The Man With His Head in the Clouds

by Richard O. Smith

  I have an opening question that I really want answered. Always ask questions you want to know the answer to, not to show what you already know. “What is a phobia?”

  “What I would define as a phobia is when the volume in that threat system is set too high, or perceiving something non-threatening as a threat - like being fearful of a cat rather than a lion, which provides no evolutionary advantage.” Great, in evolutionary terms my fear of heights is akin to being terrified of a cute kitten pawing a ball of wool. “Because you would spend a lot of your time in this fight-or-flight panic mode and thus not able to do things you need to do.”

  “What’s fascinating within psychology is that if you kept applying the fight-or-flight mechanism to something that was non-threatening, you think you would learn to adopt and select better responses and the fear would dissipate. But what’s interesting is that this doesn’t happen. So it is a conundrum how this is maintained. How do people remain fearful about something that causes them no real fear? Part of the diagnostic criteria for a phobia is that you recognise you are worrying about the topic more than you need to - so why is it still there?”

  “Do phobias lessen with aging?” I enquire.

  “Phobia is fear prompted by is a normal evolutional response, but applied too widely. If you sense a fear like a lion, fight-or-flight physiological arousal facilitates you doing something about it. So people who are not fearful around lions don’t pass on their genes very effectively - because they’ve died out.”

  So being riddled with anxiety is a good thing then. It means I get to pass on my genes. With a lady!

  “No,” interrupts Dr. Hannah, “it means you’re less likely to get eaten by a lion.” Oh.

  I frequently wonder, why does my idiot brain “know” two contradictory things simultaneously: i.e. registering the dichotomy that I am perfectly safe in this threatless environment whilst my brain is flashing a red warning “evacuate” light. “How do people remain fearful of something that causes them no real danger?”

  “Part of the diagnostic criteria for a phobia is recognising that a threat is not real and a self-realisation that they are too anxious about it. So why is it still there? Learning Theory, which is something the early psychological behaviourist theorists reasoned, was a physiological response paired with a stimulus; like Pavlov’s dogs you go through a learning stage phrase of physical autonomic and automatic arousal.”

  “Self-awareness ought to kick in after a number of events when your feared outcome doesn’t happen, shouldn’t it?” I check.

  “Exactly, so you would expect that after a while when your feared outcome has not happened you would to build up self-awareness over time. The answer lies more with cognitive theory, which exposed a couple of things going on in phobia responses. Firstly, there is a tendency for avoidance. Hence sufferers will do anything they need to do to avoid the situation coming up.”

  I nod excessively at this point. I avoid any possibility where there will be exposure to height.

  “Then something fascinating happened in the field,” Dr. Hannah continues. “We got this model of pure phobias and psychologists thought that if people are avoiding them then we’ll do exposure therapy.”

  “This is used in Obsessive Compulsive Disorder and anxiety management,” I clarify.

  “That’s true, and it often works in OCD and anxiety management. Their arousal will come down and habituate and then they learn it is OK.”

  Dr. Hannah then formulates her own question for her to answer next, causing me to suspect that she would be considerably better left to interview herself as both interviewer and interviewee whilst I went off in search of an unbroken, unclosed coffee outlet.

  “So when doesn’t it work?” she asks herself. “That’s the next thing cognitive therapy brings to the table. It shows there is something even more subtle going on for those people. Even in situations when they look like they’re confronting their phobias, there is something going on in the mind that’s still telling them they are putting themselves in danger.”

  Keen to have some input, I add: “They’re not engaging, they are somehow remaining aloof so this experience can be disqualified from providing vital learning experience.” Dr. Hannah nods: “We call it ‘safety behaviour’. It’s that person doing everything they can to feel safe in that situation. For example, if you are terrified of heights and although you’ve done everything you can to avoid them but you can’t and you’ve got to go up your tower you might say ‘if I clutch the rail really tightly, or stay a foot back from the edge I won’t be caught by the wind, or if I’m with someone I trust as they may be able to help me out,’ you have somehow convinced yourself that this cannot be treated as an experiment to learn from, as you don’t believe you are truly facing the fear. So when you return to ground, you have a whole handful of reasons why you have come back down safe.”

