Fears, phobias and furry animals
15th August, 20110 Comments
A literature review on some models of, and therapeutic options for, Phobic Anxiety Disorder
So what actually is a phobia? DSM-IV lists phobias under the topic of Anxiety Disorders and separates the sub-topic out into Simple Phobia, Social Phobia and Agoraphobia.
From the client’s point of view it can be a slight inconvenience that may be the trigger for a minor anxiety episode not of clinical proportions and may indeed result in light hearted banter between friends. At the other end of the spectrum, Phobic Anxiety may be at a level that manifests as a disabling condition with a devastating effect on social life, general health and the ability to hold down employment.
From the Psychotherapist’s point of view, to some extent, the answer to the question what is a phobia depends on the psychological model or paradigm that you choose to work with. For instance psychoanalysts tend to focus on the content of the phobia so interpreting the phobic object as a symbol of a repressed unconscious fear. Behaviourists on the other hand may focus on the function of the phobia with all phobic objects having equivalence in the means by which they are acquired.
However, if we separate out the common elements from the many definitions on offer we can come up with a reasonably global definition that satisfies most practical needs.
1. The term. As we probably all know, the word Phobia is derived from the name of the classical Greek god Phobos (son of Ares and Aphrodite) who employed the weapon of fear or terror to subdue his enemies. It has become an etymological convention that a name for a specific phobia will have the word phobia preceded by a Greek word that illustrates the problem.
For example the fear of spiders has become known as Arachnophobia from the Greek terms Arachnid and Phobos. However, in the vast list of phobias that have attracted names so far some do not follow that etymological convention and use descriptors that have their roots in Latin, French or even English.
An example of this convention is the irrational fear of being alone. If following the convention the term should be eremophobia: however, this particular fear is often referred to as either autophobia or monophobia both of which have Latin roots.
Having said that, custom and practice actually allows us to create a name for a fear of any object or situation that we care to think of. All we need to do is add a suitable descriptor with a Greek or Latin root to phobia and we have a name. However, the fact that a fear has been named and that name has been accepted by the scientific community does not mean that there is a universally accepted understanding of the phobic condition.
2. The condition.
- Simple (Specific) Phobia: “Any persistent fear of a specific object or situation. Social Phobia and Panic Disorder are excluded from this definition. . . .”
- Social Phobia: “An Anxiety Disorder marked by a persistent fear of particular social situations in which the individual is subjected to possible scrutiny by others and fears that he or she will act in some way that will humiliate or embarrass”
- Phobic Character: “A psychoanalytic term for an individual who tends to deal with difficult or anxiety-provoking situations by adopting the simple expedient of avoiding them, usually by restricting his or her activities in life and seeking a protective environment.” (Reber & Reber)
From a psychopathology point of view a phobia may be defined as: “. . . a disrupting, fear-mediated, avoidance out of proportion to the [actual] danger posed by a particular object or situation and, indeed, recognised by the sufferer as groundless.” (Davison & Neal)
Phobias: The Psychodynamic Model
Gross tells us that according to psychodynamic approaches, neurotic symptoms are described as compromises between the opposing demands made on the Ego by the Id and the Superego. Symptoms (as with dreams and defences) are expressions of the conflict arising from such opposing demands as well as the attempts by the Ego to deal with them.
According to Davison & Neal, Freud is regarded as being the first to employ a systematic approach to the understanding of phobic behaviour. Freud considered that phobic behaviour is a defence mechanism that protects against the anxiety produced by repressed Id impulses.
In his model of phobic response the anxiety in such situations is displaced from the Id impulse that is subconsciously feared by the phobic individual and is transferred to an object or situation having a symbolic connection with that Id impulse.
These objects or situations then become the phobic stimuli or triggers and so, by avoiding them, the individual deals with the repressed conflict(s). Following the Freudian model then, the phobia is the Ego’s mechanism for dealing with potential confrontation with the “real” problem i.e. a childhood conflict.
