Phobias

Phobias are irrational fears that prevent people from being able to enjoy their lives fully. These fears are often so debilitating that they can affect careers, marriages, child-rearing as well as hopes and aspirations. Many people live for years experiencing intense frustration in their futile attempts to find either cures or means of controlling their panic reactions. Most will try anti-anxiety medication which serves to reduce the severity of their symptoms. These medications do not cure the panic but serve to control the intensity. The basic phobia has not been cured. Most patients who choose this direction can expect to remain on meds forever.

Another approach to dealing with anxiety and panic disorders is through psychotherapy or the "talking cure." There are many types of psychotherapy which attempt to deal with phobias. The most common of those treatments is Cognitive Behavioral Therapy. Like medication, this type of therapy attempts to deal with symptoms related to phobias rather than dealing with the causes.

My approach, which is psychodynamic, explores the origins and causes of phobias and attempts to remove them permanently. The first step in treatment is termed demystification. This is a process by which the patient is helped to understand where and why their phobia developed and then to use this knowledge to free themselves of the underlying fears.

The Demystification of Phobias

I work on a theory of an inverted triangle. The base of the triangle is the here and now. It reflects our current personality (our fears, our angers, our interests, our passions as well as our defenses and our coping mechanisms.) The apex at the bottom is the moment of birth.

Traditionally in analysis we start at the present and attempt to delve deeper and deeper in order to understand the influences on our personalities. My approach is quite different. I start with the birth of the child and describe the process by which phobias develop and how they manifest themselves throughout childhood and into adult life.

My basic premise is that all phobias are based on and caused by built up anger.

We are all born with anger. The first thing that we do when are born is scream and cry. We can freely let it out. If we were able to release this anger (within limits) as we grew older, we would never become phobic. Unfortunately most of us are given messages early in our lives that releasing anger is wrong or bad. As a result, the anger builds up within us. There are many places for this built up anger to surface. It is my belief that most of the symptoms that bring people into therapy are the result of built up anger.

Clearly, all children become angry with all parents. This is not because parents are bad people but just that parents are generally the first to say "no" to a child. It is not possible for parents to permit a child to do whatever it wishes all the time. Some of the things that children want to do are frequently dangerous, or inappropriate or just poorly timed. The parents will have to say "no" or "not now".

The basic question is not "Why is the child angry?" but, rather, "What does the child do with the anger?" When a child is refused permission to do something it wants to do, it will become frustrated and angry. If the child can express the anger by saying, "Mommy, I'm mad at you!" and the parent can accept the anger by saying, "I know you are angry at me", and explain the reason for the refusal, the child might still be unhappy but the anger will be released and not build up.

As I said before, it is unfortunate that children get the message that the expression of anger is unacceptable. This is communicated by the parents in a variety of ways such as physical or verbal punishment, guilt arousal or threats of rejection. Most children learn early in their lives that their parents will not tolerate direct expressions of anger and, as a result, anger builds and builds. This built up anger can manifest itself in a variety of ways, but for our purposes now, let us look at how it relates to the development of phobias.

The core of my theory about phobias is that all phobias are based on wishes. We are afraid of something because we wished for it. The child who is angry would like to say, “I'm mad at you!" but can not, so the anger continues to grow to the point where the child wishes the parent gone. This is really a death wish toward the parent. It is very rare, however, for a two year old to know death as in a coffin so" go away" really means "die."

Although the child is angry enough to wish the parent dead/gone, the child's greatest fear is the fear of losing the parent and being alone. The child, in anger, wishes the parent dead and now becomes afraid of losing the parent. The child will then become phobic about the parent disappearing. This overwhelming separation anxiety is based on the wish for the parent to "go away" and the subsequent concern that it might happen.

The child, fearing he would be alone, now becomes clingy and unable to separate from the parent.

School Phobia

The dynamic described above is the primary basis for school phobia. Contrary to the common belief that school phobic children are afraid of school, the fact is that they are afraid to leave home.

