By Brian Robinson.
The problem
Pretty much everyone knows what you have to do to recover from a phobia. For the agoraphobic: you need to get out more, stop avoiding things, there is a world out there just waiting to be rediscovered. For the person with social phobia: you need to stop worrying about what other people think, just be yourself and try to enjoy being around others. For the person with contamination phobia: don’t focus on the germs, good honest dirt never hurt anyone. Leaving aside this cripplingly simplistic view of things, you could still argue that the advice is sound. What this tells us, is we all have a basic understanding of the problem, and we all know what has to change. But how do you accomplish those changes? How do you get from A to B? That’s the real problem.
When talking to people who suffer from phobias, you find the conversations can be very different. You might naturally assume this because of course there are lots of different phobias. A fear of spiders is not the same as a fear of heights. But in fact, the conversations are different for two more fundamental reasons. The first is people are not the same and their reactions to their phobias can be quite different. And the second is that phobias can vary in their essential nature. As well as be different by type, phobias can be weak or strong; simple or complicated; long or short-lived; specific or general.
Dealing with a simple phobia may be reasonably straightforward. You make suggestions as to what the person could do, and you offer guidance as to how they might achieve that. But with the more complex phobias, a more considered approach may be necessary. With these more profound phobias, and where the person’s reaction to them is heightened, the need arises to explore all aspects carefully.
Unfortunately, that leads to a problem regarding putting together a guide. How do you construct practical guidance aimed at all people and all phobias? You can’t. This then, is no more than an attempt to shed some light on some problematic phobias and set out what it might take to overcome them.
Why write this guide?
There are thousands of books in existence aimed at people who suffer from anxiety disorders, so, why write another? Well, if this was going to be one more of the same, it would be difficult to justify. This guide has to be something new, and if that’s the case, then we need to know how it will be different from all the rest. The first thing to say is this is not written from the perspective of a therapist or a sufferer. There will be no suggestion that your phobia is your fault in the sense that you have misinterpreted things and you see danger where there is none. Yes, a misunderstanding has taken place, but it has happened in the phobic mind and is largely an unwitting one. People do not bring phobias on themselves.
And there will be no ‘my story’ dragging you through the misery of what it feels like to suffer from a phobia. The internet is awash with such stories, and they can be misleading and cause considerable discomfort amongst sufferers. The suggestion here will be that all phobias are open to recovery, or are at least open to significant improvement. And the approach will be logical and systematic. This is what a phobia is; this is why it exists, and this is what you have to do to fix it. It will take you step by step through a selection of increasingly tricky phobias and explain what you might be able to do to overcome them. With some phobias, there is a reasonably quick fix. With others, it may take an amount of soul-searching and effort before we can make headway.
How to read this guide
Much of what is written about anxiety can be difficult to digest when reading from cover to cover. And indeed, many of the authors themselves suggest you should dip into what they have to say. This isn’t a dip-into guide. If you have a phobia, there is a logical place to start, and a natural place to finish. Dipping into the middle would be like walking into a movie halfway through. You might get some idea of what’s going on, but you would never get the full picture.
The General Scheme of things
The idea of this section is to set out a few of the things we can say about phobias and how they work. Phobias are not illnesses, they are disorders and there is no real mystery about them. When we become phobic, this does not mean we are under attack from some virus or that an essential part of our inner defence system has broken down. In fact, just the opposite is true. The system in the brain responsible for phobias is doing precisely what it has evolved to do. It becomes active because it believes we are in danger and it is merely attempting to keep us safe.
Somewhere during the development of a phobia, a safety connection is made in the brain. This connection links the idea of danger with the thing or situation being avoided. This connection then sits in the mind and takes responsibility for keeping the person safe and away from danger.
To de-activate this safety system, what we have to do is get the message through that we are not in danger. Where there is no presumption of risk, there can be no phobia. Regarding the possibilities of getting that message across, there is a sense in which everything we do, think or feel, holds the opportunity to pass a ‘no danger’ signal to the brain. After all, everything we do involves the mind in some way or another. And, once that message begins to get through, we can expect the phobia to weaken of its own accord. We do not actually fix anything: the phobia fixes itself. It may take a little time and some work before that happens, but one thing we can say for sure, this system in the brain does not want to be energised. A phobia is a means to an end: it is not an end in itself.
What Causes Phobias?
We are not going to dig too deep into the causes of phobias, but we do need to have some idea of how they come about. Many of us seem to be born with an instinctive fear of one thing or another. That could be a fear of spiders, rats, snakes or heights. We may refer to this fear as a phobia, but in reality, these instinctive fears would not warrant that diagnosis. It is only if the fear gets out of hand and significantly affects our daily life that it might amount to a phobia. In other people, there may be no instinctive fear, yet a phobia still develops. But what causes this fear to get out of hand in the instinctive person? And why would someone get a phobia when they have no instinctive fear?
We know for sure that many phobias develop as a complication of general anxiety or panic. The person is fearful anyway because of their anxiety, and then that somehow leads to a more specific or general phobia being born. Or, it may also be that the person is not suffering from or aware of any general anxiety, but never the less there may be underlying levels of stress which triggers the phobia. Phobias always arise from something. There must be an increasing perception of danger in the brain, or the person must have an increased sense of vulnerability for some reason. And, if general anxiety is one of the main causes, then we have to know a bit about that.
The causes of GAD are the subject of another guide, so we don’t need to go into that in too much detail. All we need to be aware of is what happens in the body as a result of these various causal elements. Fortunately, the answer to that question is simple. General Anxiety is a disorder triggered by high stress or tension levels. When physical tension reaches a certain critical level in the body, fight or flight automatically becomes engaged, and the person becomes anxious. And without getting too complicated, this physical tension is usually fed by high mental tension levels and or high emotional tension.
That sounds a bit too simple to be true, so we need to test that theory. We know, for example, that there is a natural connection between high tension levels and danger. That is self-evident. And in fact, we can say that tension is the natural reaction to a threat. For example, if you were to walk out of Poundstretchers and you found yourself in the path of a gorilla, you would immediately become tense and freeze on the spot. A system in your brain causes that to happen.
The freeze element makes you stop, and that prevents you from getting any closer to the gorilla, and the increased tension in your body acts as a facilitator. This tension allows you to run faster and longer, or it will help you shin up the nearest lamppost. It is only when you realise that the gorilla is a cardboard cut-out, that this system in the brain switches off and tension levels fall. We also know, that when we take benzodiazepines (tranquillisers), that muscular tension reduces and that in turn causes the anxiety to subside. We can be pretty sure then, that high tension levels play a pivotal role in both GAD and phobias.
However, it is also true that a person may recover completely from general anxiety, yet still be left with the phobia. In this person, background tension levels may be low, and they will only become tense and anxious when in the phobic situation. What this tells us, is that high tension levels do not have to be present to maintain a phobia. Phobic connections are maintained by our behaviours, which means by our avoiding the phobic situation.
An important point to learn from this is that it makes no sense to tackle the phobia without also addressing tension levels when they are high, or when anxiety is current. Logically, the anxiety has to be addressed first before we move on to deal with the phobia. However, there is no reason why work on the two endeavours cannot run in parallel to some degree. But, when doing this a balance has to be struck between the two. We wouldn’t want to throw ourselves headlong into dealing with the phobia when at the same time we are feeling very anxious or having frequent panic attacks.
