The Parable of the Squirrel: Alleviating the Anxiety of Agoraphobia

The Parable of the Squirrel: Alleviating the Anxietyof Agoraphobia

Donald Capps

Published online: 4 February 2012# Springer Science+Business Media, LLC 2012

Abstract This article focuses on agoraphobia, one of the anxiety disorders, and draws onWilliam James (James 1890/1905), the Diagnostic and Statistical Manual of Mental Dis-orders (American Psychiatric Association 2000) and Aaron T. Beck and Gary Emery (1985)to present and explore the psychodynamics of agoraphobia, including its behavioral mani-festations, the personality features that may predispose a person to become agoraphobic, andthe factors that may precipitate its emergence at a particular time in one’s life. A parableconcerning a squirrel having difficulty crossing the street frames the discussion.

Keywords Agoraphobia . William James . Fear instinct . Diagnostic criteria . Panic .

Agoraphobic syndrome . Aaron T. Beck . Gary Emery . Predisposing factors . Precipitatingfactors . Immobilization . Vulnerability . Freedom . Loss of control . Cognitive restructuring .

Sigmund Freud

A desperate squirrel

A certain squirrel was having a devil of a time getting across the street. He would start out,run toward his destination, then panic, reverse course, and go back to the curb. Sometimes hewould run only a couple of feet before reversing course. Other times he would get halfwayacross and then reverse himself. Occasionally he would get within a few short leaps of hisgoal and then, unaccountably, turn back. There were also times when he would run forward,begin to turn back, change course again, and do this several times before achieving his goal.“This is no way to get across the street,” he said to himself. “Even if I reach my goal, I’m anervous wreck by the time I do. But most of the time I end up where I started, and then haveto live with my defeat. It might not be so bad if I could truthfully say it isn’t affecting mybehavior in other ways, but a couple of nights ago when I was cracking nuts with my teeth Inoticed that my hands were shaking.”

Pastoral Psychol (2012) 61:589–602DOI 10.1007/s11089-011-0423-y

D. Capps (*)Princeton Theological Seminary, PO Box 821, Princeton, NJ 08542-0803, USAe-mail: [email protected]

He decided to talk with a few friends about his problem. He went to his friend the moleand told him about how he was having a devil of a time getting across the street. The molelistened and then said, “Maybe you could solve your problem by doing what I do. I burrowunderground and when I get to where the ground is soft enough, I begin digging, shoving thedirt aside and making a path. Sometimes I run into a big tree root or a rock and have tochange course, but that’s o.k., because it really doesn’t matter much what direction I takebecause I’m not trying to get somewhere specific.” “You mean, like crossing a street to theother side?” “Exactly!” “But doesn’t it get rather tedious burrowing around in the ground?”the squirrel asked. “Sometimes, I guess,” the mole replied, “but it’s what I do, and I thinkI’ve been blessed by having a couple of extra thumbs. Also, I can stay underground for quiteawhile because I inhale the oxygen above the ground and re-use it when I’m underground.”

The squirrel replied, “Well, I’ve done some burrowing so it’s not like I can’t do it; maybeit’s worth a try.” The next morning he began digging into the soil near the curb and wasmaking progress in burrowing underground when he began to think, “Why am I going to allthis trouble to burrow under the road when I can run across the street in a matter of seconds?Also, I don’t mind going underground from time to time but I’d much rather be aboveground. Is there anything wrong with that?”

So he came back up to the surface to take a break just as his friend the goldfinch droppedby. “What’s going on?” the goldfinch asked. “I was burrowing under the road because I wantto cross the road but I know it isn’t safe so I get tense and panicky whenever I try to runacross.” The goldfinch replied: “Sometimes I’ve watched you guys cross a road on atelephone wire.” “True enough,” the squirrel said, “But I want to cross here and there aren’tany telephone poles with wires crossing the street.” “Well,” said the goldfinch, “I know youdon’t have wings like me so you can’t just flap your wings and fly over, but I’ve seen youleap from one tree limb to another and I’ve got to say you really make it look easy.” Thesquirrel answered, “Thanks! I guess it’s a skill I was born with. But the problem here is thatthe distance from the trees on this side of the road to the trees on the other side of the road ismuch too far. I could leap and miss the limb I’m shooting for and plummet to the pavementbelow. But thanks for your suggestions. And I hope you have a nice day.” The goldfinchreplied, “You, too!” and flew away.

The squirrel sat and thought about his predicament and how his friends had tried tohelp but pretty much in vain. He was getting really frustrated and decided that maybehe should seek some help from the parrot, who had been recommended to him byanother squirrel. The parrot was in a cage on the back porch of the woman who hadmade sure he had enough to eat during early spring when the nuts he had buriedearlier begin to sprout and new food sources have not become available yet. Hegreeted the parrot and said, “Another squirrel said you helped him with his problem.Maybe you can help me with mine.” The parrot replied, “You have a problem andfeel that I might be able to help you.” “Well, yes, you see, every time I begin runningacross the street I get really frightened and panicky and reverse course, then mosttimes I reverse course again, and this can happen three or four times. Sometimes Imake it, sometimes I don’t.” The parrot replied, “Sometimes you make it, sometimes youdon’t.” “Yes, I think I do this because I’m afraid I’ll get hit by a car or truck.” The parrot replied,“You’re afraid a car or truck might hit you so you reverse course.” “That’s right.” The parrotsaid, “Right.” The squirrel asked, “So what do you make of it? What’s gone wrong with me?”The parrot replied, “You feel that something has gone wrong with you and you wonder what Imake of it.” “Well, yes.” Just then the nice ladywho owns the house where the parrot lives cameout to the back door and the parrot turned to her and squawked, “Got a cracker?” and thesquirrel left, feeling rather dejected.

