To Janice S., the mere mention of the word phobia brings back a personal nightmare. At one time her fear of heights was so intense that even thinking about balconies or train platforms was terrifying. Her daily life revolved around avoiding any situation that would activate the phobia.
"It's hard to tell friends that you must have ground-floor seats in a theater," says Janice. "And I even avoided visiting friends who lived in high rises with fabulous views. I didn't know how to tell them I couldn't get close enough to the window to admire a view of downtown or Lincoln Park."
Phobia is a word we use loosely--sometimes too loosely. We usually think of phobia as synonymous with intense fear, but when we say we're "phobic" about a situation or an object, more often than not it's a misnomer.
Jim M. spent years trying to hide, and overcome, his fear of insects. While few people would claim to enjoy bugs crawling on or around them, brushing away a fly now and then is, at worst, a mild annoyance. Seeing a moth or two flying around in one's home might arouse mild concern about some wool sweaters. But to Jim, a moth represented a dangerous invasion. "I reacted to a moth fluttering around a porch light the way most people would react to a terrorist with a machine gun," he says.
Janice and Jim could well understand the standard, textbook definition of phobia as exaggerated fear or dread of a specific kind of stimulus or situation. According to Kenneth Isaacs, a psychoanalyst in Evanston, almost anything can become the object of exaggerated fear--heights, water, snakes, crowds, school, elevators, etc. "And at the time a phobia activates, it is always inexplicable to the person experiencing it," says Isaacs.
The fear reaction goes beyond what is appropriate for any intrinsic danger in the situation. "My fear of crowded places appeared suddenly and for no reason, at least it seemed that way," said Steve N. "I avoided rush hour for ten years; I was afraid to go to street fairs and theaters, and I couldn't go to a supermarket on Saturday. I thought I was in extreme danger."
Different situations activated Janice, Jim, and Steve's fears, but their reactions were identical. All describe sweating and having a rapid heartbeat, difficulty breathing, and feelings of helplessness with a yearning to be rescued. "In a second or two I'd go from relaxed and involved in whatever was going on around me to extreme panic," says Steve. "I've approached a window," says Janice, "and suddenly I thought I was going to fall and die. It's indescribable terror."
If the causes of phobia were known, professionals could be educated and sufferers could be treated. Unfortunately, phobia is not universally understood in the mental health community, cure rates are difficult to determine, and some psychologists have even thrown up their hands and labeled phobia a "mystery."
Kenneth Isaacs, however, is breaking through the mysteries of phobia, and his ideas offer hope for those whose lives are disrupted by this disorder. "All the various schools of psychology devised theories of treatment that may or may not help a patient with one phobia. But none explain, or even attempt to explain, what I call the 'emotion storms' occurring in phobic patients," says Isaacs.
Isaacs's concept of "emotion storm" is key to his treatment of phobia. "A storm," he says, "occurs when an emotion response to a situation results in a feeling of uneasiness in a person. This uneasiness produces another emotion response, bringing on more uneasiness. This cycle continues, and in the case of a person with a phobia, the responses become so intense that everything else is pushed away--the ability to think rationally and sensibly is impossible because the intense emotion responses have taken over."
Isaacs has been developing his ideas about "emotion storms" and the function of emotions in human beings for over 40 years. Because he is challenging widely accepted assumptions about emotions, he is a pioneer in his field. And as happens with many pioneers, his colleagues have often paid little attention to his ideas or have dismissed them without careful examination. "Over the years," he says, "I've concluded that generally accepted--and rarely even questioned--theories about emotion are in error. Being open to my ideas means being open to changing what one once learned was indisputable truth. Once accepted, these ideas I propose change the way one views traditional thinking about numerous disorders as well as emotion in general."
Isaacs is respected by his colleagues, both personally and professionally. He has held numerous positions at the American Psychological Association, and has been president of the Chicago Association for Psychoanalytic Psychology. Nonetheless, finding a receptive forum for his ideas has been slow. "It's the younger, more open minds in the field who will, and in many cases, already have, accepted the importance of my work, and especially its value to those suffering with an agonizing disorder such as phobia," he says.
