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Tuesday Structured Recovery Evenings are suspended until 12th September 2017
SELF-TREATMENT FOR PHOBIAS
The greater part of this booklet has been drawn from two highly recommended
books on the subject of phobias and self-treatment:- “Living With Fear”
by Professor Isaac M. Marks, and ‘Fighting Fear; by Dr Frederic Neuman.
The term, ‘self-exposure’ will be used throughout these pages. This
simply means putting yourself in those situations that cause you anxiety,
in a structured and controlled way, until you become able to deal with the
panic and the other physical symptoms they cause. ‘Structured and
controlled’ means working out ways to confront the situation – starting
with something that you can do with a little difficulty and working through
gradually more difficult and anxiety-provoking steps until you have overcome
Although drug therapy, talking treatments and other approaches may be useful
as tools in the work of countering phobias, the actual effort has to be
made by the suffer him- or herself. Going through it, getting used
to the often extremely unpleasant feelings the phobic situation gives rise
to, is the only road to full recovery.
There is nobody out there with the skill, knowledge or magical cure to
take the fear away. However good their techniques, outside ‘experts’
can only help you to do it for yourself. Not believing this, and wasting
time looking for ways to be better rather than ways to get better, is just
putting off the time when the real work has to begin.
If you suffer from panics, you may suggest that ‘dealing with them’ isn’t
reasonable. You have been suffering panics for a long time.
You have been faced with countless panics (which you have probably tried
to ‘switch off’ or escape from) and have never got used to them or anywhere
close to dealing with them. So why should you be able to start now?
The reason is that your attitude is different now. If you are willing
to undertake self-exposure, you have decided to take charge. You have
accepted the point of self-exposure which is to teach yourself that panic
will subside eventually if you don’t try to escape but stay in the situation
until you feel (at least a bit) better. This means that you see taking
charge as a possibility now. You are making something happen, not waiting
for it to happen.
You have accepted that your phobia has no compassion. It isn’t going
to take pity on you and let you off sometime soon because you haven’t been
fighting it or causing it any trouble. You have accepted that your
phobia is willing to take up as much space in your life as you will allow
it. You know it is the ultimate bully. Unless you face it, your
phobia owns you.
Understanding all this, you are ready to being, as cautiously as you like,
to take some of your life back, to grow used to thoughts and feelings that
have made you a prisoner and so to begin to be free of them. You will
be starting to ‘deal with the panics’ then.
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Before you begin
1. While these techniques are fairly straightforward
and available to anyone, it may be a good idea to consult your GP or your
local Department of Clinical Psychology or Psychiatry before you begin.
If you are dependent on tranquillisers or alcohol, it may be difficult to
apply these techniques successfully without first accepting some skilled
support in order to reduce the dependency.
If you are suffering from depression, self-exposure may be difficult.
Depression can affect you without your recognising it. If you wake
up every morning with panics that take hours to disappear; only feel better
in the evenings; are losing weight – these can be indications of depression
that needs professional support even if you don’t feel particularly depressed.
It is possible, however, to do self-exposure work while taking antidepressant
It is important that you have tangible goals right from the start.
Not ‘I want to feel a lot better than this’, but actual achievable objectives,
I want to be able to go shopping alone.
I want to be able to stroke a cat.
I want to be able to touch ‘dirt’ without washing my hands afterwards.
Whatever your goals are, they should be specific and you should consider
how much better your life will be if you achieve them. If you see
no significant or worthwhile changes, then it will be much more difficult
to make your self-exposure attempts work. That is not to say that
you have to have a 100% positive attitude before you start. It can
be difficult to believe that anything is worthwhile sometimes. Having
little belief in yourself and your ability to improve your life, is very
much part of being phobic for some people. But a positive and determined
attitude really does speed recovery. So, if you lack enthusiasm, you
should not be too disappointed or cynical about slow responses to the treatment.
If you cannot visualise facing your anxiety problems alone, try to involve
someone else in the work. A family member or close friend can be of
great assistance as an exposure co-therapist, particularly in the difficult
times when everything seems to be going wrong – and there will be such times.
Having this kind of support can be at its most useful when your phobia involves
other people (such as agoraphobia and social phobia); or if you find it
very difficult to stick to things like regular therapy and keeping the written
exposure diary that you will need, without being prodded by someone else.
You may see outside help as somehow opting out – you are not really facing
anything if someone is holding your hand. Not true. The object
is to make it as likely as possible that you will achieve your goals; a
helper at first can greatly increase the chances of this. Remember
that there are no extra points for getting better the most difficult way.
Look on your helper as a crutch. As long as he or she will be useful
and not involved in helping you avoid situations that you can well manage
alone; and this help is definitely temporary, with both of you understanding
that the helper will be phased out gradually until you can do the work alone,
there is no problem.
If you take help, don’t let your anxiety bluff you into thinking that you
can only achieve things with this crutch. Certainly it will be easier
with help – most things are; but you must accept your achievements, when
they come, for what they are – something you have earned and should be proud
of. One of anxiety’s last-ditch defences is trying to persuade you
that you haven’t really achieved anything and that, without having your hand
held, you are useless. Don’t believe it.
Work out what it is you really fear. You may thing you know exactly
what it is, but a surprisingly large number of people don’t. People
often choose to believe the most likely things. Hearing noises downstairs
while you are alone in bed at night, you may believe it is the noise that
is frightening you, when it may instead be the dark itself or being alone,
if you really think it out.
So: you fear ‘going out’. Is it really …..