590 Pastoral Psychol (2012) 61:589–602

As he scampered back to his favorite hangout, the trees near the road, he looked up andsaw an owl sitting on the tree. “Gosh,” he said to himself: “I didn’t realize it has gotten thislate.” As he passed by the owl, the owl said, “Where are you going in such a rush?” Thesquirrel answered, “I’m returning home.” “Where have you been?” the owl asked. “I went totalk to the parrot about a problem I have but he wasn’t much help.” “Tell me about yourproblem.” The squirrel told the owl what he had told the parrot. When he finished, the owlsaid, “Maybe I can help. Let’s both sleep on it and you can come back tomorrow morningand maybe in the meantime I will have come up with something.” The squirrel replied, “I’mgetting pretty desperate so, sure, I’ll come back early tomorrow morning.” After he left, theowl flew to his cave and pulled a few books from the shelf. He spent the rest of the nightreading.1

The instinct of fear

In his chapter on “Instincts” in The Principles of PsychologyWilliam James (James 1890/1950,vol. 2) discusses the instinct of fear. He views fear as one of three types of instincts—the othersare lust and anger—that are “the most exciting emotions of which our nature issusceptible” (p. 415). He states that fear “is a reaction aroused by the same objects that arouseferocity” and suggests that the “antagonism of the two is an interesting study in instinctivedynamics” (p. 415). As we both fear and wish to kill anything that may kill us, the question ofwhich of the two impulses wewill actually follow is usually decided by the circumstances of theparticular situation, and this necessarily “introduces uncertainty into the reaction” (p. 415).

He notes, however, that the evolution of the human species has led to “the decrease infrequency of proper occasions for fear” (p. 415). In fact, it has become possible for largenumbers of people “to pass from the cradle to the grave without ever having had a pang ofgenuine fear” (pp. 415-416). Moreover, many of us “need an attack of mental disease toteach us the meaning of the word” (p. 416). Nevertheless, “fear is a genuine instinct” and is“one of the earliest shown by the human child” (p. 416).

He discusses the fact that young children are more likely to experience fear as a result ofunexpected noises than of horrific sights, and then identifies several other excitements tofear, including strange humans and animals, either large or small, especially ones thatadvance toward us in a threatening way; dark places, such as holes and caverns; highplaces, despite the fact that humans are “anatomically one of the best fitted of animals forclimbing about high places” (p. 419); and fear of the supernatural. He saves for last “thestrange symptom which has been described of late years by the rather absurd name ofagoraphobia” (p. 421, his italics). This is how he describes this fear:

The patient is seized with palpitation and terror at the sight of any open place or broadstreet which he has to cross alone. He trembles, his knees bend, he may even faint atthe idea. Where he has sufficient self-command he sometimes accomplishes the object

1 This article, written for The Group for New Directions in Pastoral Theology conference on the theme ofJesus’ parables and sayings, was inspired in part by William James’ comment in his essay “The Importance ofIndividuals” (James 1897/1992): “What animal, domestic or wild, will call it a matter of no moment thatscarce a word of sympathy with brutes should have survived from the teachings of Jesus of Nazareth?” (p.651). One could argue that Jesus endorses sympathy, even affection for animals in the parable of the lost sheep(Matt. 18:12-13; Luke 15:4-6; Thom. 107; see Dykstra 2010). Nonetheless, James’ suggestion that animalsmight take interest in Jesus’ teachings is itself intriguing. The idea that a wise owl might read the writings ofseveral human authors on the subject of agoraphobia builds on this suggestion.

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by keeping safe under the lee [i.e. shelter or protection] of a vehicle going across, orjoining himself to a knot of other people. But usually he slinks round the sides of thesquare, hugging the houses as closely as he can. (p. 421)

Although this emotional reaction “has no utility in a civilized man,” we may well wonderif “such an odd kind of fear in us be not due to the accidental resurrection, through [mental]disease, of a sort of instinct which may in some of our ancestors have had a permanent andon the whole a useful part to play?” (p. 422). In support of this conjecture he cites “thechronic agoraphobia of our domestic cats” as well as “the tenacious way in which many wildanimals, especially rodents, cling to cover, and only venture on a dash across the open as adesperate measure—even then making for every stone or bunch of weeds which may givemomentary shelter” (p. 422).

Note that in his description of the behavior of the person he calls “the patient” Jamesprovides a compelling reason for why this instinct would have emerged in the first place,namely, that when one ventures across the open place or broad street one makes oneselfvulnerable to being “attacked,” whether by another living being (human or other animal) orby a moving vehicle or projectile of some kind. Thus, one reduces or even nullifies the threatby crossing under the protection of a vehicle that serves as a buffer against whatever mightbe the agent of the attack, or by crossing in the company of a “knot” of other people which,by its very visibility and/or countervailing threat, will inhibit the threatening agent fromcarrying out the “attack” (p. 421). Agoraphobia is an excellent illustration, then, of the factthat fear “is a reaction aroused by the same objects that arouse ferocity” and of the corollaryfact that we “both fear, and wish to kill, anything that may kill us” (p. 415). More likely thannot, the agoraphobic patient is so conscious of his fear that he is unaware that he alsopossesses the impulse of ferocity.

What is agoraphobia?

Agreeing with James that agoraphobia is a rather absurd name for what was troubling thesquirrel, the owl nonetheless turned to the dictionary for a precise definition and wasinformed that it is “an abnormal fear of being in open or public places” and that claustro-phobia is “an abnormal fear of being in an enclosed or confined place” (Agnes 2001, pp. 27,271). So the difference between the two phobias is that the locus is open or public in the onecase and enclosed or confined in the other.2

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) includesagoraphobia among the anxiety disorders and describes it as anxiety about, or avoidanceof, places or situations from which escape might be difficult (or embarrassing) or in whichhelp may not be available in the event of having a panic attack or panic-like symptoms(American Psychiatric Association 2000, p. 429).

