Phobic avoidance

  Because of the extremely distressing nature of panic attacks, it is not unusual for the individual experiencing them to want to avoid the situations that trigger them altogether, for fear of experiencing another panic attack. In the case study of Andrew, it can be seen that as part of his recovery plan he needed to participate in a staged return to work in order to regain his confidence. Andrew had developed a very mild phobic reaction to his work situation and needed some support to overcome it and get back to work. However, in more extreme cases, the fear and avoidance can become so persistent and excessive that the condition is described as a phobia. In such cases the phobic avoidance is so severe that the individual is unable to return to work without engaging in a more intensive and structured treatment regime. More severe presentations of phobic avoidance are often rooted in a traumatic experience and form part of a post-traumatic stress reaction. However, the treatment is the same as for other causes.

Treating phobic avoidance

  Phobic avoidance is best treated using the behavioural technique of systematic desensitization. This involves the individual identifying and making a comprehensive list of all the situations that they are currently avoiding. They then rate each situation in the list on a scale from 0 to 10 on how anxiety provoking it would be for them to confront that situation (where 0 is no anxiety and 10 is maximum anxiety). Once all the situations on the list have been rated, they are then placed in a hierarchy with all the most difficult situations scoring highest on distress (10) at the top and then the scores of 9 and so on right down to the lowest scores of 1 and 0 (the easiest to confront). The individual then confronts the lowest one in the hierarchy and moves on to confront the next step in the hierarchy only when they feel confident that they have overcome the previous one. Eventually, the individual works through all the stages of this graded exposure hierarchy. The case study of Maxine illustrates the technique of systematic desensitization.

Case study: Maxine

  Maxine was a supermarket manager who had developed a phobia of working in her own supermarket after being the victim of an armed robbery at the store when she was on duty. This had resulted in Maxine feeling terrified to return to work and going on long-term sickness absence. The systematic desensitization technique was used to help her overcome her phobic anxiety about returning to work. The graded exposure hierarchy used can be found in Table 10.1. Although the actual anxiety ratings are not included in Maxine’s programme, they can be deduced from the order in which tasks are introduced (i.e., the least anxiety provoking tasks first). This programme was carried out on a week-by-week basis over three months, with the support of her managers and occupational health advisers.

Table 10.1 A systematic desensitization hierarchy for Maxine

  Week 1

Commence fl exible and informal visits to other branches of the supermarket in the area. These visits to be facilitated and supported by the managers of each store.

Week 2

Undertake more formal store visits dressed in the company uniform with the aim of working half a day in each store.

Week 3

Work one full day in one of the stores (not own store) in a nonmanagerial role.

Week 4

Work two full days 9am to 5pm in the same store (not own store) in a non-managerial role.

Week 5

Work three full days 9am to 5pm in the same store (not own store) in a non-managerial role.

Week 6

Gradually take no more managerial responsibilities and commence shift work (not own store).

Week 7

Commence working full time doing shift work and taking on managerial responsibilities (not own store).

Week 8

Commence working at own branch of the supermarket one day a week from 9am to 5pm.

Weeks 9–10

Increase the number of days working at own branch and commence shift working.

Weeks 11–12

Increase to full-time shift work, taking full managerial responsibilities at own branch.

Over a period of three months Maxine was able to return to all of her former managerial duties. She was assisted in doing this by a very supportive management team and occupational health service. Without this structured help and support, it is unlikely that Maxine would have been able to return to work, leading to negative consequences for both her and her employer. Maxine went on to get promotion to an area manager post two years after returning to work and needless to say was very sympathetic to the welfare needs of her staff.