Another interpretation of the origin of phobias from the psychodynamic point of view is given to us by Gabbard. He considers that the psychodynamic understanding of phobias is an illustration of “symptom formation”.
He illustrates that by going into detail about the nature of the consequences of forbidden sexual or aggressive thoughts, that may lead to retaliatory action, threatening to emerge from the unconscious. When this occurs “signal anxiety” is activated or triggered which leads to the engagement of certain defence mechanisms: Displacement, Projection and Avoidance.
These defence mechanisms work to protect the individual by again repressing the forbidden wish that had become a threat. However, in so doing, the anxiety has been controlled at the cost of creating a new “phobic neurosis”.
One of Sigmund Freud’s case studies gives us some insight into the psychodynamic model of phobias: that of Herbert Graf, perhaps better known as “Little Hans”, the young son of Max Graf who was a pupil / associate of Freud’s.
Hans had developed a dread of horses and his father had sought the opinion of Freud through correspondence. The first manifestation of the phobia appears to have been when Hans was walking with his nurse-maid; a horse-drawn van had tipped over, frightening the boy. He had reacted by saying that he wanted to go home to be comforted by his mother.
After this event he became reluctant to go out of the house saying that he was afraid that the horse would bite him. Some time later he expanded on the explanation of his fears saying that he was afraid of the black things around the horse’s eyes and mouth.
Freud interpreted this as Hans’ oedipal desire to have his father go away so that Hans could possess his mother. Hans’ father was considered by Freud to be the source of his son’s fear which was then transposed onto a symbol of his father – horses. The black things were interpreted as spectacles and a moustache such as those worn by his father.
Blum gives us another interpretation of this case. In the original case study Freud and Graf had concentrated on oedipal and incestuous theories for the development of the fear. However, at a much later presentation to his ‘Wednesday Group’, Freud expounds a very different view of the case: the child’s unconscious aggression towards his mother.
According to Blum this is now seen as a critically important aspect of the case. He theorises that the hostile aggression of Hans may now be regarded as being exacerbated by the reciprocal aggression of his mother towards himself, his siblings and his father.
Blum goes on to say that Hans was very fond of his parents and that his father had played horse with him: thus, from a contemporary point of view, Han’s fear of his father was partly a displacement from his fear of his mother’s aggression, and his own aggression towards his mother.
And so it would seem that, from the psychodynamic point of view, phobias are the observable results of unconscious causes. Using this model then if we consider an individual with a phobia, that person is afraid of giving way to the urge or temptation to express, or act upon, deeply rooted forbidden impulses.
So we see from this that anxiety signals the danger and that the phobia then protects the individual in situations where repressed aggressive or erotic urges are aroused by employing avoidance tactics. Hence “. . . these powerful temptations are fended off by displacing the anxiety they provoke (signal anxiety) onto some associated object”
Phobias: The Behavioural model
The central tenet of the behaviourist view is that phobic reactions are learned behaviours. However, opinions on the mechanisms involved and what it is that has been learned vary.
Although I have given this chapter the title of “The Behavioural Model” there are in fact several models within the overarching concept of behavioural psychology that seek to explain the formation of anxiety disorders. For the purposes of this short paper I will look at three of those models: Avoidance Conditioning, Observation Conditioning (Modelling) and Operant Conditioning.
The Avoidance Conditioning (AC) Model
Perhaps the case of “Little Albert”, a case study by John Watson and Rosalie Rayner published in 1920, is the most well known example of experimental AC. Indeed Davison and Neal suggests that, historically, this case is considered to be the model of how a phobia may be acquired. Paul even suggests that, with the exception of Pavlov’s experiments on dogs, the case of Little Albert has been cited in more introductory psychology texts than any other experiment.
It is relevant at this stage to look at Watson’s ideas about consciousness and behaviour. He considered that all behaviour has a physiological root. It seems that he based this premise on his reading of the works of Pavlov and Behkterev which gave Watson the last of the pieces he needed to complete his picture of the purely physiological basis of behaviour.
