HOW PHOBIC FEAR MAKES MONSTERS OUT OF MOLEHILLS
About 250,000 Canadians have irrational and frequently paralyzing fear of ordinary things like cats, birds, fire hydrants or simply the street they’ve always lived on. They have phobic fear — “the neurosis of childhood” — and, while most can be cured, some are lost: “they can do nothing but sit in a chair in the exact centre of an empty room”
WHEN IT THUNDERS in Port Arthur, Ontario, the fifty-year-old mother of a grown family pulls all the blinds down, unplugs the television, radio and refrigerator, and locks herself in her bedroom to pray that she will not be struck by lightning. A civil servant in Ottawa drives a couple of miles out of his way twice a day to avoid crossing a bridge. A middleaged Winnipeg lawyer, overweight and beginning to worry about his cholesterol level, nevertheless puffs up four flights of stairs to his office rather than take the elevator. An Edmonton woman has not ventured out of her house alone in fourteen years because of the neighborhood cats.
These people suffer from a disease knowm as phobic fear. They are possessed by anxieties which are out of all proportion to the real dangers of the situation, and which periodically interfere with fheir otherwise normal lives to a major or minor extent. In extreme cases the interference can be much greater. “I have seen cases,” says Dr. Henry Durost, a psychiatrist in private practice and on the staff of Verdun. Que.. Protestant Hospital, “where phobic patients can literally do nothing but sit in a chair in the exact centre of an empty room. This represents the end o' road for this type of patient."
Fear itself is n a disease. It is an inborn protective instinct that has helped the human race survive, a mental and physical response to danger that conditions the individual to escape or counterattack.
Fear becomes phobic—often to the extent of being a crippling disability that requires treatment — when it takes the form of a "front” for more serious inner conflicts.
“Phobic fear,” says Dr. Henry Kravitz, a psychoanalyst on the teaching staff of Montreal Jewish General Hospital, “is an externalization of an internal fear. It's easier to be afraid of being alone than to deal with your own aggressions; easier to be afraid of the dark than to face your anxiety over your sexual conflicts, and easier to be terrified of elevators than to recognize your own mounting tensions.”
What is the extent of the disease among Canadians? Is it increasing? These are not easy questions to answer, because many victims and their families still regard it as an annoying
or even endearing eccentricity rather than as a serious disability that requires treatment. Some observers believe that phobic fear is increasing, a product of the modern "age of anxiety” w'ith its nuclear threat and its high-speed, competitive way of life. But psychiatrists maintain that phobic fear is an age-old condition which is simply more often recognized and diagnosed as man learns more about his mental processes and problems.
Estimates of the number of phobic fear victims in Canada are based on the expectation that one person in ten will require some kind of psychiatric treatment during his or her lifetime. Of these, ten to twenty percent —or roughly a quarter of a million Canadians — w'ill be afflicted by anxieties that amount to phobia.
SOME CHILDREN NEVER THROW OFF FEAR’S DICTATORSHIP
How does phobia begin, and how' is it possible for an otherwise intelligent person to develop an uncontrollable terror of such essentially harmless objects as birds or cats or fire hydrants, or such everyday situations as walking down the street, driving in a car, or taking a journey?
Often phobia begins in childhood. Almost everyone at some time experiences phobic fear, even if it’s only the stepon-a-crack-break-your-mother’s-back variety. It is so common in children that it has been called “the neurosis of childhood.” Most children, fortunately, work themselves out of their fears or outgrow them. But the ones who can't and who are not helped to do this arc destined to carry over into adult life an ever-growing burden of fear which will become more and more unmanageable until in the end they may become literally the slaves of their phobias.
(Phobias sometimes start late in life, usually in connection with other mental disturbances. A little old lady, hospitalized for years at Verdun, Que., developed a phobic fear of germs and spent most of her days making face masks for the other patients. The rest of her time she devoted to knitting little jackets and trousers for the hospital mice because, as she loudly complained to the doctors. “The temperature in this building is a disgrace.")
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In many cases of school phobia, it isn’t just the child who’s mentally ill. It’s also the mother
One of the commonest phobias of childhood is school phobia. In addition to the unpleasant effects it shares with all phobias. school phobia in extreme untreated cases can seriously affect a child’s later life by leaving him undereducated.