They are not afraid of school. Most are reasonably good students who get along with both teachers and fellow students. Rather than being afraid of school, they are experiencing an overwhelming separation anxiety. They are afraid to leave the parent they were angry with and wished dead/gone.

I treated a nine year old fourth grade boy who, while sitting in class, heard a fire truck racing to a fire. Suddenly in his thoughts he pictured his house burning and his mother in flames calling for help. The boy jumped out of his seat, dashed out of the roomand out of the building. He ran home terrified that his mother was dying, only to find his house intact and his mother unharmed. Despite her being okay, the boy could not bring himself to go to school after that. When he came to see me for therapy, I was able to help him to admit to and discuss his anger toward his mother. He was also able to connect with anger and death wishes toward her. Soon he came to understand that his wishes were the basis for his fears of something happening to her.

The Over-protective Parent

Just as the child's phobia emanates from its anger and wishes toward its mother, so do the mother's fears evolve from her anger and feelings toward the child. Parents of young children invariably experience toward their children. Children, at times whining, rageful and demanding, often produce feelings of helplessness, frustration and exhaustion in parents. This, in turn, will make the parents very angry. The question now becomes, "What does the parent do with the anger?"

We can illustrate the recommended healthy way of dealing with anger as opposed to the potentially phobia-producing denial of the anger. This can be seen in the case of two mothers who have infants diagnosed with colic, a digestive disorder which causes excruciating pain. The colicky baby may sleep for twenty minutes and then stay awake screaming for two hours. Needless to say, the mothers will experience sleep deprivation.

After many nights of having their sleep disrupted by a screaming infant, both mothers would be exhausted, frustrated and irritable. After being awakened in the middle of the night for the umpteenth time, both mothers would experience the impulse to smash the child against the wall.

Mother number one, who we will call the healthy mother, will say, “Oh, you little stinker, you finally got to me! She will then gently put the baby down, walk into the bedroom, nudge her husband and say, “Hey, buddy, your turn. I need a break and tomorrow we have to get some help.This mother is able to vent her anger at the child to her husband. She is able to deal with it in the moment and, therefore, it does not build up.

Mother number two, on the other hand, is so horrified and guilt-ridden by her impulse to smash the child that she instantly represses the anger. The next day, she finds herself constantly walking I to “check the baby.Her mother, sister or her friend will ask her why she has to check the baby so often and she will reply that she is concerned about SIDS (sudden infant death syndrome). This mother is now beginning to manifest the beginnings of a phobia regarding her baby’s health and safety. Since she repressed and internalized her anger at the baby, it continued to build up. The denial of her impulse to smash the child and stop it from crying became the basis for her fear of something happening to the baby. This fear, if unchecked, will become more intense and will generalize as the child becomes older. This mother will tend to hover over the child to protect it from the harm she unconsciously wished upon him as an infant.

I have treated many over-protective mothers who were not able to allow their children to experience the normal developmental stages which children go through in order to become independent adults. These parents actually stunt their child’s emotional growth. The child may either become clingy or a rebellious teenager who has to fight the mother in order to gain his own autonomy.

It is obvious that the significant difference between the two mothers was in the ability to recognize and accept the fact that, just as all children get angry with all parents, all parents have occasions to become angry with their children. The difference in how the child develops depends on the message he receives about his anger and whether parent is able to acknowledge her own negative feelings toward the child.

Revenge Fantasies

Because most children are too afraid to even wish for something to happen to their parents, they develop fantasies of something bad happening to themselves because they believe, "If you love me and something happens to me, you'll be sorry".

The child develops revenge fantasies in which the parent would suffer if something happened to him. This wish is a manifestation of their anger toward the parent.

There are three categories of revenge fantasies:

I'll die and you'll be sorry.

I'll get sick and you'll be sorry.

I'll run away from home and you'll be sorry.

It is my belief that every phobia except school phobia originates from a revenge fantasy in which the child gets back at the parents. It is important to recognize that the person does not really want to be hurt. Even if they have suicidal fantasies, the intent is not to hurt themselves. It is to get even with everyone else. "You'll be sorry".