O’Boyle tells us that Watson considered Pavlov’s Conditioned Response to be the physiological explanation of what philosophers had termed association. He believed that association (he termed it Conditioned Reflex) explains nearly all of behaviour.
For example, he proposed that only fear, rage and love are innate emotions and that the wider range of adult emotions are explained by the mechanism of Conditioned Reflex and that: “ . . . learning is the basis of all behaviour, but it is not some mysterious conscious effort of a metaphysical will. Learning is based on the spread of cortical activation in response to sensory stimulation.” (O’Boyle)
Because the Little Albert experiment is so widely known and taught I will just present a very brief overview here. Watson and Rayner introduced a white rat [we don’t know it’s name] to an eleven month old boy who has since become known as Little Albert.
At the initial meeting Albert displayed no apparent fear of the rat and appeared to want to play with it. However, each time that the boy reached for the rat a loud noise was made by striking a metal bar behind him.
Of course, most children of that age will show a fear response to a loud and unexpected noise. So the noise, in Pavlovian terms, became the Unconditioned Stimulus (UCS) and the fear reaction to the noise was labelled the Unconditioned Response (UCR).
After a number of such pairings the boy became frightened by the sight of the rat and so that fright was the Conditioned Response (CR) and this occurred even when there was no loud noise present. Hence that fear associated with the UCS was now associated with what had initially been a neutral stimulus i.e. the rat which has now become the Conditioned Stimulus (CS).
And so it may be that the case study of Little Albert and the White Rat suggests the possible relationship between Classical Conditioning and the development of emotional disorders such as phobias. (see Davison and Neal)
Davison and Neal) go on to tell us that learning theorists have elaborated on the case of Albert by asserting that the classically conditioned fear of an objectively harmless stimulus (the rat) is at the root of an “Operant Avoidance Response”. They give us a simplistic overview of how a phobia develops according to the Avoidance Conditioning Model.
Via classical conditioning a person can learn to fear a neutral stimulus (CS) if it is paired with an intrinsically painful or frightening event (UCS). Then the person can learn to reduce this conditioned fear by escaping from or avoiding the CS.
This second type of learning is Operant Conditioning; that is, the response is maintained by the reinforcing consequences. However, for the outcome of this mechanism to be termed a phobia that fear must become generalised.
In other words the person will fear and avoid a range of stimuli; for instance he may develop an avoidance of high places when the original pairing was with one particular tall building.
The Observation Conditioning Model
This mechanism for the development of anxiety disorders, including phobias, does not involve any obvious traumatic experiences prior to the onset of the phobia. It is also known as Modelling or Vicarious Conditioning and is concerned with learning through imitation.
It is known that a wide range of behaviour, including emotional responses may be learned by witnessing the actions of a model. Perhaps the most well known of the experiments in Observational Conditioning (learning) are those of Albert Bandura and the Bobo doll carried out in the 1960’s.
I will just give a brief overview here as these experiments do not directly concern the development of phobic response although they are relevant to the general concept of learning by modelling.
In the Bobo doll experiments, children watched films of a woman beating up a Bobo doll. She hit it with a mallet, sat on it and generally threw it around the room. After the children had watched the films, Bandura and his colleagues moved each of them to a room where they were alone with a Bobo doll and, without the knowledge of the subjects, observed their behaviour.
Bandura surmised that observational learning (modelling) had taken place if the subject initiated the characteristic behaviours of the model.
Much of the underpinning theory for modelling as a mechanism in the development of phobias stems from the work of Mineka and Cook. They established strong empirical evidence to suggest a causal link between the development of phobic-like fears and observation alone.
Their work centred on the observational conditioning of snake-fear in laboratory reared rhesus monkeys. The subject animals had no previous fear of snakes however they developed a fear within 4 to 8 minutes of observing the reaction to snakes of a group of wild rhesus monkeys.
