Phobophobia.

This phobia which is the fear of fear, is often undiagnosed. A place where it is commonly found is with those suffering panic attacks. It is probably safe to say that the majority of people who suffer panic attacks also suffer from phobophobia. As many report as soon as they have experienced a panic attack they then live in dread of another one coming and hence we have the phobophobia. The intense discomfort that panic attack sufferers report leave them living in fear of the next one coming which it often does. Often panic attacks come whenever they want and are quite unpredictable hence heightening the fear of the impending fear which will appear at some unknown time in the future.

Most conventional approaches to panic attacks and the phobophobia would seek to contain the feelings of anxiety in some kind of way. To work on ways of stopping them. Whilst the goal is for the panic attacks to stop and the phobia to stop how one goes about achieving that can done in a variety of ways.

Alternatively the client is invited to experience the symptoms of the panic attack in the therapy room with the therapist. This has a number of productive therapeutic effects on the client and their relationship with the panic attack. This approach in particular addresses the phobophobia and can have quite a significant impact on the phobia for a variety of reasons.

As one can see from this treatment plan for the treatment of GAD the focus is on getting rid of it, stopping it, gaining control over it, avoiding it and so forth. This has some significant contra indications and leads to other difficulties. The alternative approach being suggested here is to engage the neurosis and to establish relational contact with it.

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Paradoxical intervention - Haley

As you can see from this and my previous posting I have been rereading some of my Jay Haley books. This actually comes from a book written in 1976. Yikes!!

“in summary, one of the reasons for failure of some therapies has been that they assume one can go from an abnormal state directly to a normal state. It is more productive to think in terms of stages between abnormality and normality. Faced with a malfunctioning system, one can think of how to transform that into another malfunctioning system that can then be shifted to normal.” Jay Haley  

As I mentioned before I have some books in my library that I have kept for many years as you can see. 2012 - 1976 = 36 years. Of course I have thrown out many books over the years but there are some that I have just intuitively kept and some of them are the Haley books. In my view they have a creativity, insight and simplicity that is rare. 

Haley’s proposal is where one suggests the client goes from abnormal state 1 to abnormal state 2  and then to normal. I find I use that approach some of the time. I was doing supervision the other day and I suggested this approach to my supervisee. And then I read about it in Haley again today!

The supervisee’s client was suffering panic attacks. I suggested to the supervisee that she request the client experience a panic attack in the session. As the client is sitting in their chair they begin to experience the panic attack symptoms and has a panic attack there and then in the room with the therapist. Some clients will do this and some will not. Clients usually find this suggestion surprising which needless to say my supervisee did as well.

What is being suggested is the client move from abnormal state 1 to abnormal state 2.

Abnormal state 1 = client in everyday life spontaneously experiences a panic attack

Abnormal state 2 = client voluntarily produces a panic attack in the counselling session.

Abnormal state 2 will tend to disempower abnormal state 1. Often in the clients mind the panic attack is seen as this large ogre that looms in the background only to make an appearance as it wishes. If the client voluntarily produces the panic attack they are at least in part taking charge of it. Or they are at least seeing that they can voluntarily control it. They see that as they have a panic attack in front of the therapist the therapist sits there with them not panicking and simply being sympathetic to the clients plight and probably nurturing to them at the same time. The panic attack does not frighten the therapist is experienced first hand by the client. In my view this will then make it easier for the client to move to the third stage which is the diminution of the panic attacks (what Haley calls the state of normality)

Another example where I could use this approach is with the patient who presents as being highly controlled or controlling of others. The usual basis for this is the person is frightened of loosing control of them self. They have created a myth in their head where they believe they can suddenly go out of control, run amok doing all sorts of weird, embarrassing and possibly dangerous things.

Abnormal state 1 = being highly controlled

Abnormal state 2 = experiencing a sense of being out of control

The client is invited to become precisely the thing they fear most. In the counselling session the client is invited to loose control. Let go of their tight grip on control, give it up for a period of time. Experience what it is like being in the counselling session with the therapist and feeling out of control. 

If the client does this then they are more likely to move to the state of normality where the need to be in control is lessened.

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The emeshed family

A video on how the emeshed family structure can result in anxiety and panic attacks



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Engage the enemy in therapy.

I have talked before about certain treatment strategies that I do with things like panic attacks and eating disorders.

If a person presents with panic attacks I will at some point ask them to have a panic attack there in the session with me. Some look at me in disbelief, state that they came here to stop having panic attacks and refuse but most will go through with it and produce the panic to varying degrees.

Others who may be bulimic I will get them to make a homework contract to throw up at least once this week. If their purging is not a physically harmful levels that is.

In the past I have tried to explain the theory behind this and never really felt that I have explained it adequately. I have not been satisfied with my explanation. The other day I was relaxing in front of the TV, surfing the channels with my remote and I happened on an interview with Mel Brooks.

He talked about a number of things including the parody that he does of Adolf Hitler in one of his comic sketches called the Hitler Rap.

This has caused quite a controversy as some argue that making fun of Hitler trivialises what he did to the Jews in the second world war. As he explained why he did such a parody I realized he was explaining exactly why I ask the panic attack sufferer to have a panic attack. There he was saying precisely why I do what I do.

If one gets to know thy enemy and engage thy foe then it disempowers them. If one only ever addresses the topic of Hitler in very sombre and serious ways then that is making him to be more important. To engage Hitler in a funny way reduces his impact and importance was the basis of Mel Brooks’ argument.

When a client comes to therapy the first thing they do with the therapist is spend a great deal of time and energy defining the problem, discussing its causes, seeking to stop it, remove it, side step it and so forth. All this focus on the problem in one way empowers it. It makes it even more important in the person’s mind.

Hence I suggest the client at times engage the foe and produce a panic attack, or for the bulimic to go and purge. Panic attacks come and panic attacks go, nobody has ever gone crazy or died from a panic attack, throwing up is throwing up, not the end of the world. It disempowers the enemy (the symptom). It is not something of great awe and immensity.

The other point that is different from Mel’s parodies is that it also defines the therapeutic relationship. If I as the therapist also hold the problem in great awe and dread, such that it must be avoided at all costs, then the client has the therapist and the therapeutic relationship confirming the belief in the power of thy enemy. If I suggest to the client they go and do purging homework they see that I am not overawed by it.

I certainly understand that it is a painful problem for the individual and empathise with that but it does not fill me with fear and dread. This will also have a disempowering effect of the problem in the client’s mind. Hence my rule of thumb about treating eating disorders, never spend more than 50% of any session discussing food, weight, eating and so forth. Talk about other non food related matters.

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