· being alone?
· being far from
· being afraid of
· being afraid of
· meeting strangers?
· some combination
Do you fear ‘touching things’. Is
· that they will
· that you will
· that you must
touch things to reduce your anxiety?
Do you fear ‘people’. Is it really…..
· that you will
humiliate yourself? (shake/faint/say something stupid?)
· be attacked?
· attack someone?
· that you are so
ugly/ridiculous that people will notice?
You need to work out what the real problem is or you will be wasting energy
struggling against something that doesn’t need to be overcome.
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Work out how long you want to spend each week doing the therapy.
Remember that an hour or more at one time is far better than lots of ten-minute
sessions. Don’t feel that tiredness, shakiness or exhausted feelings
automatically mean that you are harming yourself. You are not that
delicate. It is very unlikely that anxiety will harm you. Just
remind yourself that uncomfortable feelings are all in a good cause, that
the only really bad thing you can do is too little.
On the subject of too little, people sometimes point out that they got
this way be being in the situation, so why should going back into it stop
it this time? Wouldn’t it be much more sensible to stay out of frightening
situations altogether? Two reasonable questions. The point is,
staying away from anxiety prevents it from healing. It’s not the same
as putting a plaster on a cut. Recovery does seem to depend very much
on the length of time you are prepared to put into exposure work and the
quality of this time. Brief and irregular exposure – ‘dashing round
the shops because I just can’t avoid it today’ – probably doesn’t help much
at all and might even sensitise you further to the fear. So you need
to make a definite plan of campaign to get to those shops – a plan of attack
that goes out to meet the problem, not a ‘cornered rat’ style response to
Don’t let this plan degenerate into sneakiness. Don’t pretend to
be doing the therapy by working out steps that you can already manage easily.
People who don’t understand might be impressed for a while and leave you
alone, but in the long term, they will realise that it was just a game.
If family pressure encourages you to do this kind of pretending, you might
like to point out to the offenders that being forced or ‘punished’ (families
can punish phobic avoidance in many direct and indirect ways) could even
make you more likely to avoid it in the future.
Your phobia is maintained to running from the fear and the memory of all
those times it has beaten you so easily. You need to build up a memory
of times when you didn’t run away and the fears reduced, so that they begin
to overtake and sink the memories of the other times. If you try too
infrequently, the good, positive, achieving memories won’t have a chance
to take hold. You need to work frequently enough to demonstrate achievement
to yourself. So, be honest and work out a realistic programme and
time-scale. And remember that the more you do and the more frequently
you do it, the better. For instance, doing self-exposure only once
a week is far too little for an agoraphobic. Every day is much better.
KEEP AN EXPOSURE HOMEWORK DIARY:
Write down what happened during your self-exposure exercise after each
therapy session. Use a scale of 0 to 10 to gauge the level of your
fear each time, where 0 is fully relaxed and 10 is as panicky as you can
imagine feeling. Over a period, you will then see how your anxiety
is reducing. A little practice will make you very good at judging
and numbering your anxiety levels. Note your anxiety levels before
and after attempting self-exposure too.
This will show, over a period, if there is a pattern to it. For instance,
you might find that you were worse if you had to wait a long time before
going through the phobic situation. Or you might find that a time of
day or weather condition made a big difference. Or the presence (or
absence) of a particular person had a beneficial effect. Or the prospect
of a pleasant or unpleasant activity later did too. It all gives insight
and a better chance of dealing with panics.
You might also write encouraging thoughts in your diary:
· ‘I know I will
have setbacks but must learn to deal with them. Panic is the signal
I must do more.’
· I need to work
quickly enough to demonstrate improvement to myself.’
· ‘Today’s success
outweighs lots of earlier failures.’
· ‘Doing the same
thing for a month is not “getting use to it” – it’s avoiding the next step.’
· ‘I will overcome
my phobia by seeing it break down in the face of my effort, not from books
or other people’s words.’
· ‘The only real
failure is running at the first sign of panic.’
Get your helper to check your exposure diary each time. It can be
a good idea to contract with him or her. By this I mean actually writing
· I will show my
diary to …….after each session. He/she can also ask to see it and make
me fill it in properly if I haven’t done so.
After a tiring and anxiety-filled session, it is very easy to forget that
your helper is there for your benefit and to see him or her as bullying/prying/out
to get you instead. Something written down that he or she can draw
your attention to will help here.
After each session you should also write down what you intend to do next
and contract with your helper in a similar way with this too. Within
Anxiety Care, members involved in self-exposure groups keep ‘homework’ books
in which they work out, alone or within the group, daily exposure practice
that they will undertake until they meet again. It is quite surprising
how ‘honest’ this keeps people. Members who are used to ‘not feeling
up to it today’ within the family, realise that they are among experienced
practitioners of this avoidance art within the group and simply don’t use
excuses. They do the exposure work then because they are embarrassed
not to, and this ‘edge’ is sometimes all that is needed. This small
incentive also proves how close some people are to facing their fears without
really knowing it.
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What you do each session is obviously guided by your type of phobia.
Phobias cover virtually any activity, creature or object you can imagine,
but breaking them down requires the belief in some common truth:
Experiencing the anxiety and staying in it is working towards recovery.
Running from it maintains the fear.
Every time you manage to avoid the phobic situation, and so obtain instant
relief, however small, you are reinforcing the fear and ensuring that you
stay phobic. So work out reasonable steps that won’t tempt you to
You decide what you can do, what you want to be able to do and arrange
achievable steps in between. These steps don’t have to be huge.