School phobia bears no resemblance to simple truancy. The truant skips school to go out into the world; the child with
school phobia goes straight home and withdraws from the world. His act is not defiance or naughtiness. It does not respond to the traditional trip-to-the-woodshed treatment, nor to coercion or persuasion. It is a symptom of one of the most incapacitating neuroses of childhood, known as separation anxiety, a condition that binds mother and child so closely to
one another that any separation causes both of them overwhelming anxiety.
This closeness is not all love. Hate, resentment, and hostility are mixed in with it, and just as it’s possible to see more than one color at a time, so is it possible to feel more than one emotion toward a person simultaneously. The mother who is overindulgent, overprotective, and overdependent with her child is not just showing an excess of maternal love: she may be compensating for the fact, as a Halifax general practitioner informed a men’s club luncheon meeting, that “sometimes she hates the little beggar and wishes he were a thousand miles away.’’
Families of children with school phobia often have features in common. The father is usually weak and ineffective as head of the household, whije the mother may be an emotionally unstable person who herself had an unsatisfactory childhood and relationship with her own mother. In a recent study of seven children with school phobia at the Montreal Children’s Hospital. Dr. Stewart Agras concluded that another important factor in this disorder is depression.
Six out of tne seven children Dr. Agras treated were suffering from depression, the common symptom being weeping for no apparent reason, and whining, unhappy behavior. Six of the seven mothers were depressed. and in the other family the father was. The depression seemed to have been handed directly down to the children.
From these mothers, the children got a clinging, possessive kind of love, sometimes replaced by oversevere demands for competence and achievement. The children, in turn, made constant and unreasonable demands on the mothers, with the result that mutual hostility was constantly rekindled with subsequent feelings of guilt. The mothers and children alike were all in urgent need of psychiatric first-aid and then psychiatric treatment. (The continuing danger of suicide during depression is extreme.)
All authorities agree on the importance of getting these children back to school, the sooner the better. Unless this is done, the condition may become so difficult to treat that children may stay away from school for years, frequently developing morning sickness, fever, headaches, insomnia, loss of appetite or any of a dozen other ailments that will achieve their aim.
“The basic issue,” Dr. Leon Eisenberg of Baltimore said in an address to the Ninth
International Congress of Pediatrics a couple of years ago in Montreal, “is not going to school: it is leaving mother.” It's usually the pediatrician or family doctor who is called in first for a child with school phobia. Any symptoms which miraculously vanish around half-past nine on a weekday and do not appear at all over the week end or on holidays are grounds for suspecting an emotional problem.
In some cases, where the condition is caught early and where the mother’s active co-operation can be gained, the doctor may be able to get the child back to school without much trouble. Too often, however. he has to deal with a mother whose own overprotective, overindulgent, resentful behavior toward the child perpetuates the situation she expects the doctor to remedy. No matter how much she protests aloud that the child must immediately be returned to school, silently her actions and attitude convey the opposite desire. For she needs the child’s protection as much as he needs hers. Sensing her feelings, the child is more determined than ever to stay home.
“It’s a case of collusion in many instances,” says Dr. Nathan B. Epstein, chief of psychiatry at Montreal Jewish General Hospital and associate professor of psychiatry at McGill University. Dr. Epstein, who prefers to treat whole families together rather than individual members, says he often finds “the mother and child are in cahoots with each other.”
Changing schools or teachers solves nothing. The problem is still separation anxiety.
Severe cases may be referred to a psychiatric clinic or a psychiatrist who will work with the school and the parents to restore the child to healthy behavior. Sometimes the therapist may set a date a few days ahead and tell him that on this day he will return to school. Tears and tantrums avail nothing, and many experts feel that it is very important for the therapist to show his own feelings, including anger, so the child will realize that this doesn’t entail loss of affection and it isn’t fatal. In this way, he learns to cope with his own anger in a healthier way, and as his hostile impulses and guilt vanish, the phobia will disappear.
The author of “Psychotherapy in Medical Practice,” Dr. Maurice Levine, believes that children should certainly be permitted to express their emotions freely: for example, they should be permitted to an-
nounce that they hate Mummy without being punished.
