Living with a Social Phobia Disorder
Ken Miller, a tall man with glasses and a self-effacing manner, sits in a dimly lit office, describing the long, lonely journey that brought him to The Anxiety & Phobia Treatment Center (APTC) at the White Plains Hospital Center. Licensed master social worker Judy Lake Chessa, the program’s coordinator, sits at one desk, and Miller’s phobia counselor, Judy Shaw, sits at another, encouraging him along. They have suggested Miller speak about his issues as part of his therapy, another mile logged on the road to wellness.
For most of his 44 years, Miller says, he has suffered from what he thought was extreme shyness. As a teenager, he was often tongue-tied and awkward, especially around girls. It took him months to get up the courage to ask one girl out on a date, but, when he finally approached her, he couldn’t get the words out. Later, he broke down in tears. “I still feel embarrassed when I think about it,” he admits, even though the incident happened almost 30 years ago.
For the next 20 years, his social paralysis intensified. He made a life for himself—he has a job as a civil servant in Brooklyn, an apartment, and friends—but he was so afraid of saying or doing something embarrassing that he’d rarely open up to people. “I lacked deep friendships that could have been there,” he says. He’d occasionally go to parties, “but I’d tend to fade into the background and feel anxious, so I avoided those situations. There was a lot of avoidance—that’s how I dealt with it.”
Ten years ago, suffering from depression, Miller went to a psychologist. After several sessions, he received a diagnosis of social anxiety disorder, or social phobia. “I’d never heard of it before,” he admits, “but at least I had a name for what I was going through.” He was prescribed Prozac, but it only made him feel worse, so he stopped taking it. He pushed on, white-knuckling his way through life. “I’d tell people I have social anxiety and they’d be like, ‘You’re shy; just get over it.’ And I’d say, ‘No, you have no clue.’ It’s not your average shyness that you can just push through. It’s a lot deeper.”
Miller’s anxiety around women was especially painful. He had female friends, but if his feelings turned romantic, he kept them to himself—the prospect of sharing his feelings was simply too terrifying. There was one woman in particular. After working up his courage for days, he went in for a kiss. “It backfired. She freaked out and jumped out of the car and was gone.” In a way, the rejection was almost a relief because it spared him any further need to grapple with his fears. But then, a few days later, he says, “I was driving in my car and I became overwhelmed with this feeling that I was always going to be alone.”
When it comes to having social phobia, Miller actually has plenty of company. The National Institute for Mental Health (NIMH) estimates that 15 million adults in the U.S. have suffered from social phobia and that a third of those cases are severe—meaning the disorder interferes with everyday life. Men and women suffer equally. There is some evidence of genetic factors, and symptoms usually appear in childhood or early adolescence (though Miller recalls feelings of humiliation and embarrassment as early as the age of four). NIMH defines sufferers as people who “become overwhelmingly anxious and excessively self-conscious in everyday situations.” Unlike shyness, which is a personality trait, social phobia is a disorder, a pathology, experts say. Sufferers fear not only human interaction, but also the imagined consequences of that interaction. “People with social phobia suffer from essentially three different misconceptions that overlap,” explains Fred Neuman, MD, director of the APTC, which was founded at the White Plains Hospital Center in 1971 and is the oldest hospital-based program of its kind in the country. “One, they feel like they’re being observed when they’re not actually being observed. It’s a kind of exaggerated form of self-consciousness. Two, they tend to think that people are judging them when they’re not. And three, they think that if they commit a faux pas, people are likely to remember it when, in fact, they are not. Those are all inaccuracies, and they are learned phenomena.”
Which means they can be unlearned. For years, psychodynamic psychotherapy, with or without medication, was the most common treatment for social phobias. These days, cognitive behavioral therapy (CBT) is a popular treatment for phobias of all kinds, from fear of elevators and crossing bridges to fear of public speaking. Its basic premise is simple: The sufferer re-learns the way he or she thinks about those situations that cause anxiety, then practices these new learned ways of thinking in real-world situations.
The APTC at the White Plains Hospital Center has long been at the forefront of this approach. Its founder, the late Dr. Manuel Zane, advocated a form of CBT called “in vivo,” or “exposure” therapy, in which clients are exposed, little by little, to their particular anxiety-producing bête noir, a technique known as “desensitization.” Where psychodynamic psychotherapy is an open-ended process aimed at digging up the root of a phobia, CBT aims more at re-learning; it focuses less on the origins of a problem and more on alleviating its symptoms. For example, Miller’s goal is to go on a date and even have a girlfriend someday. His treatment includes weekly one-on-one therapy with Judy Lake Chessa, as well as a nine-session workshop. During those nine weeks, he meets seven times with his phobia counselor, Judy Shaw, to map out “exposure” sessions. The goal is to desensitize Miller to anxiety-producing situations, particularly those involving the opposite sex, and to help him cope.
