Agoraphobia

Richard  0:09  
Hello, folks, and welcome to Therapy Natters. This is episode two. Therapy natters is a mental health podcast that's here to help you to try and answer some of your lifelong questions. Or maybe not quite so lifelong, but to answer your questions about what makes us tick, and so on and so forth. I'm psychotherapist Richard Nicholls. And with me here, my co host is Fiona Biddle. Hello, Fiona. How are you today?

Fiona  0:37  
Hi, Richard. I'm absolutely fine. Thank you. How are you?

Richard  0:40  
I'm alright, I got myself a cup of tea. 

Fiona  0:42  
Oh, so have I. That's good. 

Richard  0:44  
Nice. This is Redbush it's a Redbush tea from Tetley 

Fiona  0:47  
Mine's beetroot

Richard  0:49  
You can make tea out of beetroot?

Fiona  0:51  
Well, it's a tea bag. Sainsbury's,

Richard  0:54  
And it's beetroot? Okay, that's sweet. I like the sound of that. I've made a cake with beetroot before that's been alright. Yeah, hopefully now. We'll get floods of tea bags in some from Sainsbury's and some from Tetley full of red bush and, and beet root herbal teas and things like that. You never know. They might be listening. Hey, we're British, we like tea send us some. I've already got some feedback from episode one that we put out. And everybody seems to like it so far. Lots of positive stuff. So we thought we better do it again with episode two. And this time, we have actually shall I just read out the message we had the letter and jump straight into it? Are we are we done with the the informal bits? 

Fiona  1:02  
Well, it's pretty informal isn't it? 

Richard  1:13  
 I like to think so. Yes, I think that's that's probably who we are. It's who I am. I mean, I suppose I can be formal. I can wear a tux. And that's about as formal as I get. But I'm still waiting to mature.

Fiona  1:54  
 Oh, don't bother. 

Richard  1:56  
Yeah, I'm struggling with that. It's not happening. So yes, I shall read out this message that we got from Steve from Somerset says, I think I have Agoraphobia, I have always felt better at home where it is, quote, safe. And being away from home has always caused me to be overly anxious. holidays have always been a nightmare. And even diazepam hasn't consistently helped. As I've had panic attacks at airports many times, once even leaving my family to go on holiday without me. And going back home. I'd love to hear your take on the best ways to overcome this. Thanks for everything you do, Steve. Thank you, Steve. Thank you for writing in. I'm sorry to hear you've been struggling. Steve, Fiona, your thoughts so far?

Fiona  2:43  
Well, that sounds exceptionally uncomfortable, especially having the family go away without you goodness. can't really imagine that. But I think the first thing that it would be a good idea to look at is your phrase, I think, and then Agoraphobia because

Richard  2:59  
 I think I have agoraphobia. 

Fiona  3:00  
I think I have Agoraphobia. It's a label, of course. And you then Steve, go on to explain what you mean by it, which is very helpful. Because if you hadn't given us that, we'd have been a bit up in the air because people do have different meanings for the same words quite often. So I started off by looking this up on the NHS website just to see what they say it is. And their definition is Agoraphobia is a fear of being in situations where escape might be difficult, or that help wouldn't be available if things go wrong. Many people assume Agoraphobia is simply a fear of open spaces, but it's actually a more complex condition. Someone with Agoraphobia may be scared of. And then there's a bullet list travelling on public transport visiting a shopping centre leaving home. Now, of course, the derivation of Agoraphobia is from the Greek for fear of a marketplace. So that ties in with the supermarket quite well really,

Richard  4:03  
Is Agora a place? Unless that's Greek for market or marketplace.

Fiona  4:09  
Marketplace. Yes. So that's good. I know that when I first started thinking about anything to do with phobias, it was claustrophobia was when you were trapped, and Agoraphobia was open spaces. Hmm. But somehow they've moved closer together over time. And that is borne out by stuff you can find on the internet about it. So there's a link between claustrophobia and Agoraphobia, and it's a feeling of being trapped, not being able to get out and get away. But, you know, Steve has been very helpful and explained what it means to him.

