Phobias: Fighting the Fear. Helen Saul

that delving in someone’s unconscious, looking for the cause of a phobia, does not get results. Good treatments work regardless of the cause.

      Other, less celebrated parts of Freud’s work provided a solid framework within psychiatry which still largely exists. He had a genius for making sense of the experiences described by his clients and categorising the different aspects of anxiety. The remnants of his classification are still apparent today in the mighty DSM, the Diagnostic and Statistical Manual of Mental Disorders, the bible of the American Psychiatric Association.

      Until Freud’s paper in 1894, anxiety disorders were collectively known as neurasthenia. Freud’s achievement was to distinguish ‘anxiety neurosis’, or what we now call panic disorder, from general anxiety and to describe its three aspects. The first is the anxiety or panic attack; the second is anxious expectation, or anticipatory anxiety; and the third is phobic avoidance. Further, Freud recognised that people could have more than one anxiety syndrome, and that people could have mild forms of anxiety.

      He described heart ‘spasms’ and the difficulty in breathing that can accompany anxiety attacks. In fact, ten of the thirteen symptoms included in the DSM as late as 1987 had been previously noted by Freud. Freud also recognised that specific phobias – not the term he used – were quite different from agoraphobia, and described them as an exaggerated reaction to dangers instinctively feared by everyone. The idea that most specific phobias are an overblown but essentially normal reaction surfaced again recently and is explored in the following chapter.

      Freud, who was a neurologist, drew together much of the work that preceded him and his early work reflects his interest in neurophysiology. He cut across the nature-nurture debate and claimed, in a truly modern fashion, that inborn and biological factors interact with experience in causing anxiety disorders. Interestingly enough, he was himself phobic about travel.

      Little Albert

      J. B. Watson was an impatient young American. He was irritated by the state of psychology in the early twentieth century, by its lingering obsession with philosophical questions and its fascination with the subconscious. He set out to drag it into the realms of science.

      Watson did not claim that mental phenomena do not exist, but rather that they cannot be measured and therefore might as well be ignored. In an unlikely agreement with Kant, he said that the mind, or consciousness, could not be investigated scientifically. Following on from Wundt, mentioned earlier, Watson stressed the importance of collecting data and measuring overt, visible behaviour. Little Albert, an 11-month-old baby, was the unfortunate guinea pig chosen.

      Watson’s masterstroke was a direct challenge to Freud. He and his colleague, Rosalie Rayner, allowed Albert to play happily for a while and then showed him a furry white rat, at the same time banging an iron bar on metal just behind his head. The little boy got a terrible fright. A few days later, they showed Albert the rat again, this time without the noise. He was still obviously frightened. In fact, weeks after the experiment, he remained afraid of rats, dogs and anything furry, even fur coats.

      A single, frightening event was enough to create a lasting fear in Little Albert. By extension, it suggests that the horse’s fall in front of Little Hans may have been sufficient in itself to cause his subsequent phobia. Analysis of his subconscious was therefore unnecessary.

      Russian neurophysiologist Ivan Pavlov, working at the same time, would have agreed. He famously rang a bell every time he fed a group of dogs. Eventually, the dogs started to salivate at the sound of the bell whether or not there was any food. Pavlov said they had come to associate the bell with the food so strongly that either would make them salivate. The dogs were conditioned, to use Pavlov’s term, to salivate when the bell rang.

      White rats were a convenient vehicle for studying behaviour because, like dogs, they can be conditioned. Simple experiments with rats produced simple results and fuelled enthusiasm for behaviourism. In variants of Pavlov’s experiments, rats were shown something innocuous, like a coloured light, at the same as they received a mild electric shock. With repetition, the rats came to fear the light alone.

      It provided a simple way of thinking about phobias. A single event causes lasting fear. A child is frightened when a big dog snarls and attempts to bite and afterwards fears and avoids all dogs, even small and friendly ones. Behavioural therapy attempts to reverse the process. By gradually reintroducing the child to dogs, the link between the snarling dog and others is broken, the child gains confidence and the fear disappears.

      However, behaviourism failed to see off Freud. Its practical shortcomings were, ironically, demonstrated by Watson. Like Freud, he was unable to heal himself. Watson had a lifelong fear of the dark which his behaviourist methods could not banish. It is hard to imagine anyone with a phobia believing as fervently in their treatment or being as determined for it to succeed, but it did not work for Watson.

      His personal life may have dealt behaviourism an equally serious blow. He had a scandalous divorce following his affair with Rosalie Rayner. They subsequently married, but he was forced out of his job at the prestigious Johns Hopkins University and left academia for advertising. Behaviourism was robbed of its figurehead, research started to go in many different directions and it never regained its earlier theoretical coherence.

      Behavioural learning theory may have foundered but behaviour therapy, a logical extension of the theory, is still a core feature of most treatments for phobias. Just as Watson was only interested in studying behaviour, the task of the modern behaviour therapist is limited to changing behaviour. Watson did not argue that consciousness did not exist, only that it could not be measured. Similarly, therapists acknowledge that phobias mean fear, but they do not tackle the emotion directly. Instead, they work to change behaviour and prevent avoidance of the feared object. The therapy, discussed in chapter 5, may not have helped Watson, but it is routinely successful.

      Computers, Cognitivism and Progress

      Freud and Watson’s pre-eminent positions were eventually usurped in the 1950s by the silicon chip. Computers provided the inspiration for the next way of thinking about thinking. Centuries earlier, doctors trying to understand the heart were baffled until engineers invented the pump. The pump gave them a model for how the heart could work, and it was a good comparison. In the same way, computers introduced notions of information processing and storage which were new. Doctors hijacked these ideas to explain the workings of the human mind and memory. The analogy of programming a computer to carry out tasks was a more satisfactory explanation for how we learn complex skills than anything behaviourism had put forward.

      So computers’ first contribution to the progression of thought on phobias was as a model for thought processes and the mind. More recently, computers have driven research into the physical causes of fear in a way that has never been possible before. The power of modern computers allows geneticists to trawl through immense heaps of data in an attempt to pinpoint the genes responsible for panic disorder. Advances in imaging have given scientists new ways of looking at the brain and allowing them to piece together an ever-clearer picture of the physical changes when someone thinks, laughs or is afraid. Computers are being used to design molecules that will surely give us the next generation of fear-busting pills. The neurosciences are advancing in many different directions and none of it would be possible without the modern computer.

      But if history has taught us anything, it must be that no one school of thought has all the answers. Hippocrates and the ancient Greeks gave telling descriptions of phobias, but did little to help their patients. The philosophers had some brilliant insights which failed to make it into clinicians’ textbooks. Progress has been halting over the centuries, characterised by dead ends, false dawns and the odd piece of brilliance, quickly obscured.

      Freud must be credited with separating phobias from generalised anxiety and establishing them as a new and distinct subject for study. His classification of anxiety types was a big step forward because it drew attention to the special and specific features of phobias which today’s therapists are capitalising on and which are making new treatments so promising. However, his later psychoanalytical work, with its subjective interpretations of hidden feelings,