By Dr Anthony Ataekong | Chazon PHD CIC
I see a particular pattern in clinical practice. Often enough that it no longer surprises me, but consistently enough that I feel compelled to name it publicly.
Someone comes in having already done the work. They have completed a course of CBT. They have worked through the Clark and Wells model — identifying safety behaviours, dropping self-focused attention, running video feedback. They have tried the exposure hierarchy, the thought records, perhaps medication. And the social anxiety is still there. Not exactly as it was, but present enough to keep narrowing their world.
They feel they have failed therapy. In almost every case, they have not. Therapy has simply been treating the wrong thing.
The treatment isn’t failing. The formulation is.
Social anxiety disorder is one of the most commonly diagnosed presentations in outpatient mental health settings. It is also one of the most commonly misformulated, particularly in a specific subset of people whose anxiety is not the primary diagnosis at all.
What is presenting as social anxiety is, in a significant number of these cases, a symptom of recurrent depression that was never identified as the primary condition.
This matters because depression and social anxiety disorder respond to different formulations and different treatment targets. When you treat a depressive symptom as though it were a standalone anxiety disorder, you achieve partial relief at best. The anxiety reduces temporarily, then returns, because the soil it grows in has never been addressed.
The Social Exclusion lifetrap — what it is and why it matters
The framework I draw on here is schema therapy, developed by Jeffrey Young and colleagues. Within this model, a lifetrap is a deeply held core belief about oneself and the world, formed in early childhood in response to unmet emotional needs.
The Social Exclusion lifetrap is one of the most clinically significant and most frequently overlooked.
It begins with a child who learns, through experience rather than choice, that they are fundamentally different. That there is something about them that other children reject. They do not belong to the group. They may not have been able to name what made them different. They may not have needed to. The feeling was enough: they were, in some essential way, undesirable.
As an adult, this lifetrap takes on a particular shape. The person may feel ugly, low in status, boring, or otherwise deficient in social situations. They re-enact that childhood rejection, feeling and acting inferior precisely in the contexts where acceptance matters most.
Critically, many people with this lifetrap manage well in one-to-one settings. It is the group — the party, the meeting, the room full of people who all seem to know where they belong — where the full weight of it surfaces. This is why the severity so often goes undetected. A standard clinical interview, conducted one-to-one, does not surface what only emerges in the group.
How the lifetrap becomes depression — and why depression looks like anxiety
The wound of social exclusion, carried across years, does not simply persist. It deepens. Over time, it creates the conditions in which recurrent depression takes root.
This is not the depression that keeps someone in bed. It does not necessarily present as flat affect or anhedonia, the markers most clinicians are trained to screen for. Instead it presents as chronic avoidance. As cancelling plans. As an inexplicable restlessness in social situations. As a persistent sense of being undesirable, even when the external evidence contradicts it.
The social anxiety is real. The distress is genuine. But it is downstream of a depressive process, one that originated in a lifetrap formed long before the anxiety had a name.
Treating the anxiety as primary, without addressing the lifetrap that feeds the depression that produces the anxiety, is why this pattern cycles. Each course of treatment produces some relief. The relief does not hold. The person concludes, again, that they are the problem. They are not. The formulation is.
What a different approach looks like
When the Social Exclusion lifetrap is identified and worked with directly, through schema therapy’s combination of cognitive, experiential, and relational techniques, the treatment target shifts. We are no longer managing the symptom. We are addressing the belief system that generates it.
This involves helping the person understand the origin of the lifetrap without being defined by it. It involves experiential work that allows them to feel, not just intellectually understand, that the childhood conclusion was not an accurate reading of their worth. And it involves developing what schema therapy calls a Healthy Adult mode: a part of the self capable of responding to social situations with something other than the anticipation of rejection.
The depression does not disappear overnight. But when the root is addressed, the social anxiety loses the substrate it requires to keep returning.
A note to anyone who recognises themselves here
If you have been treated for social anxiety, more than once, with more than one approach, and it keeps coming back, I want you to hold this lightly: the problem may not be your resilience, your commitment, or your capacity to change.
It may be that no one has yet looked underneath the anxiety to ask what is growing there.
That question is one I take seriously in my clinical work. If it resonates with your experience, I would welcome the conversation.
Dr Anthony Ataekong is a Specialist Psychological Therapist and founder of Chazon PHD CIC. He holds an MBBS, an MSc in Mental Health and Psychosocial Support, and a BABCP-accredited PGDip in Psychological Therapy. His clinical work integrates adaptation of models of treatments, psychosocial approaches, and cultural competency in mental health.
References
Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.
Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment. Guilford Press.