In other studies where there was prolonged exposure of about 25 minutes to the behaviour of the wild monkeys, follow-up studies showed that the conditioned snake-fear in the subject animals did not decrease over a 3 month period.
Observational studies with human subjects have only looked at “. . . .mild conditioning of autonomic responses in single-session laboratory experiments, with no tests for maintenance of the conditioning . . . ” (Mineka and Zinbarg)
Because of the limited scope of human experimentation so far [presumably for ethical reasons] a definite causal link between phobia development and observation alone in humans cannot be conclusively proven.
However, Mineka and Zinbarg propose that there is reasonable experimental evidence stemming from the work of Mineka and Cook on primates to suggest that the model is also valid in humans. They go on to link their findings to the work of Öst and Hugdahl as well as that of Merkelbach concerning the use of questionnaires with phobic subjects.
Those researchers reported that a significant number of their subjects (between 17% and 53% of the sample groups) recalled instances of direct and vicarious conditioning incidents that had contributed to the development of their phobias. The highest incidence rates of such recollections came from those subject groups that had animal-related phobias.
While it does not take much of a leap of logic to see that it is reasonable, and indeed evolutionarily advantageous, for primates to develop snake-fear through observational learning there is not the same easy link between, say, social phobia and observational learning.
Indeed, one may argue that there is a distinct evolutionary disadvantage for a social animal such as most primates, including humans, to avoid social interaction through irrational fear. Mineka and Zinbarg discuss this point and quote the work of Öst and Hugdahl who found some 13% of their subjects with Social Phobia associated vicarious learning experiences with the development of their condition.
Davison and Neal point out that not all stimuli are capable of becoming a source of acquired fear. They summarise Cook and Mineka’s follow up experiments to the snake-fear learning mentioned above.
In brief: they used spliced films to associate a fear response in a monkey to various non-dangerous objects including a toy snake, a toy crocodile, a flower and a toy rabbit. Only those subject animals that were shown the toy snake or crocodile acquired fear of the objects shown. Neal attributes this to the preparedness theory.
To my mind this is another example of an evolutionary advantage to the species. It may be that there is a genetic pre-disposition to primate species that have evolved in the same geographical region as predators such as snakes and crocodiles to readily acquire a fear response through modelling. In other words, learned fear is the key to survival of their group / tribe.
The Operant Conditioning Model
Operant conditioning may be considered as:
“ . . . the manipulation of behaviours through consequences structured to follow the targeted behaviours. Positive reinforcers increase the frequency of a behaviour and, conversely, punishment decreases the frequency of a behaviour. Negative Reinforcement is reward by the removal or avoidance of an undesirable consequence and serves, as does positive reinforcement, to increase the frequency of a targeted behaviour. ” (Preven and David, p 9) [emphasis using bold text is from the original piece by Preven and David]
At this point it is worth reminding ourselves about Thordike’s Law of Effect: In simple terms the law suggests that it is the consequences of a given behaviour that play a large part in determining if that behaviour will be repeated. In other words, behaviour that leads to a desirable consequence is likely to be repeated whereas behaviour leading to undesirable consequences is likely to be avoided in future.
Starcevic gives an overview of the role of operant, or instrumental, conditioning in the maintenance of phobic anxiety disorder. In his overview he looks at the two-factor theory concerning the formulation and maintenance of phobias. He suggests that the fear initially develops as a result of classical conditioning and that in the “second phase” that fear is temporarily reduced or even eliminated by avoidance of the feared stimulus thus maintaining the phobia through operant conditioning.
Through this mechanism the fear motivates the person to look for a means to reduce that fear (avoidance) and each time that strategy succeeds then there is a reinforcing of the fear. It may even be that the person experiences some level of secondary gain through this sequence of actions.