For instance, your first step can be staying in a situation you can just
manage now, but for a little longer. Getting close to managing a step
is better than not trying it at all. Thinking about it, looking at
the situation – this will help and get you close to achieving the step.
The closer you are, the more likely you are to cross that tiny space and
finally achieve what you set out to do.
As an example, for an agoraphobic, the steps might be:
Step one. Walk to shop at corner with helper.
Step two. Walk to shop at corner with helper walking 50 yards behind.
Step three. Walk to shop at corner with helper walking 100 yards
Step four. Walk to shop at corner with helper waiting at shop.
Step five. Walk to shop at corner without helper.
These steps are just guides – something to being with. If you find
a step is too big, then break it down again into a series of little steps
until you have worked through it. Far better this than being so enthusiastic
that you organise over-ambitions plans and become disappointed when you
cannot complete them. You are looking for ways to take some of your
life back; chipping away at the monster until it is worn away, not trying
to scare yourself half to death or to grow disillusioned through disappointment.
People sometimes look on their anxiety, particularly agoraphobia, as if
they have hired a fairly stupid bodyguard. They have instructed him
to ‘keep them safe’; but because he is so stupid, he simply shuts them right
down. He won’t let them do anything because that’s about as safe as
you can get. In order to get round this you have to trick him:
Do a little at a time while staring him in the face. Looking at it that
way, you stop treating the anxiety as some all-powerful force and recognise
it for what it is in many cases – a protective device with no real sense,
that has got out of hand.
Don’t make the first step too big. Most definitely, don’t be tempted
to make it so large that failing to achieve it ‘proves’ that you aren’t
ready for this. Everyone can do more than they are doing at present.
get to the gate?
Go to the front door.
go to the front door?
Get to one foot from it.
Think you will look silly
Pat your pockets as if you have forgotten something. If you walk ten yards
and then turn back – nobody will notice.
|Can’t even look at a spider?
|| Draw a circle on a large sheet of paper.
| Add cross lines for legs next time.
|Work up to photos.
|Can’t stand wind in the trees and nobody
can generate that for you to practise with?
|Start by thinking about it. Put yourself in
the situation in your mind. Work up to sound effects records and videos.
Get used to putting yourself in the fear-causing situation. The longer
you can stay in it each time the better. Get bored with it, but be
careful not to stay with each step too long as an excuse not to go on to
the next one. Accept that you don’t have to stay in each step until
all the anxiety caused by performing it is gone. It probably won’t
entirely disappear from these early steps until you are several steps further
on, so waiting can turn into another excuse for not doing more. Don’t
be awed by the task ahead. It isn’t four times as difficult to walk
a mile as it is to walk a quarter mile. The more used you grow to anxiety,
the easier it becomes as you progress. The final steps, if anything,
become easier to accomplish.
Particularly with the agoraphobic cluster of problems, there is likely
to be a wide range of situations in everyday life that grade from the difficult
to the virtually impossible. In these situations the overall drop
in anxiety levels will be very evident as you progress. Bear in mind
that it will be necessary to practise self-exposure with some anxiety-raising
situations as if they were separate problems. Even after you learn
through self-exposure to travel in a bus, you may not be able to travel in
a train without additional work. You might well have to go through
the same gradual, ‘habituating’ exposure with the train that you did with
the bus. Your confidence will be higher by then of course, so it should
be a bit easier.
Many people become disheartened when anxiety seems to build up ‘across
the board’. You became afraid of a number of situations almost at
the same time, particularly if you are agoraphobic or socially phobic, yet
you have to get rid of them as if they were separate conditions. Why?
It doesn’t mean that yours is a hopeless case. It doesn’t mean that
you have ‘slipped back’ when you try something else that you feared and experience
the same old symptoms. They will go as you continue exposure.
‘Sensitisation’ to fear has a wide ‘shotgun’ effect with many things getting
wounded by the original blast, while ‘habituation’ or getting used to the
anxiety stimuli needs a single bullet approach for each in turn. So
don’t allow the difference in anxiety levels between an overcome problem
and one yet to be attacked to be a reason to give up. That difference
in confidence and personal power is natural and one to be noted. Aim
to bring the next problem up to that good level of achievement too, and then
the next and the next.
Panics lessen in time as you do the exposure exercises. As you grow
more willing and able to deal with them they will become less important.
If you have been free of panic because you have been totally housebound,
then naturally starting to go out again, for the first time in years perhaps,
will bring panics back.
Going through the panics is the way out of this problem. If you weren’t
feeling somewhat less comfortable and safe while undertaking self-exposure,
if the actual number of panics experienced was not greater, then you would
probably not be doing it right.
This does not mean, however, that you need to frighten yourself very badly
and have enormous panics in order to overcome these phobic problems.
Professional studies show that a high level of fear works no better than
a moderate level when undertaking exposure.
Success is measured more by what you are achieving, than by how you are
feeling. Don’t be tempted to give it all up because you feel fairly
awful. Write everything down in your exposure diary or record book so
that you can compare your capabilities with previous times. If you don’t,
it is possible that your anxiety will try to tell you that you have always
been able to do these things and that the pain isn’t worth the effort.
It is. Cheer your victories. Buy yourself something to mark big
achievements and make sure your helper, if you have one, in expert enough
about you to understand how well you are doing. Expect and enjoy your
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Panic: Triggers and Responses
There are lots of misconceptions about ‘panics’, particularly if you do
not understand what is happening to you physically and believe that something
that feels this bad has to be dangerous and avoided at all costs.