“However,” says Dr. Levine, “children should not be allowed to kick the ankles of the mother’s guests. Children should not be allowed to eat glass.”
The therapist plays the part of the "good” parent; and then he makes a determined effort to get the mother, in turn, to accept some help for her own problems and adopt a more realistic attitude toward her child’s needs.
Once the child recognizes that his freedom at home is really imprisonment, and his loss of liberty at school means freedom, he is well on the way to recovery.
Another form of school phobia is described as examination phobia. Dr. Nicholas Malleson. of University College. London, recently outlined its typical symptoms: The student is terrified into illness by an approaching exam. He can't study because he can’t keep his mind on his work; he can neither cat nor sleep: he is completely incapacitated by the knowledge that each tick of the clock brings him closer to the dreaded ordeal from which
there is no escape. What is particularly tragic is that a student can get to his last year in university, know his work thoroughly, and still fail his final exams because of this phobia.
Dr. Malleson reports the case of a technology student who was brought to his office by a classmate. He was suffering from acute examination phobia, but showed no physical symptoms. Later in the evening, though, the doctor got a call reporting that the patient had a high fever. By the time he got to the student's lodgings, the fever was 102. Convinced that it was caused by the phobia, the doctor ordered him to sit up in bed.
"Now. imagine you have taken your exams,” he said, "and you have failed in every subject. How do you feel?”
The youth burst into tears which lasted for half an hour. Every time the sobbing showed signs of abating, the doctor would remind him of the jeers of his colleagues, the shame and financial loss he had brought on his parents, and all the other humiliations he would have to endure. When finally the student was quiet from exhaustion, the doctor leaned back in his chair. "Very good." he said cheerfully, "now let’s do it all over again.” When the patient was empty of tears and emotion, the doctor left him with this prescription: “When you get the slightest feeling of panic, encourage it: try to experience it even more strongly than before. If you have no panic feelings, create them every thirty minutes, no matter how much effort it takes.”
Dr. Malleson saw his patient twice a day for the next two days and applied the same drastic treatment. On the day of the exam the student said he was almost totally unable to feel any fear. "He had. as it were, exhausted the effect of the whole
situation. He passed the exam without difficulty,” the doctor concluded.
Dr. Malleson calls this treatment “symptom reaction inhibition therapy,” and points out that it is only one psychiatric tool being used against phobic fear by psychiatrists and by other medical doctors who are increasingly accepting and using psychiatric methods in their practices. Some patients, like the student with exam phobia, respond to an attack on the symptoms alone. In other cases it is necessary to get at the real fear which the phobia conceals.
An extreme example of the direct approach was related by an Ottawa surgeon who despises psychiatry. A twelve-yearold girl who suffered from a phobia against doctors and hospitals fled from the hospital ward just before she was to undergo a minor operation and locked herself in a washroom. “I don't know what a psychiatrist would have done,” said the surgeon, ' but I climbed over the top of the cubicle, dragged her out by the ear, put her over my knee and beat the hell out of her. From then on she was a model of cooperation.”
Doctors who prefer a gentler and more analytical approach admit that such direct treatment might work on certain spoiledbrat teenagers, but could be disastrous on children with genuine phobic fears. A dramatic example of how simple but scientific therapy removed a deep-seated and serious phobia was that of a man in his thirties who fell into panic during thunderstorms. At home, he jumped into bed and pulled the covers over his head at the first clap of thunder. At the office, he ran to the washroom and locked himself in until the storm stopped.
It was not until his wife was expecting their first child, and he realized that he would probably transmit his phobia to his child by example, that he sought help. The doctor, a general practitioner trained in psychiatry, led his patient back to his childhood in search of the underlying cause of the phobia. Reluctantly the young man remembered: when he was a little
boy his mother had caught him masturbating in the bathroom on a stormy Sunday.
She had called him a wicked, nasty child and declared that no one would love him and he'd go straight to hell if he ever did such a thing again. From that time on thunderstorms had the power to evoke in him the guilt and anxiety he had felt on that day twenty-five years ago. The doctor explained what neither the mother nor her son had known: that the Victorian belief that masturbation led to perdition had long since changed into the knowledge that the act was a natural stage in a long process of experimentation leading from infancy to sexual maturity. The patient’s phobia vanished.