Richard  4:45  
Absolutely, yes. Because words are always going to mean something different to everybody. One person's Agoraphobia is another person's COVID 2020 lockdown when everybody was housebound, and scared leave because there was this invisible virus out there. And even before that, there were people that have anxiety levels so high that they do get through feel trapped in the house, and they do feel that they can't leave. And yeah, that would be Agra phobia, I guess. But that's not all it is, is it? As we discovered, there's, there's a lot more to it. And there's a lot more to the words, words are always going to mean something different to everybody, no matter what the situation is. I, I remember my wife telling me about when she was at art college, back in the day back in the early 90s, mid 90s. And one of the things that she was taught was that if you're going to be working with people working with clients, is that when somebody says mauve just double check what they mean, because one person's move might not be somebody else's move. One person sky blue might not look the same as somebody else's sky blue. So you've got to go through all these different colours. And look at which one they really, really want. My wife was a bit of a pedant at the time, she was driving a green car, although she always called it blue, or did I call it blue, and she called it green. Because it was this metallic, strange coloured old Citroen a x. And it was it was a different colour to me than it is to her because we use different words, words mean different things to everybody else. I've got some paint in there in the room in there, that's called elephants breath, elephants breath, viola, the name of the panties, elephants breath. And that's going to mean one thing to me. And something else to somebody who works at Twycross Zoo. And I think agoraphobia, is going to be the same any sort of construct that somebody has come up with, to help explain something like personality disorders, we'll touch on those at some point in these episodes, there's there are these ideas that are given a name. And they're just there to help people understand themselves a little better that well, there's a word for this. So therefore, I'm not as broken as I thought it was. Otherwise, there wouldn't be a word for it. It's common enough a condition that it's got a name. So I get one of people jump on labels. But Agra phobia? I guess it's it's not so many layers. I'm thinking of people who have come to me over the years, with many different photos over the years that could so easily get labelled as Agra phobia. And it could be, it could be something else. A common one is emetophobia, a fear of being sick, very common condition that people will bring into therapy. And that can be so easily thought of as Agra phobia. If that's all they focused on, every time I go out, I get this horrible feeling. So I better stay in. When actually, if you play with the layers, you see there's other stuff going on?

Fiona  7:41  
Absolutely. And emetophobia. The first question I always ask is, are you afraid of being sick yourself or of other people being sick? Because if you don't find that out, you could be working on completely the wrong thing. And sometimes it's both, but sometimes it's very much one or the other as well, I don't mind if others are sunny me, or vice versa.

Richard  8:02  
And then it could be a fear of embarrassment.

Fiona  8:03  
Yeah. Fear of erm. Yes. Because I mean, it isn't it? Yeah. 

Richard  8:09  
Yeah. It's a big loss of control 

Fiona  8:10  
in public. Yeah.

Richard  8:12  
And there's something that Steve touched on. And he's not the only one that's been to an airport and thought, I can't do this. I can't do this. I can't do this. And it's gone. I've heard those stories a few times over the years. Yeah. And if that's a fear of fainting, and that loss of control, what would happen if I just passed out, because anxiety can make us feel very dizzy can make us feel sick as well, of course, all these different bodily reactions are going on. And if there's a situation that we associate with those feelings, then we can fear those things, because we're actually fearful of what's going to happen if things go wrong.

Fiona  8:49  
In fact, one of the things I found when I was looking online was that people with Agoraphobia really are more than perhaps other phobias. The fear is not the situation per se, such as being in a crowd, but of having a panic attack in that particular situation. So it's a fear of the fear. And just whilst we say that I use the term panic attack, because that was what was written, that I'm quoting. But we prefer to use the term panic episodes, rather than panic attack as an attacks not a nice thing, is it? And episode shows that it ends because, surprisingly enough, they do. And so that's a more helpful way of looking at but yes, it's the fear of the fear, very much the case.

