The New York Times reported today that there is a new rapid home testing kit for HIV that went on sale today, October 5, 2012. The kit is called OraQuick, costs $40 and takes 20 minutes to provide results. This is a major breakthrough, as it allows people to quickly determine their HIV status in the privacy of their own homes. It also opens up the potential for sexual partners to test each other before having sexual contact. I’m sure the company that makes the OraQuick test, OraSure Technologies, would love it if many people use this test before having sex. But is this a good idea?

The kit is not perfect. It is almost 100% accurate when it indicates that someone is not infected with HIV, and, in reality is not. But it is only 93% accurate when it says someone is not infected and the person actually does have the virus. This is most likely because there is a period of time after infection before the body is producing antibodies that the test detects.

Should you use this test when considering becoming sexual with a new partner? Consider some very disturbing facts based on two sexual surveys reported in this article. In the first survey, nearly 20% of infected homosexual men reported having unprotected sex with at least one partner without revealing their HIV status.

In the second study, they found that 9% of HIV-positive heterosexual men and women, and 14% of HIV-positive gay or bisexual men reported having recent unprotected sex with someone who they either knew was uninfected, without revealing their own infection! Putting this in real numbers, the authors of this survey estimated that over a year, 34,000 infected gay men and 10,000 infected heterosexual men and women had sex without telling the truth.

This really speaks to the issue of not trusting what people say about sexuality. Too often I hear experts giving the advice to ask your potential partner about their sexual history and their HIV status. Given the results of these two surveys, that seems naïve, foolish and dangerous. People lie about sex. If you are a gay male, it’s reasonable to expect that one in five infected potential partners will lie to you about their HIV status. If you’re a heterosexual, the number drops to a little below 10%. Are those the odds you want to take with your life?

What this really speaks to is the importance both of testing and of safe sex. Since the OraQuick test is only 93% accurate when the person taking it is infected, that means 7% of the time, with an infected person, the test will falsely tell you that they are not infected. So those odds aren’t very good either. So let’s calculate the probability that your new potential sexual partner might be HIV-positive, lying about it, and the OraQuick test would falsely tell you they were HIV negative.

If you are a gay man, then the probability is 20% times 7%, which equals 1.4%. If you are heterosexual the probability is 9% times 7%, which equals 0.69%. So the odds that your deceitful HIV-positive partner would not be identified by the OraQuick test are 1.4% if you are a gay male, and 0.69% if you are a heterosexual man or woman.

So even by using the OraQuick test, you can’t eliminate all risk. That’s why practicing safe sex makes so much sense. At least do so when having casual sexual contact, before you get to know the person well and can figure out whether they are trustworthy or not.

So to summarize, the new OraQuick test allows for quick at home testing of HIV status. Given the facts about how many HIV-positive gay and straight people are not honest about their HIV status, it makes sense to consider using this test. But there is still a risk, since the test is least accurate when used on HIV-positive people. The OraQuick test can improve your odds, but for ultimate safety, practice safe sex!

No joke to end this post, because this is such a serious matter.

In Part One of Understanding and Overcoming Social Anxiety, I discussed the basic core beliefs of people who suffer from social anxiety. To review, the core beliefs are:

1. Everyone is noticing me

2. Everyone is judging me, harshly

3. As a result of these judgments, I will be humiliated and rejected.

4. If people judge me negatively, I must suffer terribly.

I wrote about a simple behavioral experiment that challenged the first belief, that everyone is paying attention to you. How do we challenge the rest of these beliefs?

Let me digress for a moment into a bit of theory about change. In my opinion, there are two types of change, first-order change, and second order change. First-order change is change that occurs within a given mental system, without changing the system itself. Second order change is transformative, in that it changes the basic framework of the system.

A good example of this is the concept of a nightmare. Within the nightmare a person can do many things such as running away, fighting, screaming, etc. but they are still within a nightmare. Second order change means waking up from the nightmare.

In the case of social anxiety, first-order change would entail questioning the beliefs that people are judging you harshly. It might entail gathering evidence whether your beliefs about people judging you are accurate or not.

Although this approach would be useful, it’s not really transformative. Second-order change would be to change the belief that other people’s judgments matter. Not caring even if people are judging you negatively would be the ultimate second order change.

Now let’s come back to earth! How would we apply each of these types of change to social anxiety? To do first-order change you could check out your mind-reading perceptions. For instance, if you are worried that your boss was judging you negatively, you could sit down with your boss and ask for feedback. You could first start by asking for general feedback, such as “How do you think I’m doing?” Then you could narrow it down to your specific concerns. For instance, imagine that you are worried that you are not working fast enough. You could ask your boss, “Do you think I’m keeping up with the pace?”

With a friend or loved one you could use a similar strategy. You could tie nonverbal cues to your questioning. For instance, let’s imagine that your spouse furrows their brow at you. You imagine they are judging you negatively. You would then ask, “I noticed that you furrowed your brow at me just then, what were you thinking?”

This strategy would result in first-order change; that is, you would correct your beliefs that everyone is judging you negatively. But it wouldn’t change the power of those imagined or real judgments to upset you.

