CHAPTER
15

Self-Help for Phobias

In This Chapter

• Learning to recognize phobias and how they interfere
• The difference between simple and complex phobias
• The role of body and mind in maintaining phobias
• Using systematic desensitization to cure phobias

Howard Hughes grew up during a time when mothers didn’t let their kids play in rain puddles because of fear of the polio germs they thought might lurk there. His mother was especially cautious; she constantly worried about Howard’s exposure to germs, was extremely careful about what he ate, and checked him daily for symptoms of disease.

Howard’s fear of germs grew throughout his life. As an adult, he once wrote a manual on how to open a can of peaches. The manual included instructions for removing the label, scrubbing the can down to its metal, washing it again and pouring its contents into a bowl without letting the outside of the can touch the bowl.

Howard Hughes was creative and brilliant. He grew up to be an acclaimed airplane pilot, a movie producer, and a billionaire business tycoon. And yet, as anyone who has seen the movie The Aviator can attest, Howard Hughes is often remembered as the fear-controlled recluse who spent the end of his life in darkened hotel rooms.

Howard Hughes’s problems were complex; he had chronic pain, an addiction to codeine, and apparently severe obsessive-compulsive symptoms. Yet his fear of germs powerfully illustrates how strongly a phobia can grip a person. In this chapter, we explore phobias: how they develop and what you can do to overcome them.

Phobias Are Common

A simple phobia is an irrational fear of a situation, event, or object coupled with a strong need to avoid whatever it is. Most of us know someone who is deathly afraid of spiders or who can’t stand high places. Some of the most common simple phobias are of closed spaces (claustrophobia), heights, water, snakes, or lightning.

A phobia is different from panic disorder (discussed in Chapter 14), even though you may experience panic when faced with the thing you fear. With panic disorder, the fear is of the anxiety symptoms themselves or of losing control. In phobia, it’s the actual object or situation that you judge to be dangerous, even when you know it’s irrational or out of proportion.

Faced with a “danger,” it makes sense that you’d want to avoid that which you fear might harm you. Unfortunately, this avoidance only strengthens the connection between your fear and the object of it and, depending on how often you need to encounter it, can significantly disrupt your life.

Imagine you get a big promotion at work, but this means you’ll need to fly frequently, and you’ve developed an aversion to flying after a harrowing experience on a red-eye flight. Canceling an important trip at the last minute may seem reasonable at the time, but it can lead to your being considered unreliable at work.

Specific or simple phobias such as these may develop rapidly or build up over time. A car accident can suddenly trigger a driving phobia, particularly in a victim who was genetically or environmentally predisposed to anxiety. It’s probably no surprise that flight attendants are more likely to develop a fear of flying than someone who rarely flies; fly often enough, and you’re bound to encounter some scary (although usually not dangerous) turbulence. Phobias may also develop gradually from learning and observation, as in Howard Hughes’s mother’s fanatical focus on the avoidance of germs.

Complex Phobias

Whereas a simple phobia has just one object—such as insects, dentists, or heights—complex phobias are made up of multiple fears. For example, agoraphobia involves a whole network of them. There is the fear of entering shops, crowds, and public places. There may be fear of traveling alone in trains, buses, or planes. On top of all this is the fear of what might happen if you are unable to get yourself to safety (home) right away. The more this phobia develops, the easier it seems to just stay home.

Social phobia is another complex phobia, marked by fear of performance or interactional situations. However, this might include any number of situations and fears. You might be afraid of embarrassing yourself or of someone else humiliating you. You might worry that you’ll forget how to talk or behave. Some people with social anxiety have trouble eating in front of others; others shy away from parties and public speaking. So even though there is the general fear of social situations, what this means for each social anxiety sufferer can differ. In extreme cases, people can end up in almost complete social isolation.

Even seemingly straightforward phobias are often complex. The fear of flying, for instance, almost certainly involves the fear of crashing. However, it can also involve a fear of closed spaces (you can’t walk off an airplane at 30,000 feet when you feel closed in) or be part of a more general fear of heights. Part of the treatment for complex phobias involves peeling away the onion: uncovering and addressing all the underlying fears that make up the phobia.

MYTH BUSTER

“My phobia will just go away on its own.” Whereas childhood phobias often disappear over time, only 20 percent of adult phobias fade without any direct steps to tackle them.

What Causes Phobias?

We don’t know exactly why some people develop phobias and others don’t. According to genetic research, though, it seems likely that some of us are genetically predisposed to intense, irrational fears.

For those of us who have this built-in sensitivity, certain circumstances make developing a phobia more likely. Most phobia sufferers can identify at least one of following.

