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SELF-TREATMENT FOR PHOBIAS





Introduction

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 your phobia.

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 medication.

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, such as:
 
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 home?

·         being afraid of sudden illness?

·         being afraid of dying?

·         meeting strangers?

·         some combination of these?
 

      Do you fear ‘touching things’.  Is it really…..

·         that they will contaminate you?

·         that you will contaminate them?

·         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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Starting self-exposure

 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 unavoidable pressure.

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 down:

·         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.
 

Signed…………..’

 
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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The sessions

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 run.

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 behind.

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.

 
            Can’t get to the gate?               Go to the front door.

 

            Can’t 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 helper’s praise.
 
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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 it.

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 avoidance.

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 haemorrhage.’

‘If I stop piling frightening thoughts onto these feelings, they will ease much quicker.’

‘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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After Recovery

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 about treatment.

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 occasionally.

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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BEFORE STARTING
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 mind.

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 works.

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 later.”

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 phrase:

“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 elsewhere.

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 you.
 
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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 it casually.
 
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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 understand.

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 they say.

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 nor needed.

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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Book references:


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, TQ12 4PU.

 
Copyright ©2014, Anxiety Care UK