  That is so true. Believe me.

  Of course, that’s what I’ve been doing for years. Knowing how my brain has been actively deceiving me, and mis-crediting my achievements to others, deceptively manipulating me, instantly helps me confront my fears - like learning how a trick is done reduces how much the magician impresses you.

  Dr. Hannah also cautions: “It may turn into magical thinking.”

  Magical thinking is when survival or success is attributed to thinking particular thoughts, wearing a lucky item of clothing, performing a ritual, doing something a set number of times, repeating a mantra, praying, counting, ordering or carrying out superstitious acts, etc. I was voluntarily imprisoned by ritualistic magical thinking throughout most of my teenage years, but lacked the foresight to mention it to anyone, and thereby concluded that it was a debilitating yet isolated condition that affected only one person, thereby making them desperately unhappy. I am indebted to learning about magical thinking, and discovering the trick done on my brain immediately confiscated its power. Again, once you know how the trick is performed, the conjurer no longer impresses.

  Dr. Hannah extrapolates the damaging, spurious logic of magical thinking on a phobic patient. “Hence their attribution thinking was that ‘I was never really in danger because I did these certain things.’ A treatment of phobias can occur whilst putting someone in this situation where learning can take place. When phobias move away from behaviour or learning theory, or even cognitive theory, is when someone feels it is the belief that maintains the fear, and they can test the belief.”

  Hmm. So belief is the hydrogen in Sadler’s balloon, keeping the phobia afloat. If I can vent the belief, puncture it, then the phobia should descend rapidly. I am keen to ask: “Can this belief can be stress-tested sufficiently to undermine it?”

  “In exposure therapy you would do something over and over again, becoming increasingly challenging,” Dr. Hannah answers. “With cognitive intervention, you’d think ‘I have to put this thought under the microscope and if I do that effectively the anxiety will come down quite quickly.’ It’s the key to getting a really nuanced, well-designed experiment. So that you can get up high without gripping, friends, magical thinking, and learn my catastrophic event won’t necessarily happen.”

  This is precisely the insight I require. That we all require. Why don’t you get taught this stuff in schools? It would have helped me much more than irregular French verbs like... er... I can’t remember a single French verb.

  “The interesting thing about the learning theory of phobias,” Dr. Hannah continues, while I click the top of my pen into action, ready to write down some more dispensed wisdom, “is that you have this experience, you learn from it, move forward and apply learning to it - but it may not be correct application. Learning theory and cognitive theory is quite preoccupied with early experiences and, though there could also be later experiences - with a lot of people they are unable to identify an index event as to why this is established. And that’s one of the baffling things about res
earch. Not everyone has index events that trigger.”

  “Does that dilute the potential power of psychoanalytical approaches?” I ask.

  Without requiring even a fraction of a second’s thinking time, Dr. Hannah replies: “It dilutes how powerful learning theory is. You need to have the terrifying event stop, then air the connected thought processes together. A phobia could develop over time from cognitive attributions and then it grows. Psychoanalysis looks at phobia by viewing an early experience and, in the broad sense, trauma. Some fear of something else has been diverted or transferred onto something else. My understanding of the psychoanalytic approach isn’t the go-to approach for a phobia. PTSD [Post Traumatic Stress Disorder] research shows a cognitive intervention would be the way forward and that is because we have reasonably robust theories about neural processing. We are aware of diverse neurobiological and psychological responses in different traumatic events. So a cognitive approach with PTSD would aim to reprocess that trauma.”