Phobia (a definition)
There will be no attempt here to put forward a clinical definition for a phobia. That is best left to the experts. Besides, we do not know enough of what goes on in the brain to be able to offer a complete understanding. We are still some way off from that. However, we do know enough to get to a general scheme of things. We all have a primitive system in our brain which exists to keep us safe and ensure our survival. The definition of this type of system is twofold. It has to have an agenda, and it has to have the means to pursue it.
There are almost certainly three or more sub-systems in the brain each with set responsibilities with respect to safety. The first is involved with general anxiety and panic. This is the system which initiates the fight or flight response. Fight or flight may be something of a misnomer because it doesn’t make people feel very courageous. A better way to describe it would be as a mechanism more to do with escape. However, it has two main elements. The first is fear and that acts as a spur to action. When we become anxious, we feel we have to do something to escape. The second element is designed to facilitate that escape. This involves the release of stress hormones, which in turn gives us the power and stamina to put distance between ourselves and the threat.
The second sub-system is involved with phobias, and this is responsible for causing phobic reactions. The remit of that system is mainly concerned with avoiding danger as opposed to escaping from it. This system makes a soft-wired connection in the brain which causes the individual to associate certain things or situations with danger. Phobias are all about avoidance or negative action. They are about not doing things. They say: don’t do this; don’t go there, don’t be left alone; avoid tight spaces and so on.
A third sub-system is involved with OCD. This system is an action based system which concentrates on taking action to ensure nothing horrible happens. These actions are compulsions and could involve things like decontamination; making things symmetrical; checking doors and windows and so on. There may be other sub-systems in the brain which have specific responsibilities and can be linked to other disorders involving safety.
The interesting thing about these sub-systems is that they all dovetail quite neatly together to deal with the most vital aspects of safety. They cover escape, avoidance and the prevention of danger.
A defining characteristic of the phobic mind is that there seems to be some partition between it and the rational mind. The phobic side of the brain does not seem to be as aware as the conscious side. It doesn’t seem to be able to reason its way through things. It acts more on instinct, and therefore we have to assume that it is not as evolved as the rational side of our mind.
The phobic mind does have some primitive understanding though. It apparently has an awareness of when the person is stressed, and it has some knowledge of things that could represent a danger. In other words, there is some logic in almost all phobias. However, the phobic understanding of what is happening in the real world is limited. For example, it understands that snakes can be dangerous, and we need to be careful when around them, but it does not seem to be able to tell if snakes are in the room or not. This basic instinctive reasoning and the fact that it is partitioned off from our logical selves are the main reasons why it is difficult for us to deal with our fears and phobias. We cannot just talk ourselves out of a phobia. Pure dialogue just doesn’t seem to work.
Before we move on it’s worth making a couple of points. We shouldn’t be too worried about this idea of connections the brain. These connections are soft-wired, and that means they can be changed. The brain makes and re-makes these connections and there is nothing sinister about them. They act as short-cuts to our understanding of the world around us and the way it works. Making and maintaining these associations is an essential part of how we operate as human beings.
We should also not be too worried about this mention of a partition between our phobic mind and our rational mind. It is helpful to know of its existence, but we should not see it as a barrier. The evidence suggests that through proper communication with the brain we can weaken and perforate these partitions and cause them to change.
Types of phobias
There is an endless number of different types of phobias, and there is nothing to be gained by listing them all here. However, as has been said, phobias are different for reasons other than type, and that is worth knowing. Phobias can vary in essential nature. They can be specific or general; weak or strong; simple or complex, and they can be long or short-lived.
We have already mentioned an example of a weak phobia. This is where the person is born with a phobic tendency such as an innate fear of heights. And we have already spoken about the trend for anxiety sufferers to develop weak phobias which are better seen as phobic traits. These traits are initiated by the brain and are reflective of its concern when fight or flight is engaged. But they tend to dissolve away as the anxiety wanes. With these types of phobias, we have to assume that the connection in the brain is quite weak and not as well defined as with other phobias.
An example of a strong phobia would be, for example, where the person refuses to be left alone and insists that someone is with them at all times. But even with these strong phobias, the strength can vary and their nature can be different. For example, the person may be able to cope with being left alone for short periods of time, or they may only have a fear of being left alone at night.
A specific phobia could be where say the person is afraid of spiders or rats or snakes. And again, even with these phobias, the degree of specificity might vary. For example, the person with a height phobia may only be afraid of certain types of buildings. And even if they had a height phobia, they may be perfectly happy with aircraft travel.
A more general phobia would be something like agoraphobia, where the fear is more about going outside or being away from a safe place rather than anything specific. Again, there may be different characteristics of the phobia. For example, the person may have to be back home at a particular time or before it gets dark. Or the person may be able to make short journeys outside when accompanied by someone else.
An example of a simple but strong phobia could be something like a fear of supermarkets. The person might have experienced a severe panic attack while out shopping and subsequently developed the fear. The logic would be that going back into the shop might cause the sufferer to have another panic attack.
A complex phobia might be something like social phobia. With social phobia, there are often issues relating to self-esteem and the way we are viewed by others. Those extra dimensions tend to complicate things. There may also be interaction problems such as blushing or shaking which further tends to complicate matters.
The Approach
Now we move on to consider how to deal with phobias. It is fair to say that Cognitive Behavioural Therapy is currently seen as the best therapeutic approach to help overcome anxiety disorders. It is a proven therapy, and doctors often refer their patients to CBT therapists.
CBT is a blend of two different therapies, Cognitive Therapy, and Behavioural Therapy. Let’s look at cognitive therapy first. One of the central premises of this therapy is the idea that it is not things that make us feel bad: it is the way we think about things. This is not a new idea, it is an ancient understanding that modern therapists have adopted. There is no doubt that this idea if used appropriately can play a significant role in dealing with anxiety disorders.
However, this idea is also open to misinterpretation and over-complication, and if we’re not careful, we can lose sight of this critical understanding. With phobias, cognitive therapy focuses on the way we think about the phobic situation or object, and it attempts to rationalise that perspective. It assumes we have misinterpreted the level of threat or danger and we need to correct that. The suggestion seems to be that the misinterpretation is mostly a conscious affair.
However, while there is no doubt that the way we see our phobia can become distorted in some way, that is not to say this is always the case. Quite often, the person will have a clear view of what they are doing and they will understand that their phobia is entirely irrational. And indeed, the suggestion here will be that phobias can develop without much conscious input at all from the sufferer. We also have to remember, that all unhealthy thought patterns have the potential to feed into a phobia, and so they too should not be ignored. In dealing with phobias, we would want to relax our thinking in all respects.
Behavioural Therapy takes the view that phobic avoidance behaviours are learned. Avoiding the phobic situation makes us feel better, and we learn that the avoidance keeps us safe. And the therapy goes on to suggest, that the continued avoidance behaviour is what maintains the phobic condition. Eventually, this becomes a vicious circle, and so we have to find a way to unlearn our behaviours if we want to recover.