A second order change strategy for social anxiety would be to do some behavioral exposure tests that would help you overcome the fear of judgment. I do these with my patients frequently. For instance, we might walk around my office neighborhood wearing masks. Or we might put on two brightly colored socks that don’t match, roll up our pants so that the socks are fully visible, and walk around. Other tasks might include singing loudly (and off key) as we walk down the street. Another task might be on an elevator, announcing the floors as each passes.

The key concept behind all of these types of tasks is to overcome the fear of people noticing you and judging you. Clients quickly realize that the judgments of strangers really don’t matter.

There are literally hundreds of these types of anti-embarrassment tasks. (I’ve listed some good ones below.) One can create a laddered hierarchy of tasks ranging from relatively easy tasks to very scary tasks. Then the client can work their way up the hierarchy so that they get more and more comfortable being judged.

Another approach is to deliberately work on incurring some mildly negative judgments from people you are close to. For instance, I might ask a client to wear a shirt that their spouse disapproves of or doesn’t like. Or one could deliberately espouse an opinion that a friend would disagree with. The idea of this is to get comfortable with mildly negative judgments even from people you are close to.

A key concept regarding judgment that I try to teach clients is that if one has a clear sense of one’s self, including strengths and weaknesses, then it’s possible to be relatively independent of the judgments of others. You get to determine your own judgments of yourself, and when the judgments of others correlate with your own judgments, and then you can respond non-defensively. But when the judgments don’t correlate with your own judgments of yourself, you can gracefully ignore or dispute them. The key concept is that everyone has different opinions about almost everything, and you get to determine your own opinion about yourself.

In fact, one might view social anxiety through the lens of the sense of self. Those who suffer social anxiety usually have either a negative view of themselves which they project onto the judgments of others, or have an unstable view of themselves which depends on the judgments of others. In either case the core problem is the sense of self.

To walk around with a profoundly negative view of oneself would be even more painful if one was fully aware of the source of this negative view – one’s own thoughts. Because this is so painful, people with a negative self-concept will typically project this negative self-concept onto the world, and experience everyone around them as judging them negatively. The first step to overcoming this tendency to project and to mind-read is to make the assumption that virtually all of your beliefs about others judging you are actually a reflection of you judging yourself.  Then you can deal with the real problem – your own thoughts.

If you have an unstable view of yourself, and depend on the judgments of others to figure out who you are, then changing this is more challenging. I often give clients a variety of written tasks so that they can explore their beliefs about themselves. The challenge is to figure out who you really are, including both your strengths and weaknesses. And then accept both. Once you are okay with who you are, then the judgments of others don’t really matter very much.

Now I want to clarify an important point. Some judgments do matter. For instance, if you work in a company and your boss determines your bonuses and raises, then your boss’s judgment of you matters, at least in terms of your economic health. Other judgments that typically matter might include a graduate school thesis advisor, who can determine whether you can progress in your program or not. And in general the judgments of the people closest to you do matter, at least over the long run. If your wife or husband begins to have a generally negative judgment of you that persists, this may end up in divorce. But note that even in these close relationships, a momentary negative judgment doesn’t really matter. If my hair gets too long, and starts to look funny for a week or two until I get it cut, my sweetheart won’t reject me. (Of course, she may drop subtle hints about haircuts!)

So, to summarize:

1. Social anxiety is at its core a disorder of the self. People with a strong and confident sense of self don’t suffer social anxiety. One might conceptualize social anxiety as a frantic attempt to accurately determine one’s self by polling others.

2. There is first-order and second-order change regarding social anxiety. First-order change involves making more accurate determinations of the judgments of others towards you. First-order change involves challenging mind reading beliefs and testing whether others are even paying attention to your behavior.

Second-order change is more profound and more radical. It involves learning not to care, even when others judge you negatively. It also involves bringing back your attention from the outside world and the judgments of others to the inside world and your own judgments of yourself.

3. Almost everyone can benefit from tuning into their inside judgments of themselves. As Oscar Wilde once said, “To love oneself is the beginning of a life-long romance.” We are stuck with ourselves, flaws and all, and learning to love and truly accept ourselves is really the beginning and the end of internal comfort in life.

Appendix: Some Examples of Anti-Embarrassment Tasks

In an elevator, open your briefcase or handbag, and look inside, and ask “Got enough air in there?”

Say “Ding” at every floor.

On a bus or subway, stand up and announce each stop.

On the street, ask for directions to a store you are standing right in front of.

Social anxiety is a common psychological disorder, affecting about 5 percent of the population in a strong way and up to 13 percent of the population in a weaker way.

Social anxiety is not just shyness, but a much more profound problem. People with social anxiety disorder often become intensely anxious in social and performance settings, sometimes to the point of having a full blown panic attack.

As Jerry Seinfeld once said, “According to most studies, people’s number one fear is public speaking. Number two is death. Death is number two. Does that sound right? This means to the average person, if you go to a funeral, you’re better off in the casket than doing the eulogy.”

