Agoraphobia

A HOME TREATMENT PROGRAMME FOR AGORAPHOBIA SUFFERERS
(by Professor A Mathews-Oxford University) Published by S.W.A.G.(AUST.) INC.
ISBN 0 9591710 0 2

CONTINUATION OF DE-SENSITIZATION AND GRADED EXPOSURE STEPS- PART I

9. TREATMENT IN PRACTICE: Step 1 To begin with, you will have to decide exactly what you are aiming for; in other words, what are the treatment targets?

This is not as easy as it sounds, it's' no good saying something like, " I just want to get better " - you must decide on specific descriptions of behaviour. Examples could be,"Going by yourself to the super-market for groceries " or," Going alone by bus to the school to meet the children" and so on.

Make a list of all the things that you would like to do if you were completely recovered. Don't forget difficult things (like long journeys ) which have been avoided for many years. Anything you think might be a good idea in principle can be put on the list as a long-term target.

Lastly, you must put all the items on the list in order, from the least difficult to the most difficult. Make a careful note of this order - you will be using it later.

QUESTION-Which of the following would be a useful description of a treatment target? a) Go out for a walk. b) Practise going out every day. c) Walk alone to the school. d) Try to keep calm when shopping in the super-market.

10. WHY ARE SPECIFIC DESCRIPTIONS OF BEHAVIOUR IMPORTANT? Agoraphobia can't be treated like a physical disease, pills may help, but the people involved must also change in the way they behave. You can think of the phobia as showing itself in three main ways - feelings (of fear), thoughts (about what awful things might happen ) and behaviour (avoiding things). Of course they are all connected with each other, but the only way to start things moving in the right direction is by changing the behaviour. This will lead to other changed in thoughts and feelings later on.

Your descriptions must be specific so as to avoid misunderstandings about what is to be practised, and stop doubts and self-deception about whether something has been done successfully or not. Provided that your list includes enough specific behaviour, you will be able to use them to keep a careful track of your progress as treatment progresses.

QUESTION-If you feel terrified of large crowds, shooed you: a) Start practice in mixing with smaller groups of people. b) Tell yourself there is no reason to be afraid. c) Find ways to make yourself feel differently about crowds. d) None of these.

11 TREATMENT IN PRACTICE: Step 2 It is very important that you set aside a short time for practice everyday. Start with the easiest item on the list that you cannot do at the moment - let's suppose this is "Walking alone to the super- market for groceries". Begin practice in walking towards the super-market every day - never mind whether you actually get there or not at first. Make a careful note of how far you get each time. It is not so very important to reach the supermarket right away, but it is important to get into the habit of daily practice in trying to get there - this is the opposite of avoidance.

QUESTION-Daily practice in learning to overcome avoidance is important because: a) If several days go by without practice it may get harder. b) It builds confidence for harder items later. c) With each practice the fear will tend to get less. d) All of these.

12 TREATMENT IN PRACTICE: STEP 3 Each exercise should be repeated several times to find out if you can gradually do more each time. You must expect some ups and downs from day - to - day, depending on how you feel, so keep going for several days before deciding whether there are any sign of improvement. You will have to keep a careful check of how far you get or how long you are out, to know this. If you succeed in completing the item, don't assume that it is finished. Try it a few more times to check. If you continue to be successful, move on to the next more difficult item. If you don't seem to be making any progress, despite honestly trying your hardest, then you should move to step 3 in these instructions.

QUESTION-If you succeed the first time you practice an item, should you: a) Try it again tomorrow ? b) Try a more difficult one ? c) Try an easier one ? d) Congratulate yourself and have a well-earned rest?

13 TREATMENT IN PRACTICE: STEP 4 If your progress has come to a halt, then it may be that the item you have chosen is too difficult at the moment, or involves making too big a jump from what you have been doing. Firstly, check that the original order of difficulty of your list has not changed for some reason. It may be that some items which seemed very difficult at first are now easier than the one you are attempting. If this does not make any difference - the easiest item not yet done is still the one you have been trying - then you will have to invert some practice items in-between where you are now and the next target, to bridge the gap. Suppose that after "walking alone to the supermarket" (1) has been done successfully, the next one should be "Going by bus to the school" (2). Your job is to invent some items in-between )1) and (2) in difficulty.

QUESTION-Which might bridge the gap between "Walking to the supermarket " and " Going alone by bus to the school". a) Going with someone by bus to the school ? b) Going alone for just one stop at first ? c) Going alone, but being met at the other end ? d) All of these?