A Frightening Experience

Maybe you got bit by a spider and were sick for a few days. Maybe you suddenly felt dizzy while looking at the view from the Willis Tower. Maybe your childhood pediatrician didn’t realize that a 12-year-old girl would be humiliated because her father saw the rash on her chest. People who can identify a specific incident that either triggered their phobia or made it worse consistently describe it as personally threatening (although not necessarily dangerous) and as feeling out of their control.

Observation

Elizabeth was 6 when her 3-year-old brother was hospitalized for suspected leukemia. To keep him from walking on his stiff leg, nurses placed him in a playpen with a net on it. She vividly remembers seeing her beloved brother screaming to get out and clawing at the top of the net; while her fear of doctors did not peak until she went through a period of stress as an adolescent, she traces the seeds back to this memory.

For Howard Hughes, his mother’s fears and their impact on her parenting appear to have contributed to his developing a full-blown germ phobia. Your brain often can’t tell much difference between what you experience and what you imagine experiencing, a blessing when you start curing your phobias but a curse when you imagine the worst.

Other Problems Linked to the Feared Object/Event

It wouldn’t take many panic attacks while driving to become afraid of getting behind the wheel. Individuals with panic attacks often develop fears of the situations in which they happen. This is probably particularly true for situations from which it’s difficult to escape (for example, driving on busy interstates without anywhere safe to pull over).

A Stressful Time

A fearful thought or event packs a bigger wallop if it occurs during a stressful period. Not only do traumatic events often trigger the development of specific phobias (of specific locations, objects, or situations), but stress can make phobias worse or harder to address.

Reinforcement by Physical Symptoms

So what tips the scales from a normal level of distress to a full-blown phobia? First of all, with a genuine phobia, the fear you feel is far out of proportion to the reality. For example, it’s normal to feel some anxiety when driving late at night on a foggy, unfamiliar road. On the other hand, if I’m so afraid of driving through a tunnel or over a bridge that I would drive miles out of the way to avoid one, the fear is out of proportion to the risk.

ANXIETY ATTACK

Phobia sufferers often pay attention to information that reinforces their fears and overlook contrary data. One way to counteract this tendency is to study accurate information about your fear: How often do elevators really fail? What are their safety standards and emergency procedures?

Another difference between normal fear and a phobia is the way the body reacts to what you’re afraid of. If you’re like many with phobias, you experience the same “fight or flight” response you would if you were in a life-threatening situation. Your adrenaline rushes, your heart pounds, and you wind up feeling panicked.

Perhaps in response to the unpleasant physical and emotional symptoms, you then find yourself worrying about any possible encounter with the feared object—or anything associated with it. For example, a person with a fear of dogs may become anxious about going for a walk because he or she may see a dog along the way.

Unfortunately, this becomes a vicious feedback loop. When you remember a bad experience you had with a mean dog, your body can trigger the same emergency signal as when you were running from the dog. Your alarm goes off when you worry about it happening again. In fact, your mind often retrieves past events associated with strong negative emotion; even if you’re taking a leisurely bath in the comfort of your own home, if you start “seeing” yourself around dogs, your body will produce anxiety symptoms. In other words, your body responds to that imagery almost as if the event were happening again.

ANXIETY ATTACK

If the slightest phobia-related thought sends you into a panic, or if your phobia is causing significant disruptions in your life, it may be time to seek professional help.

Reversing the Vicious Cycle

So how do you turn this energy-draining cycle around? One way is through a process called systematic desensitization. Systematic desensitization was developed in the 1940s by a clinician named Joseph Wolpe, who found that he could use relaxation techniques to change his patients’ responses so that they no longer experienced irrational fear when faced with certain situations. Although initially used with the help of a therapist, Wolpe’s method has proven to be a very effective self-help strategy for phobia sufferers.

Systematic desensitization is a process whereby you gradually expose yourself to the things or situations or events you fear the most. The thinking behind it goes like this: a phobia is basically an irrational fear you have developed because you have learned to associate something bad (pain, fear) with the object of your phobia. Why not learn something else by pairing a different response (relaxation) with the phobia?

On a practical level, this involves three steps:

1. Becoming good at relaxing—for example, practicing breathing techniques until you feel confident that you know how to calm your body down.
2. Creating an anxiety hierarchy, making a list of frightening situations related to the phobia and ranking them in order of how frightened you would be facing them.
3. Gradually progressing up the ladder, starting with a less frightening situation and, over time, making your way to the top.

With sufficient repetition through practice, an imagined situation loses its anxiety-provoking power. At the end of training, the real thing will also have lost its power to make you anxious. In this chapter we focus on imaginal exposure (systematic desensitization), but note that the same principles work for exposure in real situations (if practical).

ON THE CUTTING EDGE

New research suggests that phobias can be successfully treated with internet-guided self-help. Successful help most often includes guided exposure exercises with backup telephone assistance from a clinician.

