Positive Health Online

Phobia is a well known term used to describe a psychological disorder. My dictionary defines phobia as: "a compelling fear or dread, especially of a particular object or situation." The word itself derives from the Greek phobos meaning fear.

More specifically, phobias are considered to be extreme, abnormal fears or aversions to such things as crowds, heights, etc.

There are two obvious differentiations here, based on the nature of the object feared.

a) The more common phobias are an exaggerated fear of those things that everyone detests or fears to some extent, such as illness, death, night, solitude, dangers in general, snakes, etc.

b) Specific phobias, the fear of special circumstances that inspire no fear in the normal person; for example, agoraphobia and other phobias of locomotion.

Sigmund Freud was especially interested in the phobias of early childhood: fear of being alone, fear of the dark, fear of small animals, thunderstorms, etc. He theorised that these might represent the atrophied remnants of an innate preparedness against real dangers which is so well developed in other animals. However, if such childhood phobias become fixed, grow more intense, and persist into later life, then they represent internal conflicts and require professional treatment.

Further, Freud believed that "phobias do not occur at all when the vita sexualis is normal." The Freudians believe that to treat a phobic patient, it is necessary to dig into unconscious processes in order to obtain the required insight into repressed complexes which will then free the patient from the phobia. However, there are now modern methods of psychotherapy which are much more effective.

These newer treatment modalities avoid going back to childhood conflicts to seek the cause of the disorder. In fact, it is not necessary to know "why" the patient is suffering from this irrational restriction on his behaviour. Once free of the Freudian Zeitgeist, it is sufficient to seek for the situational sources of anxiety and allow for some new unlearning or relearning of obsolete responses.

For example, a patient comes in the office with a typical phobia symptom, say fear of flying. Without spending months or years delving into the cause of this particular problem, it can be resolved in a relatively short time – some therapists claim to be able to do it in 20 minutes! – but one or two or possibly three 1-hour sessions is more likely. It is not unusual for patients who have instead sought psychoanalysis as a method for treating their phobia, have often turned up in my office after 5, 8, 10 or even 12 years on the Freudian couch still suffering from the same disorder they began with. I once had the audacity to ask – "Well, after 10 years of seeing your psychoanalyst, you still complain about the original problem. What do you think of your analyst now?" The answer – "I think he's wonderful." Well, whatever it is, it's not psychotherapy.

Treatment of phobias can be simplified by using a gradual desensitisation process, via guided fantasy. Afraid of flying? Imagine you are at the airport now. OK, how do you feel? Somewhat anxious.

Focus on the anxiety, where do you feel it in your body? Not breathing.

Focus on your breathing. How is it now? Next step – you enter the boarding gate. What happens? Feel stiff, a gnawing at my stomach.

Feel that and see what happens to it. It diminishes. Now go out to the plane… Using fantasy to bring the patient closer and closer to the feared situation, all the time focussing on body processes, breathing, rigidity, etc. so that he person learns that he is doing something to himself. It's not a lightning bolt from the sky that paralyses him, but his own tensions. If he can learn to relax them, then he is ready for the next stage. Finally, he is seated in the plane, the engine fires up and thrusts. How does he feel now? A bit of anxiety but not as much as expected. Feel how you are sitting in the chair, how is your body, etc.

Naturally, this synthetic case study is a bit simplified, but most phobias respond quite well to this method. Phobic patients probably account for from 3% to 5% of all psychiatric visits, and my estimate is that 9 of 10 can be helped by this type of direct work on the phobia.

There is, however, one small complication that occasionally arises. Freud, a very wise devil at times, coined the phrase "secondary gain" to explain this phenomenon. It refers to the fact that some people prefer to keep their phobia since it serves a hidden purpose.

They can be quite disappointed if you succeed in helping them to get rid of it. My own favourite example is the psychologist who came to me for help in my early days as a practitioner. She was afraid to fly, and her family was scheduled to take a vacation in Spain that summer.

After successfully treating her phobia, she called to complain that I had ruined her marriage! She realised when cured that she no longer had an adequate excuse to avoid the vacation in Spain, and faced with the prospect of a four week holiday with her husband, she left him. The phobia had the "secondary gain" of avoiding in an acceptable way the planned vacation trip.

Sometimes the secondary gain is so great that no cure is possible. A young woman was afraid of the underground. Because of this disability her wealthy grandmother was forced to drive her around town in a splendid Audi. Naturally, no therapist could get her to give up the luxury car service for mundane travel by underground. Other patients do not want to be cured since they are receiving money from medical insurance when phobias prevent them from going to work.

It's obvious here that there is a strong personal motive not to get well. These cases, however, represent only a small minority.

I once asked a very famous philosopher-psychotherapist the distinction between anxiety, fear, and phobia, etc. He described it in the following manner: You are on a very high bridge with water below. You approach the rail, and look down. Feel a bit shaky in the knees? Yes, there is fear that you might fall into the water. Anxiety that you might jump! That's the main difference. Phobia? Then you wouldn't be on the bridge at all. Then there's existential anxiety: that is when you ask yourself, why am I on this bridge anyway? What am I doing here? What's it all about?