A panic attack is “a discrete period in which there is the sudden onset of intenseapprehension, fearfulness, or terror, often associated with feelings of impending doom.During these attacks, symptoms such as shortness of breath, palpitations, chest pain ordiscomfort, choking or smothering sensations, and fear of ‘going crazy’ or losing control are

2 Some would argue that the squirrel’s problem is actually agyrophobia (or dromophobia) which is the fearthat crossing roads will cause bodily harm to oneself even if no actual threat is posed (Wikipedia 2011). Butthere is no reference to agyrophobia in the Diagnostic and Statistical Manual of Mental Disorders, so it seemsappropriate that we consider the squirrel’s problem to be one of the various manifestations of agoraphobia.


present” (p. 429). Panic attack is diagnosed if there is a discrete period of intense fear ordiscomfort, in which four (or more) of the following symptoms which have developedabruptly and reached a peak within 10 minutes: (1) palpitations, pounding heart, or accel-erated heart rate; (2) sweating; (3) trembling or shaking; (4) sensations of shortness of breathor smothering; (5) feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominaldistress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) derealization (feelings ofunreality) or depersonalization (being detached from oneself); (10) fear of losing controlor going crazy; (11) fear of dying; (12) parethesias (numbness or tingling sensations); and(13) chills or hot flushes (p. 432).

Panic disorder (characterized by recurrent panic attacks) may occur with or withoutagoraphobia. Thus, the two possible diagnoses for persons with agoraphobic symp-toms are panic disorder with agoraphobia and agoraphobia without history of panicdisorder (p. 433). There are three diagnostic criteria for agoraphobia:

1. Anxiety about being in places or situations from which escape might be difficult (orembarrassing) or in which help may not be available in the event of having anunexpected or situationally predisposed panic attack or panic-like symptoms. Agora-phobic fears typically involve characteristic clusters of situations that include beingoutside the home alone; being in a crowd or standing in a line; being on a bridge; andtraveling in a bus, train, or automobile. A diagnosis of specific phobia may be moreappropriate if the avoidance is limited to one or only a few specific situations or socialphobia if the avoidance is limited to social situations.

2. The situations are avoided (e.g., travel is restricted) or else are endured with markeddistress or with anxiety about having a panic attack or panic-like symptoms, or requirethe presence of a companion.

3. The anxiety or phobic avoidance is not better accounted for by another mental disorder,such as social phobia (e.g., avoidance limited to social situations because of fear ofembarrassment), specific phobia (e.g., avoidance limited to a single situation likeelevators), obsessive-compulsive disorder (e.g., avoidance of dirt by someone with anobsession about contamination), posttraumatic stress disorder (e.g., avoidance of stimuliassociated with a severe stressor), or separation anxiety disorder (e.g., avoidance ofleaving home or relatives). (p. 433)

The essential features of agoraphobia without history of panic disorder are similar tothose of panic disorder with agoraphobia except that the focus of fear is on the occurrence ofincapacitating or extremely embarrassing panic-like symptoms or limited-symptoms attacksrather than full panic attacks or other symptoms that may be incapacitating or embarrassing(such as loss of bladder control or vomiting in public). The DSM-IV-TR notes, however, thatin clinical settings over 95% of persons who present with agoraphobia also have a currentdiagnosis (or history) of panic disorder. In cases where there is no panic disorder there is agood chance that a diagnosis of specific phobia would be more accurate (p. 442).

On the other hand, the DSM-IV-TR presentation of agoraphobia without history of panicdisorder includes a very useful section on differential diagnosis, especially with regard toother disorders (pp. 442-443). It notes, for example, that the avoidance behavior in the caseof agoraphobia is based on fears that differ from the fears that prompt avoidance behavior inthe cases of several other disorders. Whereas, in the case of agoraphobia, the avoidancebehavior is based on fear of the occurrence of incapacitating or extremely embarrassingpanic attacks or panic-like symptoms, the avoidance behavior in social phobia derives fromfear that one might act in a way that is humiliating or embarrassing. Embarrassment is feared


in both cases, but in agoraphobia the embarrassment is directly related to the panic attack orpanic-like symptoms whereas in social phobia the embarrassment is due to anticipatedcriticism of one’s behavior, that others will judge one to be anxious, weak, stupid, or “crazy”(p. 450). Typically, one also anticipates that one will become the object of self-critique, soeven if one perceives that others are not engaging in negative judgment of one’s socialinteraction or performance, one may nonetheless feel deep embarrassment (“I made a fool ofmyself” or “They were just trying to be kind in their response to what was an obviously badperformance”).

In the case of specific phobia the avoidance is due to a specific feared object or situation,so the fear is not caused by the anticipation that one will panic but by the object or situationitself. The fears that James identifies in his discussion of instincts (noises, strangers, darkplaces, high places, encounters with ghosts or other unexplainable phenomena) are allexamples of specific phobias. Terror at the sight of “an open place or broad street” (James1890/1950, p. 421) may appear to be another example of a specific phobia, but this verydescription of the situation is sufficiently general that it could apply to any number ofgeographical locations. In this sense, agoraphobia resembles social phobia in that severaldifferent loci may provoke avoidance behavior.3 Similarly the same agoraphobic individualmay anticipate a panic attack while shopping in a grocery store, or as a passenger in a vehicleon a highway or turnpike, or when home alone without a human companion.

The DSM-IV-TR distinguishes the agoraphobic person’s avoidance of leaving home fromthe avoidance behavior of a person with major depressive disorder, who may avoid leavinghome due to apathy, loss of energy, and an inability to experience pleasure. Avoidancebehavior may be due to persecutory fears (as in the case of delusional disorder) and fears ofcontamination (as in obsessive-compulsive disorder). Also, the avoidance of leaving homedue to an anticipated panic attack outside the home differs from a similar avoidance in thecase of separation anxiety disorder, where children may avoid situations that take them awayfrom home or close relatives because they worry about losing, or about possible harmbefalling, major attachment figures (p. 125).