Overcoming phobias is not easy. Remember us talking about motivation in Chapter 4? The hardest step in overcoming a phobia is the first one: developing the commitment to see it through. To develop that kind of commitment, your determination must be voiced in terms of what you hope to get out of it.

It’s often not helpful to tell yourself things like “I don’t want to be afraid of heights anymore.” That is, there’s a lot more power in focusing on what you do want. If you have a phobia of flying, think about what you have to gain by overcoming this fear. If flying is a necessity in your profession, there are financial and career incentives. You can take faster, more exotic vacations if you travel by air. You can even focus on the increased safety of flying over other forms of transportation; it’s the safest way to travel. Steadily focusing on the positives—and developing concrete rewards as you succeed—can help you take the first step up the desensitization ladder.

Let Anxiety Come

When you resist anxiety symptoms, they often persist. For example, when your internal alarm system goes off as if it is needed to protect you, struggling against it only increases the symptoms you want to let go of. Instead, when possible, you should welcome them. Your body and emotions will acclimate to the situation.

You might tell yourself, “It’s okay I’m feeling this way. In fact, I expect to be nervous right now. I can handle this.” The point is not to talk yourself out of your feelings, but rather to just let them be there. Don’t hold them at bay, and don’t obey them, either. Just notice them and remind yourself that it’s okay to feel nervous. Feeling nervous is uncomfortable, but it won’t actually harm you.

Then while you allow your feelings just to be as they are, you move on to the next step. You breathe.

ANXIETY ATTACK

Regaining a sense of control is critical in dealing with many phobias. If you have a dental phobia, for example, select a dentist who will go slowly, offer treatment options, and allow you to call for a break at any time.

Allow Yourself to Relax

“I was in the dentist’s chair for three hours. If I hadn’t had my breathing exercises … I would have jumped out of that chair or had a panic attack. I did not have a panic attack, and I was so much more comfortable when I had something to do.”

We all have a tendency to hold our breath when we’re frightened. In fact, many of us are in the habit of breathing more shallowly than our bodies would like. The problem is that shallow or erratic breathing can feed anxiety. Conversely, learning to breathe properly can be a valuable tool, especially as we work up our nerve and begin to approach our fears.

Learning to breathe properly, and practicing various relaxation methods, is like the training before a marathon. It’s what gives many of us the courage to sign up for the “big race,” it helps us stay in tough situations during the process, and it helps us regroup after a practice session.

There is a ton of relaxation and breathing exercises; it doesn’t matter which ones you choose as long as you stick with them. Here are a couple to get you started.

MYTH BUSTER

“Systematic desensitization works equally well for any phobia.” In fact, systematic desensitization is more effective for simple phobias than for more complex ones like social phobia or agoraphobia.

Calming Counts

This breathing technique takes about 90 seconds to complete, during which time you should focus on counting. In addition to giving your mind a break, your body has a chance to relax.

1. Sit comfortably.
2. Take a slow, deep breath and exhale slowly while saying the word relax silently.
3. Close your eyes.
4. Allow your body to take 10 easy breaths. Count down with each exhalation, starting with 10 after the first breath, 9 after the second, and so on.
5. While doing this comfortable breathing, become aware of any tension in your body and imagine it loosening.
6. When you say “1” on the last long, deep breath, open your eyes.

ANXIETY ATTACK

Learning to control your breathing is one of the best ways to relax.

The Ten-Second Grip

This is a relaxation technique that helps you let go of tension in your muscles. When you tense your muscles on purpose, it’s easier to let the tension go.

1. While seated in a chair with arms, grab the armrests and squeeze them as hard as you can to tighten your lower and upper arms. Tense your stomach and leg muscles, too.
2. Hold that contraction for about 10 seconds, still breathing.
3. Let go with a long, gentle, calming breath.
4. Repeat steps 1 through 3 twice.
5. Now loosen by moving around in your seat. Shake out your arms, shoulders, and legs, and gently roll your head around.
6. Close your eyes and breathe gently for 30 seconds. Enjoy letting your body feel warm, relaxed, and heavy.

These skills work to the degree that you concentrate on them. The trick is to stay in the present moment, concentrating on the breathing exercise, and replacing any negative thoughts with thoughts of counting and loosening.

Arrange Your Fears in Order

Let’s say you’re motivated, accepting, and able to relax. Now it’s time to begin dissecting your phobia by developing a “hierarchy of anxiety.” Start by listing 15 to 20 scary but objectively safe situations related to your phobia, then rate them from 1 (relaxed) to 100 (terrified) in terms of how scary they are. Finally, reorder them so that the most frightening situations are at the top of the hierarchy.