It isn’t true and it might be useful, at this point, to explain some aspects
of the physiology of panic.
All animals have an instant reaction to danger where that part of the nervous
system that is not under our control responds instantly to a life-threatening
situation by making the body ready to fight or run. If humanity had
lost this when we began to think, plan and reason all those millions of
years ago, then we wouldn’t have lasted long. Our inquisitive natures
would have let us stand around to find out what that noise or rustling bush
was all about. Then our intelligent, but very vulnerable bodies would
have succumbed to the teeth or claws that threatened.
Instead, we retained that life-saving ability. When extreme danger
loomed, chemicals in the body set to work to keep us alive. The heart
rate increased to pump up muscles ready to fight or run (hence the ‘heart
out of control’ feeling, the urge to run and trembling, twitching limbs).
Blood was not only pumped harder, but was redirected from less currently
vital areas like the digestive system (hence uncomfortable feelings in the
stomach). This, together with the need to be as light and fast as possible
– and perhaps also to put the predator off eating us! – caused the need to
defecate, urinate or vomit; while sweating profusely helped to make us hard
to get hold of.
Breathing rate was increased too to ensure that oxygen was available for
the coming emergency hence chest pains, the feeling of ‘gasping for air’
and sometimes the dizziness and suffocating feelings caused by over-breathing
- ‘hyperventilation’. (This is the temporary and non-dangerous imbalance
between oxygen and carbon dioxide in the blood stream). At other
times, different chemical processes would have ‘frozen’ the threatened human’s
body so that he or she made no sound or movement. The predator would
then with luck, not notice and pass by.
The aftermath of such violent chemical activity experienced by a phobic
today, particularly as the increased survival potential that the body has
so quickly offered is not used, can leave this person dizzy, nauseous, tired
and with shaking, weak-feeling limbs. Regular exposure to this reaction
can leave one exhausted and beginning to mistrust one’s body. The fear
of it happening again then leads to fear of these symptoms themselves –
fear of fear. The severely phobic person is then ‘sensitised’ to fear.
He or she is walking in a mental minefield where the next mental step may
set off an explosion. People cannot live that way without becoming
exhausted, unsure and unwilling to put up any resistance.
Accept that your body is just reacting that way, albeit mistakenly,
to protect you. With no obvious external danger threatened, any intelligent
person is tempted to rationalise these feelings. If you can’t see
the threat, then it must be something inside that is ‘just sensed somehow’.
Hence the often-voiced – “I am going to have a heart attack/brain haemorrhage”.
It is so hard to accept that something that feels this terrifying is not
dangerous. People think there is a predator inside them. The
fear itself becomes the predator and they begin to believe that if they don’t
buy it off, it will surely destroy them.
To counter the internal predator, remember that panics only get so bad.
They don’t kill. Think about the half-dozen or so major panics you
have had – that is as bad as it gets. There is no, great, slavering
monster just beyond that which you have always, magically, just managed to
avoid by running away. The simple fact is that you are buying off a
toothless predator, a powerless bully. When the physical symptoms are
really severe, it is comforting in many ways to believe that there must be
some dreadful catastrophe hovering and ready, that your avoidance just manages
to counter. There must be something horribly wrong if you feel this
bad. It can’t just be anxiety. But it is, and eventually, you
have to believe it.
Don’t let horror stories in the media fuel your fears either. People
don’t die from panic. Stories to the contrary are either lies or coincidences.
People die while doing any activity you can imagine – eating, laughing,
putting on their clothes. That’s just the law of averages applying
itself. This means that, sometimes, as there is a lot of it about,
some people die soon after feeling extremely anxious. Don’t cling
to that kind of coincidence as a reason to avoid going through panic, or
allow it to build your horror of death. Understand that reading or
hearing about frightening things can bring on a lash of panic that makes
the story look somehow more serious or ‘real’. Don’t mistake your
own sensitive reaction for ‘truth’. It means nothing more than a good
scary story in the press.
Reading this won’t persuade you out of your panics, of course. Nor
will any words that doctors and therapists can offer you. The only
way you are going to believe that panics can be faced is from your own experience,
going through them enough to prove to yourself that it really is true.
A first step in dealing with panics is to drag them out of the shadows
and really look at them. To be aware of what frightens you – what
thoughts, feelings and physical situations trigger them. For instance,
with very severe spider phobia – besides being confronted by the beasts
themselves is it sudden movement?; Dark circles or small shadows?;
A time of day, a climatic condition or a season of the year? With
agoraphobia – besides feeling unsafe away from home – is it wide roads?
Railings? Sudden noises? Bright lights? People?
Being alone? Conversation about any of these?
Once you are aware of your triggers – that the rising feeling of panic
is not coming out of the blue but has been triggered by something, you will
not be taken by surprise and you will be in a better position to deal with
Too many people treat their fear like some malignant, internal monster
with a mind of its own over which they have no control. Knowing yourself
enough to be aware of triggering thoughts, feelings and events shows that
this is not true. It also gives you the chance to see how often these
triggers don’t build up into panics and that there is no inevitability with
potentially panic-causing situations. Know how long your panics last
and don’t think that you have no say in how long or how severe they are
going to be. Don’t lump several short panics over a relatively
long period in your mind into ‘hours of gibbering terror’ that will terrify
you nicely, ready for the next time.