In order to understand Dr. Isaacs's approach to phobia, it helps to look at how other schools of psychology approach its treatment. "The pop psychologies, the cognitive, and the behavioral schools treat the symptoms of phobia," says Roe Chase Bernardini, a therapist in practice in Lincoln Park and Winnetka who has studied with Isaacs and incorporated his theory and techniques into her practice. "But they view the symptoms as a manifestation of a disturbance they don't understand. Nevertheless, they claim that amelioration of the symptoms is possible."
Some phobia sufferers seek medical help and/or medication to help them cope with their panic, and some seek psychotherapy to try to understand the root cause of the phobia. Isaacs believes that many phobia sufferers are being treated only with antianxiety drugs and tranquilizers. "They may be relieved of symptoms," he says, "but their ability to feel any emotion becomes reduced as well."
Behavior modification is another popular method of treatment. The behavior modification approach trains sufferers to withstand the intense fear caused by a phobia and to become accustomed to whatever situation triggers the fear. "The patients 'wear out' the fear," says Isaacs, "by putting themselves in the terrifying situation over and over again, usually accompanied by a person trained in this method."
If it works, what's wrong with it? "How often it works is open to question," says Isaacs. "But we know that it is a slow, tedious process, and no matter how well intentioned, painful to the patient. I can't accept 'torturing' patients in the name of treatment," he says.
Janice had tried this approach for her fear of heights, but she found the cure more difficult and painful than spending all her time avoiding heights. "Her situation isn't unusual," says Isaacs. "I hear stories like hers daily in my practice. Anticipation of the treatment sessions becomes as painful as the problem itself."
Dr. Isaacs also sees problems with the way phobia is approached by the psychoanalytic school (in which he was trained). "My colleagues in psychoanalysis view phobia as rooted in psychological conflicts built into our character patterns. Treatment is the process of working through the infantile conflicts, and having done that, dissolv[ing] the phobia," says Isaacs. This approach is often effective, but for most phobia sufferers it is not immediately helpful.
In other words, phobias may grow out of processes or patterns begun in infancy and early childhood. Fear of abandonment, withdrawal of love, and punishment all cause conflicts in a young child that shape his patterns of behavior throughout life. "These patterns may be useful and efficient," says Isaacs, "or they may be disabling."
"Patients like Steve and Janet often start long, expensive, and arduous treatment in psychoanalysis," says Isaacs. "Although they can expect to be relieved of the phobia eventually, they continue to live restricted lives for years." Steve tried to overcome his fear of crowds in analysis, but after several years he became discouraged with the process. "The time and expense I was investing weren't improving the part of my life that was troubled," he says.
Phobias and other "symptom disorders" are characterized by symptoms that are either overt and noticeable to others, or internal and easily hidden. "A patient with voice changes, paralysis, a compulsion to carry out some ritualized behavior, obsessive thought processes, or panic reactions has definable symptoms," he says. "This differentiates a symptom disorder from the other reasons people seek psychotherapy--unsatisfying lives, lack of success, unstable relationships, etc."
Isaacs believes that although a patient in analysis may work through other personality difficulties and eventually become free of a specific phobia, the person may still be vulnerable to other phobias. In other words, because the conditions that caused the phobia aren't dealt with, a person who gets over a height phobia may develop another phobia or symptom disorder at some other time.
"In the treatment of phobia and other symptom disorders, psychoanalysis is only slightly ahead of all the pop psychologies, behaviorism, and so on. Fortunately," says Isaacs, "there is another way to help patients."
Isaacs's method represents a third way to view phobia and other symptom disorders. Both professionals and patients can treat the phobia once they understand what Isaacs calls the "emotion storm." His method is such that patients can learn about "storming" and be relieved of their phobias in only a few sessions with Isaacs or one of his trained colleagues. "We dissolve the current phobia and any tendency to develop any other symptom illness," says Isaacs.