There is no doubt that there is a real sense in which we learn our phobic behaviours, but the above explanation may sound entirely different from what has already been suggested. Here it has been said that phobias are connections made in the brain and have little to do with learning. Now it may well be that we are playing with words and we are both saying the same thing. No doubt the reader will make their own judgments. However, that still leaves us with some things to clear up.
Although it is true that there is an element of learning in all phobias, it doesn’t explain how they come about in the first place. There must be a reason why the phobic mind becomes involved so we have to address that. In many cases, the phobia develops as a consequence of general anxiety or panic. And where anxiety is current, we would want to deal with both the anxiety and the phobia.
Then there is the question of how does the idea of learned behaviour explain how someone is born with phobic tendencies? How can we say that has been learned? If we are born with a phobic tendency then it must be genetic. Or, if someone develops a phobia as a complication of General Anxiety, how has that been learned? The nature of the phobia may come as a complete surprise to the sufferer, so it is difficult to see how we can describe the new behaviour in this way.
There is also an implication in this theory of learning that suggests an involvement on the part of the sufferer. With this in mind, the sufferer may come to feel they are to blame for their phobia and that wouldn’t be a great place to start a recovery process. No person wittingly brings a phobia on themselves, and therefore, we should never feel we are to blame for them.
What is being suggested here, is that there are elements in several therapies that might be useful in recovering from a phobia. But we have to think carefully about these elements to see how appropriate they are and what they have to offer in terms of how they might help.
There is also a danger of taking too narrow an approach. For example, would it be wise to focus on cognitions and ignore the emotional element of a phobia? After all, we can describe a phobia as an emotional disorder as well as a behavioural one. Or, would it be wise to concentrate on behaviours and abandon relaxation techniques? After all, the argument here is that tension lies at the root of everything.
What this amounts to, is that there are lots of things we can do to try and weaken this phobic connection made in the brain. And we can tackle this on a number of different levels, cognitive, emotional, behavioural, and through relaxation techniques. We could describe this overall approach as a form of communication therapy in the sense that everything we do is a way of learning that we are not in danger.
However, having said all that, there is a therapy which is particularly disposed to treating phobias, and that is Exposure Therapy. This is a form of behavioural therapy which is widely used and considered to be one of the most effective techniques. So, what is Exposure Therapy?
In one sense, Exposure Therapy isn’t a therapy at all. It is just something that happens naturally given the right circumstances. We’ve all watched wildlife programs on TV where a presenter is seen either close up to or amongst wild animals. In some cases, the presenter is even seen interacting with these animals. This state of affairs between humans and animals does not arise naturally, or indeed because the presenter has a particular affinity with nature. This can only happen when the animals have first been desensitised to the presence of human beings. This desensitisation process is something that happens naturally and gradually over a period. The people will get closer and closer to the animals, and because they do not threaten them in any way, the animals will take less and less notice of them and begin to tolerate their presence more and more.
What happens, is a connection in the animal’s brain, i.e. the idea that humans are dangerous, becomes modified and the association with danger weakens and is eventually lost. And then, once the desensitisation process is complete, along comes David Attenborough who is then able to be amongst the animals and interact with them and make his programme. This modifying of a brain connection is known as habituation, and it can work in much the same way in humans. This happens for example when we become desensitised to traffic noise or the noise of aircraft passing overhead. In the end, the sound doesn’t register in our brain and so we don’t feel stressed by it.
There are two essential elements to the habituation process that have to be in place before it works. These are sometimes referred to as ‘in trial habituation’ and ‘between trial habituation’. To understand this, let’s look at an example where a man has developed a supermarket phobia. He had a severe panic attack while in a supermarket, and ever since, he has made the association between supermarkets and danger. Whenever the man enters a supermarket, he gets a phobic reaction and immediately becomes anxious, or indeed, he may become anxious even thinking about going to the supermarket. This is quite disruptive for the body, but his brain is quite happy to create that disruption because it does so in the interests of safety. This phobic reaction then encourages the man to leave the supermarket, and his brain achieves its purpose.
For exposure therapy to work, the first thing the man has to do is to go to the supermarket and resist the urge to leave. And ideally, he should stay there for quite some time. When he does that, he will find that his anxiety levels will fall significantly as time passes. This is known as ‘in trial habituation’. What happens, is his brain lessens the phobic reaction when it becomes clear that the man is not going to react. This makes sense because the brain is not comfortable with maintaining anxiety at such high levels for long periods. However, the brain won’t change the safety connection because of this one-off exposure. It simply makes a temporary adjustment to avoid prolonged disruption. But, this exposure to danger incident will register with the brain and will not necessarily be lost.
With this ‘in trial habituation’, or you could call it ‘in trial desensitisation’, the critical thing to remember is ideally we have to stay in the supermarket until the anxiety begins to diminish to get the best results. This is when the brain learns the most regarding the exposure to the perceived danger. However, although this one-off exposure will have a positive effect on the brain, it won’t count for anything unless it is repeated. This brings us to ‘between trial habituation’.
‘Between trial habituation’ refers to what happens in the brain when the exposure is repeated over and over again. This is central to understanding how exposure therapy works. Think of it this way. A phobic reaction is quite disruptive on the body, but the brain is quite prepared to induce this if it serves the purpose of removing the person from the danger. However, when the exposure is repeated over and over again, the brain is not quite so prepared to put up with this. This is what causes the brain to reconsider matters and change the danger connection. What this means in practice, is the person would have to visit the supermarket several times each week to encourage the brain to become desensitised. In fact, if we were to call this ‘repeated trial desensitisation’ that might reflect better what happens.
With this type of straightforward phobia, there is another crucial point to note. It doesn’t matter what’s going on in the sufferer’s head while in the supermarket. Just like with the animals in the jungle, which are not inwardly agonising over the pros and cons of being around humans, the desensitisation process happens purely with the passing of time. This is a simple phobia, and there is little or no psychological dimension to it. Our sense of reason more or less tells us that supermarkets do not pose a danger, and therefore we can be quite sure that the fear is wholly irrational.
Exposure therapy in the narrowest sense is about placing the phobic person in the dangerous situation repeatedly, and this is done to encourage the brain to reassess matters. In the broadest possible sense, exposure therapy can be seen as any endeavour, behavioural or otherwise, which encourages the brain to make the necessary changes.
This idea of exposure to the danger helps us to see the suggestion of a partition between the phobic mind and the rational mind in a different light. If there is a partition, it doesn’t have to be seen as being permanent or like a brick wall. The brain may not easily be persuaded that there is no danger, but persuasive techniques such as exposure therapy can eventually get the message across that the perceived danger does not exist.
The approach being suggested here is a broad one where people are treated individually; where phobias are not all seen as being the same; where the run-up to phobias is not ignored; and where all therapies can be seen as having something to offer concerning recovery. Now we need to move on to look at some individual phobias and see how we might deal with them.
Dealing with phobias
It has already been hinted, that the way forward with all phobias is not quite as straightforward as our man in the supermarket. When he does his exposure by sitting in the shop, there is little or no psychological element. He doesn’t believe that supermarkets are dangerous places. He has a fear of them, but he knows that fear is entirely irrational. However, suppose our sufferer had been involved in a supermarket fire, and it was this that led to the phobia. At the time he panicked but managed to escape, and this left him with profound fear. Now, all of a sudden the phobia has a psychological dimension. The man has not misinterpreted the situation, and the fear is not wholly irrational.