  Twice as a toddler I fell down the stairs. Both were events of such magnitude that, even though they occurred as a three-year-old, I recall vividly my traumatic tumbles today. One fall constitutes my earliest memory. I was so proud of my red wellington boots that I wanted to show them to everyone. And I would only remove them, with immense coaxing and reluctance, to go to bed. Unfortunately, they proved to be impractical footwear for descending stairs, and sure enough I fell down the stairs. This fall downstairs remains my reference point for the worst pain I have ever experienced. And given I am unlikely to experience childbirth, my maximum encounter with pain is likely to have peaked when I was only three years old.

  Which prompts me to ask Dr. Hannah: “Does giving a phobia sufferer a name risk entrenching it i.e. a patient or client may say “I am agoraphobic and therefore I am defined as that?”

  She pauses. “That is a really, really...”

  ...Please don’t say “shit”...

  “Excellent question,” she confirms. Phew.

  “Yes, it is a double edged sword. It’s validating, it’s helpful, it’s containing, it shows other people have this problem. We know what a fear looks like and we know how to treat it, and it’s not you going mad, silly or being selfish.”

  Such validation would definitely have helped me, had I sought it earlier in my life.

  “On the other hand,” Dr. Hannah continues, “if people typically equate it with a medical term and condition, then it allows a definition of what this means, so it won’t go away. Diabetes cannot go away, but it can be managed. With a phobia there is often scope for both managing it effectively, but also eradication. Then there is a certain amount of personal responsibility that comes into play - an agency to deal with it psychologically. If I have a label that means ‘it is not my fault’ and also means ‘there is nothing I can do about it, this is how it is going to be’ then that is very limiting.”

  I ask her: “Why do I encounter physical symptoms with a mental response, when stepping on a ladder? My brain floods with fight-or-flight response triggers. My body’s detected an anxiety.”

  “Those feel like anxieties,” Dr. Hannah concludes, “the tendency to run away from life. Then what often happens, and this is where panic cycles and panic disorder come into play. In acrophobia and agoraphobia we make catastrophic misinterpretation judgements on those threats and feelings. You notice palpitations and dizziness, think ‘I’m going to faint and fall off’, or we make an inference about the situation based on our feelings. We call that ‘emotional reasoning’. Conclude that if I feel fearful then we interpret that as ‘I am fearful therefore I am under threat’ which equals false reasoning. Therefore the lack of an actual threat is not missed.”

  “Vertigo” sufferers and height avoiders like me are terrified of becoming dizzy or fainting at altitude. You can see why the summit of something extraordinarily high is not the best place for an involuntary lie-down. Phobic responses generate a “fight or flight” stimulant. Or in my case, a “flight and flight” reaction, as the prospect of a flight is now predominantly responsible for filling my days with undiluted terror.

  “Fight or flight” dispenses an adrenaline shot, increases the heartbeat and pumps oxygen to the brain. In other words, it is nature’s way of putting on your best trainers to flee threats, or ensuring that you hang around for the ensuing scrap. Therefore, with the brain insistently ordering the manufacture of adrenaline and oxygen, fainting is the last thing that is going to happen when encountering a triggered response to a phobia.

  Then Dr. Hannah serves up an indisputable Top Fact - scientific knowledge to the rescue. “There is one beautiful exception to this rule. With blood and injury phobias you are fearful of bleeding to death. And in that phobia the exact opposite physiological occurrence happens. Your heart beat is lowered, your blood rate drops. Blood phobics are the only people who can faint. Many phobics believe they will faint, but in fact you have so much oxygen in your system that you cannot faint. It is evolutionarily advantageous to lower your blood pressure. Lowering your heart rate stops you bleeding so profusely - even by passing out if you need to. Isn’t that a brilliant treatment?”

  There, told you my brain was clever. This information is revelatory, portentous on a grand scale. Moreover, it offers enormous practical help with bathmophobia and acrophobia. One of my biggest, although admittedly unrealised fears, until having this conversation with an expert, was that I would become faint and dizzy, and risk falling over on stairs or somewhere else at high altitude. Not only will this be physically impossible, but I now know the opposite will occur, and my brain will provide me with a double espresso shot of adrenaline and oxygen. I just need to avoid cutting myself at altitude!

