Agoraphobia used to be considered a fear of open spaces, but this isn’t always the case. At its most severe, people may avoid leaving their home entirely — but most agoraphobics are troubled by specific issues. The most common of these include public transport; enclosed spaces such as shops, theatres, and tunnels; as well as social gatherings like parties.
The common thread with all of these examples is the potential difficulty of a rapid escape. Other problem areas may include crossing bridges, sitting in traffic, or traveling long distances from home.
Ways of coping
It is quite possible for a person with agoraphobia to get on with his or her life so long as the person is able to avoid the issue(s) most troubling. It can, however, represent something of a challenge, mainly because of avoidance.
I knew one lady whose route to work was four miles longer than necessary because she felt unable to cross a railway bridge. Another person I helped to treat was incapable of walking through certain busy streets unless she could hold on to her bicycle. She would never go certain routes alone, but felt confident enough when I accompanied her. In fact most agoraphobics find they are capable of doing things they would never tackle alone, so long as someone they trust accompanies them.
Using activity as part of treatment
The treatment of agoraphobia has changed over time. Early treatments tended to involve training in relaxation and then a program of “systematic desensitization,” in which the patient would be asked to imagine feared situations while they were in a state of deep relaxation. A list of feared situations would be devised by the patient, in which they rated their level of anxiety on a 0-100 scale. The therapist would then systematically and repeatedly work from the least to the most feared situations.
For example, if opening the outer door and taking a step outside was the least fearful item on my list, I would first be relaxed and then asked to imagine doing this. This same scenario would be repeated until I could imagine doing it without fear. I would then progress to the next item on my list, and so on. Once my fear ratings reduced I would then be encouraged to work through my fear hierarchy in real life with my therapist, and hopefully backed up by a loved one or trusted friend.
This was both a lengthy and fairly costly approach (although some therapists still prefer it). These days it is more common to use something called exposure therapy. Not only are the results quicker, the whole approach is considered superior and less costly. Some patients find it helps to take medication for their anxiety alongside the exposure exercises.
As with the systematic desensitization approach I would, as the patient, be asked to compile a list of fearful situations ranging from least to most feared. So let’s imagine my list is:
- Standing outside the train station with John, who I trust not to leave me.
- Going inside the station but still with John.
- Staying in the station, with John, for 10 minutes.
- Getting on a train for a short journey, with John.
- Standing outside the train station, alone.
- Going inside the station, alone.
And so on. But my therapist will also want me to keep a record of these experiences, which might look something like:
- My anxiety level before getting to the station: 85/100
- My anxiety level standing outside with John: 50/100
- My anxiety level afterwards: 25/100
I’ve made these ratings up simply to illustrate a point. It’s very common to see high anxiety ratings in the build-up to the feared situation. So my anxiety score of 85/100 shows how much anticipatory anxiety I’m experiencing. Not uncommonly the anxiety rating drops when one is actually in the feared situation.
Finally, and perhaps not surprisingly, the anxiety rating drops to its lowest once the activity is over.
However, my task isn’t over because my therapist wants me to repeat the exercise at 30-minute intervals. Once again I return to the station. I use the relaxation exercises I’ve been taught and I record my anxiety. This time my therapist would expect my anxiety ratings to have dropped. The more often I undertake the activity, the more my anxiety reduces, and the more progress I make. The pattern continues until I work my way up the hierarchy and, with practice and support, begin to feel relief from the worst of my symptoms.
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Jerry Kennard, Ph.D., is a chartered psychologist and associate fellow of the British Psychological Society. Jerry’s clinical background is in mental health and, most recently, higher education. He is the author of various self-help books and is co-founder of positivityguides.net.