The DSM-IV-TR also notes that individuals with certain medical conditions may avoid thesame situations that persons with agoraphobia avoid due to realistic concerns about beingincapacitated (e.g., fainting, as in the case of an individual with transient ischemic attacks[i.e. mild strokes]) or being embarrassed (e.g., diarrhea in the case of an individual withCrohn’s disease). Thus, a diagnosis of agoraphobia is only appropriate in such cases if thefear is clearly in excess of that usually associated with this condition (p. 443).

Given the fact that agoraphobia and panic disorder commonly occur together, the diagnosticfeatures of panic disorder are also important to note. The essential feature of panic disorder is thepresence of recurrent, unexpected panic attacks followed by at least one month of persistentconcern about having another one, worry about the possible implications or consequences of theattacks, or a significant behavioral change related to the attacks (p. 433). Typical worries about

3 Thus, Rapee et al. (1988) presented socially phobic subjects (n0160) with a list of nine situations known tobe ones that socially phobic persons fear. They wanted to ascertain whether subjects had slight or moderatefear of the situation and whether their degree of avoidance of the situation was slight or moderate. The greatestdegree of fear was prompted by situations involving public speaking. The least amount of fear was promptedby situations involving eating in public. Other feared situations included attending meetings, going to parties,talking to authorities, self-assertion, dating, writing in public, and using public restrooms. In general, therewas a direct correlation between degree of fear and avoidance behavior, but a notable exception was that fearof attending meetings ranked second overall but was tied for fifth as far as avoidance was concerned. Thisdiscrepancy was probably due to the fact that attending meetings cannot be avoided, i.e., is considered anintegral part of one’s occupation (see also Capps 1999/2010, pp. 51–65).


the consequences of such attacks are losing control, having a heart attack, and “going crazy.”Other criteria for a diagnosis of panic disorder are that the panic attacks are not due to the directphysiological effects of a substance (e.g., a drug of abuse or medication) or a general medicalcondition (e.g., hyperthyroidism); and that the attacks are not better accounted for by anothermental disorder, such as social phobia (e.g., occurring on exposure to feared social situations),specific phobia, obsessive-compulsive disorder, or separation anxiety disorder (p. 440).

The agoraphobic syndrome

Aaron T. Beck and Gary Emery’s groundbreaking book on anxiety disorders (Beck andEmery 1985) has a chapter titled “The Agoraphobic Syndrome” (pp. 133–145). It beginswith the heading “The Riddle of Agoraphobia” and with this opening sentence: “Certainfeatures of agoraphobia seem to defy common sense or reason” (p. 133). For example:

Why should a woman who has progressed into her twenties, ostensibly with aminimum of psychological problems, suddenly develop a fear of going into publicplaces, riding in cars, buses, trains, and elevators? Why should this person who iscompetent in many ways jeopardize a job or marriage or refuse to leave the house?Why should a woman who has engaged in numerous activities on her own in the pastbecome so dependent that she will not travel without a companion? (p. 133)4

Noting that these questions sorely vex those theorists who try to make sense of psychi-atric disorders, the authors cite the large number of books published in recent years that haveaddressed the problem of agoraphobia from clinical, behavioral and pharmacological van-tage points in hopes of yielding some answers to this riddle.

The vantage point from which they themselves seek to find answers to this riddle isessentially developmental. They believe it is important to know whether there werepredisposing factors that made the individual a prime candidate for the development ofagoraphobic symptoms (which tend to appear after the age of twenty) and, if so, what thesefactors were. They also consider it important to know whether there were more immediateprecipitating factors that were responsible for the emergence of agoraphobic symptoms atthis particular time.

As for predisposing factors, they note that some persons have a history of separation anxietydating back to early childhood and have managed to maintain their equilibrium as long as theyhad available one or more protective figures (parents, siblings, peer group) (p. 134).5 Precipi-tating factors may therefore be a prolonged stay away from home (e.g., attending a distantcollege) which removes this “prop” and makes one subject to agoraphobia. Similarly, adisruption of marital adjustment may jeopardize the availability of a supportive person. Thus:

The general circumstance that seems to be prevalent among most agoraphobics is theincreasing expectation that the individual take on the demands of adulthood orparenthood and at the same time function more independently. Birth of a child, loss

4 Beck and Emery use the female sex (“she” and “her”) throughout their discussion of agoraphobics. As theytend to use the male sex (“he” and “his”) in their discussion of other anxiety disorders, the fact that they alterthis pattern in their chapter on agoraphobia is evidently due to the much greater prevalence of agoraphobiaamong women. According to the Diagnostic and Statistical Manual of Mental Disorders, “This disorder isdiagnosed far more often in females than males” (American Psychiatric Association 2000, p. 442).5 In How Does Analysis Cure? Heinz Kohut (1984) suggests that agoraphobics were deprived of the necessarycalming structure usually provided by one or both parents in early childhood.


of a caregiver through separation or death, increased demands at home or at work, allmay precipitate agoraphobic symptoms. The increased responsibilities representthreats to the patient since she believes that if she performs inadequately there maybe disastrous consequences. Thus, her self-confidence may be threatened by theincreased expectations and/or by a removal of a social support. (p. 134)

What contributes to the riddle, however, is that in a typical scenario the individualperceives herself as being suppressed by another person on whom she depends forsupport. She “has a large investment in her own sense of self-control and competence,shaky though it is; but the domination by another person tends to erode her confi-dence in her ability to function adequately on an independent basis” (p. 134). Becauseshe believes that the new demands and responsibilities require competent performance—afterall, inadequate performance on her part may have disastrous consequences—she is likelyto revert to an earlier stage of dependency. As a result, she becomes more threatened byexternal and internal problems and relies increasingly on her supporter to help her tocope with these dangers. Hence, there emerges the seeming paradox of resentment of thedomination of another person, on the one hand, and increased need for this person’s helpin coping with the situation.