Understanding an emotion storm requires an individual to examine the assumptions, beliefs, or attitudes he or she has about emotions and emotional life. Unfortunately, according to Isaacs, we fear emotion and emotional processes, but are so accustomed to the fear, we aren't aware of our discomfort."Emotion phobia is a universal human ailment," says Isaacs.
"When we look at the language of emotional life we see that an emotion--any emotion--is discussed as if it were a thing, a substance. This is nonsense, but language reflects a muddled understanding of emotion," says Isaacs, "and this distorted view creates illness."
Isaacs believes that emotion phobia is reflected in such psychoanalytic terms as "catharsis," which imply purging or purification. The tendency of pop psychologists to urge a patient to "discharge" or "get your feelings out" reflects this same misconception. "Both of these are examples of the popular wisdom about emotion--emotions are substances, and beyond that, they are stored somewhere. Psychological theory reinforces the popular view," says Isaacs, that we must "actively 'get rid' of our emotions or they will harm us."
Not only did Freud not question the traditional wisdom of stored emotion, but he integrated that concept into his psychoanalytic theories. "It's ridiculous to carry on the notion that emotion is bad and a cathartic process must be used to clean the psyche of this 'matter,'" Isaacs says. "Freud made tremendous contributions, of course, but he like all human beings had a fear of emotion, and he simply didn't raise the questions to challenge the validity of the fear. I consider this Freud's blunder, but we don't need to continue living with it." He adds that this acceptance by Freud has encouraged the notion that emotions are dangerous "events."
In response to commonly held misconceptions, Isaacs asks people to observe their inner processes and carefully and honestly note their discomfort about certain emotions. "Most of us are so accustomed to an uneasiness with emotion that it seems natural," he says. "But when carefully noted, a pattern sequence usually emerges. For instance, we may feel guilty and then become irritated about it. We may feel shame and then become sad about feeling that way. We might become afraid about being angry. If we feel lonely, we may become frightened about it."
Isaacs contends that too little attention has been given to the description of the normal shift of emotions--their natural flow. "Emotions are transient," he says, "and when we observe within we can see that as one emotion vanishes another replaces it. Ideas and emotions appear and vanish as responses to whatever passes through our minds."
This process isn't unusual; it's commonplace. You are walking down Michigan Avenue on your way to work. You may be feeling slightly apprehensive about a presentation you're giving to your colleagues that morning. You see a friend you haven't talked with for months. Your apprehension is immediately replaced by surprise, followed by pleasure as you talk. You leave feeling satisfied because the two of you have set up a lunch date. You become mildly annoyed when the traffic light begins flashing "Don't Walk" because you are now running a little late. However, you're relieved that the elevator has room for one more person--you. Most of the time we don't concern ourselves with evaluating, or even noting, these emotions as they pass.
Isaacs believes, however, that each of us has some uneasiness about emotions, and that this is the root cause of phobia. "If a person with a phobia is afraid, he or she might become afraid about feeling the fear. The process in such a person is one where he or she is afraid about being afraid about being afraid about being afraid and so on. It is this 'fear of fear' that creates what I call the emotion storm," says Isaacs.
When Janice became Isaacs's patient and was able to observe herself and the minute step-by-step process of her emotion reactions, and her reactions to her reactions, she conquered her phobia. Like most of us, Janice had an instinctive fear of falling. This fear protects us, as do other instinctive reactions such as our startle reflex. But to Janice, and to many people, fear is a "big event." Rather than using fear to evaluate a situation, the fear becomes a distraction, and this made Janice's fear more intense. Eventually she created an emotion storm.
"When a person is in a storm," says Isaacs, "he or she is no longer able to use thought processes efficiently. Intelligence level plummets. That's part of the reason an irrational phobia can seem so rational to the patient at the time."