It is also important to know how you respond to the phobic or panic
situation. What physical symptoms, among those discussed earlier,
affect you? Do you want to scream? Run? Feel your head
or heart is about to burst? Feel your legs are turning to jelly?
Feel you are going to faint? Fall over? Vomit? Lose control
of your bodily functions? Be unable to breath? Once you realise
that one or two physical reactions are ‘yours’, and that they are simply
bodily reactions to fear and no more than that, you are starting to take
control and can begin to think about applying coping techniques to them.
These ‘finding out’ suggestions are the very first self-exposure steps
– turning on the metaphorical light and seeing that the monster looming
over the bed is just a flapping curtain and an old dressing gown.
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Coping and recovery
Coping techniques are simply those mind-distracting or calming things that
help to keep us from drowning in the thoughts and feelings brought on by
frightening life situations; For instance, the well-known technique of concentrating
on one face if you are asked to speak to an audience. We all use them
to reduce anxiety, so refining your coping techniques and developing new
ones as described below can help to ease particularly difficult phobic situations.
However, academic studies suggest that facing the phobic situation ‘head
on’ without denying it or finding ways to hide from it in your head is by
far the best and quickest way to overcome the condition. That is,
you need to experience the fear as it was learnt, in all its unpleasantness,
so that you can habituate to the actual fear rather than to something that
you have watered down with mental techniques or other kinds of denial or
Having said that, many people, from Anxiety Care’s experience, feel unable
to tolerate self-exposure, at least in the early days, without some temporary
crutch. So, understanding that the crutch has to be thrown away eventually,
if you wish to use coping techniques to start with, work out what techniques
you use to deal with panics normally and try to refine these.
Work out more and better ones or try some of the suggestions below in order
to stay in the frightening situation. (These techniques can work equally
well with non-panic reactions. That is, if you are prone to morbid
thoughts, feel that you might hurt yourself or someone else or have any other
frightening but panic-free response to the phobic situation.)
Some people find it easier to work out coping techniques if they look on
their anxiety as a small, demanding infant and apply the methods they used
on their own children at such times.
So, some examples might be:
· Talking to your
helper about prearranged subjects
· Counting cars
· Working out the
distances between objects
· Pricing the clothes
people are wearing
· Counting the Marks
& Spencer’s jumpers you see on people.
Or there could be more ‘adult’ things – like doing mental arithmetic or
reciting poetry or repeating a comforting phrase. Some people use emotions,
like anger, to overcome the fear while others drive themselves on by holding
the though of how delighted their families will be with their achievement.
Obviously, in an outright panic, it is hard to select a coping technique.
At such a time, the good ideas may go completely out of your head.
It is therefore a good idea to write down your chosen techniques on cards
and to carry them with you so that you can read them when necessary.
For instance, orders to yourself might be:
‘Recite three lines of ...(a favourite poem) then I can run.’
‘Count one more red car – then I can turn back.’
(Or take one more deep breath. Or count to ten etc.)
Helpful phrases that you need to remember might include:
‘Going through fear is the way to become free of it.
It’s doing me a favour by letting me practise.’
‘The longer I stay in this situation, the sooner I will be free of my phobia.’
‘These feelings are just normal bodily reactions multiplied a few times,
they won’t hurt me.’
‘I will not frighten myself with “What if…?” thoughts. I haven’t
died/fainted/done something terrible yet because of these feelings and that
means I never will.’
‘These feelings need not mean I am going to have a heart attack/stroke/brain
‘If I stop piling frightening thoughts onto these feelings, they will ease
‘I think I’m going to die/faint/scream now, but I’ve thought this many
times before. This will pass too.’
‘I must regulate my breathing. Concentre on slow, regular breaths.’
(This is not a good idea if breathing is one of your problems as it will
only tend to concentrate your mind on it.)
The list is endless. Use anything that works to get your mind of
negative feelings. Avoid flat and easily – disproved statement like:
‘I will board this bus/stroke this cat/etc. and feel no fear.’
This is because the first flash of anxiety can shatter the thought, and
your confidence and make you feel even more ‘silly’, ‘pathetic’, ‘helpless’
(or whatever other self-deprecating name you are in the habit of using on
yourself). Be realistic. Accept that you will feel some level
of anxiety and find ways to deal with that.
Some people find it useful to go along with their very worst fears and
write down the ultimate thing that they fear could happen to them.
This can give relief of the kind – “This is the ultimate horror for me.
If can stay in this thought, I can get through anything.”
Remember: It is definitely not possible to get better without feeling
panicky. Although panics become shorter and less distressing as you
work through your steps, they don’t stop: you must feel some degree
of anxiety in all your practice sessions. If, at the end of your self-exposure,
the very occasional panic is still looked on with terror and foreboding,
then you have not dealt with them.
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SOME GENERAL ADVICE
Recovery can be very rapid. Read these remarks made by a charity worker
who was extremely disabled by his anxiety disorder: ‘When I was completely
housebound, I could not afford to look at the probable scenario of the rest
of my life – it was too unpleasant. I comforted myself with the thoughts
that I might, one day “with one mighty bound, be free”. I thought that
somebody would look after me and that I could build a reasonable life confined
to the house if I tried. I was so deeply enmeshed in the condition that
all I could see was myself as I was. Recovery looked an unbelievably
difficult journey away. I didn’t dare project my life, five, ten,
twenty years ahead. I didn’t want know that you don’t become less
anxious by avoiding the anxiety-causing situations because even very casual
relief in your head is enough to keep the feelings active. I wasn’t interested
in the fact that if you do little, you will gradually do less. That
you retreat inch by inch until even the things you can do become difficult
and perhaps impossible.’
