A Case Presentation: Social Phobia

    Social phobia is a very common disorder, among children and adults. Millions of people all over the world suffer from it. Like other phobias, Social Phobia is a fear reaction to something that is not actually dangerous, although the body and mind react as if the danger is real. Individuals who suffer from Social Phobia may develop hypersensitivity to criticism, negative evaluation, or rejection. They often have difficulty being assertive; and have a low self-esteem or have feelings of inferiority. They may underachieve at school due to test anxiety or avoidance of classroom participation. They may underachieve at work because of anxiety during, or avoidance of, speaking in groups, in public, or to authority figures and colleagues. They often have few friends. In more severe cases, individuals may drop out of school, be unemployed and not seek work due to difficulty interviewing for jobs.

    Like many other anxiety disorders, genes may play a role. If a biological parent or sibling has or has had Social Phobia, there is at greater risk for it. Environmental factors, such as an overprotective or hypercritical parent, or being rejected and humiliated in school, may lead to Social Phobia. An interesting study was performed on very young butterflies that were hatched in the laboratory. When the investigators made a sharp noise in the corner of the cage, some of the butterflies flew in the direction of the noise, apparently to investigate its source, while others flew away and hid. People who raise dog puppies are aware that some of the puppies are afraid of sharp noise, and run fast to hide or seek the protection of their mother, whereas others moved closer to the source of the noise and barked. The same is the case with very young children. Some cry when they see a stranger, while others smile.

    The patient, who was instrumental in my developing the relaxation technique, which I dub the "Protective Shield", was 32-year old Mark.

    From an early age, Mark suffered from various fears, which increased once he graduated college with a Bachelor's degree in Economics and began working in an industrial plant. The plant's manager was extremely authoritative and critical. Most of the employees feared him but learned to cope. Mark, on the other hand, being very sensitive, was extremely hurt. As a result, he began feeling anxious and depressed for several days after each incident. In the beginning of Mark's treatment, he related that he father was also very critical. During his childhood, Mark feared his father and tried hard not to anger him. I explained to Mark that he experiences his boss in the same way a doe in the jungle experiences a predator chasing her. Even though the predator does not physically harm the doe, the doe is always on the lookout.

    "I understand that what you mean is that I related to my father as if he were a lion." Mark responded to my explanation. "It is important that you understand that today my father is practically senile. He resembles an old toothless lion, and as for me I am now an adult, much stronger than he is. Why is it that I still fear him? In any case, my boss is not my father, so why is it that I am afraid of him?"

    "Let's imagine that the doe who lived in the jungle all her life, moves to a location where there are no beasts of prey and befriends a local doe. When an unfamiliar sound is heard, the doe who came from the jungle would take flight, while the other one will turn to the location of the sound in astonishment."

    "Is that what I can expect for the rest of my life? To take flight when I hear any little sound?" asked Mark frustrated.

    "Do not blame yourself" I answered. "This is nature, or a higher power, that programmed our brains. An animal residing in a place where there are beasts of prey will immediately be overly cautious, and certainly much more so than those who reside in a totally protected environment."

    "You keep explaining to me what happens with jungle creatures, but I am neither a doe nor a rabbit, I am an intelligent human being, a college graduate, who had never resided in the jungle. I live in a large metropolis where other humans reside, sometimes with dogs or cats but not beasts of prey."

    "You are correct, you are neither a doe nor a rabbit and neither am I. All of us, however, contain within us the primitive instincts of our ancestors. Since human history began developing, approximately ten thousand years ago, we learned to control some of our primal instincts. As an example, men do not rape the women whom they desire. They court them and conduct their sexual activities privately by mutual consent. When we are hungry, we do not steal food from stores and climb trees to consume it. We buy fruits and vegetables in the market and when we come home, we clean them, peel them, set the table, wash our hands and then consume the food in a civilized manner. Despite these changes in education and culture, however, the primitive survival instinct has not undergone much change. When we perceive something as dangerous, or when we anticipate trouble, our bodies change gear from relaxed to cautious."

    "Is it possible for me to learn to control the survival instinct? Will you be able to help me develop a protective shield such as an elephant has, so that I will not be afraid of every comment my father or my boss make?" Mark asked defiantly.

    On my way home I wondered "would Mark really be happy with an elephant's skin? With an elephant's skin will his wife continue to love him? Will he be as good a father to his children as he is today? Will he be able to continue to enjoy an exciting movie or book? And, in fact, what is the harm with thick skin? After all, there are many people with thick skins, such as politicians and CEOs who do marry, have children and have loving families. The thick-skinned people often search partners with thicker skins. They complement one another. And, what would happen to Mark's marriage if I help him develop a thick skin? Would his wife, who is a strong woman and somewhat authoritative, will be able to get along with the newly formed Mark?" I answered myself with an unequivocal no. Even a lengthy couple therapy would be unable to allow two individuals with thick skins to live together happily. They would quarrel, or become apathetic and indifferent to one another. So what is the solution? Perhaps I need to teach Mark to develop flexible skin?"