There are several core beliefs that drive social anxiety.

The first of these beliefs is that everyone is paying a lot of attention to you and your behavior. People are noticing.

The second belief is that when people notice you, they will then judge you harshly. (Since most socially anxious people are very judgmental of other people, they assume that everyone is equally judgmental.)

The third of these beliefs is that as a result of these harsh judgments, people will reject and/or humiliate you.

And the fourth belief is that as a result of these judgments you must feel very badly, full of shame and worthless feelings.

All of these beliefs are what we in Cognitive Therapy call ANTS, or automatic negative thoughts. Let’s go through them one by one and analyze how accurate or distorted they are. Then we can talk about some behavioral experiments you can do to dispute these beliefs.

The first belief: that everyone is paying a lot of attention to you and your behavior, is simply not true. Most of the time, most people are fairly oblivious, mostly thinking about things of concern to themselves. You’re not in the spotlight unless you are a genuine celebrity.

The second belief depends on the first belief. If people don’t even notice you, then they certainly aren’t judging you harshly. The other distortion in the second belief is that people will judge you harshly. Even when people do make judgments they are typically not particularly harsh.

The third belief, that as a result of judgments people will reject or humiliate you, most likely stems from grade-school teasing and bullying. In adult life, most judgments are never acted on, and they are never expressed. After all, the modern workplace has very little tolerance for negative teasing or humiliation. People may think some judgmental thoughts about you, but unless you imagine them thinking those thoughts, they will never have any impact on you.

The final belief that you must feel badly if someone else judges you negatively is also quite distorted. It’s quite possible to know that someone is judging you negatively, and feel fine about yourself. After all, all judgments are simply another person’s opinion, not truth. If another person thinks your haircut looks funny, that’s just their opinion. You have the right to have a different opinion.

An important concept in all social anxiety is the idea of mind-reading. Most socially anxious people practice this form of cognitive distortion constantly. They assume that they can read minds, and will read into every subtle expression a negative judgment. This is of course a major cognitive distortion. Nobody can read minds. A furrowed brow can mean many different things, and can even mean the person has a mild headache, or needs a new eyeglass prescription.

Most of the time, when the socially anxious person is mind reading, they are actually projecting their own insecurities about themselves onto other people’s judgments. Let’s imagine that I am particularly self-conscious about my thinning hair. As a result of this insecurity I may imagine whenever someone looks at my head that they are actually looking at my hairline, and thinking negative thoughts about my impending baldness. This is called projection.

In almost all cases of imagined judgment, what is actually happening is projection. You can quickly figure this out by asking yourself, “Is the imagined judgment coming from the other person actually something I feel quite insecure about?” If the answer is yes, then most likely you are mind-reading and projecting.

It would be nice if just a rational discussion of these distorted beliefs created change, but in my experience as a cognitive behavioral therapist, simple discussion rarely changes beliefs completely. But there are some behavioral experiments that are very powerful in challenging these beliefs.

The first belief, that everyone is paying a lot of attention to you, can be challenged using the following behavioral experiment. Do this with a friend or a therapist. Have the friend or therapist wear something quite odd, like a mask or something equally outrageous in terms of dress. Have them walk down a busy street. Walk about 10 feet behind them so that you can observe carefully people’s reactions. Before you start, write down your prediction as to what percentage of people will notice and react to your friend or therapist looking very odd.

Walk around, and keep a running count of everyone who seems to notice, and everyone who seems oblivious. When you have collected a fair amount of data, calculate the percentage of people who even noticed your friend or therapist wearing a mask. You can also track the type of response that you notice. Do people smile or laugh, or do they frown and seem judgmental in a negative way? Compare your actual data to your predictions.

I think you will be surprised at the results of this experiment. Once you have done this experiment I recommend putting a mask on yourself and walking around and noticing people’s responses.

In Part Two of this article I will discuss some other behavioral experiments that can help you overcome social anxiety, as well as discussing some issues of deep change.

Now I’m off to give my eulogy, which is scary but better than the alternative!

In a previous post I wrote about my experience with JetBlue and Orchard Supply Hardware customer service.

Here’s a followup which shows one Epic Success, and one Even More Epic Fail!

An executive vice president from Orchard Supply Hardware called me up to discuss the situation. He was apologetic, friendly, and agreed with me that the right policy would have been to honor the coupon. We had a nice chat about customer service, and at the end of it he offered me a gift card to compensate for any inconvenience. I was impressed that a) someone at Orchard Supply Hardware cared enough to call, and b) that he appreciated my feedback. Kudos to Orchard Supply Hardware!

JetBlue on the other hand, managed to make things even worse. When I asked them to fix the miles problem, their unilateral response was to take away my JetBlue miles, and then tell me to contact American to get the miles there. At the end of all of this effort, basically what they did was to take away my JetBlue points permanently, and give me American Airline’s phone number to see if I could get miles from them! Thanks JetBlue for absolutely nothing!!!!

JetBlue turned an Epic Fail into an Even More Epic Fail. That’s a good trick.