Agoraphobia

A HOME TREATMENT PROGRAMME FOR YOUR HELPER-PART II
(by Professor A Mathews-Oxford University) Published by S.W.A.G.(AUST.) INC.
ISBN 0 9591710 5 3

This section is designed as a guideline for relatives or friends of someone suffering from agoraphobia. Although agoraphobic can do a great deal to help themselves, the right kind of support and encouragement from others is extremely invaluable and for this reason you may well be in a position to help a great deal. To understand the nature of this problem, you first must read and understand Graded Exposure notes and then continue on to this section for details of what you can do to help in practice. This part is addressed to helpers, assistants, carers. However, it is as useful to any friends or relatives of people having this problem, regardless of sex. Remember to try answering the questions at the bottom of each page before checking your answer.

1. WHY YOUR HELP IS NEEDED! What you have already read about in part one, could be done by the agoraphobic himself or herself. You may think if any extra help in needed, then it should be given by qualified people, doctors, psychologists, or social workers, community nurses. THIS IS NOT TRUE - IN THE LONG RUN IT IS THE PEOPLE CLOSE TO AN AGORAPHOBIC WHO CAN HELP MORE. Often there are special difficulties connected with situations at home, or journeys from home, which you may know about, but other people don't. When treatment is done away from the home, say in hospital, any improvement may sometimes disappear when back home again, which is caused by special problems there.

You may feel that advice from professional people could carry more weight, but every day, in many different ways, how people behave and feel is influenced by others close to them. BECAUSE WE ARE TREATING AGORAPHOBIA AS A CLASSICALLY CONDITION EMOTIONAL REACTION AND NOT A DISEASE OR ILLNESS YOUR INFLUENCE IS MORE IMPORTANT

QUESTION-YOUR HELP IS IMPORTANT BECAUSE: a) You know more about special problems b) Practice is best done from home c) Your influence counts more in the long run c) All of these.

2. Unlike a disease, agoraphobia always depends in part on things which other people do, often with the best of intentions. For example, people with agoraphobia often have to depend a lot on others for getting out. This tends to become a habit, in the same way as avoiding things (this is not by choice on their part) in fact it makes them feel guilty to put others out. In some cases it could be very difficult to discourage this dependence on you in the early stages. If a husband worries about his wife's health, he may think of her and invalid, needing to be looked after and kept at home. Sometimes it can be reassuring to know that a person depends on you to get out at all. Or it might be convenient for the family that one person stays at home all day. There are many other ways that we can encourage agoraphobics to depend on us, without realising it - and that means we are keeping the problem going.

QUESTION-AGORAPHOBICS TEND TO DEPEND ON OTHERS BECAUSE: a) They feel safer with familiar people b) Other people don't always encourage self-help and independence c) It is a way of avoiding the most frightening situations d) All of these.

3. Many things that people do can be very helpful - like getting the shopping because the sufferer of agoraphobia finds it frightening - in the long run it is not so helpful. Making it too easy for the agoraphobic to stay at home just makes the pattern of avoidance and the fear, grow stronger. To be really helpful means finding ways to help oneself efforts of getting out, even if the gains seem slowly that way . It's easy to feel inpatient if things seem to be moving slowly and even more so after a set-back. But this is when YOUR encouragement will be most needed. Understanding and sympathy are important too, but that does not mean that it helps to talk too much about the unpleasant feelings, since that is what keeps it going longer. Praising her or him for their efforts and reassurance that nothing too awful can happen is much more important. But even more important than talking about practice IS DOING IT and as often as possible.

QUESTION-OF THE AGORAPHOBIC MANAGED TO GET TO A SHOP THAT THEY HAVE BEEN AVOIDING, SHOULD YOU: a) Tell him or her how pleased you are and suggest to try again? b) Tell him or her not to make a fuss until success? c) Check if he or she felt any strange, panicy feelings? d) Tell him or her to have a rest from trying that shop for a while?

4 WORKING TOGETHER TO OVERCOME THE PROBLEM At each step in the plan described earlier there are some particular points where your help may be very important. Before deciding on treatment targets, discussion may help to find items that you both agree would be useful. You may be able to suggest targets that have been avoided so long that they are being overlooked, but remember that in the end he or she MUST CHOOSE THE TARGETS THEMSELVES. - find out which target seems right to begin with (practising), with what you know, and from how he or she feels about it. It should not be too easy (something that can be done already), not be too difficult (something that he or she doesn't feel ready to try yet), but somewhere in between. - if it is something you can do together, then it may be a good idea to start that way, and gradually move towards it being done alone (see suggestions for practice items further on). - every day, ask about what practice has been done and make a point of showing that you are pleased with the effort he or she is making.

QUESTION-WHICH WOULD BE THE WRONG THING TO RECOMMEND FOR SOMEONE WITH AGORAPHOBIA: a) Doing things one step at a time? b) Having someone help by doing the shopping? c) Practice going out every day? c) Having firm encouragement from others?

5 WORKING TOGETHER TO OVERCOME THE PROBLEM 2 To keep you in touch with practice that he/she does alone, it is very important that a diary is kept (if not doing so already) to note down every day how long the practice time lasts and where he/she went. If you keep a list of agreed practice targets, then you can check them off every time the record shows it has been achieved. Once the target has been managed several times, you could ask how he or she feels about trying something more (don't forget to congratulate her or him at the same time!). Try not to complain and be impatient if progress is slow or variable - remember that the first aim of practice for an agoraphobic is to learn how to cope with the unpleasant feelings that keep it going, and these will alter quite a bit from day to day. Pay no special attention to failures other then encouraging him or her to try again, in a different way next time, perhaps with your help or after taking a tranquilliser. However, never forget to praise him/her, either for carrying on despite feeling tense, or for doing something that was avoided before.

