If you have a phobia – be it of needles, heights, snakes or public speaking – you have likely learned to keep it to yourself. That probably has something to do with the fact that on the one occasion you quietly disclosed your intense fear of needles, everyone in the room thought it entirely appropriate to regale you with their 10 worst blood-draw experiences.
Similarly, if you disclosed your fear of flying, you probably discovered too late that the room was full of Delta’s most elite customers, all of whom had multiple tales of close-calls and near-crashes while earning their frequent-flyer miles.
But even if you’ve never experienced the who’s-got-the-worst-story-about-the-object-of-your-phobia competition, you’ve almost certainly met the well-meaning yet completely clueless individual who tells you just how irrational your fear is and why.
Given the significant lack of understanding of phobias by those who don’t suffer from them, it is no wonder that those who do often feel intense shame on top of their already excruciating and debilitating fear.
Furthermore, since the traditional treatment for phobias involves gradually exposing the phobia-sufferer to what they fear most, the vast majority of phobia-sufferers would never dream of seeking treatment. It is only when the object of their fear becomes completely unavoidable, or when their attempts to avoid it become so untenable, that initial (and brave) enquiries about treatment might be made.
In an attempt to honor the significant courage of phobia-sufferers who do dare to research treatment options available, Jane has written this page to explain how she conceptualizes and treats phobias in her practice.
The different types of phobia
One of the reasons why there is so much insensitivity around the phobias is the basic misunderstanding that they are all the same and all equally irrational. But this is not the case. In fact, there are different categories of phobia, and all are quite rational – since it is indeed quite rational to be concerned about one’s survival.
Jane believes that there are three core categories of phobia, all of which need to be treated differently. They are:
- Ancestral phobias
- Trauma-based phobias
- Anxiety-organizing phobias
Fascinatingly, there are many phobias that come down the generational line. If your mother is terrified of cats, the likelihood is that you will learn (by observing your mother’s reaction when Smokey from next door comes wandering through the garden) that you should be afraid of cats too. But generational phobias can go back much further than your mother, and may even form part of our biological instincts.
A great example is the fear of snakes. Most people who fear snakes have never encountered one in the wild, let alone suffered a life-threatening snake-bite. So where does this fear come from? If we consider that those who maintained a healthy fear of snakes in years gone by were more likely to survive long enough to bear children, we can start to speculate that over thousands of years, fear of snakes became a dominant trait passed down the generations that helped to enable survival.
Similarly, fear of heights, tarantulas, water and flying – all of which may have helped preserve the survival of our predecessors – could fall into the category of an ancestral phobia, provided the sufferer has never undergone a traumatic experience with one of these stimuli. Because there is no direct trauma, ancestral phobias frequently respond well to treatment with systematic desensitization, where the person with the phobia is gradually exposed to the feared stimulus until they are able to tolerate it without undue stress.
Trauma-based phobias are typically much more severe than ancestral phobias due to the fact that the sufferer has a first-hand experience of the feared stimulus. If you were mauled by a dog when you were four years old, it would be entirely appropriate and understandable if you then developed a life-long fear of dogs.
Similarly, if you were forced to undergo painful and frightening medical or dental procedures as a child without the necessary explanation, care and respect, you could well develop a fear of doctors, dentists, needles or hospitals.
Even if you didn’t have a traumatic experience of the medical kind, the powerlessness of lying back – often in a state of undress – while someone else gets to look, poke and prod can often evoke the memory of other unwanted physical or sexual attention that may have occurred in childhood or adolescence, making routine healthcare a significant ordeal.
Unfortunately, because the traumatic nature of many phobias is so frequently misunderstood, trauma-based phobias become more embedded every time they are confronted.
Sadly it’s not unusual for healthcare staff to be unsympathetic towards those who fear blood-draws, fillings or pap-smears, which not only causes significant shame to the traumatized patient, but also validates their fear of the procedure. Furthermore, if treatment has been historically approached from a systematic desensitization standpoint, clients often end up being re-traumatized, rather than helped, by their therapy.
For treatment of a trauma-based phobia to be effective, it is extremely important that past traumatic encounters are appropriately addressed BEFORE the feared stimulus is introduced in the present.
The third category of phobias is possibly the least understood.
These phobias manifest in issues such as fear of driving, fear of vomiting, fear of germs, fear of death, any many more ways that serve to limit the sufferer’s ability to “do” life. Typically, such phobias serve as a “hook” or “container” to help manage anxiety that would otherwise be completely pervasive and incapacitating. Often such phobias can be quite metaphorically ingenious, for example, a fear of vomiting (emetophobia) may relate back to never having been allowed to express emotion and always needing to be perfect, resulting in a persistent fear of the rejection or punishment that might happen if the real self, with all its ugly (and disallowed) feelings, were to force its way out.
It is extremely important for the treating clinician to understand the function that the phobia is serving, and to work on the underlying anxiety BEFORE tackling the phobia itself. By targeting only the phobia, the treatment might inadvertently take away the “hook”, resulting in an explosion of completely unmanageable anxiety in every area of life, or alternatively, causing the phobia to evolve into something even more debilitating – such as turning a fear of driving over bridges into a fear of driving all together.
Generally, the phobic symptoms will reduce as the underlying anxiety is treated, often serving as a useful gauge of the treatment’s success. Only once the underlying anxiety has reached manageable levels is it appropriate to tackle the incident that caused the phobia to be linked with the underlying anxiety in the first place, and work on uncoupling the automatic response.
Treating phobias in therapy
Jane’s treatment of phobias in her practice starts in the same way as any other issue brought to therapy – a genogram. This provides a significant amount of context to what the client grew up with and is bringing to life – including places where anxieties may have been set in. She will then seek to understand – in detail – how and when the phobia came about, what was the worst incident of dealing with the phobia, and how it manifests in day to day life.
Treatment starts by providing the client with a number of tools to use to manage the daily manifestations of the phobia – including Thought Field Therapy (Tapping) and learning how to identify and tolerate feelings of anxiety in the body.
Because phobic reactions are stored in the limbic system and not in the cognitive, rational part of the brain, treatment then proceeds with EMDR Therapy which looks a little different depending on whether the phobia is trauma-based or anxiety-based.
Broadly, anxiety-based phobias require greater examination of the early life of the client, including prenatal and preverbal anxieties that are felt in the body but do not have a narrative memory attached to them. Trauma-based phobias focus more specifically on the traumatic event.
Jane is extremely careful to pace the therapy so that treatment is not overwhelming or re-traumatizing for the client.
She also seeks to engender in the client a respect for the ingenuity of their phobia and how it is organized around issues of protection and survival. Not until the very last phase in the process is the client asked to imagine being faced with the phobic situation, in order that a new template may be created to deal with it.
While there are no quick fixes in working with phobias, the majority of clients see significant improvement over the course of their treatment.