14 TREATMENT IN PRACTICE: STEP 5 These in-between items will not necessarily be useful for their own sake - it might be pointless for example, to travel on a bus for just one stop. The point is , of course, that they build confidence for practising later items (which are important, and which will seem much too difficult at first). It is obviously very important to choose them carefully to decide how many might be needed, and how many times to practice them. However, you will have to be prepared to be flexible about these items. If you experience persistent difficulty in making progress with the in-between items chosen at first - try out some alternatives. Once the target item has been successfully completed a few times, it will probably not be necessary to practise the in-between items any more, but at regular intervals the target item must be practised, or better still made a part of everyday life - a habit.

QUESTION-Practice items in-between target behaviours are useful because: a) They are easier than the last target item successfully practised? b) They build confidence? c) They bridge any large gaps in difficulty between targets? d All of these?

15. TREATMENT IN PRACTICE: STEP 6 Suppose that progress seems to be held up because you are experiencing too much fear, during practice or just before it . It may be useful to take a single dose of a tranquilliser (provided your doctor has prescribed some) shortly before the practice. Find out when the tablet seems to have the most effect (this might be anything from 10 minutes to a few hours after taking it) and note when you generally feel most tense (before going, on the way, or coming back). Take the tablet so that the effect comes at the time when you are likely to feel at your worst. Don't exceed the maximum recommended, don't drink anything alcoholic and look out for side effects like drowsiness. This does not matter as a rule, but it might if you were going to do any driving. Otherwise you could start with a reasonably large dose, and if this overcomes the problem then you can gradually bring the dose down. You should ask your doctor if you are unsure about the dose to take.

QUESTION-Suppose you succeed with practice after taking several tablets but cannot manage without any. Should you: a) Go on to the next most difficult item.? b) Repeat the same item several times ? c) Stop practice for a while ? d) Gradually reduce the dose while practising the same item ?

SUMMARY OF TREATMENT IN PRACTICE 1) Decide on target behaviours. 2) Start practising with least difficult items. 3) Repeat each item a few times - if successful move on. 4) If progress stops, find some in-between items. 5) Use tranquillisers for new or difficult items, then reduce the dose. 6) Try to establish the habit of practice every day.

QUESTION-Which is a correct description of treatment practice ? a) Try each item once, if successful move on? b) Decide on target behaviours and practise one every day? c) Start practising with easier items and progress to more difficult ones? d) Use tranquillisers during all treatment practice sessions.?

16 COPING WITH FEELINGS OF PANIC As was mentioned earlier, panic feelings at the beginning of the phobia seem to come 'out of the blue'. Later on, panic is often triggered by the (conditioned) fear reaction to some places or situations. These reactions die down quite quickly if they are allowed to. Usually they are kept going by the alarming thoughts they cause, (fear of the fear itself) and by attempt at avoidance. The best advice (and the most difficult to follow) is - 'let it happen and wait for it to pass'. Practising in stages and occasional use of tranquillisers makes attacks of panic unlikely, but of course, some fear must be expected. After all, everybody gets twinges of fear and other unpleasant feelings sometimes. More than this, it is part of recovering from agoraphobia to accept these unpleasant feelings for what they are, and cope with them - without running away or givin g up.

QUESTION-Which of these is likely to cause or contribute to a panic attack: a) The conditioned fear reaction to certain place ? b) Worry about strange feelings during practice ? c) Thinking that the fear is going to get out ot control ? d) All of these ?

17. COPING WITH FEELINGS OF PANIC (2) At the beginning agoraphobia was described as a fear of going out alone, but just as important it is a fear of the symptoms of fear themselves getting out of control. For this reason an essential part of practice must be to deliberately do things which produce some fear in order to practice coping with it. This does not mean getting into a total panic, but it does mean that the most useful practice involves doing things that bring on the feelings, coping with them, and going on. Practising things which don't cause any fear at all - to make sure of them - is also helpful, but this is not how real progress is make. It is important to remember that one of the purposes of practice is to learn a new attitude of mind to panic feelings, not to try and avoid them at all costs, but to go out to meet them, to deal with them as much as possible but also to accept the rest as natural (even of unpleasant) bodily feelings.

QUESTION-Which would you say indicates most progress: a) Doing something new without any trouble the first time ? b) Trying something new but coming back because of tension. ? c) Doing something new despite experiencing some panic at first. d) Doing something new but finishing in a total panic?

18 COPING WITH FEELINGS OF PANIC 3 Suppose you are out practising when suddenly you feel frightened by a strange feeling. Do not immediately go home. Try to find somewhere to rest, sit down somewhere, walk back a little way - or do anything that will help you stay in or near the place where the feeling started. Remind yourself these are just unpleasant bodily feelings that you had expected anyway - they cannot harm you. They do not mean that something awful will happen (it won't) so don't be fooled into thinking that way. In time the feelings will go down and although you can then go back home, it would be better still to go on practicing for a little while before doing so. Fortunately once panic has come and gone it is unlikely to come back again for a while - so you can sometimes use this and push on further. The golden rule is try never to leave a situation until the fear is going down.