In the most frequent of the death fantasies, a person sees himself dead in a coffin in a chapel. They see the family standing at the open coffin, filled with remorse, guilt and self recrimination. They imagine the parents crying, "Oh, dear God, if only we were nicer to him! If only we hadn’t treated him that way!" In this fantasy the person has two roles. He is both the dead person and the observer standing in the back of the chapel, watching the mourners suffer.

This fantasy is the basis for the phobia. The fear is that what they wished for would happen. The wish is to die and lie in a coffin while everyone mourns and feels regret.

The wish is to be in the coffin.

The phobia is that the coffin closes with them alive inside.

This fantasy is the basis for claustrophobia. Every patient that I have treated for claustrophobia has had this fantasy or a variation of it.

If you know the wish you can predict the phobia.

If you know the phobia, you can deduce the fantasy.

Many phobics, in their attempt to protect themselves, develop a pattern of ritual or Counter-phobic defenses. These are thoughts or behaviors which a person might use to avoid the overwhelming irrational terrors which characterize phobias.

As an example of claustrophobia and a counter-phobic defense, I recall the case of a young woman I treated many years ago. During a session, she related a question that her husband had asked. He wanted to know why his wife always scratched the bed sheets every night.

Neither she nor I had any idea why she did this, but she couldn't stop. As we delved into her childhood fantasies, she remembered occasionally being angry with her parents when they would make her go to bed earlier than she wished. She remembered lying in bed and imagining herself dead. She would hold her breath, fold her arms across her chest, and imagine a rose on her body. She would fantasize about her parents coming into her room, finding her dead and becoming grief stricken. She remembered seeing the movie "Snow White and the Seven Dwarfs" in which Snow White takes a bite of a poisoned apple and appears dead. She remembered the dwarfs mourning for poor

Snow White, till the prince kissed her and the apple fell out of her mouth. She now became afraid that if, as in her fantasy, she appeared dead, her parents would bury her alive. This bright five year old thought that if she wiggled her finger while she was asleep, her parents would know she was alive and not bury her.(Of course, she was not aware that her finger would stop wiggling after she fell asleep). This finger wiggling became her counter-phobic defense and now, more than thirty years later, she was still doing it. She just happened to scratch the bed sheets and cause her husband to raise the question.

***

In another death related phobia , a young woman remembered growing up on the fifth floor of an apartment building. When she misbehaved, her parents would send her to bed early, as many other parents have done to their children. She remembered standing at the window watching children playing in the street below. She would be angry and crying.

She fantasized opening the window and jumping. She imagined her parents devastated at seeing her crushed body in the street below. Her fantasy wish was truly an act of revenge.

However, it eventually became a phobia. She developed a rather severe acrophobia or fear of heights.

The wish is to jump from a high place.

The fear is a fear of falling which acrophobics describe as a fear of heights.

In another type of fantasy, rather than see himself dead, the child sees himself seriously ill either in the hospital or at home with parents worrying and praying for the child to get better. The child uses illness to punish the parents.

The wish is to be sick.

The fear is that what they wish for will happen.

The phobia is hypochondriasis, which causes them to imagine that every headache is a brain tumor and slight indigestion is a heart attack.

Hypochondriacal patients are forever running from one doctor to another, convinced that they are dying..

***

In the third revenge fantasy, the child does not die or become sick, but rather wishes to run away from home. In this fantasy, the parents come into the child's room and find an unslept-in bed. The parents become hysterical, fearing the loss of their child and promising never to be mean again if the child would only come home.

The wish is to run away.

The fear is of not being able to get home.

The phobia is agoraphobia.

Agoraphobia is commonly thought to be a fear of leaving home. However, this is not true. Agoraphobia, a Greek word meaning the fear of the market place, is not a fear of leaving home, but rather a fear of being out in the world and not being able to return home. Agoraphobic patients have trouble travelling distances and, in some instances, are completely housebound.