Richard  9:39  
And that's what anxiety in many ways is, it's the fear of itself. Often it just keeps going round around, because obviously, if you fear fear, then you're experiencing fear because of the fear. And those origins of how it started has long been forgotten. And it's now become just the fear of anxiety itself and it's At the airport, or the open spaces, or the getting away from home problem, it's the fear of fear and the reactions that might have. That's useful because when you can play with that you've then got a treatment plan? 

Fiona  10:12  
Yeah, 

Richard  10:12  
you've got a way of looking at how can I overcome this.

Fiona  10:16  
So yes, and the treatment plan, I would say it's twofold. Firstly, to reduce the chances of it happening in the first place. So look at the reasons why, and build up resilience to it. But then, secondly, how to cope with panic episodes, if they do happen. Because if you know that you can cope perfectly well, with a panic episode, you're not so likely to fear it.

Richard  10:42  
There are many different sort of what we call modalities within psychotherapy, different theoretical frameworks that we would call it in our profession, but the public, they wouldn't call it that, in fact, the public probably doesn't even realise that there are these different types of therapy that there's that there is a difference between cognitive behavioural therapy, and body psychotherapy, and Freudian psychoanalysis. But they've all got their part to play in all of this, and all of these things. If a therapist knows what they're doing, and hopefully we do, then their framework is going to help no matter what their theoretical framework is, right? 

Fiona  11:20  
Well, Iwould hope so. I think that probably would be some types of therapy, where going with something as specific as this might be greeted with a look of surprise, because they're more interested in sort of long term work, as we briefly mentioned last time about the what's it all about? But certainly, there's many different ways of approaching a specific, such as this,

Richard  11:47  
would you say, a cognitive behavioural framework is probably the one that most people would think of when they when they think about anxiety and phobias?

Fiona  11:55  
Yes, I mean, certainly, there's, there's elements of cognitive behavioural therapy. And with that, meaning that you've got your thoughts, your feelings, your sensations, all working in a loop that can start at any point goes round around around. So you can attack an issue, from a cognitive point of view. So how you think about it, a behavioural point of view, what you do about it, and an emotional point of view of how you feel about it. So any of those would be a good way in to such an issue as this. But I think Cognitive Behavioural Therapy wouldn't really be looking at why you feel it, which might be a missing piece of the jigsaw.

Richard  12:37  
Much as I love the CBT framework, and theories and with my clients, I do do cognitive work, I do do behavioural work, and I do a lot of emotional regulation work, and they all do fit very well together. For some reason, the last decade or more, maybe 10 15 years, CBT seems to be this catch all for everything. And although I'd like it, I think we've got to be realistic that CBT isn't going to help absolutely everybody. It's going to help some people quite well. But there are other modalities out there that might have a more permanent solution to their problems.

Fiona  13:19  
The thing with CBT is that it is mechanistic. And so it's following a procedure. So you do this, then you do that, then you do this, then you do that. And so it can be measured. And the National Institute for Clinical Health and excellence, if I got that, right, NICE, we tend to call it haven I got the words, right? Nice, likes things that can be measured. And those of you who listened to our first episode we talked about the relationship as being the key. And we said about it being two unique individuals together. How do you measure? How do you replicate? You can't. So the the measurement for nice is a problem, which is why CBT has got to be the foremost tool that is used in the NHS, because of that reason. That's not saying that it's not good. It can be very, very effective, but it's missing something. And we don't have to have the missing pieces you can have the whole whole caboodle. 

Richard  14:24  
I've certainly had clients that have already had CBT. The fact that they still then come to me is is something to look at. They often are in a better place. Of course, they can they can think a little differently. They can feel a little differently. They do things in slightly different ways. They've got some benefits from their CBT therapy, but they still recognise that the reason the problem was there in the first place, they're still there in the background causing some other problems and they're frightened that it's maybe going to get worse over time rather than get better because they want to tackle it now.