One idea that's often difficult for Isaacs's patients to grasp is the knowledge that emotion--any emotion--is not dangerous or a big event. "Emotions give us information about what is going on in and around us and then they're gone. This information is useful," says Isaacs, "never dangerous; it's constructive, not an encumbrance. I helped both Steve and Janice focus their attention on what their emotions were telling them. They were able, in a very few sessions, to disassemble the storms, learn to prevent them, and finally eliminate the tendency to storm in any situation."
According to Isaacs, a phobia occurs when there is a joining of some psychological conflict with an emotion storm. It's the convergence of the two that causes a phobia to develop--the storm creates an exaggeration of the childhood conflict. It takes both the storm and the earlier conflict to create the phobia, but according to Isaacs, either getting rid of the storm or dealing with the conflict through analysis is enough to relieve the specific phobia.
"The psychological conflicts that psychoanalysis has worked with is an important basis of the form of symptoms," says Isaacs. "But the incident which causes the symptoms to appear, the phobic reaction to a situation, is based in the tendency to have emotion storms. We deal with the storms first, relieving the patients of the immediate distress which brought them to a therapist in the first place. This approach is astonishingly effective."
In Janice's case, the conflict was a fear, from infancy, of being abandoned by her parents. Psychoanalysis would have concentrated on this conflict, and over time, Janice could have expected to be relieved of the phobia. However, she had become so fearful of her emotions that she was unable to live normally while she was delving into the psychodynamic cause of the phobia.
"If your life is run by fear, and you also believe that the fear itself is dangerous," says Isaacs, "you're apt to become impatient with long therapies. Both Janice and Steve had tried other kinds of therapy. It was difficult for them to believe that their fear wasn't storing up somewhere, ready to cause problems for them at any time."
"Most therapists know that physiologically and psychologically storing emotions is impossible," says Bernardini, "but most of us were trained to talk and act as if emotions could be pent up somewhere inside. No wonder we're afraid of them. It makes sense to be afraid of anything we believe is harmful. Isaacs's ideas are freeing to patients and therapists."
Bernardini also believes that Isaacs's theories and applications are going to change all psychological theories. "Acceptance of feelings, rather than avoidance or fear of emotional life, is a breakthrough. It's new knowledge about neurosis," she says, "that once absorbed by the psychologic community and the population in general will eliminate problems like those that Janice and Steve suffered with. I see people with the same 'emotion phobia' in my practice whether or not they are complaining of phobia."
John Friedman, one of Isaacs's colleagues in the analytic community in Chicago, thinks that Isaacs's ideas add a new and very positive dimension to psychological theory and technique. "We often see patients who, while not expressing it in exactly these words, view themselves as containers for feelings," says Friedman. "A patient may verbalize the concept of a burden, as in 'carrying around a burden of anger.'"
Friedman agrees that distorted language has led to distorted concepts that should now be reexamined. "When we understand Isaacs's ideas, our treatment models can be altered to include his information. And patients generally understand his ideas and respond positively."
Elaine Caruth, a psychoanalyst in Los Angeles, doesn't agree that all of Isaacs's ideas add significantly to psychological theory, but she does believe that he offers an alternative to the "let it all hang out" philosophy. "It's true that many people believe it is not only desirable, but necessary, to act on their feelings. This is reinforced in the so-called 'pop' psychologies. Certainly, the goal of treatment is to help people be free to experience their feelings in relation to the events in their lives," she says.
Caruth also believes that Isaacs is able to help overwhelmed patients understand, on an intellectual level, what the emotion processes are all about. "Isaacs helps phobic patients become comfortable with the idea of fear, and this understanding can help distressed patients. Certainly, the psychoanalytic community has recognized that something more is needed in work with phobias."
Isaacs began his breakthrough work when he was studying for his PhD in analytic psychology over 40 years ago. The language used to describe emotion puzzled him, but it also helped him construct his theories about universal "emotion phobia." "It all begins with the mistaken idea or impression that emotion stores somewhere," he says.