It is hard lesson to learn – that nothing and nobody is going to take the
fear way for you. No miracle drug or silver-tongued therapist is going
to make it all right. Of course there are miraculous recoveries.
We have all heard about them and comforted ourselves with the thought that,
one day, it would be our turn. But this is not a good option.
Any treatment from the totally tested medical to the downright freaky fringe
can claim its successes – perhaps because they have been applied to people
who were in the right frame of mind to recover and just needed the confidence
of something outside themselves to take that last step. Waiting for
that kind of fortuitous mix is not a good gamble and it lead to ‘butterflying’
This is the game of chasing after mirages thought to have worked for other
people as part of that quest to find something to take the pain away with
no personal effort involved. It is a dangerous game, for, as you dip into
lots of things once or twice and move on as they each fail to cure you,
it offers the illusion and comfort of ‘trying to get better’ without actually
performing any positive steps towards recovery at all.
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With agoraphobia and social phobia, it is important to build confidence
and self-esteem again as soon as possible. Increasing social involvement,
doing voluntary work, and if possible, getting a job during the last part
of exposure therapy or the early days of recovery are very good ways to
stay free of the problem.
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Notes for Helpers
If you are helping a phobic person to undertake a self-exposure
programme, you will, first, need to read the ‘Self-treatment’ part of this
booklet. You could also read any of the online works on phobias and
exposure work. Secondly, you will need to understand a few basic points
Even if the phobic person has received professional treatment, a non-professional
helper can be very important for maintaining progress. The sufferer
has to know that he or she doesn’t need to be protected to stay well.
This person particularly needs to do without the help of someone who can
easily be seen to be in possession of ‘special’, almost magical knowledge
– ‘The Expert’. He or she is capable of maintaining progress with no expert
advice or support, but that doesn’t mean that some kind of help wont be needed
If there are problems and you are called upon to give support, don’t think
that you cannot possibly help without the qualified behaviour therapist’s
expertise. The only expert around is the sufferer – on him- or
herself. Also, don’t put too high a value on that professional therapy.
However good it was, it needs reinforcing with continual practice, at least
in the early days, and that’s where the lay helper is at his or her most
valuable. As an ordinary person you can give a helping hand when needed.
Our main influences in life come from the people around us, not from the
expert’s occasional pearls of wisdom. Nobody should be left with the
illusion that only ‘an outside expert’ has the qualities to help us to be
free and to maintain this freedom.
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The phobic person knows the situation is not dangerous. He or she has been
in it lots of times with no terrible outcome so it clearly won’t respond
to careful explanations detailing his or her mistaken ideas and beliefs;
or to any other reasonable, logical argument. Reality is how bad this
person feels and how much he or she needs to be free of these very unpleasant
feelings. This freedom is usually achieved by running away from the
situation. Your task is to help the phobic person to face the fear,
not try to talk him or her out of it.
Discuss the programme and make sure that you can maintain the commitment.
In the case of ‘fieldwork’ as will be necessary with agoraphobia, don’t
even let it cross your mind that this might be a good opportunity to show
how nice you are while obtaining two extra hands to carry the week’s shopping.
Your job is to be a ‘Minder’ (unobtrusive, fully attentive, fully supporting,
always exactly where you should be), not a ‘grudging companion’ (complaining,
bored wandering off, looking in shop windows).
Work out the steps together. Get to know the person you are helping
as well as you can. Even if you are a family member this suggestion
is not as odd as it sounds. Living in the same house is no guarantee
that much personal information is shared. Situations really can be
horrifying. The person you are helping may well lie awake at night
sweating and worrying about something that you can barely comprehend as a
problem. See it as real. Don’t explain his or her extreme reaction
to it by thinking to yourself that this person is somehow weak or unstable.
Too often we hear people say such things as – “Well, we’re all phobic about
spiders/snakes aren’t we?” Even if you are phobic about spiders or
snakes, there is a very wide gap between mild fear and clinical phobia.
You may well loathe spiders or snakes but do you spend a good deal of your
time defending yourself against the fear of encountering one? Anxiety
Care workers have encountered people who seal up their houses at ‘spider
time’. One counsellor talked to someone who put dishes of petrol under her
bed legs and lay awake for hours in the dark contemplating suicide because
she couldn’t stand the suspense of waiting for a spider to fall on her.
There are also people who not only won’t watch television when jungle programmes
are on, but who even disconnect the set for fear of snakes; others who won’t
open a magazine, newspaper or book until it has been checked by someone,
for the same reason.
So, see the level of the phobic fear as real, but don’t involve your emotions
in it. The shock of finally understanding how badly someone is suffering
can make you feel very guilty. But don’t be tempted to pay off the
guilt by offering excessive sympathy and dwelling on the feelings and symptoms.
This only intensifies the seriousness of the situation in the sufferer’s
The essence of being a helper is in structured support – regular, planned
activities with definite goals and limits. The phobic person may well
have no experience of the positive rewards of trying hard and may, consciously
or unconsciously, not even believe that trying is going to work and be worth
the effort. In these circumstances, pushing him or her too hard, nagging
or threatening, is much more likely to result in abandonment of the project
than increased effort. This is not to say that you should permanently
wear velvet gloves. Once you have gained the person’s trust, then
you will know when a little pressure, humour or good old-fashioned nagging
Praise is important and should be given as soon as possible after the exposure
activity is completed. If you are not helping practically with this
particular attempt, make sure that the person you are helping phones you
as soon as possible after completion. Praise helps to reinforce the
effort (particularly when given soon after the accomplishment) and can be
absolutely vital – especially if the sufferer has grown used to a cynical
or dismissive attitude to his or her efforts from family or friends.
