162
(‘ASI HISTORILSAN,) SHORTtR COMMLINICATIONS
is no1 a large proportlon of the clinical sample and IS surpristng I” view of the apparent hea\! locu\ on the clinical fears and phobias of adults. A more complete and representative survey 01 behavior therapists is needed. Also more questIon\ regarding the type:duration. Intensit). etc.. of the referred fears would be helpful. However. until that larger sur\c! is completed. our tentative estimate of 6.X per cent. based on S47 recent cases (l97& 19771 of I9 beha\lor therapists hopefully will be useful. ANTHONI M. GKALIAXO INA &I. Dt- GIOvANXl
REFERENCtXS BI~RECZ J. M. (1968) Phobias of childhood: Etiology and treatment. Ps~xho/. Bull. 70. 693-720. GRAZIANO A. M.. DEG~OVANNI 1. S. and GARCIA K. A. (1977) Behavioral treatment of children’s fears: a review. Unpublished manuscript. State University of New York at Buralo. JONES M. C. (1924) The ehmination of children’s fears. J. e.up. P.~~~c/to/. 7. 382-390. MILLEH L. C.. BARRETT C. L. and HAMPE E. (1974) Phobias of childhood in a prescientific era. In Clti/[l Prrsomlit~~ ad Ps,xhoparho/oq~~: Curretlr Topics. Vol. 1. (Edited b? A. DAVII>S) Wile!. New Yorh. MARKS I. M. (1969) Fcar.5 ad Phobias. Academic Press. New York. RUTTER M.. TIZARI) J. and WHITMORE K. (1970) Erlucuriorr. Hralrh at~rl Brhrrrior. Wile!. New Yorh.
A note on the treatment of agoraphobics with cognitive modification versus prolonged exposure in uiuo
(Rrcriced
I5 Juw
1978)
In an unusually well planned and executed study of agoraphobics. using three main methods of cognitive modification versus prolonged exposure in ciao. Emmelkamp et al. (1978) found that the latter procedure “proved to be a definitely superior form of treatment to cognitive restructuring. as measured by the behavioral !,I riw measurement and the phobic anxiety and avoidance scales.” Although this study. like virtually every experimental approach to therapy. has its methodological limitations. I am inclined to accept its basic conclusion and to consider it important. Two salient questions that it raises. and that I would now like to discuss. are: (I) What are the main reasons for this interesting finding? and (2) Assuming that their conclusion is valid. what lessons can we draw from Emmelkamp er a/.‘~ study to improve the efficacy of cognitive restructuring I” treating agoraphobia and other serious clinical phobias’! In answer to the first of these questions. Emmelkamp (‘I ul. gave a partial answer that I think has a truthful ring: “Giving a form of treatment a name is not the same as elucidating the therapeutic process involved. Whether the treatment ‘cognitive restructuring’ does actually produce a modification of cognitive processes is a debatable point. On the other hand. the effects of prolonged exposure it1 rim could at least partly be explained in terms of cognitive restructuring. During treatment with prolonged exposure itI oivo clients notice, for example. that their anxiety diminishes after a time and that the events which they fear. such as faintmg or having a heart attack. do not take place. This may lead them to transform their unproductive self-statements into more productive ones: ‘There you are, nothing will go wrong with me’. A number of clients reported spontaneously that their ‘thoughts’ had undergone a much greater change during prolonged exposure i,r ritw than during cognitive restructuring. It is possible that a more effective cognitive modification takes place through prolonged exposure it1 rim than through a procedure whtch is focused directly on such a change.” This seems to be a very sensible explanation of some of the obtained results of ))I P!PO exposure; and it was because of this theory that I first incorporated it1 ttw homework assignments in the clinical use of Rational-Emotive Therapy (RET) and why I virtually never use it. especially in the case of agoraphobics. without such tr1 viro assignments (as Emmelkamp ef al. rightly acknowledge in their paper). Pure cognitive restructuring works relatively poorly for almost any kind of a phobia-as I have always tried to make clear (Ellis. 1962, 1977a. 1977b; Ellis and Grieger, 1977). For unless phobic individuals acr against their Irrational beliefs that they I~IUS~not approach fearsome objects or situations and that it is horrihk if they do. can they ever really be said to have overcome iuch beliefs’? There is another very important reason why serious phobics, including agoraphobics, irrationally avoid people. ob_iects. and situations: and that is because of what I now call their discomfort anxiety (Ellis. 1978. 1979). Ego anxiety (EA) I define as emotional tension that results when people feel (I) that their self or personal worth is threatened. (2) that they should or ~nusr perform well and/or be approved by others. and
CASE HISTORIES AND
SHORTER COMMUNICATIONS
163