Thus far, there are no symptoms as such. The conflict is an internal one. But symptomsemerge as the individual begins to perceive a variety of potential dangers in the “outsideworld,” such as losing control of the car, getting lost in traffic, getting caught in a revolvingdoor, or being bowled over by a crowd. The authors note that these dangers resemble therelatively realistic fears of young children. As these fears accumulate and expand, eventuallyalmost every stage in the process of going out to a store or other place away from homebecomes a serious confrontation. The result is that one becomes increasingly vulnerable asone goes through a series of steps:

1. The perception of an unlimited number of opportunities to be immobilized, humiliated,crushed, suffocated, or attacked (in crowds, elevators, buses, tunnels, streets) and ofhaving no reliable defense against these external “dangers.”

2. Automatic reflexive reactions producing symptoms suggestive of a serious internaldisturbance (heart attack, stroke, fainting spell, going crazy) and no way of wardingoff these internal “attacks.”

3. The sense that one is “malfunctioning” and losing one’s competence (e.g., ability tokeep the car on the road, maintain equilibrium while standing still, communicate orallywith other people without blocking or stuttering, etc.).

4. The loss of control over reactions to threat reinforces the idea that one is a victim ofinternal and external forces over which one has no control.

5. This loss of a sense of competence plus fears of the “internal disturbance” lead one toseek assistance from a caregiver (e.g., insisting on someone’s company when oneventures outside the house). It is not unusual for this person to be an older child whoseown normal development is inhibited as a consequence.

6. The anxiety in the threatening situation (department store, supermarket) may escalateinto a panic attack. But, in any event, the strong anxiety triggers a strong wish to fleefrom the situation and return to a safe haven (generally home).

7. Home, or an equivalent haven, represents safety from the external danger. One experi-ences a strong resistance to venturing out again and generally feels anxious if she doesleave the house.

8. The multiple inhibitions, submissive tendencies, and negative appraisals of selfundermine self-confidence and thus lead to disequilibrium in relationships, further


sense of inadequacy, and ultimately the sense of being trapped and dominated by otherpeople (p. 135).

Noting that a panic attack typically occurs relatively late in these steps of increasingvulnerability, Beck and Emery observe that the Diagnostic and Statistical Manual of MentalDisorders (American Psychiatric Association 1980, p. 226) lists agoraphobia without panicattacks as a distinct diagnosis. They suggest that the fact that many people may experienceagoraphobia long before their first panic attack, and that many never have a panic attack,raises some question about the role of the attack as a necessary condition for the develop-ment and maintenance of agoraphobia. Moreover, many individuals who have had panicattacks state that their primary fear, prior to entering the phobic situation, is of having a heartattack or of losing control rather than simply of having another panic attack. In addition,some persons who have overcome their avoidance of the phobic situation may continue tohave panic attacks without relapsing into their former avoidance (p. 136).

At the very least, these facts indicate that a physiological reaction is not what instigatesagoraphobia. Rather, agoraphobia begins as a cognitive process and physiological symptomsemerge only later—if at all—in its development and maintenance. Thus:

In many cases, the progression to a panic attack starts with a period of “tension”stemming from life problems that are novel to the patient (new demands or risks athome or at work) and for which she has no available coping strategies. The unsolvedproblems lead to a sense of helplessness and various somatic and psychologicalsymptoms. The origin and nature of these symptoms are mysterious to the patient:she has difficulty explaining them to herself. Rather than correlate her increased levelsof tension with specific stressors or fears, she is likely to regard her symptoms as anexpression of an inexplicable and dangerous internal process over which she has nocontrol. (p. 136)

Also, she may have a strong “disease” orientation that leads her to think of explanationsin terms of a serious pathological process, and the fact that she “is unable to arrest theprogression of symptoms confirms her belief in their extreme gravity. As a result, she notonly makes negative interpretations of her symptoms but predicts the worst possible con-sequences (pp. 136-137).

In their discussion of “thinking disorder in clinical anxiety” in their chapter on symptomsand their significance, Beck and Emery introduce the concept of catastrophizing originallyproposed by Albert Ellis (Ellis 1962). Persons who engage in this type of faulty thinking—which is characteristic of many persons with anxiety disorders—tend to dwell on the worstpossible outcome of any situation in which there is the possibility of an unpleasant outcome.Thus, the anxious person overemphasizes the probability of this catastrophic outcome andusually exaggerates the possible consequences of its occurrence. A successful college studenttaking an examination was preoccupied with the possibility of his failing, and imagined that ifhe failed the test, he would flunk out of college and would end up as a drifter. A new collegeinstructor faced with giving his first lecture to a large group of students was afraid that he wouldforget what he had to say and would make a fool of himself and faint or start screaming in aninsane way, and the ultimate outcome would be a ruined career and a ruined life (p. 33).

Beck and Emery also note that some agoraphobic persons are able to train themselves tohead off a full-blown attack through techniques such as distraction or cognitive restructuring—that is, through viewing the symptoms as an emotional reaction, not as a sign of catastrophe(p. 137). They point out that as the agoraphobic person approaches the phobic situation shetends to lock into a vulnerability cognitive set, i.e., an anticipation that some affliction is about


to befall her. Before entering the situation, she does not regard the state of disturbance as beingindicative of serious physical, behavioral, or mental disorder. When in the situation, however,she believes she may be developing a serious affliction (p. 138). This belief appears to be basedon the concept or idea that when alone one is vulnerable to a sudden serious medical, mental, oremotional disorder. There is also the corollary belief that this disorder can be remedied if onehas quick, unobstructed access to a place of safety, such as one’s home, a physician, or ahospital. But if one is blocked from such assistance due to distance or some other factor, onemay not be able to ignore the symptoms (such as chest or abdominal pain, choking, feelingfaint, or physically weak) and these symptoms become viewed as a sign of an impendingdisaster. The increased fear leads to anxiety and its concomitants, which may further enhancethe somatic symptoms. Thus, a vicious cycle is set up and finally one is unable to use one’sreasoning powers to negate the exaggerated fears (p. 138).

