Episode #102

Agoraphobia & CBT

Agoraphobia is a form of anxiety or anxiety disorder that can be crippling to individuals suffering from it.

Is it possible to feel safe again?

How can you use CBT to improve your anxiety?

Join me, Dr Julie Osborn, as I share with you some powerful CBT tools to help you cope with agoraphobia.

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Full Episode Transcript

Hi, welcome to My CBT Podcast! This is Dr. Julie. I'm a Doctor of Psychology and a licensed clinical social worker specializing in Cognitive Behavioral Therapy. I'm here to help you bring the power of CBT into your own life.

Welcome and thanks for being with me. As always, I want to share a review I got this time on Apple podcast. I appreciate you guys that listen off Apple podcast to take the time to put in a review and get the word out. As I always say, my intention here is to get CBT out to the world and help as many people as possible with the tools. And you guys helped me doing that by writing reviews and sharing my posts on Facebook or Instagram. I have a lot of you guys share on your own page, which is super cool because then you can reach all your people. I always wanted to share this one. It says, Thank you, Dr. Osborne. I listened to a couple of newer episodes and enjoyed them so much. I scrolled to the older episodes. I was so grateful to see your series on cancer. I was diagnosed in July 2022 with stage 3 colon cancer.

It's been such a hard time in my life. I appreciate your wisdom on this complicated topic because you know exactly the emotions that come with a cancer diagnosis. Wish you health and happiness in 2023. Thank you so much. I'm wishing you health as well in 2023. I hope you get through your treatment and you start to recover and thrive again. Using the tools will be a huge help, that's for sure. Again, I appreciate that review and I appreciate the time you guys take to reach out to me and to others about what we're doing here together. Today's episode is going to be about agoraphobia. Based on a recent experience I had with a client that I've had permission to at least share the story. I'm going to obviously summarize it to give you guys an idea of what we're talking about and also how this affects many people in many different situations. So the client I was working with was in a very long term marriage over 20 years where there was a lot of emotional and physical abuse, and she was finally able to get out of the marriage, which obviously took a lot of courage.

But now, when she's out and about doing errands or going places, she will see the X. Now she's getting scared to go out and is feeling more agoraphobic and now wanting to go out into public, afraid she's going to see him. So I thought, Well, I haven't talked about agoraphobia, which is again under this umbrella that I talk about with anxiety disorders, right? That there's this umbrella saying anxiety, and then underneath there's agoraphobia, panic, generalized anxiety, OCD, and others there too. But that's what I mean when I have this umbrella. So there's many types of anxiety. It's not all just one. It can overlap, but I'm going to focus on the agoraphobia today, so I hope that's going to be helpful to everybody. So let's talk about what agoraphobia is. So it's an extreme or irrational fear of being in open or maybe crowded places, leaving your home, or being in places which you don't think you can escape is difficult. So what I mean by I don't know if that came out. So people don't want to leave their home because if they go to places they don't think they can escape, it makes them feel very helpless, or if they're going to be embarrassed if they think that would happen.

Their help wouldn't be there or available if things go wrong. So with this client, if she's going to go out by herself, say grocery shopping or to the mall, and then she sees this ex who she thinks is possibly following her, and she's going to think I'm with all these strangers, nobody's going to be here to help me. What am I going to do? I feel embarrassed. All of these thoughts go through. So what's the option in her mind is like, Well, I'm just going to stay home because this is where it's safe. So there could be a lot of triggers where people decide to have this behavior. So you can experience a stressful event such as death, like this one, a divorce, maybe losing your job. Also, if you're in a relationship where the partner is very controlling, like my clients, if you have a history of depression, anxiety, any eating disorders, any alcohol or drug use, these can all be triggers to decide to have that behavior that we call agoraphobia, which is you don't want to leave your house. And the other thing that I find very, very common with people that are struggling with this is they've had a history of panic attacks, or they've even had one.