“Judy and I will discuss and agree upon what difficulties I need to work on and come up with an exercise that will put me in a manageable phobic situation, so that I can recognize and help build my confidence in that area,” Miller explains. For instance, they will go to a restaurant, where Shaw will role-play the part of a female dining partner. They will go shopping, where he will practice taking a compliment from salespeople. He even took a dance lesson, “so that I could work on my comfort ability in a situation where I was one-on-one with an attractive woman.” Sometimes Shaw will give him homework: strike up a conversation with a woman on a topic of his choosing. Post a profile on an Internet dating site.
A broad and varied form of therapy, CBT can be implemented differently depending on the treatment center. For example, The Therapy Center in Bedford Hills employs a number of alternative methods to facilitate CBT, including hypnotherapy. “Hypnosis is luxuriating in a single focus where suggestions can make a big impact,” explains Will Cook, LCSW, director of Mind/Body Innovations at The Therapy Center. “When a person gets nervous, they’re in a state where they’re asking ‘What if’ questions like, ‘What if I blow it? What if I embarrass myself?’ This is their projection. You need to ask new questions to challenge the thought itself, like ‘So what? So what will really happen if I embarrass myself? What is the worst thing that can happen?’ Let them answer the question on their own. In a hypnotic state, you’re more readily available to accept the idea of a new possibility or a new outcome. The subconscious mind doesn’t know the difference between imagination and what is actually happening. In other words, it will start to feel as if the good stuff is already happening.”
“Social phobia is treatable; it can be overcome,” agrees Nabil Kotbi, MD, chief of The Haven and The Retreat, inpatient units for psychiatric and addiction issues, respectively, at Payne Whitney Westchester, the psychiatric arm of New York-Presbyterian Hospital in White Plains. “It depends on how severe a case is, and it depends on the treatment.” A serene enclave of historic Georgian-style buildings perched on a hill across from Neiman Marcus, Payne Whitney Westchester has been attending to the county’s mental health needs since 1894 and today offers a comprehensive, outpatient-only, Anxiety and Mood Disorders Service. Dr. Kotbi rarely sees someone admitted to inpatient treatment specifically for social phobia, but that doesn’t mean they don’t have it. Someone may come in for substance abuse or depression, but, as the layers of his or her psychology are peeled away, social phobia may be revealed as the heart of the problem. Ideally, a sufferer doesn’t wait that long, but this is the catch-22 of social phobia: he or she can be too fearful to seek help. “You can find the pure version of social anxiety disorder if you catch it early,” Dr. Kotbi says. “If it remains for a while, the person evolves maladaptive coping skills, such as withdrawal from society, which can lead to depression and poor self-esteem.”
Social phobia can be very effectively treated using CBT, he adds, “but sometimes you might need some help with medication throughout this journey.” According to Dr. Kotbi, the “first-line treatment” for anxiety disorders like social phobia is selective serotonin reuptake inhibitors (SSRIs). Known by the brand names Lexapro, Celexa, Paxil, and Zoloft, among others, they flood the brain with the neurotransmitter serotonin, which helps alleviate feelings of anxiousness. While SSRIs are marketed as a magic bullet for anxiety, Dr. Kotbi urges that they be used only in conjunction with psychotherapy or CBT, adding, “If you don’t have an underlying mood disorder, you must get through it with therapy alone.”
At the APTC at the White Plains Hospital Center, “we do not do medication management,” says Chessa. “If somebody comes and they’re on medication, that’s fine, but it’s not part of our program.” That’s fine with Ken Miller, too. “I have an aversion to medication. As long as I feel like I can function without it, I do not want anything to do with it.” He has something better than a magic pill—he has Judy Shaw.
What truly sets the White Plains Hospital Center program apart is the fact that many of its phobia counselors are former sufferers themselves. Shaw came there in 1980, a single mother of two from Scarsdale who was severely curtailed by fear. “I was afraid of everything, but social anxiety was my main problem,” she confides. “I could go to Manhattan and be anonymous, but I couldn’t be around people I knew. I’d go to the grocery store or the library and worry that they’d see my anxiety and criticize me later. The walls were closing in. Then I came here. It saved my life.” She ended up entering its phobia counselor-training program, as did Chessa, who originally came here for agoraphobia.
“I’m in recovery,” she says. “But there are times where the old thoughts come in. And that’s normal. I’m not afraid of them anymore. My life is not limited anymore.” She looks across the room at Miller, with whom she has a special empathy, having suffered from an anxiety disorder herself. “Ken knows what he wants to do, and at some point he needs to take a risk. He needs to take a chance.”
Miller smiles. He knows it too, and he is almost ready.