Why do specific locations or situations appear to trigger these attacks? One factor is thatthey block easy access to home or a helping person. Crowded stores interfere with mobility.Riding on a train, a superhighway, over a bridge or in a tunnel blocks access to emergencyhelp. Being blocked from the exit in a crowded restaurant or theatre also impedes escape to asafe haven or access to help. The authors note, “The key word in these situations is‘trapped’” (p. 139).

Another, perhaps more important factor is that these situations are perceived to beinherently dangerous. Traveling to a specific “agoraphobic” situation such as an enclosedshopping mall presents a host of potential dangers en route, including driving the car off theroad, hitting a pedestrian, losing one’s way, getting struck by a car while crossing the street,or getting mugged while entering a subway station. Furthermore, subways and tunnels cancave in, bridges collapse, buses crash, and elevators get stuck or fall. Agoraphobic personsare typically concerned with free movement and access to help but, paradoxically, one oftheir characteristic behavioral reactions is immobility and feeling faint. This reaction makesmatters worse because the immobility interferes with freedom of action.

The authors believe that mobility has a meaning for agoraphobic persons that goesbeyond providing a mechanism for escape, that they place a premium on mobility for itsown sake—freedom, self-determination, individuality. Noting that some agoraphobicpatients have fantasies of complete freedom (e.g., flying in the air) and of flagrant sexualescapades for which they are arrested, the authors hypothesize that the fear of loss of control,so prominent in agoraphobic patients, is due, in part, to recognition of an impulse to breakloose from conventional rules of behavior—by yelling, acting crazy, doing destructive acts,etc. Thus, the agoraphobic’s conflict seems to revolve around issues of dependency,autonomy and control, for on the one hand, one believes that one cannot deal with thedangers in the outside world by oneself and is therefore impelled to obtain help from a“caretaker” but on the other hand, seeking the caretaker’s help may lead to surrender ofsovereignty to another person, resulting in less claim to personal freedom, autonomy, andself-control (p. 140).

A case that supports Beck and Emery’s argument is presented in Lisa Capps and ElinorOchs’ Constructing Panic: The Discourse of Agoraphobia (Capps and Ochs 1995). Itconcerns a woman who accommodates herself to her husband’s proposal (e.g., taking hisvisiting cousin to lunch) and drops what she is doing (e.g., baking cookies). Havingaccommodated herself to others, her “objections” come out later in the form of thoughtsand feelings that seem unreasonable to others: “Can’t you get us out of this bumper-to-bumper traffic?” “How?” “Well, drive on the shoulders.” “But there aren’t any shouldershere.” Stuck in traffic, she begins to feel panicky and seeks to escape from the situation andto make her desire to escape known to others. Thus, her own “agency” is relinquished at the


beginning and she becomes a victim of “external forces.” She could have said, “Why don’tyou go to lunch with your cousin without me while I finish baking the cookies, then bringher back home and we’ll have coffee and freshly baked cookies.” The authors suggestteaching her to use language that expresses her own desires and wants, thus transforminghelplessness into a narrative of voluntary action: “I’d rather not go.”6

An unpublished study by Beck himself (Beck 1983) compared the responses of 39agoraphobics to the Sociotropy Autonomy Scale with those of 36 persons withgeneralized anxiety disorder, 36 depressives, and 72 control subjects. He found thatthe agoraphobic patient had “a greater investment in mobility and self-direction, andsensitivity to being restrained or controlled, than the other psychiatric patients andnormal controls” (p. 140). The agoraphobics had extreme scores on the followingpersonal statements: (1) It is very important that I be free to get up and go wherever Iwant to; (2) I feel confined when I have to sit through a long meeting; (3) I getfidgety when sitting around talking and would prefer to get up and do something; (4)I prefer to make my own plans—so I am not controlled by others; and (5) It bothersme when people try to direct my behavior and activities (p. 140). Beck and Emeryalso note the interesting fact that the agoraphobic person’s reluctance to be too closeto the caregiver, lest she be dominated, or too far, lest she encounter a situation whereshe needs help, is paralleled by her sensitivity to spatial configurations, as she avoidsspaces that are too narrow (crowds, closets, elevators) and too expansive (super-markets, shopping centers, flat meadowlands, amphitheaters) (p. 141).7

The case of Sigmund Freud

Paul Carter begins his book Repressed Spaces: The Poetics of Agoraphobia (Carter2002) with an anecdote in Theodor Reik’s The Search Within (Reik 1956). Oneevening, Reik encountered Freud in the Kaertenstrasse in Vienna and accompaniedhim home: “We talked mostly about analytic cases during the walk. When he crosseda street that had heavy traffic, Freud hesitated as if he didn’t want to cross. Iattributed the hesitancy to the caution of the old man, but to my astonishment hetook my arm and said, ‘You see, there is a survival of my old agoraphobia, which