So we have to ask, how would exposure therapy work with this individual? Would it be as simple as repeated visits to the supermarket? Or, would we also have to deal with the psychological element. And if that is the case, which would come first, going to the supermarket, or dealing with the real risk of fire?
In this new example, the phobia was experience based and experience is a big thing for the phobic mind. It was by living through the fire that the phobia was born in the first place. And it is highly likely then, that this experience will to some degree stand in the way of straightforward exposure therapy. The logical way forward then, would be to deal with the psychological element first, and in this case, that would involve getting back to a more accurate perspective of the risks involved in going into a supermarket. Indeed, we could argue, that his perception of supermarkets before the phobia was where the misinterpretation lay. He believed supermarkets were safe, whereas now his experience suggests otherwise.
Now let’s look at what this reassessment of supermarkets might involve. Just saying to yourself that they are not dangerous repeatedly doesn’t seem to work. The assessment needs to be more of a process than mere dialogue, so we need to know how that might look. There is no real formula for this, but it would involve some form of analysis; asking lots of questions; drawing some conclusions and making some decisions. The man might research the real risk of a fire in supermarkets by looking at the evidence. He might conclude that such occurrences are rare and that he was very unlucky to be involved in one. He then has to decide whether or not to return to the supermarket. Once that decision has been made, he is then ready to undergo the exposure work. This is just a snapshot of what a process might look like. In reality, it would take some time to work through the analysis before being able to reach conclusions and make decisions.
In this example, however, the work on the psychological element becomes part of the desensitisation process, and in fact, paves the way for the actual exposure. This process of analysis is critical. Often things go around and around in our heads without leading anywhere. So, the evaluation has to be thorough taking into account all the crucial elements. And the conclusions should flow naturally from our analysis and be founded in reason. And likewise, the decisions should be informed ones with which we can feel comfortable. Without these elements: asking the right questions; drawing the right conclusions; and making the right decisions, the process is at risk of failure.
We can learn several things from this example as to how the brain works. Firstly, where there is a psychological element to the phobia, that element has to be addressed. And logically, that should be the first port of call. Secondly, although there seems to be a partition between the phobic mind and the rational mind, a proper evaluation of things can have the potential to relax matters. And thirdly, even after the psychological element is dealt with, there still needs to be the actual exposure to seal the deal. However, the chances are that when the man comes to the actual exposure in the supermarket, he will experience less of a phobic reaction as the desensitisation process has already begun.
We should also bear in mind the role of inner disruption caused by the repeated exposure to danger. It is this internal and repeated disruption that applies pressure on the brain and gives it the incentive to make the necessary changes. I’m not keen on the term ‘facing the fear’, but in the case of all phobias, that is precisely what has to happen. If the sufferer doesn’t feel anxiety and discomfort at some level during the trial, then this is not habituation, and nothing will change.
The supermarket example was for illustration purposes only. It is not being suggested that this is precisely how exposure should be tackled. In this example, we paid little attention to the sensitivities of the sufferer. We’ve simply dumped him in the place of danger and waited for habituation to take place. This is referred to as flooding. Flooding, we could argue, is often more about the time limitations of the therapist, and less about the sensitivities of the sufferer. Exposure therapy doesn’t have to be organised in that way.
A better approach would be to use a far more progressive system of exposure where the sufferer is not thrown in at the deep end. This is sometimes referred to as a Hierarchy of Steps or Gradual Exposure. The sufferer sets out a series of manageable steps where he gradually gets closer and closer to the supermarket. Or it could be that he only stays in the place of danger for a short period to begin with, and then gradually works towards staying there longer and longer. Or, he could go to the shop accompanied by someone for support. You don’t necessarily have to march into the supermarket and plant yourself in its innermost recesses. If going to the shop’s car park makes you feel uncomfortable, then that’s a good enough place to start.
But you should also be aware, that the gentler the approach, the longer it will take for the brain to change things. However, we have to be realistic about who we are and what level of disruption we can tolerate. For example, with the animals in the jungle analogy, if you marched straight into their group they would just run away and desensitisation would never happen. Our supermarket example would be equivalent to capturing a group of gorillas and forcing them to stay in a cage with humans milling around them. That wouldn’t be a great way to start off a wildlife programme. So, there is no right way to do this: there is only the way that suits you and that you can manage.
Even though we made this example of a supermarket phobia more complicated, the psychological element wasn’t that difficult to deal with. Fires in supermarkets are rare events, and people being killed or injured in those fires are even more unusual. And so, the sufferer was easily able to decide to go back to his shopping. There are three things to bear in mind with this example, firstly, the risks were minuscule. Secondly, the sufferer was largely in control of what he was doing. He could escape from the shop if he felt he had to. And thirdly, the exposure was voluntary. With some phobias, the risks are higher; there is far less control, and there may be fewer options as to how to gradually become exposed to the danger.
Flying phobia
It has already been mentioned that dealing with any general anxiety or any underlying tension is the logical place to start when dealing with a phobia. It is after all, only from these states of affairs that phobias emerge in the first place. And you would not want to undergo exposure therapy, without first initiating a program of relaxation. This would provide the ideal background for exposure and the perfect background for any psychological work. Recovering from anxiety is another book, but the whole idea of any relaxation program would be to create a relaxed inner environment in which fight or flight cannot exist. This would undoubtedly involve managing thought patterns; managing emotions; managing stress etc. And all with a view of bringing down overall tension levels.
When dealing with phobias, it is challenging for the sufferer to believe they can recover. A therapist can’t say ‘believe in me and believe in the process’. This is just more dialogue. However, the idea of trust turns out to be a good substitute for belief. Trusting is far less complicated than believing. A belief has to aim at the truth, whereas trust does not need a foundation in truth. Trust is a gift we can give to the therapist; give to our self, and give to the process. We may not wholly believe what our sense of reason is telling us, but we should never stop trusting in our ability to reason our way through things.
Suppose the person we’re talking about now has a flying phobia? What is different and perhaps more complicated about that? The first thing to say is it’s not obvious how we can organise a program of exposure. We can’t get the person onto a flight every day. That just wouldn’t be practical. But because exposure therapy seems to work so well, and because it works in such an uncomplicated way, we wouldn’t want to abandon it altogether. There may be a way of getting around the fact that we cannot fly frequently.
The second thing is that with a flying phobia there is a distinct psychological element in a similar way as with the man caught up in a supermarket fire. Phobias are all about avoiding risky situations, and we could never argue in honesty, that there are no risks involved in flying. A higher element of risk is present, and we have to find a way to get around that.
And thirdly, flying in an aeroplane involves giving up pretty much all control. We hand over that control to the airline, the pilot and the crew. The phobic mind is not very keen on giving up control. It takes the view, perhaps not unsurprisingly, that where it is less in control: there will be more risk.