Fiona  15:01  
Yeah. And of course, we do have to recognise that we don't see the ones for whom CBT has worked perfectly. Of course, yeah. So we only see the ones who who have it, for whom it hasn't worked perfectly.

Richard  15:12  
So for somebody like Steve, and Steve himself as well, of course, what would you suggest would be the best place to start? If they're going to, if we're going to start tackling their issues like this?

Fiona  15:26  
I would start by talking to Steve about how long it's been an issue, if he has any idea of where it started. And there's a clue in there, which please bear in mind, Steve, this is just a thought it might not be the case at all. But there's a clue in there I think about being away from home, and how home is safe.

Richard  15:49  
Yeah, he specifically used the word safe. 

Fiona  15:52  
Yeah, I would be thinking that there's something some experience or experiences. In the past, were going away from home, probably as little boy wasn't safe, maybe on sleepover, or a school trip or something like that, that could be looked at, again, through adult eyes. But that's not necessarily the case. But that's just my thought with that.

Richard  16:17  
Well, if it's not Steve, it's, it's somebody else. Who might well think that they had a fine childhood, they don't see any evidence of any neglect or abuse or anything like that in their childhood. But what I think we all need to recognise is that we don't necessarily need to have had these great significant traumas in our life in our childhood, to develop a personality trait, where we might get anxious over things, even the slightest of traumas, if we're going to use that word to a to an eight month old child is going to have a significant impact. And we have to be okay with that, especially as parents because these things are inevitable. If a six month on child is crying, and it takes them an extra two minutes to come and get to them because they're in the bath, then that child is going to be abandoned for two minutes. And they don't have the words, all they've got is feeling at that age. And if that happens a few times, maybe because there are siblings to look after. There's an 18 month old, that's crying, but the parent is changing the nappy of the youngest one and can't get to them, then that's going to create some sort of attachment insecurity.

Fiona  17:36  
Yeah. And so it can be that sort of thing, definitely. But it could also be simple things like I mentioned about a sleepover, let's say his eight year old goes on a sleepover. And they're served up a meal for tea that they've never tried before. And they are laughed at because they've never heard of spaghetti carbonara for example. And then they feel well embarrassed. And that sort of internalises I wish I was at home, at home, I'm safe. And it's very often simple little things. That's why I was saying about looking at it again, through adult eyes at the adult can see, oh, well, that didn't really matter, did it? It did. But it doesn't have to now. So that's where I was getting at with those sorts of things. As you were saying about the abuse, very often, these sorts of things are not due to major issues, they can be really quite simple things easy to deal with.

Richard  18:42  
Yeah. But like you're saying he's looking at through adult eyes now. And I know that people can do that without a therapist. It's easier with one. But I know that there are people out there who because of the because of the internet and the way we communicate nowadays, there's a lot of information out there a lot of people who maybe have some independence streaks in them might think that they can do all of this themselves. And that may be why people are listening to this so they can learn to be their own therapist. And I know that those exist. I I've met people on training courses, and they have no, no intention of going into private practice. They just want to be their own therapist. You think why? And they go, Well, I don't trust anybody else to be my therapist. I'll do it all myself. And you think well, yeah, they've got some trust issues, and they probably do need a therapist, if we're honest. You've had that. I suppose you've met those of you?

Fiona  19:44  
Yes. Yes. And I mean, I It's a bit like things that you might do around the house. You know, I quite like to do a bit of DIY, but I've just had a kitchen put in I didn't do that myself. But it doesn't mean you can't do a little bit. So one of the things things, if you in that situation of feeling that home, is your safe place, and anywhere else isn't a very simple little thing that you can do for yourself is to sounds funny if I've just put it straight like this. But imagine that you're a snail or a tortoise and take your home with you. So, put it in with you in you put a bubble around your shell on your back, not literally just think of it being there. And put all the feelings that you have from home in there. Take it with you. 