6 In light of the fact that she frequently agreed to her husband’s plans, it is significant that Beck and Emeryalso note that agoraphobics are frequently caught in a complex marital situation in that they want to receivesupport from their mate and to be free and autonomous. They suggest that the agoraphobic person’sexpression of autonomy is inhibited because it may alienate the spouse and, thus, threaten the patient’s abilityto rely on the spouse for help and that “the spouse might use his position as caretaker to dominate hisagoraphobic wife, to promote his own objectives, and to depreciate her” (p. 140). In noting that the result ofthis unequal relationship is to reduce her self-confidence and make her more dependent, Beck and Emeryimply that this “unequal relationship” is an effect of the agoraphobia itself. We may well wonder, however,whether it may be more accurate, at least in some cases, to say that it was a major causal factor in thedevelopment of the agoraphobia.7 Beck and Emery also emphasize the value of preceding exposure to the feared situation with some form ofbehavioral rehearsal prior to the exposure (pp. 271-272). This view reflected the belief that was gainingstrength among clinicians at the time that repeated exposures without some form of preparation is usuallyineffective. Today, due in large measure to the pioneering work of Beck and Emery and their contemporaries,clinicians usually advocate a combination of graded exposure and cognitive restructuring. In my course on“The Minister and Mental Illness” I regularly show a video titled “Fight or Flight: Overcoming Panic andAgoraphobia.” It provides a step-by-step overview of treatment from cognitive-behavioral specialists Dr.Ronald M. Rapee and Dr. Lisa Lampe (Guilford Publications 1998) and explains the importance of combiningthe two.


troubled me much in younger years’” (p. 260). Carter notes that although Freuddismissed his “slight phobia” as of little importance, Reik took an entirely differentview, attributing to it “a central role in the history of psychoanalytic theory,” andviewing it as “‘the hidden missing link between [Freud’s] primarily psychologicalinterests and his later occupation with the neuroses’” (p. 7).

Assuming that Freud’s own agoraphobia was a personal motivation for Freud’sinterest in neuroses, Carter asks whether, in “interpreting his agoraphobia as aneurotic symptom concealing something else, Freud turned away from the possibilitythat his hesitation at the roadside was an entirely reasonable response to the sicknessof the urban scene?” Was his fear of the “heavy traffic” due to “his own unrulyinstinctual drives” or to “a more mundane and measurable form of driving: theimmensely increased volume and accelerated pace of traffic in Vienna’s newlyenlarged roads and squares?” (p. 8). Carter goes on to explore the fact that sinceagoraphobia’s first clinical description in the late 1860s “cultural critics and clinicalpsychologists have disputed its nature,” the former viewing it as “a symptom of urbanestrangement” and the later treating it “as a symptom of psychic displacement” (pp.8-9). Although Carter comes down on the side of the cultural critics, one could arguethat this very question preoccupies the mind of the agoraphobic person.8

The squirrel succeeds in crossing the street

It was nearly dawn when the owl finished reading. He ate a few insects and then flew to thetree where he had met the squirrel the previous evening. As he sat yawning he wondered ifthe squirrel would even show up. But soon the squirrel returned, a sign, the owl thought, ofhis desperation. He climbed up and found a branch adjacent to the owl’s and lookedexpectantly into the eyes of the owl. The owl spoke first, “I’ve been thinking about yourdilemma and I’ve been reading some books by members of the human species that seemrelevant to what you are experiencing. One man, a learned Harvard professor, said some-thing that struck me as being helpful. He mentioned that if a human being is having troublecrossing a broad street due to fear, he may keep himself safe by using the protection of avehicle or join himself to a knot of other people. He emphasized, though, that the fearfulperson may not be able to do this unless he somehow acquires “sufficient self-command”(James 1890/1950, p. 421).

The squirrel scratched his face and said, “Using the protection of a vehicle won’twork for me because where I go across the cars and trucks are coming toward me—

8 Freud’s case of “Little Hans” has bearing on Freud’s own agoraphobia. He treats the case of “Little Hans” asone of a specific phobia—“an infantile hysterical phobia of animals” (Freud 1926/1989, p. 22). But in light ofthe fact that Hans refused to go out into the street because he was afraid of horses, his symptoms resembledthose of agoraphobics. In fact, Freud notes that as Hans’ originally expressed fear that horses might bite himreceded and he began instead to express fear of watching horses falling down, he also began to express fear ofcarts, furniture vans, and buses, their common quality being that they were all heavily loaded. At this time healso “showed signs of an impulse—though this was now inhibited by his anxiety—to play with the loads onthe carts, with the packages, casks and boxes, like the street-boys” (Freud 1909/1959 p. 160). This soundsvery much like Beck and Emery’s suggestion that the agoraphobic’s fear of the loss of control is due, in part,“to recognition of an impulse to break loose from conventional rules of behavior—by yelling, acting crazy,doing destructive acts” (Beck and Emery 1985, p. 140). Although Freud views Hans’ horse phobia as a“reaction formation” relating to his jealousy of his father, it would appear that his agoraphobia was itself a“reaction formation” to the impulse to break loose from conventional rules of behavior, to become a “streetboy” himself. Perhaps “Little Hans” reminded Freud of himself when he was a young boy.


and from both sides.” “I agree,” said the owl, “but what about the second approach?”“That won’t work either,” the squirrel replied, adding, “Can you imagine a bunch ofus squirrels agreeing to go across the road all at the same time?” “I thought youwould say this,” the owl replied, “So I have a suggestion. When you leave to go backto your road, observe the Canada geese.” With this, the owl flapped his wings andflew away before the squirrel could respond.9

Later that day the mole was rummaging around in leaves under a tree and thegoldfinch was perched on one of its branches. Suddenly they noticed that a dozenCanada geese were walking in a line across the street. The cars traveling in bothdirections had stopped and none of the drivers were honking their horns. At the endof the procession was their friend the squirrel, walking upright on his hind legs andlooking very dignified. The goldfinch warbled his cheerful per-chic-o-ree as he flewover the procession below and as the squirrel looked around and saw the mole, themole gave his friend a double thumbs up!10