When Isaacs studied infant development he concluded that each infant "invents" emotion phobia. "To an infant," says Isaacs, "feeling is the same as doing. Seeing an object and reaching for it isn't a two-step process, it isn't differentiated. The mental processes simply aren't defined as separate in this stage of development. The infant thinks or feels and an action follows. As adults we know this is a process, but to an infant it is all happening at once. This infantile belief is reinforced by the external world--parents, teachers, etc--and even as adults we then believe and fear that some action must follow anger, shame, guilt, and so on."
To believe that we have to "do something" about any emotion is part of the popular wisdom that Isaacs labels "nonsense." "We misguide children when we have them hit an inanimate object such as a balloon clown when they are feeling angry," says Isaacs. "We give children the message that hitting or some other action must follow anger. Anger, like any other emotion, gives us information. Let's learn to examine the information instead of worrying about releasing the feelings," he says.
Elaine Caruth, however, challenges the importance of the question of whether or not emotions are stored. "If a recall of a memory releases an emotion response, how different is that from the original emotion? It is inevitably different, of course, because the person is different--older, more mature, influenced by other events, etc, but that response may be distressing nonetheless." She emphasizes, however, that regardless of how important the storage concept is, she believes Isaacs's patients have benefited enormously from his treatment approach.
According to Isaacs, the recall of a memory produces a new feeling which may be identical to the feeling originally aroused, but it is not a "chunk" of that original feeling. Isaacs believes this distinction is crucial. Patients, and people in general, having accepted the concept of stored emotion, believe these emotions will pile up if they're not discharged--the "container for feelings" idea. "The result in patients such as Steve and Janice," says Isaacs, "is a dread of repeating a situation which causes fear. Using a feeling as information can take away the dread of experiencing any feeling."
Interestingly enough, the concept of stored emotion and the importance of its release is applied only to those feelings we label as "bad." "Have you ever heard anyone say, 'If I don't release all this pent-up joy, I'm going to give myself an ulcer'?" asks Isaacs. "All emotions give us information, not just a few of them."
"One problem we often see in patients," says Bernardini, "is the mixing up of feelings and beliefs. We say we feel, when we really mean we think." Isaacs believes this mislabeling has resulted in the concept of "pseudo feelings." "True emotions are distinct and can be distinguished from any other emotion. We know when we're angry or surprised. We know the difference between joy and loneliness. But we have muddled our clear distinctions with the language of 'pseudo feelings.'"
What Isaacs means here is obvious if we listen to the small talk around us. "I feel there should be more parking garages in the Loop," or "I feel that lakefront erosion should be stopped." These are attitudes, beliefs, and judgments, but by assigning the language of feeling to them we no longer distinguish between emotion and thought.
"Some of my colleagues believe that Isaacs is deprecating emotional life," says Bernardini. "But nothing could be further from the truth. This system encourages the recognition of feelings on a moment to moment basis, not as dangerous, but as useful. Patients often can't believe that it's safe to let themselves 'feel' outside the therapist's office," she adds.
The healing of some other disorders follows the same pattern as dissolving a phobia. Because Isaacs works with the processes of emotional life in general, the tendency to storm is eliminated in patients like Steve and Janice.
A person with a compulsive disorder, like a person with a phobia, suffers from both a psychological conflict and the emotion storm. According to Isaacs, regardless of the original conflict that started the behavior, a person who cleans house compulsively is terrified of dirt; it is the convergence of the original conflict and the storm that causes the compulsive behavior. "The conflict may be resolved easily, it may not, but the tendency to storm can be alleviated, and the person is then free of the disorder," says Isaacs.
A similar approach is followed in other symptom disorders. For instance, Isaacs treated a businessman for dysphonia, a disruption of speech sounds. This man's voice sounded hoarse all the time. He had spent ten years in his quest for diagnosis and treatment--allergy testing, surgery on his larynx, psychiatry, etc. He was referred to Isaacs by a voice coach with whom he started working in another attempt to relieve the problem.
