The
Diagnostic and Statistical Manual of Mental Disorders IV (2002, p. 917)
classifies Taijin Kyofusho, fear of social and interpersonal relations as
culture-bound syndrome similar to social phobia which is very common in Japan.
An individual who suffers from this syndrome manifest an intense fear that
their physical appearance, body functions and attitude may offend and harm
other people.
Choy
et al. (2007) includes core fear features such as body odor, fear that other
people may notice physical defects, awkward behavior or gestures, trembling,
blushing or fear of staring that would make another person feel uncomfortable.
This extreme fear would result in withdrawal of interpersonal and social
interactions. Such intense feeling of fear and worry would lead to depression
and anxiety. Taijin Kyofusho has also been distinguished as a “neurotic”
symptom. In East Asian cultures self-
understanding is where an individual’s perception of himself is an extension of
his social group. In Japan it is consider a virtue if one shows a concern for
others and it is encourage to be obedient, passive and submissive which would
result to concerns of how the person would affect others.
Maeda
(1999) stated that TKS is a compulsive feeling of shame and anxiety which is
common in Japan. People would often bring themselves to the Mental Health
clinics and report that they have Taijin Kyofusho and they want a cure for the
symptoms. However, in order to be diagnosed with KTS the following criteria
must be met:
- Individual
reluctantly avoid interpersonal and social interactions.
- Intense
worrying that she/he may not be able to maintain a healthy relationship
due to shame, anxiety, tense feeling in social situation and
embarrassment.
- Intense feeling of fear that his/her attitude, physical appearance and body functions are inadequate.
Culture
and Body Image: The Japanese Case
Background
Although,
Ryder (2000) states that acculturation, where individuals experience a change
of environment different from their own may alter the individuals’ sense of
self and may have played a significant effect in the development of TKS
syndrome.
Kowner
(2004) also added that ideal self image due to the rampant exposure to Western
Caucasian body ideals as well as the presentation of the ideal body depicted in
Japanese comic figure have influenced
the perspective of self image.
Reality,
Behavior and Cognitive - Behavior Therapy Treatment for individuals suffering
from TKS
Austad
(2009) stated that reality therapy is based on Glasser’s choice theory which
emphasized on the individuals’ personal freedom which means that behavior is
chosen and that one has a total control on how to act and think. Whereas,
behavior therapy is consist of underlying principles that outlines a scientific
approach in assessment, treatment methods, evaluation of treatment outcome, and
the actual application of treatment to everyday life.
Miltenberger
(2008) distinguish behavior as a way people do and say and the occurrences has a great impact to the
environment whether it may be physical or social. Behavior may at times
recognizable or at times it may only be known to the individual who engage in
the behavior.
Therapy
Procedure: Application of Therapy Procedure to individuals suffering from TKS
Austad
(2009) emphasizes that although it is not rational to present a strong sense of
individualism due to cultural diversity it is important that individuals
maintain a healthy interpersonal and social relationship with others across
multicultural difference.
Application
of Treatment
In
the first stage of the treatment procedure, Thomas & Hersen (2010) it is the goal of the therapist to
development a working alliance with the patients, record important details
through observing body language, gestures and verbal cues as well as to
identify the underlying problems. It is also important to discuss clinical formulation
and agreed on an appropriate treatment plan. As a therapist it is best to encourage the client to self – evaluate and
ask significant questions such as:
·
Is the current direction of your life
best for your own interest?
·
Is the cause of fear helping or hurting
you?
·
Is your current situation help or hurt
other people around you?
·
Does your feeling of extreme fear affect
your daily functions?
The
clients will then be asked to identify the underlying cause of fear and the
effect as well as the physiological manifestation. As the therapist it is
important to discuss with the client regarding his/her interests and his
perception on how to enhance quality behavior as well as her level of
commitment and the plan of action.
Therapy
procedure is based on Wubbolding (2000) SAMI2C3 plan:
Simple, Attainable, Measurable, Immediate, Involve, Controlled, Committed,
Consistent.
The
client will describe and identify the antecedents and consequences of his
behavior so that appropriate therapy procedure can be applied. The clients will
be informed about basic principle in behavior and how it will help them change.
Important data and information will be collected and discuss how the treatment
progress and procedure be evaluated to determined the significant factors
affecting the treatment procedure and its outcome (Austad 2009).
Case presentation for individual
suffering from TKS
At
this point the case of Larry is presented as a patient who suffers from Taijin
Kyofusho Syndrome or also known as TKS. The initial assessment shows that Larry
suffers from extreme fear of embarrassing or hurting other people due to what
he thought his body functions, physical appearance and his attitude may cause.
Because of this, he suffers severe feelings of anxiety and depression and has
often experience a series of panic attack in social situation and has severely
affected his day to day function. His cultural background may have contributed
to the cause of the problem. As a child raised in Japan it is perceived rude or
impolite to look people in the eye or show assertive behavior toward others.
Through adolescence he as well suffers humiliation from bullies and parental
neglect due to the fact that both parents are often out of the house to look
for jobs.
