Many people suffering from phobias attempt to pursue the course of greatest safety being preoccupied with security. Inner emotional conflict and anxiety are not dealt with. Disturbing sexual thoughts or aggressive impulses are repressed (i.e. ‘Out of sight out of mind’). However when the defense mechanism of repression begins to fail, trouble ensues.
For example, let’s explore the phobia of an obsessive personality. Obsessives deal with the ambiguities of life with an urgent need to control. They’re often preoccupied with details and usually miss the bigger picture. Many are workaholics, overly dutiful and miserly in giving affection to themselves and others. There is tremendous conflict surrounding the issues of obedience vs. defiance. With the obsessive-phobic there is an avoidance of aggression. When analyzing a man, who has a phobia of knives, we find that he harbors tremendous anger and aggressive impulses towards his wife, but becoming conscious of this rage is too dangerous because he is also dependent on her. As he doesn’t want to become conscious of his aggressive impulses he displaces these fearful thoughts onto a knife. As long as he avoids a knife, he doesn’t have to deal with his aggression as the anxiety is confined to a specific object (i.e. a knife). The defense mechanics of displacement and avoidance are always part of phobias.
Outside of aggression, another dangerous impulse some phobics attempt to avoid centers around sexuality. For example, the young woman who was phobic about going anywhere by herself. Initially she wasn’t sure of what she was afraid of. Weeks later she expressed concern over a man possibly making sexual advances towards her. Months later she revealed that she is afraid she might not decline those sexual advances. In other words, as long as her phobia kept her from going anywhere by herself, she would not have to deal with her ‘dangerous’ sexual impulses. The origins of this phobia led back to a fanatical religious upbringing, which is always abusive. Outside of the defense mechanism of displacement and avoidance, this also included the defense of projection, as she projected her own sexual desires unto men in her environment. Many train and subway phobias have similar dynamics.
Agoraphobia comes from Greek and means ‘Fear (phobia) of the marketplace (agora)’. It is a very crippling condition because these patients are housebound, always fearing the unpredictable and losing control. Many are aware of the absurdity and irrationality of the symptoms leading to problems with self-image and esteem. Panic attacks, severe depression and sometimes addiction to prescription drugs can accompany this phobia. This condition might be related to fears of abandonment and separation anxiety incurred early in life.
Sometimes this phobia occurs in dependent personalities, who manage anxieties by avoiding decisions and commitments and who surrender personal integrity in order to receive crumbs from someone they depend on. There can be an ‘advantage to being ill’, because if one assumes the role of the afflicted one, one can avoid any stressful demands. One can also express hostility through demanding services and sacrifices of others. As the patient’s fear of anxiety is highly contagious, the partner who accompanies the patient might have accepted the patient’s belief that anxiety must be avoided at all cost. As the agoraphobic gets better, the partner might sabotage the progress and then needs to be included in the therapeutic enterprise.
Acrophobia (fear of heights), like all phobias, can have many different origins and dynamics. In one woman’s case the fear of heights at bottom symbolized her fear of losing ground and anchoring if she openly explored her talents. She feared her own heights and the risk of believing in herself. To act and pursue her true vocation would be to step out, unsupported and possibly risk failure, rejection, humiliation or worse and fall from the heights into a bottomless void.
Historically, it is not unusual to uncover phobic patients having a phobic parent or grandparent, who offers a phobic pattern for the patient to imitate. Phobic individuals learn as children that the universe is an unpredictable and frightening place, either through their parent’s timidity or their explosive or violent outbursts. They overestimate both the dangers of the outside world and of the inner world of anxiety. This exaggerated fear of anxiety is related to either neglect or over-protection by a parent. It can be very harmful for a parent to totally refuse to let a child out of sight, to restrict contact with new people or to deny sexual or aggressive impulses.
When the time is right it is very important to encourage a child to go to camp. Overemphasizing the dangers of bullies, for example, can actually provoke bullying behavior by classmates because of the child’s timidity. One of the major tasks of parenting is to help the child develop a normal tolerance for anxiety. We grow through facing and not running away from anxiety. Tolerance for anxiety is an absolute pre-requisite for change and positive growth.
One of the first hurdles to overcome with phobic individuals is their expectation of a ‘magical cure’, which obviously does not exist. They have to fully and actively participate in treatment, by being willing to consciously enter arenas in their psyches they’ve avoided all their lives. Sometimes medication is helpful, but only if it increases the range of activity and allows patients to enter anxiety-provoking situations. Medication can be harmful if it is prescribed to alleviate normal anxiety, as the phobic is at high risk to become dependant without improving the phobic condition. At times, phobic patients become depressed after the initial stages of treatment. If this depression is related to them giving up their dependant gratifications, this is progress, as the depressive mood will lift as soon as they attain more inner authority.
The refusal to enter anxious arenas becomes one of the most difficult tasks in working with phobics. They will instinctively run and bail out of ‘forbidden arenas’- yet it is the task of the therapist to take them exactly into that turf. Sensing the amount of anxiety that a phobic patient can tolerate is a major challenge to the craft and art of psychotherapy.
Dr. Peter Milhado © 2011