Phobias: The Cognitive Model
In the context of explaining the cognitive perspective on phobia formation Davison and Neal refer to the work of Beck and Emery and their proposal that anxious people operate within a “vulnerability schema”. That is, they are continually concerned with danger and harm and with what unpleasant events may befall them in the future. Stirling and Hellewell also pick up on the work of Beck and Emery in this context. However, they go on to point out the flaw in the vulnerability schema model of phobia formation. They tell us that the argument is “circular”. That is, it is simply a re-definition of the behaviour and attitudes of the anxious person rather than an explanation of why individuals behave in the way that they do. They also propose that there is a lack of evidence that these styles of thinking precede the onset of anxiety, rather than simply accompany it. They are therefore saying that unless these styles of thinking directly precede the anxiety they cannot be clearly identified as the cause.
Leahy and Holland give us another perspective on the cognitive model of phobia formation that focuses on the early developmental experiences of the phobic individual. They make the distinction between generalised anxiety and phobic anxiety in terms of the different roots of the personal schemas that the model suggests are involved in phobia formation.
“The cognitive model of phobia proposes that early developmental experiences may give rise to specific threat schemas that result in selective attention, evaluation, memories of, and strategies for dealing with feared stimuli. However, unlike more generalised ‘personal schemas’ that refer to issues such as autonomy, abandonment, or demanding standards, these specific phobia threat schemas are centred on the content of the biological threat (e.g., water, heights). The cognitive model for phobia is less focused on automatic thoughts and assumptions and more focussed on information-processing biases. Since there is individual variation in the effects of biological disposition and traumatic experience in giving rise to phobias, the cognitive model attempts to explain these differences as a consequence of the meanings attached to the specific stimulus and to the experience of anxiety.” (Leahy and Holland)
Some Therapeutic Options:
In 1860 Joseph William Reynolds, who at the time was the incumbent priest at St Stephen’s in Spitalfields, published an extended essay entitled Historic and Mental Imagery. Although his piece was not aimed at health professionals it was an excellent description of how the mind may be both harnessed and explored through guided imagery and imaginal processes. He recognises that not everyone is capable of experiencing intense imaginal visualisation but that, with practice, most can make use of this faculty of the mind to induce feelings of well being and contentment.
Perhaps one can extrapolate that to make the assumption that he was describing his experiences of a form of self-hypnosis using imaginal modelling to improve mental agility and understanding and hence, perhaps, improving his ability to cope with the pressures of daily life. Many hypno-therapeutic methods used in the treatment of phobias make use of the methods described by him, most notably in allowing the client to imagine their ’safe place’ in order to have a retreat from the intense feelings that may be generated (or re-lived?) during imaginal desensitisation sessions such as the NLP Fast Phobia Cure.
The following is a short extract from Reynold’s essay:
“God has given to the man who cannot travel into strange countries, who cannot cover the walls of his house with creations of the painter’s genius, a faculty by which foreign lands may be brought home, distant scenes, near; and beautiful pictures painted at his will.
This faculty dwells in the mind, and when carefully trained, can be put quickly into practice. It is the power of drawing and painting mental pictures: the forming of clear ideas of facts and scenes, whether past or present, at home or abroad: the ideal placing of fine full forms, with brilliancy and colour, beauty of composition, and pure feeling, within a mental chamber; and then, with the light of imagination, going through the door of thought, to look at the gorgeous scenes which fancy has created.
. . . It is the seeing and realising by the mind, that which is read by the eye, or heard by the ear.” (Reynolds)
This train of thought can reasonably lead us toward an examination of Systematic Desensitisation which combines training the client in deep relaxation methods with the use of imaginal visual imagery for the purpose of eradicating maladaptive thought patterns and anxiety reactions.
The process briefly consists of the client being encouraged to imagine a series of anxiety-producing thoughts or images while in a state of deep relaxation. The images will have been agreed with the client prior to the start of the session and placed in a hierarchy of effect by the client perhaps using a SUDS type system.