So a lot of times when people have a panic attack at the grocery store, then they blame the grocery store for them having the panic attack, so now they're not going to go there. Then they go to a movie. They have a panic attack there. Well, I can't go to the movie theater anymore. Or I'm at the mall, I have a panic attack. Wherever you're at, you think that that's the reason that environment is creating the panic for you. So you don't go there anymore. So your world can become very small and you end up just being at home, which just feeds the anxiety in reality. So actually, over 200,000 individuals in the United States suffer from agoraphobia, just to give you an idea. And some other symptoms that you can experience, this is all part of the anxieties. If you're short of breath, you might be like sweating, even though you're not hot, it's not hot outside. You may feel dizzy, your heart rate can increase, you can feel nauseous, feelings of extreme fear or dread. But it is common, as I mentioned earlier, there are a lot of people who have a history of panic attacks.

About a third of people who have panic disorder develop agoraphobia. As I was saying, you're in an environment, you have a panic attack, and then you avoid that environment. So don't get caught up in the numbers here. If you're having panic disorder, doesn't mean you're going to be agoraphobic, but I wanted to give you guys an idea how common it is because you may not know anybody that's struggling with this, or they might not share that with you. Or they may say, Oh, I don't like going to the movies, but they're really not telling you it's because they had a panic attack and they're afraid to be there, or they feel like they can't get out or they're going to be trapped, or they'll embarrass themselves if they start being in a panic attack and other people will be looking. So these are all the hot thoughts that people have when they're struggling with this, and they just want to avoid. Avoiding is the number one behavior with anxiety. If I don't go put myself in that situation, then I'm not going to feel bad is what we tell ourselves. That's not true because wherever we are, if we're having anxiety and we're having irrational thoughts and all these hot thoughts and cognitive distort, where all or nothing thinking, meaning I can't go, it's going to be bad.

All this stuff is what's really feeding the anxiety. That's where the cognitive therapy comes in. We have to really address that. There's so many layers in helping this client and helping you out there if you're struggling with this as well. It's not just, which I'm going to talk about, exposure therapy, which is the number one part of treatment with cognitive therapy with anxieties. You actually have to go to the places that scare you or you feel fearful, but you also have to work on other tools as well, which I'm going to share. So exposure therapy. So you're exposing yourself to your fear also helps you desensitize the emotions connected to it. So let me give you some examples. So exposure therapy would be for my client. So say she's nervous to go to the grocery store because she has seen her ex there before and is feeling really uncomfortable. What she actually needs to do is go to the grocery store. But there's lots of different steps. So I'm not going to say, Hey, just go by yourself. If you can have a friend go with you, someone you're comfortable with, someone that knows the situation and understands how nervous you are, they can be there for support and push you if you're like, No, I just want to go.

I want to go. And with exposure, we take it in steps. We don't just like, If you can't swim, I'm not going to throw you in the deep end. So I'm going to tell you to like, You know what? Go drive by the grocery store. Go sit in the parking lot. Go walk around, maybe the center, if the grocery store is in a shopping center. Then go into the store. So we're not here to freak you out and then you're like, No, I'm not going to go do that. I recommend people take steps. If they're ready to just boom, go in the grocery store. Some people are sick and tired of feeling this way. They're like, I'm just going to go. Fabulous. But also if you want to take steps, I've had a lot of client take some smaller steps, and then they finally get to where they're avoiding, and they see that it's not as bad as they think it is. And with this situation, if you're almost feeling like you're being stalked, then that's where I would create a action plan, which is planning ahead for a situation. And what is my client going to do if she goes to the grocery store and she sees her ex there?

So that's where maybe having somebody with her for a little while until she's feeling more comfortable, she can at least go and walk around and do her shopping and see that she's safe. Coming up with the plan when she does go by herself. And if she sees him, we'll talk about go up to find the store manager, right? Or even going up to a clerk and telling them you're uncomfortable. Can you walk me to my car? My ex is here. There's lots of things you can do. And people are out there and they are willing to help. And they want to help you feel safe, especially if you go to someone that works at the store. So there's lots of different things. You could even talk to the manager ahead and say, If this happens, are you someone I can come to? Or, Who could I come to in the store to help me with this? A lot of times there are security guards at grocery stores too now. So there's lots of different things that you can create a safety net so that you can still go have your life and you don't let this control you until you get to a point where if you see this person you're not going to be scared, you're not going to be scared.