The first thing to say is we are not trying to remove the psychological element from the equation altogether. We are not trying to brainwash the person into believing there are no risks in flying. What we would want to happen, is for the person to have a more realistic view of the real dangers and subsequently become more relaxed about the idea of travel by plane. Yes, it makes things more difficult, and the same would be true of the animals in the jungle. If they had experienced ill-treatment by humans, for example, they would be far less likely to submit to the desensitisation process. However, I hope we have established that there is a psychological pathway to desensitisation as well as an experienced based one.
A fear of flying can be described more as a mindset as opposed to a simple fear. In other words, there are several issues involved, and this will inevitably mean a bit more processing. However, the same rules apply as with the supermarket example. Recovery involves putting matters through a proper process of analysis; drawing some realistic conclusions about the risks, and making some decisions based on those conclusions. Before we do that, let’s consider what a mindset could involve.
As the term implies, a mindset is not just one thing it is a set of things. In the broadest sense, it will involve our overall outlook. Is it positive or negative? Are we optimists or pessimists? Are we subjective or objective? Are we rationally driven or emotionally motivated? It will also involve things like beliefs, perceptions and understandings. Has our view of things become distorted in some way? Have our beliefs become skewed away from reality? These cover a whole host of issues which might involve the way we see our self; the way we see existence; the way we see our past, the way we see the world and so on.
It can also involve things like expectation, standards and attitude. For example, suppose we adopt the view that no matter what we do about any perceived risk, at the end of the day, we are fated. In other words, when our number comes up, that’s when the end will come regardless of what we are doing at the time. Is this a view which we could add to our mindset? And if we did, would it make us feel better as we go up the steps to the plane?
The idea here is not to go through an in-depth analysis to solve the problem. That is something sufferers have to do for themselves. However, a rough idea of what the process could look like might be helpful. Any analysis automatically involves asking lots of questions and sometimes it’s a good idea to start with some basic ones. For example, we need to have thought seriously about why we want to fly and have made a decision about that. This might involve two decisions, i.e. that we want to fly; and that we are determined to do everything we can to achieve that goal. These decisions about flying will act as the driving force behind the analysis. But remember, deciding you want to fly, is not the same as choosing to fly. That comes at the end of the process.
The next logical step would be to assess the actual risks involved. All the figures regarding the safety of flying are out there, but just to give you some idea, a fully booked jumbo jet would have to crash every day to equal the deaths by car in the US. And travelling by train, which is an extremely safe way to go, is still ten times more dangerous than air travel. This is the strange thing about phobias, they always ignore the reality: and they always exaggerate the risk.
The other reason why we see aircraft travel as being dangerous is that we have to give up control to fly. We place ourselves in the hands of the pilots and the airworthiness of the plane. But if we compare this to driving a car, we can ask: how many cars have dual controls with two trained pilots at the wheel; how many cars go through the strict testing and maintenance regimes that aircraft do? The reality is, sometimes it is safer to give up control and the safety record of air travel proves that to be so.
There is another feature of flying which makes it more complicated. There is a common perception that when a plane crashes, this almost always means there will be no survivors. We believe it is usually catastrophic. The phobic mind perceives this as an added threat or an increased risk. This is in contrast to a car crash, for example, where the perception is that people often survive. This is, in fact, a false perception and has no relevance when calculating the actual risks. This would be a bit like saying that sky-diving is riskier than horse riding. When in fact, far more people are killed or injured by falling from a horse than are when a parachute fails to open. We take this view because of the catastrophic nature of parachutes failing and planes crashing. However, this is not the way risks are calculated. They are assessed by looking at the statistics involved in various activities and using those statistics to make comparisons. The plain fact is, there is no such thing as a risk-free existence. We are all at risk in many ways, but these risks are so low that most of the time we don’t even consider them. We need to accept the truth of this and realise that all we can do is manage the risks sensibly.
We’ve already said that making a simple statement about the risks of flying in your head is not the same as reviewing the evidence and coming to a considered view of things. Conclusions and decisions are the things that have the power to change our mindset. However, even though we apply logic, we shouldn’t expect our phobic mind to be fully persuaded. We have to be sensible about what this application of reason is likely to achieve. It is unrealistic to hope to be able to convince our brain completely that there is little or no danger in flying. Anxiety changes our perception of things and this is a characteristic of phobia. While the phobia exists, the risks will always be exaggerated to some extent. If they weren’t, we wouldn’t have a phobia. But our phobic mind might be partially persuaded, and at least the real dangers of flying will be more evident and at the forefront of our thoughts. Reason may not be sitting at the table: but our assessment of the actual risks will at least allow it into the room.
Drawing realistic conclusions about flying is straightforward in theory. The evidence is out there, and it is refutable. And, once we’ve done all the psychological processing, this is when we are in a better position to make a final and considered decision about flying. If you had a child, and they were thinking about going down to Spain from the UK but weren’t sure about the safest way to travel, then I hope we would advise them that the safest thing would be for them to fly rather than drive. And when we finally decide to fly, it should be for the right reasons, that it is quicker, safer and the most convenient way to travel.
The other thing to bear in mind, even after we’ve made our decision, is that a large number of people without phobias are still not entirely comfortable with flying. And this is true for more or less the same reasons that lie behind the phobia. What that tells us, is that we too may never become wholly switched off when we get onto a plane. There may always be a small amount of apprehension. However, if we were to fly several times every week, we would probably end up regarding air travel more or less in the same as we see driving a car. We may even come to view flying as something which spices up life. After all, some people deliberately expose themselves to increased levels of risk and get a buzz from doing just that. I’m not suggesting that’s what we should do. I am suggesting we need to see flying for what it is, something that is safe and where the real risks are low.
There is another point to emphasise when dealing with phobias. These phobic connections in the brain are quite pliable and plastic. They are not merely on/off as in a light switch. They can strengthen or weaken and this, in turn, will have a direct bearing on the intensity of the phobia. Any and all effort we put into dealing with our fear of flying will affect the phobia.
Let’s sum up what we have been doing so far: we’ve dealt with any underlying anxiety, and tension levels have reduced. We have a clear perspective of all the issues relating to flying, and we hold these in the forefront of our thinking. Now we can turn our attention to the more straightforward exposure therapy process.
It has been mentioned previously, that when it comes to the more complicated phobias such as flying phobia, we may have to be a bit more imaginative when it comes to putting together a programme of exposure. And fortunately for us, there is more than one way to encourage the brain to become desensitized. There are three types of exposure therapy. There is actual exposure. That’s what we’ve been talking about so far. But there is also imagined exposure and interoceptive exposure.
A straightforward example of actual exposure would be our man in the supermarket. The person is placed in the dangerous situation, and we have already made the point that actual exposure doesn’t have to be in at the deep end. It could mean, for example, just getting closer and closer to the supermarket. Proximity is a significant factor in most phobias, and in our flying case, there may be ways in which we can get closer to flying or to an aeroplane. The definition of actual exposure then is any physical activity or behaviour which brings the person closer to the danger and causes the person to become anxious or at least very uncomfortable.
In the case of our flying phobia, this could mean packing a suitcase or looking through holiday brochures. Or it might mean watching videos of planes flying or going to an airport and getting up close and personal with planes. Many airlines have programmes where people can try and become desensitised to aeroplanes by being in them without flying. If any of these activities make you feel uncomfortable. Then you should do them repeatedly until the reaction diminishes and this will serve to weaken the phobia.