(3) that it is awful or catastrophic when they don’t perform well and/or are not approved by others as they should or n~usr hr. As can easily be imagined, ego anxiety is often an important part of agoraphobia (and other phobias). since phobic individuals are demanding of themselves that they I~USI be able to approach fearsome situations and that they are worthless individuals if they don’t. Discomfort anxiety (DA). however, is frequently even more important in serious phobias. This consists of emotional tension that results when people feel (I) that their comfort (or life) is threatened, (2) that they should or must get what they want (and should not or must nof get what they don’t want), and (3) that it is nwfu\ or catastrophic (rather than merely inconvenient or disadvantageous) when they don’t get what they presumably must. Discomfort anxiety, moreover. exists as both a primary and a secondary disturbance in serious phobias. especially agoraphobia. Thus, agoraphobics first tend to make these cognitive demands on themselves: “1 must not experience any discomfort or handicap when I am in open spaces. buses. or similar situations: and it is terrible if I do!” With this absolutistic demand that they have IO be comfortable, they naturally avoid situations in which they feel uncomfortable: and they wrongly label themselves as being afraid of these situarions instead of (more accurately) as being afraid of the discomfort they will probably feel when they approach such situations. They are not truly afraid of the open spaces or the buses but of their own reactions to the spaces or the buses. Once they actually do ‘become frightened’ (actually. fiighren rhemselves) about the spaces or the buses. they then, as a secondary symptom. become even more ‘frightened’. They again call this secondary symptom, ‘fear of the spaces or the buses’ but it is actually fear of the discomfort of being frightened. Their secondary symptom could be called fear of fear, or anxiety about anxiety (just as a depressed individual can be depressed on a primary level about losing a job and on a secondary level about being depressed). But ‘fear of fear’ or ‘anxiety about anxiety’ is a shorthand phrase for ‘fear of the discomfort of fear’ or ‘anxiety about the discomfort of anxiety.’ Secondary symptoms of all kinds-such as depression about feeling anxious. depressed, guilty, or angry may well have a strong element of ego anxiety (EA) in them (e.g. “1 am a rotten person for causing myself to feel anxious, depressed, guilty or angry”); but they also, and often more importantly. include an enormous element of discom‘fort anxiety (DA) (e.g. “I can’t bear the discomfort of feeling anxious. depressed, guilty, or angry”). If I am correct about this, and discomfort anxiety (DA) is both a primary and a secondary cause of many or most serious phobias, then I would hypothesize that this especially holds true for agoraphobics. As Emmelkamp et al. (1978) point out, clinical agoraphobics probably differ from subjects in analogue studies in that they have a higher degree of physiological arousal-in anxiety engendering situations (Lader, 1967). They note that “it is quite possible that cognitive restructuring constitutes an effective form of treatment for low physiological reactors (such as the subjects of analogue studies), while such treatment will be effective for high physiological reactors (such as agoraphobics) only after the autonomic component has been reduced.” Quite correct. I would say. Or, as I shall show below, after their discomfort arrxiety ahour their autonomic component has been reduced. For if it is true that agoraphobics (and many other serious phobics) are high physiological reactors-and my own clinical observation of them for many years leads me to strongly espouse this hypothesis-then we can predict that they would tend to feel more discomfort, and presumably more discomfort anxiety, than certain other kinds of phobics. Consequently, I would guess. they would develop more phobias in the first place and hold on to them much more strongly in the second place than would these other kinds of ‘lighter’ or less physiologically involved phobics. Which brings me directly to the second question raised by Emmelkamp et afs study: Assuming that their conclusion about the relatively efficacy of in vivo prolonged exposure over cognitive restructuring is valid, what lessons can we draw from their experiment to improve the efficacy of cognitive pcocedures in treating agoraphobia and other serious clinical phobias? My answer would be: We might use an important cognitive technique that I use with virtually all my agoraphobics and that I sometimes find helps them more than any other method. I explain to them that they seem. on the surface, to be terribly afraid of open spaces, buses. elevators, or what you will but they really have abysmal discomfort anxiety or low frustration tolerance about their own emotional reaction to these feared ‘objects’ or ‘situations’, They know full well. from past experience. that they will most probably over-react to agoraphobic ‘situations’. and they keep telling themselves. “I mar not