The more expert a helper is on the person’s problems, the more genuine, spontaneous
and, therefore, useful, the praise is likely to be.
You won’t be able to work out the exact number of times you have to perform
specific helping acts (like accompanying the person on walks, or sitting
in cafes, etc.) right at the start. But it is important that you work
out, fairly quickly, when to reduce your help so that the sufferer can do
exposure work on his or her own. With agoraphobia for example, endlessly
accompanying the person on the same shopping trip, down the same streets,
is not working at recovery. If the phobic person just wants someone
to take him or her shopping occasionally, this is not exposure therapy.
However, it is important that the helped person has the final say on the
type and duration of steps attempted. He or she is in charge of the
recovery work. He or she has to make the decisions on it and is in
a better position to tell what is going to work. As a helper, you can
never know exactly how this person feels and must accept that it is very
unlikely that progress will be nice and neat and regular. There will
be hiccups and sticking points and moments of great despair.
When a hurdle looms, a good helper should be ready with ideas for mini-steps
and coping techniques, particularly if the hurdle appears while actually
undertaking exposure work. In this situation the person may well be
too frightened to think logically and will need prearranged ways to deal
with it. For instance, being faced with a long supermarket queue after
an exhausting hour of basket filling may seem too much to bear. Prearranged
coping techniques might be:
· Agreeing to stand
with him/her all the time.
· Agreeing to take
his/her place for a specific time – one minute say, while s/he ‘pops out’
– (said for the benefit of any eavesdroppers. In reality, going outside
to give the panic an opportunity to ease.)
· Working out a
little play-acting for if the anxiety gets too bad: “Oh dear, I forgot
the roast. Don’t bother keeping my place. I’ll line up again
Read the earlier section on ‘Coping Techniques’ and try to avoid helping
to water the exposure down too much. Also be very aware that any technique
that involves running away must be understood to be a last resort: and that
getting back immediately into the feared situation is then of prime importance.
It would be useful if you could become familiar with the person’s trigger
events too. If you are aware that a very wide street, strip lighting,
high walls, lace curtains, tumbling leaves, whatever, triggers panic or
physical symptoms, you can be ready to distract him or her. This can
be accomplished with conversations; by looking in shop windows; or supporting
with any one of the coping techniques that may have been worked out previously
for when the thing looms.
Knowing the person’s bodily reactions too will help. If you know
that sweating, shaking, biting lips, an ashen face, walking too fast, pulling
at clothing etc. is a usual precursor to a panic, it gives you, as the helper,
the chance to be ready to apply these techniques or the opportunity to talk
gently and firmly, in an encouraging way, perhaps using a version of a comforting
“Wide roads aren’t frightening in themselves, you know that. Your
fear will pass.”
Remember: Being ready to distract means just that – nothing more.
Don’t offer distraction as soon as the feared situation presents itself
or the person will never learn to face it in the way he or she needs too
– alone and ‘head on’.
When the ‘minder’ element of support is easing a few notches, it can be
worthwhile to improvise, particularly with problems like agoraphobia and social
phobia. If things are going well one day, suggest trying something a
little harder or even a lot harder on impulse. If it works, accept that
it may be a ‘one-off’ but understand that achieving something large can give
the phobic person a huge boost and bring the regular carrying out of this
activity a step or two closer. Don’t let this degenerate into pressure
to do more after every step. Your strength is in being totally trustworthy
and predictable. Undue and unwanted pressure is often too freely available
Many families latch on to ‘one-off’ achievements saying – “If he/she can
do it once, he/she can do it every time”. This simply isn’t true.
Anyone can ‘gear up’ beyond their capabilities if the emergency situation
calls for it. Charity workers have encountered several agoraphobics who
managed to put aside their fear when their children were in danger or seriously
ill. This doesn’t mean that they were ‘cured’ by it or that they were
faking and could ‘really do it all the time if they tried harder’.
It just means that, once, the weight of fear was balanced by an equal weight
of the need to overcome it. Trying to make the phobic person achieve
this balance every day is obviously ridiculous. Trying to ‘equal the
balance’ by adding bullying or anger also doesn’t help. As mentioned
earlier, if anything, bullying and punishing just make avoidance more likely.
Unfortunately, many families fall into this system of demanding that the
sufferer maintains any and all progress however ‘one off’ it was.
This leads quite naturally to the phobic person avoiding anything ‘unusually
good’ just in case the family shut the metaphorical door behind him or her
and won’t let this person go back to ‘normal’. (‘Normal’ in this case meaning
the prevailing situation, whatever point that might be on the road to recovery).
Understanding all this, you have to recognise the situation and remember
that the phobic person needs to be able to put all his or her energy into
working with you, not wasting some in defending him- or herself against
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TRY NOT TO BE SELF-CONSCIOUS
Don’t be afraid of entering a bus or train together and sitting apart.
Don’t be afraid of driving your car behind a bus for a few stops if that
is the only way the person you are helping will travel alone. It may
confuse the driver a little (although there are so many public transport
phobics around that he may be used to it) but it can be a tremendous help
and give such a warm feeling of fellowship – ‘Us doing silly things together’
– that panic eases and the activity becomes that much easier. Naturally,
if you are not based in England, you should make sure that your local traffic
laws allow this.