Richard  20:37  
I love that. 

Fiona  20:38  
And Steve was saying about his he was going with his family. Well, I would imagine that his family are part of his home. So to just think of those sorts of things, and really contemplate on it, so I'm actually taking my home with me. The bricks and mortar don't matter so much do they? It's the people the feelings within it. So be a snail or a tortoise, whichever you prefer. Or turtle. 

Richard  21:09  
Yeah, the imagination is often under underutilised resource, it really is. There's a phrase I use a lot, which is the brain doesn't know the difference between fact and fiction. And if we can use our imagination to help us then we need to make sure that we do rather than use it to hinder us by only thinking about what could go wrong. We also what I suggest to people is to make sure that when they've got this story going on in their head that they follow the story on they keep it going. They say to themselves, well, this is the worst case scenario. Okay, well, what happens then? What What if I have a panic attack? Well, what happens after? Well, I suppose I'll sit in the corner, backwards and forwards. And maybe I'll find and then what and what happens if you keep on going, ultimately, you get to the point where it's over, and the safe and everything's okay, it comes to an end.

Fiona  22:01  
Because it's that episodes thing. Everything does finish, I just got the image of Steve going through the airport very, very slowly. Very slowly, you don't have to take it quite to that level. But you can

Richard  22:15  
you can do it at your own pace, like a snail.

Fiona  22:19  
There's there's an element of within Agoraphobia about feeling out of control. I think you mentioned that earlier, Richard, but we didn't go into it. I think that's an important thing to think about. You were sort of going there anyway, in terms of that, going through the story as to what will happen. But there is only a certain amount of things that we are ever in control of. So there's a phrase that I like to use, and I've used it myself in airports, because often you do feel quite out of control in airports, because you're queuing up and things are delayed, and you don't know what's happening. And so generally speaking, it's a place where you don't feel in an awful lot of control. The phrase is, I can't control everything, but I can manage anything. And if Steve as the snail thinks of that as well, he can manage whatever happens. 

Richard  23:17  
Yeah, yeah, we can. 

Fiona  23:19  
Yeah. I mean, I don't know, Steve. But I know he can manage anything, because he always has hasn't he.

Richard  23:23  
Well, he's still here to tell the tale. So yeah, yes, everything that's ever been thrown at him is managed. It might not have been in control of any of it. But he's managed.

Fiona  23:33  
But he might not have managed it. He might not have managed it as well as he could have done. He might he might not have been brilliant, but he's managed.

Richard  23:42  
Yeah, I think we often forget that we have experiences, that show us what we can accomplish. But we often go in our imagination to what we can't, out of habit. Maybe we filter these things. And we forget that we learn to walk. Yeah, we fell over. But we did learn to walk. Well, most of us. Most of us who learned to ride a bike fell off the first time we got on it. I'm sure I did. Or remember, I got these vague memories of learning how to ride a bike and not knowing how the brakes work and using a skip that was parked outside a neighbor's house as a brake. I was just crashing into that. Because that was how I thought I'd stop. I don't think it went well. But I got back on the bike, and now I can ride a bike anytime I like.

Fiona  24:33  
And you managed your managed. You weren't in control. But you found a way. Even if it was not necessarily the best way that you did it. You're not still going down the road.