experience this kind of exceptionally painful reactions! It’s a@/ to feel that uncomfortably anxious! I can’t stand that amount of inconvenience!” As soon as they ‘awfulize’ or ‘horribilize’ about their actual or potential anxiety, and thereby make themselves anxious about bring anxious, these agoraphobics (1) increase the actual pain or frustration that they experience in agoraphobic ‘situations’, (2) anticipate beforehand that they will experience ‘unbearable’ pain in such situations. (3) obsess almost constantly about the possibility of such “horrible” experiences, (4) compulsively withdraw from virtually all ‘danger’. (5) ‘awfulize’ about the ‘intolerable’ discomforts created by their withdrawal from the world. etc. These are all forms of serious discomfort anxiety (DA). But they may also well be accompanied by forms of severe ego anxiety (EA)-that is, putting themselves down and seeing themselves as worthless because they view the agoraphobic ‘situations’ as ‘terrible’ and because they irrationally and self-defeatingly permit themselves to keep withdrawing from such ‘situations.’ In instances such as these. 1 try to see that my agoraphobic clients fully understand their discomfort anxiety (as well as their ego anxiety) and that they rationally dispute it-that they convince themselves. in other \yords. that it is inconvenient for them to risk going into open spaces. buses, elevators etc., and that it is also unpleasant and annoying for them to feel so uncomfortable (including physiologically uncomfortable) when they do risk such approaches. But I try to help them see that discomfort of virtually any kind is on/!, inconvenient (never aw/u/ or horrible); that they can stand (although virtually never like) it; and that by avoiding it. as they so ‘cleverly’ manage to do all their lives. they mainly serve to prolong and intensify it. Yes. I agree with them. it is hard, very hard, if they go into open spaces and if they allow themselves to experience the painful anxiety that, at first, will almost certainly ensue if they do so. But it is much harder. and will probably be so for rhe resr of their lives. if they don’t! By usmg this kind of cognitive restructuring, and using it especially with agoraphobics’ symptoms (anxiety
164
CASE
HISTORIESAYI> SHORTER COMMUNlCATlONS
and depression) ahouf their symptom (agoraphobia), I am sometImes able to persuade them to mahe slgnlhcanr inroads against their discomfort anxiety-and thereby to effect a remarkably new and radIcalI> different basic philosophy of life. Not only does this new philosophy-which may be called a high degree of frustration tolerancedirectly help them overcome their agoraphobia but it also makes it much easier for them to do the in uiuo prolonged exposure which I routinely give them as RET homework assignments. Frequenti!. in fact, as they surrender their low frustration tolerance and their consequent discomfort anxiety. the! are able to do the in viuo desensitization on their own or with friends or relatives. rather than in the presence of a trained therapist. A final word. I would hypothesize that almost all severely disturbed Individuals-includmg agoraphoblcs. obsessive-compulsives, borderline psychotics, and schizophrenics-not onlt have strong elements of ego anxiety; but even more importantly, and what is often overlooked by therapIsts and researchers. the! almost always have abysmal low frustration tolerance and powerful discomfort anxiety. And they not onl! have DA in regard to their original symptoms-the situations. the objects. and the people of which the! are enormously afraid-but also, and often more crucially about their own uncomfortable feelings q/tc~ the! create their original fears and anxieties. My clinical impression is that the! to some degree learn their prlmar! and secondary symptoms of discomfort anxiety; but they almost invariably do so because they are born with powerful tendencies to learn (and mainly to condition ~hernsehes rather than to he or qcr conditioned) in these ways (Eysenck, 1967: Thomas and Chess, 1977). Their vulnerability or susceptibility to environmental influences. rather than these influences in their own right, constitutes most of the variance responsible for their serious disturbances. They are also born. I believe, with strong tendencies to indulge themselves in their original innate predlspositions; so that although they are theoretically capable of following therapeutic regimens and changmg thsmselves and their disturbed behavior to a significant degree, they usually onlv partially avail themselves of the opportunities to do so. They are therefore likely to be what I call DC’s (difficult customers). and to require powerful intervention, of a highly cognitive and behavioral nature. to help them help themselves. Agoraphobics are especially prone to be in this category and therefore require the best kmd of clmical and research program that we can devise for them. Institute
for
Rational-Emotive
At-BERT ELLIS
Therapy.