QUESTION-If you become frightened in a store, would it be best to: a) Try to snap out of it ? b) Get home as soon as possible ? c) Go to another store ? d) Stay until you feel better ?

19 SET-BACKS Hardly anyone recovers from agoraphobia without having at least one "set back". Feelings vary, sometimes from day-to-day, and what you did successfully yesterday may seem impossible today. Even then you could make real progress - what counts is how you cope with whatever feelings you experience. So, a little done on a bad day may be worth more than a lot done on a good day. Most people feel that they have their worst set-backs following severe panics, especially if they ran away from them before the fear started going down. If this happens and you feel that you are back to square one, don't give up. Simply try again the next day, preferable after taking a tranquilliser, and you should find that the lost ground can be made up quite quickly. Provided you don't give up when things look black, then your chances of eventual recovery are very good indeed.

QUESTION-You are on a bus, when in a panic, you find yourself getting off earlier than planned. Should you: a) Force yourself to get on the next bus ? b) Try again soon after taking a tranquilliser ? c) Try an easier "in-between" item ? d) All of these ?

SUMMARY - COPING WITH FEELINGS OF PANIC 1) Expect some fear, encourage letting it happen and learning ways to cope with it. 2) Try to stay in or near the places where it started, rest somewhere, and wait for it to pass. 3) Go back slowly a short way if necessary, but don't rush away. 4) Remind yourself of the ten rules for dealing with panic. 5) When the fear goes down, continue practice if possible. 6) If you have to return home before the fear dies away, try to go back soon. 7) Some set-backs are inevitable - so expect them and don't give up.

QUESTION-The best way to cope with panic during practice is: a) Continue practice without stopping ? b) Let it happen and wait for it to pass ? c) Go home and relax ? d) Take a tranquilliser as soon as possible?

20 PLANNING FOR THE LONG-TERM Many people find that their difficulties in going out have progressively cut them off from friends, social activities and other outings they used to enjoy and they settle unto a routine which centres on the home, leaving no time for anything else. An essential part of recovery is to change this routine completely and to make time for developing interests outside the home - visiting friends, joining clubs or classes, and, best of all, finding a job. These are not things to do later on - they are important ways of helping yourself now, by providing regular opportunities for practice in going out and meeting people, quite apart from the satisfaction which they provide in themselves. Always try to use visits or outings as practice, by varying and extending how much you do - anything from going to a further store, to going off alone when out on a trip with others. When going out changes from something to be avoided, to an opportunity to practise extending your limits, you have taken the most important step to recovery.

QUESTION-A job or outside interest is important because: a) It provides regular practice in going out ? b) It is a source of satisfaction away from home ? c) Meeting new situations and people helps to break the habit of avoidance.? d) All of these?

RULES FOR COPING

When panic starts, sensible thinking stops. So you can't depend on being able to think very clearly at the time. Instead of that you should read through the ten rules below very carefully before practising, so that they are clear in your mind. When you feel panicky run through them again, or if you prefer, make a copy of them to carry with you to read at the time. If you find other ideas that help, then add them to the list. Following is a shortened version of the rules designed to act as reminders. Read the rules in full, then check that you can remember them using only the reminders below to prompt you. 1) THE FEELINGS ARE NORMAL BODILY REACTIONS 2) THEY ARE NOT HARMFUL 3) DON'T ADD FRIGHTENING THOUGHTS 4) DESCRIBE WHAT IS HAPPENING 5) NOTICE WHEN IT FADES 6) NOTICE WHEN IT FADES 7) IT IS AN OPPORTUNITY FOR PROGRESS 8) THINK OF WHAT YOU HAVE DONE 9) PLAN WHAT TO DO NEXT 10) THEN START OFF SLOWLY

TEN RULES FOR COPING WITH PANIC
1) Remember that the feelings are nothing more than an exaggeration of the normal bodily reactions to stress. 2) They are not in the least harmful or dangerous - just unpleasant. Nothing worse will happen. 3) Stop adding to panic with frightening thoughts about what is happening and where it might lead. 4) Now notice what is really happening in you body right now, not what you fear might happen. 5) Now wait and give the fear time to pass, without fighting it, or running away from it. Just accept it. 6) Notice that once you stop adding to it with frightening thoughts, the fear starts to fade away by itself. 7) Remember that the whole point of practice is learning how to cope with fear - without avoiding it. So this is an opportunity to make progress. 8) Think about the progress you have made so far, despite all the difficulties, and how pleased you will be when you succeed this time. 9) When you begin to feel better, look around you, and start to plan what to do next. 10) Then, when you are ready to go on, start off in an easy relaxed way - there's no need for effort or hurry.

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

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