Going shopping can work in a similar way too. There is nothing wrong
with standing in the doorway of a large store and working out a route round
the counters so that you are both clear exactly where you are going to be
at specific times. If self-exposure is undertaken by a small group,
this kind of discussion and splitting up in the doorway can draw the interest
of security, but it’s not illegal and the slightly mischievous element is
a definite plus.
While on the subject of working in groups, if you are using these pages
as a basis for group work, be careful that an unspoken but very real truce
is not formed between some or all of it members. That is – “If you don’t
push me to go on to my next step, I won’t push you; and we’ll tell each other
how well we are doing regardless of what is actually being achieved.”
This is always a danger in the group situation and should be guarded against
and discussed, if possible, before group work begins.
Another ‘group’ point to remember is with reference to ‘coping techniques’.
Working together to overcome problems can be an excellent way to involve
those who are particularly afraid of trying anything in the self-exposure
line. However, this does give these sufferers the opportunity to experience
exposure ‘second hand’ through those who are actually achieving things.
This can offer the illusion of recovering and facing the phobic problem –
“I’m going out aren’t I?” – without really being of any benefit. Simply,
if they are only able to face the situation when heavily protected, not
experiencing the fear ‘head on’ in any shape or form, then they are not
really undertaking exposure at all.
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A FINAL POINT
People are helped best by those whom they know they can trust. If
you agreed to be a helper you must stick with your commitment and you must
prove that you can be trusted. It’s not what you say but what you do
that is important. If you agree a time and are five minutes late; if
you agree to perform a certain act and are distracted into performing it poorly,
then you are proving that you cannot be trusted to someone whose effort pivots
on this trustworthiness. The helped person doesn’t have to be grateful
for the few scraps you toss him or her. You have agreed to perform a job
and the contract is a binding as any you will undertake. Don’t treat
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A WARNING TO HELPERS
Self-exposure can work very well and very quickly, but that does not mean
that it can be used with any phobic person and that friends and relatives
of a phobic person should try to ‘apply’ these techniques to that person’
for his/her own good.’
For many people, their anxiety problem is not something laid on their normal
life that can be peeled off or unlearnt, but is part of their existence.
Particularly with problems like agoraphobia and social phobia, their previous
life experience may have ‘proved’ to them that it really is dangerous out
there, that people cannot be trusted; that being safe and secure is more
important than self-esteem and feeling useful and needed; that they should
be grateful for what small pleasures they get – just for breathing in and
out, let alone achieving anything; that their lot in life is just not to
cause any waves while the rest of the world thunders on: happy, brave and
almost a different species.
Some people see themselves as useless, ineffectual lumps, yet their strength
and resilience can be, in fact awesome: People who are ‘getting by’
in face of dreadful current lives; horrifyingly wounding pasts and very
bleak futures. If any helper can persuade such people that the world
is a friendly place and their problems are just minor, learning errors,
they are miracle workers.
In the experienced of some people, and their experience is all that matters,
it truly is dangerous out there and they really are pathetic and doomed
to failure and ridicule. Such feelings will not be wiped out by cheery
encouragement. Possibly they never will be wiped out completely.
In this situation, the person asked to undertake exposure therapy would
be going against his or her beliefs and experience and attempting something
frightening in itself, in order to become involved with an even more frightening
outside world as the prize for success. This double-bind is hugely
difficult; breaking it down can take a very long time and require much gentle
and slow exposure to life outside the phobic condition with proven trusted
friends or professionally trained therapists. Telling a person in this
situation that life is wonderful and that he/she doesn’t know what he/she
is missing is not only pointless but proves that the helper doesn’t truly
Even if the phobic person has no obvious problems with his or her life,
it would be foolish to assume that the phobia is not bound up with the life
situation. It may be well to understand that if people say that they
want to achieve something but, somehow, manage to avoid anything that would
make this likely, then it may have to be accepted that their real intentions
are mirrored in what they do and what results from what they do – not what
This is not great revelation about anxiety conditions. We are all
prey to this. We are all too closely involved with feeling good, or
at least not totally disgusted, about ourselves not to choose the most attractive
reasons for our actions out of all those offered as possibilities.
So it is simply that outsiders, not interested in our self-esteem, are often
in a better position to judge our motives than we are ourselves.
People don’t want to be phobic, of course. But their extreme reaction
to the phobic situation means that they have a very good reason to avoid
it. Right now, they may not be ready to do anything about the situation
– whatever they or their families say to the contrary. Helpers should,
therefore, not offer their services where these seem to be neither wanted
Helping of the kind detailed in this booklet, should never be forced on
anyone. The phobic person must make a conscious decision of his or her
own. But if any potential helper thinks that discussing these techniques
might encourage someone they know to try them, they must be ready to accept
a refusal. If they are fortunate enough to persuade the person to try,
however, they must be empathic: They have to see life as this person
sees it for the duration of the helping. Trying to fit the phobic person
into what the helper thinks he or she ‘should’ be like is dooming any attempt
at helping to failure.
This is a non-profit publication. It must be clearly understood that
none of the above is offered as medical advice and that a qualified medical
practitioner should always be consulted about treatments for anxiety disorders.
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Living with Fear by Professor Issac M. Marks M.D.
McGraw-Hill Book Company (UK) Ltd, Maidenhead, Berks, SL6 2QL
Fighting Fear by Dr Fredric Neuman
David & Charles (Publisers) Ltd, Brunel House, Newton Abbott, Devon,