45 East 65th Street. New
York.
NY
10021.
U.S.A.
REFERENCES ELLIS A. (1962) Reason and Emotion in Psychotherapy. Lyle Stuart. New York. ELLIS A. (1977a) Rational+motive therapy: research data that supports the clinical and personality hypotheses of RET and other modes of cognitive-behavior therapy. Counsel. Ps.~chol. 7. 242. ELLIS A. (1977b) Rejoinder: Elegant and inelegant RET. Counsel. Psycho/. 7. 73-82. ELLIS A. (1978) Discomfort anxiety: A new construct in cognitive-behavior therapy. Paper presented at the Annual Meeting of the Association for the Advancement of Behavior Therapy. Chicago. November 17. ELLIS A. (1979) New Developments in Rational-Emotive Therapy. Brooks,‘Cole. Monterey. California. ELLIS A. and GRIEGER R. (1977) Handbook of Rational-Emotive Therapy. Springer. New York. EMMELKAMPP. M. G.. KUIPERS A. C. M. and EGGERAAT J. B. (1978) Cognitive modification versus prolonged exposure in uiuo: A comparison with agoraphobics as subjects. Behars. Res. Ther. 16, 33-41. EYSENCK H. J. (1967) The Biological Basis of Personality. Charles C. Thomas. Springfield. Illinois. LADER M. H. (1967) Palmer skin conductance measures in anxiety and phobic states. J. Psychosom. Res. 11, 271-281. THOMAS A. and CHESS S. (1977) Temperamenr and Derlelopmeur. Brunner/Mazel. New York
The return of fear
(Receired
24 August
1978)
It is said that learner riders who fall off a horse should remount as soon as possible and that learner fliers who suffer an accident should get airborne again as soon as possible. The advice seems to apply only to those tasks in which the learner is expected to experience fear during the course of acquiring the requisite skills. The assumption underlying such advice appears to be that unless the learner resumes his training without delay, his fear will grow-or return. If the drift of this paper is correct. such an assumption is well-founded and the advice is sensible. Fear can return and a lengthy interval between exposures to fearful stimulation. whether preceded by an accident or not, may provide the opportunity for such a return. The probability of a return of fear may well be increased by aversive incidents.
(‘ASI HISTORILSAN,) SHORTtR COMMLINICATIONS
is no1 a large proportlon of the clinical sample and IS surpristng I” view of the apparent hea\! locu\ on the clinical fears and phobias of adults. A more complete and representative survey 01 behavior therapists is needed. Also more questIon\ regarding the type:duration. Intensit). etc.. of the referred fears would be helpful. However. until that larger sur\c! is completed. our tentative estimate of 6.X per cent. based on S47 recent cases (l97& 19771 of I9 beha\lor therapists hopefully will be useful. ANTHONI M. GKALIAXO INA &I. Dt- GIOvANXl
REFERENCtXS BI~RECZ J. M. (1968) Phobias of childhood: Etiology and treatment. Ps~xho/. Bull. 70. 693-720. GRAZIANO A. M.. DEG~OVANNI 1. S. and GARCIA K. A. (1977) Behavioral treatment of children’s fears: a review. Unpublished manuscript. State University of New York at Buralo. JONES M. C. (1924) The ehmination of children’s fears. J. e.up. P.~~~c/to/. 7. 382-390. MILLEH L. C.. BARRETT C. L. and HAMPE E. (1974) Phobias of childhood in a prescientific era. In Clti/[l Prrsomlit~~ ad Ps,xhoparho/oq~~: Curretlr Topics. Vol. 1. (Edited b? A. DAVII>S) Wile!. New Yorh. MARKS I. M. (1969) Fcar.5 ad Phobias. Academic Press. New York. RUTTER M.. TIZARI) J. and WHITMORE K. (1970) Erlucuriorr. Hralrh at~rl Brhrrrior. Wile!. New Yorh.