Unfortunately, although phobias generally originate in childhood, they frequently do not emerge until adulthood. This may develop slowly or might erupt as a sudden panic attack, which can be severely debilitating . An example of such a phobic reaction occurred with a forty-two year old salesman who experienced a major panic attack at an airport. As he was approaching a boarding gate for a shuttle flight, he suddenly began to feel dizzy, nauseous and sweaty. He thought he might be coming down with a virus. He went to a kiosk to get some coffee, with the thought that if he felt better he could take the next flight. As the time approached for the next boarding call, his heart began to pound.

He had trouble breathing. He thought he was having a heart attack. He called his wife and asked her to make an emergency appointment with his doctor. Then he drove himself twenty five miles to the appointment. After examining him, the doctor told him he was not having a heart attack, but rather a panic attack. His doctor referred him to me.

Upon questioning him in my office, I was able to determine that the patient had been living for many years with a low level depression. When people would ask him if was afraid because of all the flying that he did and the possibility of crashing, his answer emanated from his depression.

"Hell, no, if it's my time, it’s my time! Three-four minutes and I'm out of here."

He was not overtly suicidal, but he felt if he died, it was no big deal. As he approached his forty second birthday, his life began to improve. His income had gone up appreciably. His relationship with his wife had improved. His children were off to college. In other words, he now began to enjoy life. His fear was that, although he was not a deeply religious man, now when he no longer wanted to die, God would punish him.

The fear surfaces when the wish is no longer there.

Very often phobic patients are unable to connect with the wish that made them phobic in the first place. These wishes often surface in dreams. A dream may be considered to be a play and the dreamer the playwright. Since we write our own scripts, dreams are reflections of our wishes.

This was clearly evident in a dream, presented in therapy by a woman who was so terrified of violence that she would not see any movies that contained even the slightest hint of aggression or violence. Her husband and children would pre-screen her movies and television programs in an attempt to protect her and help her avoid a panic attack.

One day some of her friends decided that they were going to try to behavior modify her by attempting to desensitize her. They thought they were being helpful and recommended the movie "Clockwork Orange", which had just been released.

Neither she nor her husband had any idea about the movie. The title sounded benign.

Trusting their friends, they went to see the movie. Within the first ten minutes of the film, there was a particularly violent rape scene. The woman immediately experienced a severe panic attack and bolted out of the theater. Her husband was furious with their friends, confronted them angrily, and left to take care of his wife. When he reached the back of the movie theatre and couldn't find her, he assumed that she was in the ladies’ room. After waiting for some time, he asked someone to check on his wife and was told no one was in there. He ran out of the theater and found her in an alleyway, crying hysterically, vomiting and shaking like a leaf. They decided at that point that her panic attacks were getting out of hand and that she should enter therapy.

After several sessions, I suggested to this woman that beneath her sweet, gentle façade was a violent, angry, raging person. Totally disbelieving and not able to fight with me, she said in her characteristically mild voice, "No, doctor, you are wrong. It couldn't be that. I'm not angry." She totally denied any anger until one day she came into a session with the biggest grin on her face. When I asked her about the grin, she said, "Doctor, you might be right" and told me of a dream that she had in which she was standing with a machine gun in her hands, firing bullets and cutting two men in half: first her father and then her husband. Would you think that she was just a wee bit angry?

You can fool yourself for awhile, but you are not going to fool yourself forever.

Our dreams express our true wishes. In this case, the woman, through her dreams, was able to confront herself with the cause of her panic attacks. She was afraid of her own rage … her violence… and hid it from herself. It explained why she had such an aversion to witnessing violent acts and why she always resisted expressing extremely angry feelings.

Defenses vs. Phobias

Most people who have phobias do not seek treatment. There are literally millions of people who experience chronic fears and attempt to cope with them through various types of ritualistic behaviors. They develop superstitions like knocking on wood, not stepping on cracks in the sidewalk, avoiding black cats, etc. in order to prevent "something bad happening." These behaviors are meant to protect the person from harm.

For most, the belief in these superstitions is enough to avoid debilitating anxiety and the behaviors do not really interfere with their lives. On the other hand, there are many people whose lives are encumbered by time and energy-consuming obsessive-compulsive behavior. While compulsions are physical behaviors like tapping or blinking, obsessions are thoughts that one must have in order to feel safe. Obsessions would include counting, praying, or reciting.