  But I still need to tame my amygdala. The amygdala is the primitive part of the brain with the authority to shut down the clever part of our mind - the sophisticated Guardian-reading, latte-sipping frontal cortex that’s thinking of booking tickets for the new British Library exhibition. Our amygdala reacts to cars back firing, loud bangs, and any other highly unpleasant over-loud noises, by immediately shutting down all other processing parts of the brain. Dr. Hannah reassures me that there is also a specific part of the brain whose allocated job is to step in and deal with conflict.

  It transpires, then, that there is still some hope, if I can get my amygdala to listen to common sense.

  “There seems to be emerging data that talking therapies or CBT [Cognitive Behavioural Therapy] can alter brain functioning. Now there are a couple of important things about the brain - one is structure and one is functioning. Function is ‘how well do the separate brain areas co-ordinate together?’ I don’t know if there’s evidence to say structure can recover, but there is evidence that function can recover. So if you’re undergoing therapy you can find that neuro-chemical changes occur as a result.” At this point Dr. Hannah cites a research article by David Clark and Erin Beck reviewing neuro-chemical changes following CBT. She just happens to have a copy on her - as her downtime out-of-office reading material of choice. I am impressed by her off-duty dedication.

  “Cognitive therapy can be attributed and associated with a reduced activity in the sub cortex regions in which both the hippocampi and amygdala function. So it would reduce firing the activation in those areas and increase activity in the pre-frontal cortex.” I am flattered that Dr. Hannah considers she can start to get slightly technical with me now, without losing my attention or comprehension.

  I report my experiencing of increased anxiety, driven by trivial things. Sometimes I have intense difficulty getting on a bus or going anywhere- yet I can perform an hour of public speaking to a packed hall. My anxieties seemed to be strangely selected, my brain categorising almost at random potential experiences as “calm” or “panic”.

  Modern workplace managers have sullied a once decent phrase by over-use and corporate adoption: “Think outside the box.” Having worked in an offic
e for decades, I can confidently report that the worst thing anyone could do was to think outside the box. This was viewed as an aggressive challenge to each individual stratum of defined authority. Think outside the box and you risked execution as a dangerous anarchist, challenging the hierarchies clinging to their narrowly defined powers. And yet every team meeting supposedly cherished thinking outside the box as an aspirational value of the organisation.

  But now I really do need to start thinking outside the box - the small, dark box of anxiety with just a few air holes allowing me to glimpse parts of the world others take for granted. Instead of being trapped by negative thinking loops and constant catastrophizing. It’s time to hit the “refresh” button on my mind. Which means it’s time to recruit some counselling.

  ***

  Proving that youth is fleeting, yet immaturity can last a lifetime, I needed to be 49 years old before I realised that if a phobia or psychological condition remains untreated, it’s probably going to either (a) last a very long time before it goes away (b) never go away.

  Something has to be done about my festering phobias. Prevalent in many phobias is the contradictory cognitive dissonance needed to sustain them - that a phobia is often not a fear of direct dangers associated with the fear: i.e. darkness is unlikely to attack you. It is the fear of concealed dangers, predictably of the exclusively imagined variety, that cause the problems. If I am going to replicate Sadler’s flight, then I am in desperate need of counselling expertise.

  There are supposed to be only two certainties in life: death and taxes. Which means Starbucks and Jimmy Carr must be immortal. Since I am not a giant international monster conglomerate, faceless and rapacious (a big hello at this point to Google, Vodaphone and Amazon), I am filling out a tax form online. As a freelance comedy writer it soon becomes clear that, like Jimmy Carr, I too have ingeniously devised an airtight strategy to avoid paying income tax: earn less than £9,000 a year. Who needs specialist tax accountants?