The situations on your list will most often be those that you have actually experienced. However, they can also be situations that you’re afraid of even though they have never actually happened to you. For example, you may want to include “Having to wear the oxygen mask during a flight” even though this has never actually happened to you. The important point is that items included in an anxiety hierarchy describe situations that produce varying levels of anxiety, some more fear-inducing than others; this is what we mean by the term hierarchy.

STRESS RELIEF

If you have a fear of plane crashes, limit your news watching and newspaper reading. Media coverage of airline crashes and catastrophic car collisions can skew your sense of the relative danger involved in these modes of transportation.

Describe the items on your anxiety hierarchy in sufficient detail to enable you to vividly imagine each one. It might be sufficient to say, “Standing in line at the ticket counter,” but it might be more graphic to say, “Standing in a long line at the crowded ticket counter, with nothing to do but wait to get my luggage checked.” Remember that items are most effective if they can help you experience the event in your imagination, not just describe it.

The following is a sample hierarchy worksheet to help you develop your own hierarchy. Your items should, of course, be more fully detailed. For the sake of convenience, these items are ordered temporally in terms of what might happen for a particular flight, not by what would be most anxiety provoking.

Anxiety Hierarchy Worksheet

(1 = least anxiety-arousing; 100 = most anxiety-arousing)

As you start listing your feared situations, it’s normal to feel some unease. Just remember that you can let these feelings be what they are and practice your new breathing skills, even as you move forward in this next step.

To create the actual anxiety hierarchy, re-order the items so that the most anxiety-provoking one is on top, and the least anxiety-provoking is at the bottom. The following anxiety hierarchy could be used for imaginal systematic desensitization, moving from the bottom of the hierarchy to the top. For this particular phobia, exposure in imagination is more practical than exposure in real life (that is, you may never experience an emergency landing, and you can’t actually land before taking off).

Anxiety Hierarchy

(1 = least anxiety-arousing; 100 = most anxiety-arousing)

ANXIETY ATTACK

As a general rule, systematic desensitization practice sessions should last no more than 30 minutes and should tackle no more than three items on your list.

The Three R’s: Reintroduce, Refocus, and Repeat

Self-administered systematic desensitization consists of seven steps. These steps should be repeated—in order—for each item of your anxiety hierarchy:

1. Use your favorite relaxation technique to create a state of calm.
2. Read the appropriate item from your hierarchy. (In the first session, this is the bottom item in the hierarchy. In all other sessions, this is the last item from the preceding session.)
3. Imagine yourself in the situation for a tolerable time. (Start out slowly and work your way up until you can tolerate at least 30 seconds of exposure. This might take more than one practice session.)
4. Stop imagining the situation and determine the level of anxiety that you are experiencing (on a 0–100 scale). Reestablish your relaxation again and relax for about 30 seconds.
5. Reread the description of the situation. Imagine yourself in the scene for a tolerable time.
6. Stop and again determine your level of anxiety. If you are still experiencing anxiety, return to step 2. If you feel no anxiety, go on to step 7.
7. Move on to the next item of your hierarchy. Repeat the above procedure for this next item, beginning with step 1.

Experiment with your hierarchy, fine-tuning the level of anxiety each item generates to make it challenging enough but not overwhelming. If your first few items don’t cause any anxiety at all, perhaps you’re not imagining the situation vividly enough or for a long-enough time period, or perhaps the situation would not be particularly anxiety provoking in real life. If an item is still terrifying after several cycles, maybe this item should come later in the hierarchy and be assigned a higher anxiety rating.

It may be tempting to rush up that list, but stick with each item until you’re comfortable with it. End each session with several minutes of relaxation. This process is not complicated, but it requires persistence. When you become bored or discouraged, it’s okay to take a break, but aim for a minimum of two practice sessions a week.

ANXIETY ATTACK

Be practical. If you have a rational fear of crashing your car, lower your odds of having an accident or getting hurt in one by driving a car known for safety. If you fear poisonous snakes, keep an emergency or poison control phone number handy.

In this chapter, we’ve discussed an effective phobia self-help technique. Developing strong relaxation skills and slowly pairing them with the feared object or event can help you face long-avoided situations. But what if the object of your fears isn’t so simple? In the next chapter, we explore the most common complex problem, social phobia, and how you can use what you’ve learned in this chapter to get a leg up in reducing your social anxiety.

The Least You Need to Know

• A phobia is an intense, irrational fear coupled with a strong desire to avoid the object or situation that triggers the fear.
• Phobias can develop suddenly, often after a bad experience with the feared object or situation, or they can be learned gradually.
• Simple phobias involve only one fear, whereas complex phobias involve a collection of related fears.
• People are more likely to develop a phobia during periods of prolonged stress, especially if they already have a built-in sensitivity to fear.
• Systematic desensitization involves learning to associate a relaxation response with the object of your phobia.