Imagined exposure is where you imagine yourself to be in the dangerous situation. You create scenarios in your mind where you place yourself in the supermarket or on the plane. And the idea is that a part of your brain will see the scenario as being real and react to it. This reaction will make you feel anxious and repeated imaginings will again begin to weaken the phobia. There is a therapy called Situation Inoculation Therapy or SIT, and this works in much the same way. Through creating the flying scenarios in the mind, the person becomes inoculated against the fear of flying. This type of exposure is particularly useful, where we have already said, it is impractical to place the person in the dangerous situation.
Interoceptive exposure could be used where the sufferer had a phobia of the internal symptoms caused by GAD. The person may develop a phobic reaction to heart palpitations for example. Interoceptive exposure would be where the person attempts to make their heart beat faster say through vigorous exercise. This would be done to try and replicate the symptoms they fear the most. The idea being, that when we experience these symptoms repeatedly, we naturally become less sensitive to them. The other factor in this type of exposure is that symptoms become less fearful when we know precisely how they come about. When they arise from exercise, we can see that they are not meaningful and we don’t need to give them too much attention. The same applies to symptoms generated by anxiety or a phobic reaction.
Once we’ve decided to fly, it’s essential for the person to manage things in the run-up to the air travel. Typically, a sufferer will ruminate over their forthcoming flight and go through all sorts of scenarios involving terrible outcomes. They may return to their decision to fly again and again with increasing doubts. This will inevitably build up tension about the anticipated event and this will not help matters.
Once the decision has been made to fly, we have to apply as much control to our thought patterns as we can. The most basic method of thought control is blocking and distracting away from these troublesome thoughts. Blocking could be where you bring to mind an arresting image. This could be a policeman with his hand held up saying stop. This alerts you to the unhealthy thought trend, and you can then distract away.
Distracting would be where you turn your attention to some physical or mental activity to take your mind away from flying. You could plan something in your mind or do a visualisation. Or, you could turn your attention to doing a crossword or playing a game on your phone.
Another idea might be to try to keep your thinking in set modes. Women are usually good at doing this. They can switch from being a wife to a cook to a mother to their career etc. You can see flying in the same way. Once you’ve decided to fly, you can move into anticipation mode where you plan your activities for the forthcoming holiday. Being strict about modes of thought and developing the mental agility to switch between modes can be a helpful strategy.
This then is what it takes to deal with a flying phobia. We need a programme of tension reduction; trust in your ability to reason; a detailed risk-analysis drawing the right conclusions and making the right decisions. We need a willingness to adopt a more accepting attitude towards things like risk, uncertainty and loss of control. We need to use actual and imagined exposure to further the desensitisation process. We have to try and control our thought patterns in the run-up to the flight. And if you’ve done all that, then when you walk up the steps to that plane you will do so with a different mindset. And in theory, your phobic connection/reaction should be far weaker.
We now ought to ask what is likely to happen when this person finally gets on the plane. Well, as we said, if we’ve got the theory right, then we would expect less of a phobic reaction, and we would expect the person to be a bit more relaxed about things. We can’t be exactly sure about how things will go on the first flight, but whatever happens, it is likely that the person will deal with things a whole lot better. The brain will certainly be paying close attention to proceedings, and when the flight goes according to plan, this will further reinforce the new perception of flying, and that too will play a part in relaxing the phobia. You may still feel like you want to give a round of applause when the plane eventually lands, but hopefully, the experience will have been better and far less traumatic.
So, what are the things to remember from this example? Firstly, there has been no single approach to solving the problem. We’ve had to look carefully at exposure therapy and ask how it will work for us. We’ve had to put reason in charge of matters and encouraged it to become more dominant. We have deconstructed this particular phobia and tried to address each element. And we have done all this to develop a mindset which is more conducive to flying.
Perhaps we should also ask what we shouldn’t be doing in trying to solve the phobia. There is no doubt that facing the fear in some way or another will be an inevitable part of recovery. Unfortunately, there is no escape from that. But what we learn from exposure therapy is that it has to be done in a certain way. Toughing it out; taking a sedative before flying; travelling with a companion; or using sheer willpower; all may be something we can admire in people for their sheer determination. And indeed, these strategies may well get you from A to B. But they are essentially coping techniques; enabling strategies, they are not necessarily recovery strategies. To recover correctly, we need to get on the plane with that new mindset having made the necessary psychological changes. Then we might begin to enjoy the flight; begin to enjoy the risks.
Health Phobia
Many people who suffer from general anxiety also develop worries about their health. The tendency for these worries to emerge is a common characteristic of GAD and panic. When this happens, this could be no more than raised concerns as an offshoot from general anxiety. Or on the other hand, it could be that the person has developed a health phobia.
As with other phobias, when we become anxious, a system in the brain becomes partially aroused. This system believes something has gone wrong and begins to look for problems. More often than not, our brain gets the idea that something has gone wrong inside. General anxiety often brings with it a variety of physical symptoms, so it should come as no surprise that the brain jumps to that conclusion. This increased concern may mean that thoughts regarding health become a significant feature of our thinking, and we may feel forced to act on those concerns to some extent. However, this would only merit a diagnosis of health anxiety or health phobia if it begins to take over and get in the way of everyday life. Quite often, this increased concern tends to dissolve away as the general anxiety wanes and tension levels fall.
When someone has health concerns, they may be presenting to their doctor insisting on more and more tests, or they may be turning up at accident and emergency on a regular basis. Quite often, the concerns are general and wide-ranging, and they are not directed at any specific issue. Worry at this level would naturally impinge on normal life and would merit a diagnosis of health anxiety.
If someone had a specific health concern, for example, if they worry only about their heart or lungs, then this would probably be referred to as a health phobia. Whenever their heart beats faster, they get a phobic reaction, and this may be quite acute. These specific concerns sometimes defy logic. On the one hand, the person may be suffering from a severe illness, yet they do not worry unduly about that, but on the other hand, some other trivial symptom may be enough to send them into a tailspin.
Generally speaking, a health phobia is something more complicated than our previous examples, and there are obvious reasons why that’s so. We can’t just abandon concerns for our health or chose to ignore symptoms. In that sense, a health phobia can sometimes mean we feel in the grip of the phobia with no apparent means of escape. You can’t walk away from your health like the man in the supermarket example can. We may feel that our only option is repeated visits to the doctor or hospital and the subsequent repeated tests.
Exposure therapy doesn’t seem to offer a distinct way out either. No therapist can guarantee a sufferer that their symptoms are not caused solely by anxiety and not by a real condition. And no therapist can insist that the sufferer should not visit their doctor when they have symptoms. We can’t just ignore symptoms and abandon our concern for health in the hope our brain will somehow change the unhelpful connection. If we take the theory of exposure therapy literally, that would mean taking real risks with our health.
It is also true that the risks to health are known to be far more significant than say the dangers of flying. People do fall ill, and of course, we all eventually die. We are all open to those risks, and it makes good sense to be aware of them. Let’s not dwell on that too much for now, even though it represents the truth of the matter.