It is this hierarchical approach that gives the title “systematic” to this type of de-sensitisation. An imaginal safe-place will also have been arranged prior to the session so that, in imagination, the client may remove his or herself from the anxiety provoking imaginal situation if it is becoming intolerable.
By gradually exposing the client more and more to these imaginal situations and by allowing them to relax away the anxiety symptoms, it becomes easier for them to face this type of situation not only in imagination but also in real life. Gross considers that the basis of this type of work (where anxiety is induced in a deeply relaxed state) is that it is impossible for two opposite emotions e.g. anxiety and relaxations, to exist at the same time. In effect, we are looking here at a form of counter-conditioning.
A great deal of work was done on this therapeutic methodology in the 50s and 60s by Wolpe. However, this was by no means a new idea and Richards (p 328) reminds us of that by looking at the writings of 17th century philosopher John Locke and quoting:
“If your child shrieks and runs away at the sight of a frog, let another catch it and lay it down at a good distance from him; at first accustom him to look upon it; when he can do that to come nearer to it and see it leap without emotion; then to touch it lightly when it is held fast in another’s hand; and so on until he can come to handle it as confidently as a butterfly or sparrow.”
Locke’s methodology is an in-vivo approach with actual frogs being placed in close proximity to the phobic child. That is fine with small, innocuous (in reality) and easily transportable trigger-factors such as frogs. But what if it is impractical to bring the trigger object into the therapy room. For instance, a family member of mine is perfectly ok about being near small animals such as mice, snakes or kittens when there is a small number of them but experiences significant levels of anxiety when faced with images of large numbers of them writhing about each other. Now it would be quite impractical for most therapists to arrange an in-vivo session to deal with this. Hence the value of imaginal systematic de-sensitisation methods. It should be noted though that it may be that not all clients have the necessary visualisation abilities to allow the effective use of this technique.
Another therapeutic option that may be considered for the client is Cognitive Behavioural Therapy (CBT). This is essentially a learning (or, indeed, re-learning) process whereby the client is encouraged to self-analyse their negative thought patterns and come up with realistic and viable alternatives that they can implement in order to replace the negative with the alternative positive outlook.
Because CBT is quite an intense learning process it does not suit all clients. Indeed, I have had clients give up using this technique because, in their perception, it takes too much effort and results can be slow in becoming apparent to them. One way of getting around this is to combine CBT with Hypnosis. As we know, hypnosis creates a deep physical relaxation combined with heightened and focused mental awareness. This raised mental or cognitive awareness may be thought of as an accelerator of learning processes. Term Cognitive Hypnotherapy was coined by Dr Assen Alladin for this integrated approach to the treatment of emotional disorders.
On the topic of increased ability to learn through the use of hypnosis, Alladin (p 13) has this to say:
“Hypnosis facilitates divergent thinking by maximising awareness along several levels of brain functioning, maximising the focus of attention and concentration, and minimising distraction and interference from other sources of stimuli. In other words, through divergent operations the potential for learning alternatives is increased.”
There are of course many other approaches to the treatment of phobic anxiety. Almost as many approaches as there are therapists. Some of the more well known approaches include The Fast Phobia Cure from the NLP camp; Eye Movement Desensitisation and Reprocessing (EMDR); Emotional Freedom Technique (also known as ‘tapping’ therapy) and of course not forgetting Psychoanalysis. However, it is probably not unreasonable to suggest that many of these other options (if not all of them) use elements of imaginal projection of the self, systematic desensitisation and cognitive self-analysis as part of the process.
So it can be seen that there is no one single model of phobic anxiety formation that is universally accepted. Each of the models looked at in this paper have elements which overlap other models. So, which is the one that should be used to formulate a therapy programme for one of our clients?
My opinion on that issue is that all of the models have something of value to bring to the practicalities of the therapy room. To a large extent, the inclusive practitioner will choose the elements of each model that have relevance to the phenomenology of the individual client.
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