Richard  24:47  
Exactly. If I get on a bike now I now know how the brakes work. And it astonishes me that nobody showed me how the how the brakes worked, although maybe they did but I just went oh, I can do it on my own me alone. I'll do this on my own. I'm being reminded, rather bizarrely, that I'm supposed to have some dining room chairs being delivered ordered them six months ago, supposed to take three weeks, six months later, they're still not here. And nobody really knows where they are. Because there's all these problems with shipping containers and ports being closed and things like that my poor wife is pulling her hair out, because she needs to know where these things are. Because when she doesn't, it gives this horrible feeling that she's not in control, because she's not in control. And the knock on effect of that can spoil things. Because in the case of these dining room chairs, how easy would it be to just simply cancel the order and buy chairs from somewhere else that does have stock, and that's something that my wife was looking into doing. And then she saw the original images of the chairs she wants and goes, Ah, but I really liked those chairs. And she's having she's been forced to wait. But the only thing that could help her to get a head around having to wait is to understand why. Why am I having to wait? What are the reasons, and there are reasons, there are problems with shipping containers, ports are closed problems with drivers. There's lots and lots of problems within the within the import and export business around the world at the minute. And until she could see that there's a reason why she's having to wait. It was the only way that she could make sense of it. I think it's important that we that we do that, that we try to make sense of all these things, because that makes sense.

Fiona  26:30  
It does so it's so that that combination for people with Agoraphobia of understanding why they're feeling it, recognising that it will be over recognising that it's an episode, and that they will get through it will lead to a diminution of the fear in itself. And then they will feel more in control.

Richard  26:54  
One of the things that helps with that, that feeling of control is what we'd look at with every client that comes to us with it with any anxiety issue. And that's emotional regulation skills. And that's just taking some control over their body. And if there's one thing that would suggest to everybody that comes to us to learn how to control about their body, it's it's this

Fiona  27:14  
Breathe. 

Richard  27:16  
Yeah, 

Fiona  27:16  
Breathe. 

Richard  27:17  
Yeah. it's learning how to breathe properly. And I know that might sound a bit strange, and a lot of people think I already know how to breathe. I see these things on social media all the time where influencers and bloggers and writers and mental health professionals will say, hey, remember to breathe. And you think, Oh, I for gods sake I know how to breathe. If I'm not, if I'm not breathing, I'm dead. So of course, you don't need to tell me how to breathe. So it's kind of inherited a bit like Emile Coue's, every day in every way, I'm getting better and better. The only reason we hear about that is because people have parodied it over the years, where actually, these these things come from a good place. And something as simple as breathing can definitely help us to slow our heart rate down. If we're getting oxygen into the bottom of our lungs, take a deep breath in, push the belly out a little bit on the in breath, hold it let go slowly, it gets oxygen into your blood gets oxygen into the muscles, it trains your body that you're safe, and it doesn't need as much adrenaline anymore. And to look at the rest of your body. Where are you holding tension? Are you holding tension in your fists? Are you holding it in your jaw? Are you holding it in those those long muscles either side of the spine? The erector spinaes muscles, are they?

Fiona  28:30  
I'm not sure but stomach as well is one really big place when people hold tension. It's as though this they're tightening up the stomach ready to get punched in it? Which probably isn't going to happen. It's the same as you know, really fit person would do if they were going to get punched in the stomach. We do that naturally.

Richard  28:48  
Hmm. Yeah. And that's where all our all our really important organs are. Yeah, and when we're nervous it's quite interesting to look at body language, we hold ourselves in such a way to protect those soft and fleshy bits. So that if we are being attacked by something, whether it's a tiger or a spear, that is going to get our hands and our arms rather than the really important bits. So we do need to look at our body, and all the different things that we do with it and look at what we can control.

Fiona  29:18  
So it's about learning in more ways than one, but it all comes together.

Richard  29:23  
Hmm. Yeah. Well, Fiona, I think we've come to time look at that. Time really does fly doesn't it?

Fiona  29:30  
It does, doesn't it? Yes, absolutely. It's good conversation. And thank you, Steve, for that question.

Richard  29:35  
Yes, thank you very much, Steve. Do let us know how you get on keep in touch. And if anybody else has any questions that they'd like to put to us that we can answer here on therapy natters. In the show notes, there will be some links to contact us. So please do in the meantime, have a great day. Have a great week. Have a great life and if you need anything, you know where to find us Speak to you soon