A health phobia may be different from other phobias in several ways. This serves to complicate things so it might need a bit more analysis than say a flying phobia. Let’s go over again why a health phobia might develop in the first place. This is most often a progression as follows: the person becomes anxious or panicky due to fight or flight being aroused; a system in the brain becomes active; it casts around for the source of the danger, and it comes up with the idea that something must be wrong inside, we must be ill. This conclusion seems to be reinforced by the fact that the anxiety sufferer is usually experiencing real symptoms, and as we know, real symptoms are often an indicator of illness. There is no mystery then, as to why the brain has become involved, and as to why it has picked on health as the possible source of the danger.
You would think, however, that the brain would soon become aware that it has jumped to a rather hasty conclusion and dismiss this idea of ill health. But as mentioned previously, there seems to be some logic bypass at play here. The phobic mind is not in touch with other realities that exist in the body, and this seems to preclude any further rationalisation on the subject.
Before we move on to suggest how we might tackle this, we ought to be clear in our minds about what is being avoided. Avoidance behaviour is usually about not doing something, not going out, not being left alone, not going into tight spaces etc. However, with a health phobia, the opposite seems to be true. The person usually takes positive action by making frequent visits to the doctor, or they may spend hours trawling the internet trying to understand their symptoms. So the question is, what is being avoided here? The answer is they are avoiding risk. By continually checking symptoms; seeking reassurances; presenting to doctors; and getting test after test, the sufferer believes they are reducing or minimising the risks of becoming seriously ill. We should also mention, that a health phobia can involve more conventional types of avoidance, for example, the sufferer may begin to avoid things that might induce symptoms. This could be like avoiding physical exercise or avoiding stimulants such as caffeine for example.
Our ultimate goal regarding dealing with a health phobia would be to normalise our response to health concerns and symptoms, and this again would involve some analysis. We would want to try and ask the right questions. Are the symptoms serious? Is there evidence that I might have this or that condition and so on? We would then be able to draw some conclusions and make some decisions as to how we should act. These conclusions, even though they may be provisional, are essential and have the potential to relax our minds and the same is true of the decisions we make.
When we’re trying to find the answer to a difficult question such as how do you manage a concern for your health, it can sometimes be helpful to look at extremes of behaviour and see how we feel about them. For example, we could ask, how we would feel about finding a significant lump somewhere on our body and doing nothing about it. Would that make us feel apprehensive? Would that be a sensible way forward? On the other hand, we could also ask, how would you feel about presenting at accident and emergency so many times that you are on first name terms with all the consultants there? It should be fairly obvious to most of us that either extreme of behaviour would not be useful strategies for maintaining good health. What this reminds us of, is that we have to find a middle way, a balanced response to our health concerns.
It is not possible to set out here what amounts to a balanced response. The subject of health is too complicated and the symptoms too various for that. But it is possible for the sufferer to try and rediscover what might be a reasonable response. We could ask trusted friends or a family member what they would do if they had your symptoms; if they were in your position. There is also expert advice available on the internet which suggests how we should react to various symptoms. If the symptoms are minor, the advice may be to ignore them. Or we might decide to wait and see if the symptoms persist before acting on them. And if we have already spoken to a doctor and been checked or tested, then we might decide not to re-visit. These responses, which we might describe as normal, will almost certainly leave us feeling anxious and at risk. However, in acting this way we are not taking any real risks with our health. We are only dealing with the exaggerated risks, which in fact are not risks at all. And by doing so, these normal responses will feed into the desensitisation process and have a positive effect on our phobia.
So, to recap, we know that dealing with any underlying anxiety is likely to have a direct effect on the phobia. Secondly, trying to take a balanced view of health concerns and symptoms, and trying to act in line with those, will in itself be a form of exposure therapy. And in all this, our sense of reason should serve as our guide. But is there anything else we can do?
If we are to become psychologically relaxed about our health, then we ought to have a settled idea of what it takes to maintain good health. We already know that how we interpret and act on symptoms is fundamental. And conversely, it is also true that acting inappropriately with symptoms isn’t a good idea either. This can lead to over-testing, and no amount of checks can ever guarantee continued good health. Repeated checking and visits to the doctor only serve to maintain the phobia. In extreme cases, visiting doctors repeatedly does nothing to foster good relations with our healthcare professionals. And even if you had a full body scan today, how can you be sure that something won’t develop tomorrow or in a month’s time?
Maintaining a healthy lifestyle is also essential for good health. Are we eating healthily and maintaining a good body weight? Are we smoking or drinking too much? Do we keep reasonably fit and lead active lives? Do we manage stress well? Do we have an outlet for our creativity? Do we do things that are interesting and make us happy? Do we have a wide-ranging focus across all the things that make life worthwhile? There are two ways these questions could go. If we’re already doing all the right things, then we could bring this to the forefront of our thinking and take comfort from that. And if we’re doing too much of the wrong things, then we could see that as scope for work to be done.
Behaviours are always relevant when it comes to phobias. Our behaviours are a crucial part of how we communicate with the brain. Unhealthy behaviours would be things like continually talking about your symptoms; endless research on the internet; attempting to diagnose yourself; abandoning exercise because you think you are too ill; excessive avoidance of caffeine or other stimulants; constantly seeking reassurance. These are the behaviours that reinforce the idea that something is wrong and that we are right to be overly focused on our health.
An excellent way to help switch from this unhealthy focus would be to come up with relaxing statements which reflect the outcome of our analysis. Examples of these would be as follows: I am doing everything I need to do to maintain good health. I do not ignore symptoms; I try to listen to them and respond appropriately. And even if I did become ill, there has never been a better time for that to happen. Medicine has advanced by leaps and bounds over recent decades. These types of statements are an excellent way to seal the process of deciding the best way to manage health.
And accepting the realities of what we realistically can and cannot do about our wellbeing is an excellent end-position to adopt. Realising this in itself can have a relaxing effect.
Social Phobia
The phobias we’ve been looking at so far have been getting increasingly complicated. That is true in the sense that dealing with them means doing more things and not just one thing. However, even though that is true, we should remember that all phobias are fundamentally the same. They all involve a connection made in the brain; they all have one imperative namely to keep us safe; they all have to resources to follow their agenda, and they are all open to being changed. That is the theory being pursued here.
Social phobias can be even more complicated, but that is not always the case. But before we get into that, let’s ask the question what is the sense behind a social phobia? Why would the brain fix on being around people as being a situation involving danger? You might argue for example, that there is safety in numbers, and that would go against the idea that it’s dangerous to be in a crowd. However, as we’ve already mentioned, this system in the brain is not very evolved and to understand it we have to apply Stone Age logic. That logic might suggest that it is only safe to be with other people if they belong to the same grouping or tribe. Or indeed, there might be a danger if you felt you were somehow different from the other members of your tribe or were in some way alienated from them. And let’s not forget, there doesn’t have to be much logic in a phobia.
The other element of danger involved with social situations applies when you stick your head above the parapet. When you become noticed, or you become the centre of attention, there is a risk that the focus on you may be hostile. It is far safer to keep a low profile and stay away from the crowd or hidden in the crowd. When you remain silent and stay out of the way, you are far less likely to annoy or anger others.