An example of obsessive-compulsive behavior can be seen in the case of an eleven year old girl who became fearful of "something bad" happening to her parents. Her compulsions started with her having to brush her teeth a certain number of times on each side of her mouth. Soon she also had to stand on her right foot while she brushed the right side, then on her left foot while she brushed the left side. Later she had to brush her hair a certain number of times. Then she felt she had to wipe herself the same number of times. The rituals eventually came to include having to turn her window shade pulls a certain number of times. The routine extended out to having to turn her dolls and books a progressively greater number of times. These rituals eventually took over an hour of time each evening. They began to interfere with her bedtime as well as her homework schedule.

The girl's parents decided to seek help when the night came that she lost count, became hysterical and insisted that she needed to begin the rituals again. In therapy, the girl was able to understand that the fear of harm coming to her parents (and the rituals she needed to perform in order to protect them) were based on the anger she felt toward them.

She had repressed much of her built up rage and her fantasies in which she wished to kill her parents.

The wish was to kill her parents.

The fear was that something bad would happen to them.

To ward off the panic at the thought of losing them and being alone, she developed her counter-phobic rituals. Her magical thinking was based on the belief that her rituals would keep them safe.

***

A five year old child was referred because of an overwhelming fear of robbers. He would no longer sleep in his own room and insisted on sleeping in his parents' bed. The fears became so intense that he could not even walk to his room to get his toys. When questioned by his parents about what the robbers would take, he would say, "They are going to rob me." The parents, in their attempt to reassure the boy, would promise that they would replace whatever the robbers took. He would scream, "No! They are going to rob me!". As I listened to him, I realized he did not know the word "kidnapper" and therefore, when he said the robbers were going to rob him, he meant that the kidnappers were going to take him away. The boy agreed and said, “Yes, they are going to rob me!".

The parents, who were in the session, remembered their son running into their bedroom screaming after he had a nightmare about robbers. Apparently, the boy had had a dream about being kidnapped.

We now had to find out why the boy was so fearful about being kidnapped. When I began to question him about what he did when he was mad at his parents, he responded,

"I don't get mad at Mommy or Daddy." I asked him what he would do when his mommy or daddy made him go to his room after he misbehaved. He said he would "cry and want to run away." When I asked him about what his mommy or daddy would feel if he ran away, he said that "they would be sad". This was his revenge fantasy. It was his way of punishing his parents for sending him to his room. I helped him to understand that he really was angry at his parents and wanted them to be sad, but that he also felt guilty about hurting them. I helped him to understand that when we feel guilty, we expect punishment and that since he wanted to run away, now in his dream, the kidnappers were going to take him away.

Therapy with young children generally progresses much faster than with adults, because there are fewer layers to unpeel. The relief which this young boy felt was immediate. The therapy then focused on helping the boy and his parents to deal directly with anger. The boy was encouraged to tell his parents when he was angry and the parents were encouraged to take the boy seriously when he was angry and to discuss and resolve the issues which made the child angry in the first place.

A Note About Nightmares

Nightmares in young children should be taken seriously, especially if they are repetitious. Since dreams reflect wishes, much of the child's anger is acted out in their dreams. These wishes frequently produce guilt which is then followed by a need for punishment. If unchecked in childhood, these punishment needs can later evolve into phobias of all sorts. These phobias will often be followed by rituals, superstitions, and various forms of coping behaviors which people develop in order to function.

One of the goals of therapy is to enable children to verbalize their anger to their parents. It is, therefore, imperative for parents to understand the importance of encouraging their child to confront them, rather than to repress the anger, and face the possibility of dealing with phobias later on.

Rather than being angry or hurt when a child says "I hate you" or "I'm mad at you," parents would be well advised to acknowledge the feeling and explore the reasons. This could very well save the child a lot of pain … and the parents a lot of money for therapy.


copyright 2007 - Dr. Gerard Bomse - All Rights Reserved - duplication and re-publishing prohibited without consent from Dr. Bomse (drbomse-at-gmail.com)
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