My dear high school friend will not take the down escalator. She will take it up, but when we shop together in department stores, we must always take the elevator down. Even for one floor. It’s a minor inconvenience and one that doesn’t disrupt her life. But another friend is unable to fly and this is emotionally costly to her, particularly because her son and his family live on the west coast.

There are many different phobias and many ways to treat them. But some people feel they just cannot overcome them. As a consequence, their lives become constricted to a greater or lesser extent.

First a definition from Harvard Health Publishing: “A phobia is a persistent excessive, unrealistic fear of an object, person, animal, activity, or situation. The person with the phobia either tries to avoid the thing that triggers the fear or endures it with great anxiety and distress.”

According to Johns Hopkins, about 19 million Americans have one or more phobias ranging from mild to severe. They can occur in childhood, but usually are first apparent between ages 15 and 20. No one knows the exact cause and sometimes they can be traced to a traumatic event with the feared object. But usually they just happen — a fear somehow becomes linked to an object or situation.

Harvard Health cites three specific groups of phobias:

• Specific, also known as simple, which is the most common. This focuses on specific objects, meaning a particular object or situation that is relatively safe will bring on severe anxiety. Some common examples are fear of dogs, heights, tunnels, or thunderstorms. Fun fact: fear of spiders (Arachnophobia) and fear of snakes (Ophidiophobia—count me in) are the most common.

• Social phobia is usually a fear of being humiliated in front of people. Sufferers feel that all eyes are on them and are watching and waiting for them to say something stupid. Following social interactions, they often examine everything they have said, believing that people are endlessly critical of them. Fear of public speaking, a very common phobia, falls into this category. It is usually associated with believing that the speaker will “fall on his or her face” and be publicly humiliated. The National Institutes of Health estimate that 5% of the population suffer from this fear.

There’s a difference between social phobia and shyness. Shyness is not an anxiety disorder, but a personality trait characterized by temporary feelings of discomfort in social situations. Most people feel shy in certain situations and it is perfectly normal.

• Agoraphobia (from Greek, meaning fear of the marketplace) is an irrational fear of being trapped. This can mean elevators, public transportation, crowds, or any enclosed spaces and at its most severe can lead someone to be afraid to leave home.

In all phobias there is a chance of danger. But what makes it a phobia instead of a legitimate fear is that the chances of the danger actually occurring are minimal. Take Mary, my escalator-fearing buddy. She thinks she first became afraid in the bowels of London when a long wooden escalator took her into a tube (subway) station, but she’s not really sure. Her realistic self knows that the danger of escalators is minimal. However, for the last 40 years she’s found it terrifying to look down an empty escalator to the floor below; she sees herself falling and is therefore too frightened to take that step. It’s less frightening if people are in front blocking her view and reducing her chances of falling.  But her solution has been to avoid down escalators altogether. Her solution: Take the stairs or find an elevator. It’s really a minor inconvenience.

But what do you do when the phobia causes greater restrictions on your life?

I’ve known Barbara since our childhood. As a kid she had a lot of anxiety, but grew up to become a successful entrepreneur and the mother of three terrific sons. Yet for all of our adult lives I knew she was afraid to fly. I’ve recently learned why: It began in college with a plane aborting take-off while flight attendants screamed for passengers to crouch in the center aisle.

She thought the plane was about to explode. Subsequent trips (and very rare ones at that) required hefty amounts of valium, a substance that she no longer feels comfortable taking. She now just doesn’t fly at all, even with children and grandchildren living on the west coast. Reflecting on the fear, she thinks it has to do with dying without control. At least in a car accident one has some control.

Over the years, Barbara has embarked on many attempts to relieve this anxiety such as a TWA informational class, hypnosis, a simulated flight desensitization course, and the SOAR course, a well-respected technique based on regulating stress and calming the nervous system. But now at age 73, she’s made the decision to just not fly. While it does limit her family visits, something that saddens her, she decided to eliminate the anxiety associated with airplanes.

Along with SOAR (which was originally developed for fear-of-flying), here are some better known therapies to combat phobias.

Systematic desensitization has been a successful way of treating phobias and anxiety disorders for many years. The method has the patient list a “hierarchy of fears” from least anxiety-producing to most. The therapist helps the patient to relax using breathing, guided imagery (visualizing happy scenes) and other relaxation techniques. Then the therapist begins to expose the patient to the smallest fear (either in reality or simulated) and helps the patient relax while gradually working their way up the “fear scale.” This generally takes from 4—12 sessions depending on the severity of the phobia.

Exposure therapy forces the patient to confront their fears in a safe environment. For example, someone with a fear of snakes may be asked to handle a harmless snake with snake handlers present. Whereas systematic desensitization is a gradual step-by-step process, exposure therapy goes straight to the fear.

Cognitive behavior therapy (CBT), which has proven helpful for a wide range of problems, is considered the best treatment for social phobia. People suffering from social phobia fear they will be negatively judged so they develop anticipatory anxiety and avoid social situations. CBT sessions enable the patient to confront their faulty assumptions of how people view them with evidence-based facts. The therapy helps people learn better ways of coping by coming to understand distortions in their thinking. Then systematic desensitization techniques (i.e., simple social interactions moving gradually to more complex ones) might round out the counseling.

Treating agoraphobia is more complicated. Fortunately, since COVID, with the advent of remote therapy, patients can see their therapists from home. However, as the therapy progresses, going to the office or clinic is a goal. Anti-anxiety or anti-depressant medication may be indicated to manage the symptoms. According to the Mayo Clinic, if the anxiety is so severe that it continues to be incapacitating, an intensive out-patient stay in a hospital or clinic may be necessary.

Nelson Mandella famously said, “I learned that courage was not the absence of fear, but the triumph over it. The brave man is not he who does not feel afraid, but he who conquers that fear.” People with phobias have a choice to either succumb to or fight it in the best way they can. It may be a minor inconvenience like taking an elevator or staying away from places where snakes abound. But if it is a life-constricting social phobia or agoraphobia, measures need to be taken to be able to live a satisfying life. Everyone deserves that.

Nancy Green is a social worker and the Co-chair of the Shelter Island Health and Wellness Committee

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