    In our following session, I explained to Mark the following: "I gave your request to help you develop thick skin much thought. I came to the conclusion that you should be happy you do not possess thick skin, since both skin types have advantages and disadvantages. The advantage of a thin skin is that it affords its owner positive sensitivity to other people and the environment. People who possess thin skin usually develop very deep and significant relationships with family and friends. They rarely offend or hurt people they come in contact with, as they are familiar with the consequences. They also find the landscape, good art and a sad movie exciting and moving. The disadvantage of thin skin is that those possessing it are easily hurt. On the other hand, thick skinned people are less offended. Mostly they take on leadership roles, such as your boss. However, unfortunately, they do tend to hurt and offend people. I would assume that they are not particularly moved by any landscape or a sad movie. Since we are now living in an advanced technological era, the choice is not between a thick or a thin one, but a flexible skin which a person may choose to change at any given time by himself at will."

    "That makes sense to me! Come on now, teach me how to control my skin" Mark requested.

    At the conclusion of a relaxation exercise which lasted about ten minutes, I continued with a guided imagery. "Imagine, Mark, that your skin is covered by a transparent Protective Shield. Similar to natural skin, soft and flexible, but somewhat thicker." This Protective Shield covers your entire body from top to bottom, and affords you a feeling of safety and security. It shields you from outside pressure. The shield is transparent, light and flexible. You can also control its thickness. There will be instances when you will prefer a thinner skin, when you are with your wife and children for example, when you read a book or see an exciting movie. However, there will also be times when you will prefer to be covered by a thicker skin which will protect you from outside pain. The advantage of this method is that you are in control of the thickness of this shield by taking several deep breaths (for more details review chapter: How to Attain Relaxation Trough Breathing). The shield expands exactly in proportion to the stressful situation in which you find yourself. You need several relaxation breaths that will expand the protective shield. I will be quiet now for a few minutes at which time I ask you to recall one or two situations that occurred recently, in which you reacted as you always have. Use situations in which you felt hurt. I suggest that in the first stage you reconstruct in your imagination the exact situation and your original response to it. In the second stage, remember the hurtful sentences said to you. Take a deep breath which will blow up your Protective Shield. In your imagination, the insulting sentences will touch the Protective Shield, break up into syllables and disintegrate. At this time, since you will be relaxed, you will be able to respond in a manner you deem appropriate. When you feel you are satisfied with the new scenario, you will take a deep breath, smile and open your eyes."

    I observed Mark's body and face for about five minutes as he moved deeper and deeper into the world of imagination. Sometimes his face expressed pain and sometimes a winning smile. When he opened his eyes, his face seemed relaxed. He said that he reconstructed in his imagination two situations. In the first one, he saw the manager being angry with him in front of other employees. The manager's words to him were very hurtful. Mark took three deep breaths and saw these words hitting his Protective Shield disintegrating. He answered the manager firmly, yet in a relaxed manner. He explained to the manger that it is not acceptable for him (Mark) to hear this tone of voice. Mark told the manager that if he has anything to say to him, he should invite him to his office and talk about it in private and in an acceptable tone of voice. In the second scenario, Mark imagined himself to be 15-years old and have his father yelling at him for watching TV instead of studying for an exam. Mark again expanded his Protective Shield, looked directly in his father's eyes, a thing he never dared to do in the past, and in short sentences told his father that the exam was his own personal business. That if he chooses to fail the exam it is his prerogative. He is no longer a young boy who takes orders from his father. Mark imagined his father being stunned by his firm approach, and for the first time in their relationship, the father lowered his eyes and left the room.

    I acknowledged Mark for his success in imagining and using the Protective Shield and for his ability to both deal with the manager and his father in such a positive and respectable manner. However, I also needed to prepare him for setbacks. I explained to him that the new Protective Shield needs many adjustments and tryouts. Experience and recurring usage gives us confidence in our responses. In order to empower Mark�s achievements and overcome the fear of failure, I told him that I hope that this week the manager will scold him more times than in the past in the company of other employees, and that his father will look at him disapprovingly more frequently as well. At first, Mark felt uncomfortable with this request, but he calmed down when I reminded him that "what does not kill us, strengthens us." Mark continued in therapy and focused on experiences from the past, which caused him pain. With the help of the imaginary Protective Shield, he began developing positive coping mechanisms.

    In 1991, during the Desert Storm operation, I worked as a psychologist in an Israeli hospital. I was asked by the hospital's director to prepare subliminal relaxation tapes in order to assist the hospital's staff and their families, as well as the patients, to cope with fears due to the Iraqi attacks. With the help of a donation, I was able to tape and copy approximately 1000 tapes called "Protective Shield". These tapes were highly acclaimed. These recordings can be heard in Hebrew under the title of "Coping with Stress and Anxiety" on the website www.baruch-elitzur.com. Currently these tapes help many of Israel's citizens who reside in the areas which the Hamas attacks with rockets.

    Since there is great sensitivity and social phobias stemming from fear and stress, which raise hormone levels, it is important for any listener wishing to cope with these symptoms alone to first review the relaxation exercises in this site. Also, prior to using this technique, please review the chapter: "How to Best Use The Relaxation Sessions". In time, anyone will be able to use the relaxation technique that is most appropriate for him. Should this technique not provide relief, it is recommended that the person consult a psychologist.

    I encourage everyone who suffers from Social Phobia to try to help himself / herself by practicing relaxation techniques and mental imagery. If these steps are not sufficient, it is highly recommended to seek professional help.