QUESTION-IF HE OR SHE SUCCEEDS THE FIRST TIME, HE OR SHE PRACTICES AN ITEM, SHOULD YOU: a) Suggest that he/she try it again tomorrow ? b) Tell him/her to try a more difficult one ? c) Point out how he or she exaggerates himself or herself ? d) Congratulate the agoraphobic and have a rest ?

6 WHAT TO DO ABOUT A PANIC Suppose you are out together when suddenly he/she says that he/she feels frightened by some strange feeling or situation. Do not IMMEDIATELY take the agoraphobic home. Try to find somewhere to rest, sit down somewhere, walk back a little way or do anything that will help him/her stay in or near the place where the feelings started. Do not KEEP ASKING how he/she feels or get involved in lengthy discussions of the panic feelings, since this might make them worse. Find something ELSE to talk about until you judge that he/she is feeling better from looks and behaviour. In time the feeling will die down, and although you can then go back home, it would be better still to go on practising for a little while before doing so. Fortunately once panics have come and gone it is unlikely to come again for a while (sometimes). The golden rule is - try not to leave a situation until the fear is going down.

QUESTION-IF HE/SHE BECOMES FRIGHTENED IN A SHOP, WOULD IT BE BEST TO : a) Tell him/her to snap out of it ? b) Help her to get home as soon as possible ? c) Go to another shop ? c) Help him/her stay until feeling better ?

7 WHAT TO DO ABOUT A PANIC 2 Sometimes it may be impossible to stay somewhere long enough for the fear to die down. If this happens when the agoraphobic is alone, then it may be possible to overcome the problem by asking her/him to go back to the same place as soon as possible. If you were together, you should arrange for a return visit as soon as possible, having a tranquilliser. If it is not possible to get back soon, you may notice a set back - that item or others like it seem more difficult again. There is no need for alarm - simply go back a bit and arrange practice with some in-between sub-goals. If this is done without delay, the lost ground will be made up quickly. Very occasionally you may have more than one set-back with the same situation. This probably means that the item is more difficult than you realised and it may be better to go on and by-pass that particular item.

QUESTION-YOU ARE ON A BUS TOGETHER WHEN, IN A PANIC, SHE INSIST ON GETTING OFF EARLIER THAN PLANNED: a) Insist that he/she get on the next bus ? b) Try again soon after a tranquilliser has been taken ? c) Ask him/her to try it by herself or himself next time ? d) All of these ?

8 ENCOURAGEMENT FROM OTHERS To get the regular habit of practice started and keep it going, the most important thing is constant encouragement from other people - especially close relatives and friends. To understand this, remember that the practice is likely to be frightening at first and other times, boring and hard work. In other words most of the effects of practice on an agoraphobic have become unpleasant or punishing. Obviously this makes it easy to think 'it's not just worth the effort' and to stop trying for a while. At this point the battle is lost. To stop this you have to arrange things so that efforts to practice and get back to normal are encouraged and rewarded. Strengthening the pleasant associations of new behaviour in this way is called 'reinforcing' it.

QUESTION-TO HELP IN ESTABLISHING THE HABIT OF REGULAR PRACTICE, IT IS BEST TO REINFORCE IT BY: a) Praising him/her more often ? b) Praising him/her when the practice has been done well ? c) Telling him/her off when he/she has not done any practice ? d) None of these ?

9 ENCOURAGEMENT FROM OTHER 2 1. Remember to ask how practice has gone every day. It does not help to criticise lack of progress, but genuine praise for the effort made is important. Discuss progress regularly and try to suggest ways round the difficulties. 2. Make sure other people know about the problem - the more help the better. Remember that 'help' by doing things for him/her does't really help at all - but they can be encouraged to do things to help themselves if others understand the problem. 3. Make a point of giving a small present (it doesn't have to be expensive) whenever a land mark is passed in practice. If you do this sometimes anyway, from now on you must only give something when it follows progress in practice.

QUESTION-REINFORCING EFFORTS BY PRAISE OR PRESENTS IS AN IMPORTANT PART OF TREATMENT BECAUSE: a) Makes him/her more cheerful generally ? b) Strengthens the connection between his/her efforts and pleasant things ? c) Shows him/her you care for him/her ? d) Will make him/her do things that he/she couldn't have bothered to do otherwise ?

10 ENCOURAGEMENT FROM OTHERS 3 4 . One of the best ways in making progress in the long run, is for him/her to find a regular outside job away from the home. Obviously a paid job may seem a good idea - the extra money is bound to come in handy and can be saved for special awards or large things that would be difficult to get other wise. If a paid job is not possible it may be worth thinking about voluntary work, or some outside interest, evening classes and so on. All these help by the practice in getting them meeting people, and may be a source of satisfaction in themselves. It is not usually a good idea to wait until he/she is better before thinking of a job, the sooner the better. 5

. You may be able to think of other ways to encourage practice - perhaps the better ones. Whatever you use, some form of reinforcement is essential for success.
QUESTION-A JOB OR OUTSIDE INTEREST WILL HELP BECAUSE: a) The money will be useful ? b) It reinforces self-discipline ? c) It will be able to help the sufferer become independent ? d) It is a source of reinforcement away from home ?

HELPFUL HINTS FOR HELPERS AND A FEW MORE EXPANATIONS

STATE WIDE AGORAPHOBIA GROUP (AUSTRALIA) INCORPORATED
Email address: swag@tne.net.au Phone: 08 8294 6543 Mobile: 0412 226 117

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