The term Social Phobia is another example of a blanket label, but it can present in a variety of different ways. For example, some people become anxious by merely being in or near a crowd or in a situation where there are lots of people. This could be in a cinema or shopping precinct. Or it may be that the sufferer becomes anxious when someone gets too close to them and enters their personal space. The phobic person may tend to avoid these situations in an attempt to control their anxiety.
If the only triggering element is proximity, and no other considerations are involved, then in theory, there is no reason to suggest that simple exposure would not work. The more the person places themselves in the social situation, the less of a problem it becomes and this is so because exposure therapy works consistently well when the phobia is simple. However, the reality seems to be that there are few cases where there is no problematic thoughts relating to the phobia. It’s almost never, that it’s just a proximity thing. If that were the case, it would be better described as a proximity phobia rather than a social phobia.
With social phobia, the reality seems to be that exposure therapy doesn’t work. No matter how many times the person enters the social situation the phobic reaction is always the same. Nothing seems to change. That seems to defy much of what has been said about exposure therapy, and we have to ask why that is. We have to understand what is different about social phobia.
There are three fundamental differences. With social phobia, most sufferers enter the social situation bearing the burden of a problem relating to ‘self’. The person might feel they perform poorly in social situations; they may be very shy or self-conscious; they may have low self-esteem; they may have little or no self-confidence, or they may feel inadequate in some way. There will always be something about them which sets them apart and lesser from the others in the social situation. There is always a reason why they don’t fit in or why they might stand out.
A second significant difference is that there is always an element of ‘the others’ with social phobia. That is self-evident of course, but none the less it lies at the very heart of things. The sufferer may feel threatened by the others; they may think that other people will discover their fundamental flaw or innermost secret; they may feel they are being judged by them, or they may believe their presence makes other people feel uncomfortable in some way.
Then there is a third essential difference, and that relates to interactions between self and others. The phobic person may blush in social situations; they may begin to blink or twitch; they may start to sweat and act as if on edge; or they may think that they make others feel uncomfortable and they make them begin to blink, twitch or swallow. These interaction problems serve to make the phobic situation even more problematic and challenging.
The person with the supermarket phobia has none of these extra elements. And so, if we are to deal with social phobia, that must involve dealing with these additional issues. However, it goes without saying, that solving these types of problems will take some time and effort. Working away from a socially phobic mindset is not something that happens overnight. It’s something we have to chip away at, and the only way to move a mountain is a shovelful at a time. And even when we make progress with the changes, we have to allow time for the new mindset to bed in.
So, what then is the way forward? Again, it has to be emphasised that there is only one place to start. We have to address any existing anxiety. Anxiety, phobias and panic can all be bound up together. And it makes no sense to deal with the phobia while ignoring its cause. With that in mind, we would want the person to initiate a proper programme of relaxation coping with stress and tension on all fronts.
Problems relating to confidence and self-esteem are common amongst anxiety sufferers. And there is much information in the public domain as to how we might deal with those issues. Some people argue that we should learn to love ourselves. A better suggestion would be to get to know ourselves. To feel comfortable in a social situation, we ideally should have a clear view of our strengths and weaknesses; we should be aware of our talents and qualities, and we should know the principles we’ve adopted and the values we hold dear. These are the things that lie at our core selves and allow us to become more relaxed about who we are. And the only way to arrive at a settled view of who we are is to ask the difficult questions of self. Sometimes involving others like friends and family can help. It’s a good idea to know what others think about us, and this will help towards a more objective view of who we are. And perhaps we should also mention, that if we come across things which we feel may let us down, then we can always try to make the necessary changes.
Many people who suffer in social situations will have a distorted view of the way other people see and react to them. They may feel they are likely to be harshly judged; they may believe they make others feel uncomfortable; they may feel that others will see them as being inferior or unworthy, or they may feel that they will not be loved or admired by the other person.
To overcome this, we cannot just say we shouldn’t care about what other people think. That would be taking things too far. We can say, however, that we should care less about the supposed levels of disapproval in others and be less sensitive to what may or may not be going on in their minds. This means we have to change our attitude to others and not try to get inside their heads.
Our expectations of others should also be realistic. No matter who we are or what we stand for, the odds are we will not be universally loved. It is not what others think that counts: it is who we are and how we conduct ourselves regarding being respectful and fair to others that is important. If others have a problem with who we are then that’s their problem. It is not a problem we have to take on ourselves.
What then can we do about the interaction problems like blushing or twitching? The first thing to say is these are not things you can switch on or off or escape from in the way we would like. We have to be realistic and accept that. And indeed, they are also not the obvious place to start when trying to deal with social phobia. However, there may be some things we can do that might help. We could, for example, be a bit more open about our phobia. We could tell others that we have a bit of social phobia and that might explain why we may look a bit uncomfortable when around others. Sometimes having a distraction like a newspaper or a phone handy can help switch the focus away from the people around us. When in the company of another person, it may help to be doing something together like a crossword or a word puzzle. This can help take away the emphasis from having to keep the conversation going. These are only a few ideas, but there will always be other things you can do to help. Never forget, that being yourself is the best way to react when in the company of others. Trying to be something you’re not, is bound to be fraught with difficulties.
So, where does this leave us? Social phobias can be a bit tricky, and the things we need to change can’t be undone overnight. Making the necessary adjustments will take time and there will be work involved in that process. But if we have a clear and positive view of self, this can act as a defence shield when in social situations. If we have a realistic view of others and care less about them, and if we don’t expect too much from them and don’t try and to get inside their heads. Then the chances are that these interaction problems will become less and less of a feature and we will begin to relax in the presence of others.
Summary
What has emerged from our survey is that dealing with any underlying anxiety is where everything starts. Lowered tension levels create the best possible background when getting to grips with a phobia. This is the environment we want to establish in the body, and this is the environment that is less conducive to all forms of anxiety. Tension levels may rise when in the phobic situation, but they will increase from a lower starting point, and that will make a difference.
Phobias themselves can be entirely different, especially regarding how we deal with them. Simple behavioural methods of exposure may not always produce the required results. Changing the way we think about things comes more into play the more complex the phobias. However, we can be optimistic about dealing with them. Our brain does not want a phobic state of affairs to exist. It exists only because danger is perceived.
A predominately psychological approach to a phobia works in an entirely different way to a behavioural one. It sets out to build a calm and positive mindset with each step of that process resolving part of the problem. And when the point of exposure to the phobic situation arrives, when you come to make your speech, for example, you will do so with the benefit of a different mindset; with a different view of who you are; and a different view of what matters. There may still be a phobic reaction, but the likelihood is it will be less intense and shorter lived. The actual exposure works more to reinforce and consolidate the new perspective.
One positive thing we can say about a predominately psychological approach is that although the changes in mindset may be difficult to accomplish, the actual process of changing the connection in the brain is a far gentler and less disruptive one.
One final note, doing nothing and hoping the brain will self-correct is not the wisest of strategies. Phobias can and often do weaken over time, and we shouldn’t exclude that possibility. But they are best dealt with, even though that process may be a difficult and anxiety-producing one.
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