Larry
came to seek professional help upon realization that he needs to change his
perception and “survive through his fears” in order to eventually function as
what he considered to be a normal life such as to eventually get a good job,
get married, have a family of his own.
Therapy treatment plan for Larry
who suffers from TKS.
- Assessment
and Formulation:
Larry
identifies the presenting problem which is extreme fear and shyness which made
him to avoid social and personal interactions. He isolates himself which cause
depression and hopelessness.
When
faced with a dilemma, Larry would often experienced feeling restless, tense,
nervousness of expecting the worst to happen, and his mind would suddenly
become blank. He would also experience excessive sweating, his heart pounding
so fast, shortness of air, tremors and extreme head ache.
The
fact that Larry personally decided to seek professional attention is an
indication that he is willing to commit himself in therapy that would change
his behavior.
- Therapeutic
Relationship:
As
a therapist it is noted that an effective treatment environment is based on
assuring Larry of confidentiality which would create an open and honest
interaction. Each session should also be structured so that there is a total
focus on significant factors that would aid the process of recovery. It is also
important to empathize and that a therapist is always willing to listen and
never judge. Open-ended questions are ask so Larry can elaborate on the reasons
that made him seek professional help.
The
goal of each session is to make Larry feel that there is a hope for him to change
and that if he is motivated and committed to a treatment plan his behavior will
change, after all he is the only one who is in control of himself.
- Contract,
Goals and Treatment Plan:
It
is the role of the therapist to guide Larry in order for him to achieve
effective behavior, overcome his fears, and interact with other people without
the feeling of anxiety. As well as let go of the past and move on to become a
better person.
Larry
is also expected to commit to every session and maintain his focus on attaining
his goal.
Larry
will also be guided how to deal with social interactions and expose himself for
just an enough amount of time for the fear to disappear. He will learn to deal
with his fears and anxiety in social situation in order for him to realize that
his presence will not cause harm or embarrassment to others (Hofmann & Otto
2008).
- Techniques:
Larry
is encouraged to involve himself in creating a specific treatment plan that
would best work towards achieving his goal. It is also the goal of the
therapist to help Larry realized that unless he stops blaming his parents, the
bullies in his childhood or his cultural background he cannot be able to move
on. The emphasis is focused on what he can do in the present that would change
his way of life. He is encourage to take social skills training, learn a hobby
that would include social interaction, exercise and join a fitness club and go
on a date.
The
therapist may also consult with a professional image consultant to help Larry
get an assessment and advice on personal appearance and hygiene.
As
a therapist it is important that Larry gains self awareness and confidence by
helping him perceive himself as a competent person.
- Process
of Therapy:
Larry
will be informed that each session will be videotaped to provide a basis of
references whether the therapy is addressing towards the specific problem or it
is leading to the direction of what the goal is.
Larry
is introduced to assertive behavior techniques. Assertive behavior responses
will be developed in hierarchy so he can slowly practice them with the
therapist through role play situation.
Larry
is taught breathing techniques and social skills. He will be introduced to
different social scenario through suggestion and rate his fear from 0 being the
lowest and 10 being the highest. After breathing technique and appropriate
skills has been related to different social situation Larry is slowly
introduced to actual social situation through In Vivo flooding.
Social
challenges will be given and Larry will be guided to be able to generalized one
situation to another. Consequent relief to fear and anxiety is expected as well
as to recognize the use of positive reinforcement.
- Termination
and Outcome:
The
treatment will be considered effective following the result of which Larry can
be able to change from his problematic behavior which is an extreme fear of
hurting and embarrassing others to an adaptive behavior. Larry will be able to
associate positive reinforcement whenever appropriate behavior is successfully
practice in social and interpersonal interactions. There should be an increase
of positive behavior and that Larry’s respond to every treatment is positive.
Towards the termination of the therapy, Larry is expected to display mastery in
social skills learned as well as the effective response to difficult and
challenging situation such as the use of breathing technique and relaxation.
References
American
Psychiatric Association: Diagnostic and Statistical Manual of Mental
Disorders. Fourth Edition, Text Revision, Washington D.C, American
Psychiatric Association, 2000
Austad
C.S. (2009). Counseling and Psychotherapy Today. The McGraw-Hill
Companies Inc.
Choy,
Y.; Schneier F.R.; Heimberg R.G.; Oh K.S.; Liebowitz M.R. (2008). Features
of the offensive subtype of Taijin-Kyofu-sho in us and Korean patients with
DSM-IV social anxiety disorder. Wiley-Liss Inc. 25, 230-240.
Hofmann
S.G. & Otto M.W. (2008). Cognitive Behavioral Therapy for Social Anxiety
Disorder. Routledge Taylor & Francis Group, LLC
Kowner
R. (2004). When ideals are too “far-off” Physical Self-Ideal Discrepancy and
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Maeda
F. & Nathan J.H. (1999). Understanding Taijin Kyofusho through its
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Science Inc. 46, 525-530.
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R.G. (2008). Behavior Modification: Principles and Procedures. Thomson
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