"With some help," says Isaacs, "this patient was able to observe within and identify his feelings as they were experienced. By his second session, he'd noticed that the hoarseness became worse when he was angry. He then became ashamed about being angry, and then became angry about being ashamed about being angry. Once this process was observed, his voice began returning to normal."
How long did this man's treatment take? Three visits. But what about the psychological conflict that caused the phobia in the first place? "Delving deeply into built-in character patterns is an option for patients," says Isaacs. "Steve and Janice both had undergone extensive therapy and they didn't choose to continue once their phobias were gone. That's their right. Jim continued treatment to resolve some other troubling issues."
The lack of a defined technique is part of the controversy in the psychological community over Isaacs's work. "I've known about Isaacs's theories for years," says Helen Golden, a psychoanalyst in Larchmont, New York, "but it's never been clear to me how he gets the results he gets. I have no doubt that he is able to help his patients, but his results and techniques [as opposed to his theories] aren't published. The ideas won't be readily accepted if the professional community can't read about them," she says.
"People often ask me about techniques," says Isaacs, "as if a technique can just be added to the therapeutic process based on the traditional theories. But, what I'm proposing is change in basic theory. And when patients understand the change in theory and can learn to observe the emotion process without judging it or fearing it, they get better. It's not a question of technique; it's a question of new ideas and information."
The reeducation process that Isaacs uses involves having patients become careful self-observers. "It's sometimes difficult at first for patients to note the minute changes within," he says. "But it's the key to permanent change." For example, Jim reported that he was uncomfortable with anger because he felt guilty about feeling anger. "I'd try to talk myself out of the guilt and then become angry again. I was stuck in the cycle until I stopped judging the anger itself."
Jim's ability to identify that cycle of anger and guilt made it possible for him to identify the "fear of fear of fear" process in an emotion storm. "Once he was able to observe that process," says Isaacs, "he was able to disassemble the storm. His rational thinking, his knowledge about insects, was no longer obliterated by the storm. The storm no longer existed."
The same reeducation took place with Janice. "When I learned to observe within myself, I noticed that any feeling of fear led to more fear, and I tried to fight the fear, usually making it worse." Eventually Janice stopped fighting the fear, or denying it, and the terror of heights disappeared along with her general discomfort with emotion.
The key issue in Isaacs's theories and applications is the usefulness of all emotion. "Remember, emotions are benign and each has a constructive function. We're eliminating the idea that one must deny, fight, repress, endure, or merely tolerate emotion. We embrace emotion as useful and stop attaching negativity to the process itself. When we do this, emotional life is a blessing, not a burden," says Isaacs.
About 80 percent of the patients Isaacs treats for simple phobia are improved enough to end treatment within two months. Why do some people take longer? According to Isaacs, an inability to observe one's mental processes interferes with rapid improvement. For people unable to identify emotions and observe the storming process, the longer-term behavioral approach may be the only option. "But most people are able to become self-observers," says Isaacs, "and they can be rapidly helped."
Isaacs believes his ideas will be accepted when the psychological community and the public are willing to examine the common wisdom about emotion. "Some people catch on very quickly," says Isaacs. "People have been able to get a basic understanding of my ideas from listening to me on the radio or even from reading about them," he says. "They have observed within themselves enough to become comfortable with their emotion processes. A few with symptom disorders have become symptom-free--just from having new knowledge."
How long will it take before Isaacs's ideas gain wide acceptance within the psychological community? That's still an open question. "There's no doubt that Isaacs's ideas are significant," says John Friedman, "but unfortunately acceptance doesn't automatically follow. Acceptance involves more than simply adopting successful techniques--that's a surface issue. The psychological community has to be willing to reexamine its entrenched beliefs and long-held theories. This may be a slow process."
The professional therapeutic community, as unwilling as it may be, must accept that some disorders can be treated in dramatically shorter periods of time than previously assumed. However, acceptance by the patient population itself will no doubt be part of the long-term change in the profession.
Art accompanying story in printed newspaper (not available in this archive): illustration/Tom Herzberg.