A note on the treatment of agoraphobics with cognitive modification versus prolonged exposure in uiuo
(Rrcriced
I5 Juw
1978)
In an unusually well planned and executed study of agoraphobics. using three main methods of cognitive modification versus prolonged exposure in ciao. Emmelkamp et al. (1978) found that the latter procedure “proved to be a definitely superior form of treatment to cognitive restructuring. as measured by the behavioral !,I riw measurement and the phobic anxiety and avoidance scales.” Although this study. like virtually every experimental approach to therapy. has its methodological limitations. I am inclined to accept its basic conclusion and to consider it important. Two salient questions that it raises. and that I would now like to discuss. are: (I) What are the main reasons for this interesting finding? and (2) Assuming that their conclusion is valid. what lessons can we draw from Emmelkamp er a/.‘~ study to improve the efficacy of cognitive restructuring I” treating agoraphobia and other serious clinical phobias’! In answer to the first of these questions. Emmelkamp (‘I ul. gave a partial answer that I think has a truthful ring: “Giving a form of treatment a name is not the same as elucidating the therapeutic process involved. Whether the treatment ‘cognitive restructuring’ does actually produce a modification of cognitive processes is a debatable point. On the other hand. the effects of prolonged exposure it1 rim could at least partly be explained in terms of cognitive restructuring. During treatment with prolonged exposure itI oivo clients notice, for example. that their anxiety diminishes after a time and that the events which they fear. such as faintmg or having a heart attack. do not take place. This may lead them to transform their unproductive self-statements into more productive ones: ‘There you are, nothing will go wrong with me’. A number of clients reported spontaneously that their ‘thoughts’ had undergone a much greater change during prolonged exposure i,r ritw than during cognitive restructuring. It is possible that a more effective cognitive modification takes place through prolonged exposure it1 rim than through a procedure whtch is focused directly on such a change.” This seems to be a very sensible explanation of some of the obtained results of ))I P!PO exposure; and it was because of this theory that I first incorporated it1 ttw homework assignments in the clinical use of Rational-Emotive Therapy (RET) and why I virtually never use it. especially in the case of agoraphobics. without such tr1 viro assignments (as Emmelkamp ef al. rightly acknowledge in their paper). Pure cognitive restructuring works relatively poorly for almost any kind of a phobia-as I have always tried to make clear (Ellis. 1962, 1977a. 1977b; Ellis and Grieger, 1977). For unless phobic individuals acr against their Irrational beliefs that they I~IUS~not approach fearsome objects or situations and that it is horrihk if they do. can they ever really be said to have overcome iuch beliefs’? There is another very important reason why serious phobics, including agoraphobics, irrationally avoid people. ob_iects. and situations: and that is because of what I now call their discomfort anxiety (Ellis. 1978. 1979). Ego anxiety (EA) I define as emotional tension that results when people feel (I) that their self or personal worth is threatened. (2) that they should or ~nusr perform well and/or be approved by others. and
CASE HISTORIES AND
SHORTER COMMUNICATIONS
163
(3) that it is awful or catastrophic when they don’t perform well and/or are not approved by others as they should or n~usr hr. As can easily be imagined, ego anxiety is often an important part of agoraphobia (and other phobias). since phobic individuals are demanding of themselves that they I~USI be able to approach fearsome situations and that they are worthless individuals if they don’t. Discomfort anxiety (DA). however, is frequently even more important in serious phobias. This consists of emotional tension that results when people feel (I) that their comfort (or life) is threatened, (2) that they should or must get what they want (and should not or must nof get what they don’t want), and (3) that it is nwfu\ or catastrophic (rather than merely inconvenient or disadvantageous) when they don’t get what they presumably must. Discomfort anxiety, moreover. exists as both a primary and a secondary disturbance in serious phobias. especially agoraphobia. Thus, agoraphobics first tend to make these cognitive demands on themselves: “1 must not experience any discomfort or handicap when I am in open spaces. buses. or similar situations: and it is terrible if I do!” With this absolutistic demand that they have IO be comfortable, they naturally avoid situations in which they feel uncomfortable: and they wrongly label themselves as being afraid of these situarions instead of (more accurately) as being afraid of the discomfort they will probably feel when they approach such situations. They are not truly afraid of the open spaces or the buses but of their own reactions to the spaces or the buses. Once they actually do ‘become frightened’ (actually. fiighren rhemselves) about the spaces or the buses. they then, as a secondary symptom. become even more ‘frightened’. They again call this secondary symptom, ‘fear of the spaces or the buses’ but it is actually fear of the discomfort of being frightened. Their secondary symptom could be called fear of fear, or anxiety about anxiety (just as a depressed individual can be depressed on a primary level about losing a job and on a secondary level about being depressed). But ‘fear of fear’ or ‘anxiety about anxiety’ is a shorthand phrase for ‘fear of the discomfort of fear’ or ‘anxiety about the discomfort of anxiety.’ Secondary symptoms of all kinds-such as depression about feeling anxious. depressed, guilty, or angry may well have a strong element of ego anxiety (EA) in them (e.g. “1 am a rotten person for causing myself to feel anxious, depressed, guilty or angry”); but they also, and often more importantly. include an enormous element of discom‘fort anxiety (DA) (e.g. “I can’t bear the discomfort of feeling anxious. depressed, guilty, or angry”). If I am correct about this, and discomfort anxiety (DA) is both a primary and a secondary cause of many or most serious phobias, then I would hypothesize that this especially holds true for agoraphobics. As Emmelkamp et al. (1978) point out, clinical agoraphobics probably differ from subjects in analogue studies in that they have a higher degree of physiological arousal-in anxiety engendering situations (Lader, 1967). They note that “it is quite possible that cognitive restructuring constitutes an effective form of treatment for low physiological reactors (such as the subjects of analogue studies), while such treatment will be effective for high physiological reactors (such as agoraphobics) only after the autonomic component has been reduced.” Quite correct. I would say. Or, as I shall show below, after their discomfort arrxiety ahour their autonomic component has been reduced. For if it is true that agoraphobics (and many other serious phobics) are high physiological reactors-and my own clinical observation of them for many years leads me to strongly espouse this hypothesis-then we can predict that they would tend to feel more discomfort, and presumably more discomfort anxiety, than certain other kinds of phobics. Consequently, I would guess. they would develop more phobias in the first place and hold on to them much more strongly in the second place than would these other kinds of ‘lighter’ or less physiologically involved phobics. Which brings me directly to the second question raised by Emmelkamp et afs study: Assuming that their conclusion about the relatively efficacy of in vivo prolonged exposure over cognitive restructuring is valid, what lessons can we draw from their experiment to improve the efficacy of cognitive pcocedures in treating agoraphobia and other serious clinical phobias? My answer would be: We might use an important cognitive technique that I use with virtually all my agoraphobics and that I sometimes find helps them more than any other method. I explain to them that they seem. on the surface, to be terribly afraid of open spaces, buses. elevators, or what you will but they really have abysmal discomfort anxiety or low frustration tolerance about their own emotional reaction to these feared ‘objects’ or ‘situations’, They know full well. from past experience. that they will most probably over-react to agoraphobic ‘situations’. and they keep telling themselves. “I mar not experience this kind of exceptionally painful reactions! It’s a@/ to feel that uncomfortably anxious! I can’t stand that amount of inconvenience!” As soon as they ‘awfulize’ or ‘horribilize’ about their actual or potential anxiety, and thereby make themselves anxious about bring anxious, these agoraphobics (1) increase the actual pain or frustration that they experience in agoraphobic ‘situations’, (2) anticipate beforehand that they will experience ‘unbearable’ pain in such situations. (3) obsess almost constantly about the possibility of such “horrible” experiences, (4) compulsively withdraw from virtually all ‘danger’. (5) ‘awfulize’ about the ‘intolerable’ discomforts created by their withdrawal from the world. etc. These are all forms of serious discomfort anxiety (DA). But they may also well be accompanied by forms of severe ego anxiety (EA)-that is, putting themselves down and seeing themselves as worthless because they view the agoraphobic ‘situations’ as ‘terrible’ and because they irrationally and self-defeatingly permit themselves to keep withdrawing from such ‘situations.’ In instances such as these. 1 try to see that my agoraphobic clients fully understand their discomfort anxiety (as well as their ego anxiety) and that they rationally dispute it-that they convince themselves. in other \yords. that it is inconvenient for them to risk going into open spaces. buses, elevators etc., and that it is also unpleasant and annoying for them to feel so uncomfortable (including physiologically uncomfortable) when they do risk such approaches. But I try to help them see that discomfort of virtually any kind is on/!, inconvenient (never aw/u/ or horrible); that they can stand (although virtually never like) it; and that by avoiding it. as they so ‘cleverly’ manage to do all their lives. they mainly serve to prolong and intensify it. Yes. I agree with them. it is hard, very hard, if they go into open spaces and if they allow themselves to experience the painful anxiety that, at first, will almost certainly ensue if they do so. But it is much harder. and will probably be so for rhe resr of their lives. if they don’t! By usmg this kind of cognitive restructuring, and using it especially with agoraphobics’ symptoms (anxiety