One of the problems in treating phobic fears is that some patients subconsciously don't want to be cured, because a phobia may carry with it what medical men call “secondary gain.” A man with crowd phobia can't be expected to travel downtown during rush hours; he can't be asked to compete in the hurly-burly of today. If he must work, it must be at a quiet job. very safe, very circumscribed, and one that never requires him to ventme outside his secure little boundaries.
Similarly, a woman with street phobia cannot be expected to do her own shopping, take clothes to the cleaners, pick up the children at school, walk to the post office, do any volunteer work, or, in fact, perform any of the tedious but necessary errands in running a house. Somebody else must help her.
No phobia will be removed as long as there is any benefit to be derived from keeping it. The therapist’s first job is to make sure that all secondary gain is taken away. The next is to make the patients honestly want to get well. This is sometimes thwarted by the apparent readiness of families to adjust to the phobic fear of a member. If mother is afraid to venture out on the street alone, members of the family tend to accept this fact uncritically and take turns accompanying her or running errands for her. This passive acceptance is well-meant, but it strengthens the
phobic fear. Perhaps it is because, as Dr. Durost says, "Phobias tend to ooze around: often no definite object is settled on. the phobia can shift from one thing to another until the patient hits on one which will be satisfactory to everybody — that is. a phobia which the family will accept without question and tacitly agree to live with.
In treating the phobic fears of very you nr children. Dr. Mary Jones, a U. S. psychoanalyst, has achieved good results through direct conditioning. I he phobic object — say a dog — is brought into the same room as the child but no attempt is made to bring them together. Any time the child voluntarily goes nearer the dog he is rewarded with a piece of chocolate. Gradually. in this way. the fear reaction is replaced with the pleasure reaction until the child is no longer afraid. But this method does not uncover the fear the phobia hides, and the question arises: how does the analyst then decondition the child from expecting to be rewarded with candy in any fear-provoking situation?
Systematic desensitization can be used in treating adults, ('at phobia, which is common, was successfully removed from a woman who was severely handicapped by an intense terror of cats, a fear which went back to a traumatic experience in her early childhood. Her doctor first gave her a piece of velvet to touch and stroke: then, in successive interviews, presented her w'ith angora wool, rabbit fur mittens, a picture of a cat which she was to hang in her apartment, a cuddly toy cat. and. as the crowning achievement, a gentle kitten which she immediately adopted and adored.
Sometimes parents who think they are taking an intelligent approach to their children's fears can be wide of the mark. Dr. Alastair MacLeod, a McGill professor and associate director of the Mental Hygiene Institute recently told a Montreal Home and School association of the case of wellmeaning parents who were so determined that their child should grow up unscarred by normal childhood fears that they always referred to darkness as "the Friendly Dark." emphasizing how safe and cozy it was. how protecting. Until the night their four-year-old son demanded that his bedroom door be left open, his window bolted shut, and the hall light left on. Asked why, he replied succinctly: "Because 1 hate the damn Friendly Dark, that's why!"
Fear of the dark is universal with the human race. "We arc a meat-eating species." Dr. MacLeod explained, “and our primitive instincts probably still tell us it’s always possible that some other meat-eating animal may pounce on us. But a curious thing often happens to children w'ho have this common fear and who insist on a night light. A point is reached where they quite suddenly realize that the dark can be an ally: if they can't see the bears, neither can the bears see them. And w'hen this happens, they lose their fear of the dark.
When is a fear a phobia? Many parents would like to know how seriously they should take the fears of their children. An unknown number of adults are walking the streets or hiding indoors, victimized by a terror they cannot explain or control. When a fear is inappropriate and unnecessary, when it's beyond voluntary control and out of all proportion to the danger of the feared situation or object, w'hen it is incapacitating and constantly gets in the way, and when there is no understandable reason for it. then it is probably a phobia, and whoever has it needs medical help.
One practitioner adds: "If a doctor advises parents to ignore a phobic child's fears, to punish him, scoff about it, or force him into contact w'ith the phobic situation unaided and without therapeutic support, they would be well advised to seek another medical opinion. ★