help with performance anxiety. It’s just very hard. You can go to—I have two podcasts. One is entitled “Public Speaking Anxiety and Fear of Being Noticeably Nervous: Mind Surgery for High Performers.”
The other podcast is called “Parenting: Parenting for the Socially Phobic Avoidant Adult.” If you listen carefully to these clinical interviews, you can get a lot of insight into the healing process. I’ve been doing this for 45 years plus. I couldn’t do it if there weren’t good results, but it’s a very hard thing to do.
Kevin Pho: I’m a primary care physician. If I see a patient in my exam room, tell us the type of patient, clues or symptoms I should be looking out for that may suggest social anxiety and may require further intervention from a psychotherapist like yourself.
Jonathan Berent: Well, it’s not likely that you’re really going to see the social anxiety in the exam room.
People are very, you know, people are very good at hiding that type of thing. That comes down to, you know, when the physician-patient relationship gets really personal and the patient can open up, then you can do something, but 99 out of 100 times with social anxiety. I’m not talking about the person having a panic attack necessarily.
“Hey, give me medicine, doctor. I need help.” But the performance anxiety—what drives it is shame. So, the people are going to do everything they can to hide it. But that’s why we do shows like this is so people can get educated, and the, you know, information is power.
Kevin Pho: Now, are there any medication routes that may help, or are we talking purely that psychotherapy-based techniques are the most helpful? How does that contrast with, say, medication?
Jonathan Berent: When I started my practice in 1978, I started with biofeedback and therapy. The goal was to help people get off of medicine using therapeutic techniques. Forty-five years later, I have learned there are wonderful ways to use psychopharmacology. OK, the problem is this: there’s a proactive effect and a non-proactive way to use medicine—the medicine that we use. And obviously, it’s important to have a psychopharmacologist to do the right prescribing. But in terms of performance anxiety and social anxiety, the way that we use medicine primarily is—I refer to it as a metaphorical pregnancy.
“You’re going to do it for nine months to a year,” but there’s all kinds of comorbid situations that go against this. But the bottom line is we want to use the medicine to create neuroplasticity, to lower the obsessive and compulsive ticking that’s going on—the excessive critical mind state.
It gives the other mind states an opportunity to grow. Then, when a person gets to the point where they have sustained the top of their therapeutic mountain, we like to methodically go off the medicine. OK. That said, a lot of people come into treatment having been on medicine for a long time, and they have no clue what they’re doing with it, and that becomes complicated.
And another situation is sometimes the medicine can be so good that people don’t want to get off. But what we try to do is to train them, do the right work, use it the right way, and then go off.
Kevin Pho: We’re talking to Jonathan Berent. He’s a psychotherapist. Today’s KevinMD article is “When High Achievers and Isolated Adults Share a Common Enemy, Social Anxiety.” Jonathan, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Jonathan Berent: OK, this is the message I want to leave. In 1988, after I was on Oprah, I was interviewed by the producer of the Sally Raphael show. He said, “You are on Oprah, we don’t want you.” Nice opening statement. “Why do you have a PR firm?”
My response: “I want to educate the world.” OK, bottom line, I bought four patients on the show, there were a few thousand phone calls, there was no internet at that time. And what I want to leave the audience with is the world still needs to be educated about this phenomenon. And one more point: it’s very important to know what your most valuable asset is.
“Do you know what your most valuable asset is?” Trick question. “Time.” Oh, got it. OK. It’s not your house or your bank account. It’s time. And people with social anxiety are the world’s best experts at manipulating to avoid at all costs. People like the physician with public speaking anxiety—she waited until the last minute, years after the problem was accruing, when her career was in jeopardy.
So, your most valuable asset is time. It’s very insidious, and the time to take action is now versus later.
Kevin Pho: Jonathan, thank you so much for sharing your perspective and insight. Thanks again for coming on the show.
Jonathan Berent: Thank you for having me.