164
CASE
HISTORIESAYI> SHORTER COMMUNlCATlONS
and depression) ahouf their symptom (agoraphobia), I am sometImes able to persuade them to mahe slgnlhcanr inroads against their discomfort anxiety-and thereby to effect a remarkably new and radIcalI> different basic philosophy of life. Not only does this new philosophy-which may be called a high degree of frustration tolerancedirectly help them overcome their agoraphobia but it also makes it much easier for them to do the in uiuo prolonged exposure which I routinely give them as RET homework assignments. Frequenti!. in fact, as they surrender their low frustration tolerance and their consequent discomfort anxiety. the! are able to do the in viuo desensitization on their own or with friends or relatives. rather than in the presence of a trained therapist. A final word. I would hypothesize that almost all severely disturbed Individuals-includmg agoraphoblcs. obsessive-compulsives, borderline psychotics, and schizophrenics-not onlt have strong elements of ego anxiety; but even more importantly, and what is often overlooked by therapIsts and researchers. the! almost always have abysmal low frustration tolerance and powerful discomfort anxiety. And they not onl! have DA in regard to their original symptoms-the situations. the objects. and the people of which the! are enormously afraid-but also, and often more crucially about their own uncomfortable feelings q/tc~ the! create their original fears and anxieties. My clinical impression is that the! to some degree learn their prlmar! and secondary symptoms of discomfort anxiety; but they almost invariably do so because they are born with powerful tendencies to learn (and mainly to condition ~hernsehes rather than to he or qcr conditioned) in these ways (Eysenck, 1967: Thomas and Chess, 1977). Their vulnerability or susceptibility to environmental influences. rather than these influences in their own right, constitutes most of the variance responsible for their serious disturbances. They are also born. I believe, with strong tendencies to indulge themselves in their original innate predlspositions; so that although they are theoretically capable of following therapeutic regimens and changmg thsmselves and their disturbed behavior to a significant degree, they usually onlv partially avail themselves of the opportunities to do so. They are therefore likely to be what I call DC’s (difficult customers). and to require powerful intervention, of a highly cognitive and behavioral nature. to help them help themselves. Agoraphobics are especially prone to be in this category and therefore require the best kmd of clmical and research program that we can devise for them. Institute
for
Rational-Emotive
At-BERT ELLIS
Therapy.
45 East 65th Street. New
York.
NY
10021.
U.S.A.
REFERENCES ELLIS A. (1962) Reason and Emotion in Psychotherapy. Lyle Stuart. New York. ELLIS A. (1977a) Rational+motive therapy: research data that supports the clinical and personality hypotheses of RET and other modes of cognitive-behavior therapy. Counsel. Ps.~chol. 7. 242. ELLIS A. (1977b) Rejoinder: Elegant and inelegant RET. Counsel. Psycho/. 7. 73-82. ELLIS A. (1978) Discomfort anxiety: A new construct in cognitive-behavior therapy. Paper presented at the Annual Meeting of the Association for the Advancement of Behavior Therapy. Chicago. November 17. ELLIS A. (1979) New Developments in Rational-Emotive Therapy. Brooks,‘Cole. Monterey. California. ELLIS A. and GRIEGER R. (1977) Handbook of Rational-Emotive Therapy. Springer. New York. EMMELKAMPP. M. G.. KUIPERS A. C. M. and EGGERAAT J. B. (1978) Cognitive modification versus prolonged exposure in uiuo: A comparison with agoraphobics as subjects. Behars. Res. Ther. 16, 33-41. EYSENCK H. J. (1967) The Biological Basis of Personality. Charles C. Thomas. Springfield. Illinois. LADER M. H. (1967) Palmer skin conductance measures in anxiety and phobic states. J. Psychosom. Res. 11, 271-281. THOMAS A. and CHESS S. (1977) Temperamenr and Derlelopmeur. Brunner/Mazel. New York
The return of fear
(Receired
24 August
1978)
It is said that learner riders who fall off a horse should remount as soon as possible and that learner fliers who suffer an accident should get airborne again as soon as possible. The advice seems to apply only to those tasks in which the learner is expected to experience fear during the course of acquiring the requisite skills. The assumption underlying such advice appears to be that unless the learner resumes his training without delay, his fear will grow-or return. If the drift of this paper is correct. such an assumption is well-founded and the advice is sensible. Fear can return and a lengthy interval between exposures to fearful stimulation. whether preceded by an accident or not, may provide the opportunity for such a return. The probability of a return of fear may well be increased by aversive incidents.