9 The owl in this case took an essentially cognitive behavioral therapeutic approach and utilized the idea ofcognitive restructuring. Parables, however, invite alternative endings. In his poem “Palermo” Billy Collinstells about being outside on an empty plaza with his companion on an extremely hot day in Palermo. “Thebees had knocked off for the day” and “The only thing moving besides us/(and we had since stopped under anawning)/was a squirrel who was darting this way and that/as if he were having second thoughts/about crossingthe street,/his head and tail twitching with indecision.”While his companion looked in a shop window Collins“was watching the squirrel/who now rose up on his hind legs/and after pausing to look in all directions,/beganto sing in a beautiful voice/a melancholy aria about life and death,/his forepaws were clutched against hischest,/his face full of longing and hope,/as the sun beat down/on the roofs and awnings of the city.” Later thatevening as he and his companion sat in a café, Collins stood up on a table and sang for his companion and theothers “the song the squirrel had taught me to sing” (Collins 2011, 7-8). This poem suggests a different endingto the parable than that suggested here, one that would have the owl (who is traditionally viewed as theharbinger of bad luck, ill health, or even death) exploring the deeper meanings of the squirrel’s struggle tocross the street. This might mean that the owl would take a more psychoanalytic or existentialist approach,perhaps focusing on the deeper, metaphorical meanings of the very act of “crossing the street.” The owl might,for example, read Freud’s Beyond the Pleasure Principle: A Study of the Death Instinct in Human Behavior(Freud 1920/1959).10 I sent this article to a friend who had previously written to me about his longstanding struggle with anxietyand panic attacks. His first panic attack occurred when he was two-years old and the family was staying at acabin near a lake. He calls it “night tremors.” He had another panic attack when he was four-years old, andthey continued through third grade and then tapered off until he entered college. In college, his grades began toslip and he often couldn’t force himself to sit through a lecture, even when sitting at the seat closest to the backdoor. At its worst he didn’t leave his dorm-room for a week, feigning the flu. This went on for periods lastingmonths until many years later he began seeing a therapist who suggested that perhaps there was a constructivebasis for his anxiety. This was the catalyst for the beginning of a life-long quest for authentic identity andexistence, and today he no longer fears feeling like a fish out of water (often in the context of his family andother social circles) but appreciates and even relishes his sense of individuality. After reading the paper hewrote me and said that “the poor squirrel is a perfect metaphor for many memories I have of struggling withanxiety and panic,” adding that “one of the last frontiers that causes me anxiety is the ocean. Although I have aprofound love and connection with the ocean environment and it is a central source of recreation and pleasurefor me, I have established a boundary of distance from shore within which I feel confident I can paddle back tosafety in time to avoid a panic attack that (according to my irrational fear) might otherwise cause me to drown.I ‘enjoy,’ in a somewhat perverse way, testing and tempting that boundary when I go out paddling on my surf-ski or standup paddleboard. Like the squirrel, I hesitantly venture further out, pause and look to shore,calculate the distance, then take inventory on how much further I am prepared to venture (i.e., my confidencelevel based on the overall level of success I feel in the career tasks performed that day, my caffeine and blood-sugar levels, etc.). Some days it feels silly and I chuckle aloud at the absolute irrationality of it—I’m 45 yearsold and have spent most of my life in or on the ocean in challenging conditions and have not drowned. Otherdays I feel almost magnetically pulled to the security of shore. There is a large buoy roughly a mile off-shorethat now represents a mid-life project. It is large enough to climb onto if I ever need to, but like thesquirrel I have gotten much closer to it than the land behind me and yet, due to fear, have turnedaround for shore.”


References

Agnes, M. (Ed.). (2001).Webster’s new world college dictionary (4th ed.). Foster City: IDG Books Worldwide.American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders DSM-IV-TR

(4th ed.). Washington: American Psychiatric Association.Beck, A. T. (1983). Comparison of sociotrophy and autonomy in agoraphobics and other psychiatric patients.

Unpublished study.Beck, A. T., & Emery G. (1985). Anxiety disorders and phobias: A cognitive perspective. With R. L.

Greenberg. New York: Basic Books.Capps, D. (1999/2010). Social phobia: Alleviating anxiety in an age of self-promotion. Eugene: Wipf & Stock

Publishers.Capps, L., & Ochs, E. (1995). Constructing panic: The discourse of agoraphobia. Cambridge:

Harvard University Press.Carter, P. (2002). Repressed spaces: The poetics of agoraphobia. London: Reaktion Books.Collins, B. (2011). Horoscopes for the dead: Poems. New York: Random House.Dykstra, R. C. (2010). Finding ourselves lost. Pastoral Psychology, 59, 737–746.Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart.Freud, S. (1909/1963). Analysis of a phobia in a five-year-old boy. In S. Freud, The sexual enlightenment of

children (pp. 47–183). P. Rieff (Ed.). New York: W. W. Norton.Freud, S. (1920/1959). Beyond the pleasure principle: A study of the death instinct in human behavior.NewYork:

Bantam Books.Freud, S. (1926/1989). Inhibitions, symptoms and anxiety. A. Strachey (Trans.). New York: W. W. Norton.Guilford Publications (1998). Fight or flight: Overcoming panic and agoraphobia. With R. M. Rapee.

Monkey See Productions, NSW, Australia.James, W. (1890/1950). The principles of psychology, Vol. 2. New York: Dover Publications.James, W. (1897/1992). The importance of individuals. In Writings 1878–1899 (pp. 647–652). G. E. Myers

(Ed.). New York: The Library of America.Kohut, H. (1984). How does analysis cure? A. Goldberg (Ed.). Chicago: The University of Chicago Press.Rapee, R. M., et al. (1988). Social phobia features across the DSM-III-R anxiety disorders. Journal of

Psychopathology and Behavioral Assessment, 10, 287–299.Reik, T. (1956). The search within: The inner experiences of a psychoanalyst. NewYork: Farrar, Strauss and Cudahy.Wikipedia (2011). Agyrophobia (http://en.wikipedia.org./wiki/Agyrophobia). Accessed August 12, 2011.


http://en.wikipedia.org./wiki/Agyrophobia

Documents

The Parable of the Squirrel: Alleviating the Anxiety of Agoraphobia