You're going to feel strong, you know what to do. You have a plan, you're going to continue on with your life. And having that strength and feeling powerful can change everything for you. So that's the exposure where you literally go to the place that you're feeling anxious about, whatever that environment might be. Desensitization could be where, if you're with a therapist or even on your own, that you actually imagine in your mind a scary situation and you allow your feelings to get heightened. So you feel that anxiety, maybe even the panic. And you manage the feelings by seeing yourself in your mind coping, What would I be doing? Doing some deep breathing. I can't get into all the specifics because it's a lot, but this would be really helpful if you have a therapist or if you're going to go find somebody and say, Is this something that you can do? Do you specialize in the cognitive behavioral therapy? This is what I'm struggling with. I know these techniques, the exposure, desensitization, those are things to ask for. I want to give you a little direction on what I'm even looking for when I'm looking for some help to deal with this.

Those are some things you can ask for. Again, the severity can vary. There are some people that don't leave their house at all, and then there's some people that there's just certain places they don't go to. I remember hearing a story years ago about the chef, her name is Paula Dean. I don't know if you guys know who she is, but I was shocked when I heard she was agoraphobic for 20 years. I'm like, 20 years? She had kids. So she started her catering business and she'd have them go deliver the food to the people that ordered. And she didn't leave her house until she finally obviously got well. And then she's on TV and she's doing show. She's so bubbly and has this phenomenal personality. You're like, You were stuck in your house for 20 years? It can happen to anybody. It can happen to anybody. So again, and it's not all or nothing, but it starts, I think, small where I'm not going to go there, but then I'm not going to go here and here. All these places I go, now I'm just stuck at home because nowhere safe is what I tell myself.

And again, it's not the environment. The environment, not that it can't trigger you, like, Oh, something bad here happened. Last time I was at the movies, maybe I had a panic attack or I was uncomfortable. That's true. But it's not necessarily because you're at a movie theater. We need to figure out by understanding what are my thoughts at the time? I must be thinking like, I'm not safe, or I can't leave, or I'm stuck, right? Or I'm going to embarrass myself. I'm not going to feel good. These are all the thoughts that we're thinking, right? And those are the hot thoughts, the ones that aren't 100 % true. And then our behavior is like, I'm just not going to go. Why would I put myself through that? Why would you put yourself through that? Because you want to have a full life and you don't want any situation to control you, right? You want to manage your anxiety, not have your anxiety manage you. So that's why it's important to work through these things and know that you're worth it and you deserve it and you can have a very happy, fulfilled life. And this isn't something that you have to drag with you the rest of your life.

You can get past this for sure. So when I said earlier that my answer to my client was a very layered answer, meaning there's so many things to do. So obviously what I'm talking about first, but you also want to address the trauma from the abuse. Why is she scared of him in the first place? Obviously, because what she's been through, we need to address that. If possible, in some situations, and this one's more specific, but obviously looking to file a restraining order, documenting, I've gone here and he shows up, I've gone there and he shows up. I feel like he's stalking me. I feel uncomfortable. So you always want to document, document, document when things are going on in your life. So that's more specific for this situation. There's a lot of great books out there, and obviously my go to is Mind over Mood to help you learn the cognitive behavioral therapy tools. So that's something else to do. I also wanted to practice breathing with her. In that moment, I need to get centered. I need to be calm. If I'm even home thinking about going somewhere, I can get anxious. Just the thought of going.

You want to use your breathing techniques. I know I've shared somewhere along the line that there's lots of great ones. I really like the 4 7 8 breathing where you can go on YouTube and look up 4 7 8 breathing. There's a five minute video that will show you how to walk through that. And so far, my clients actually say that's the one that they feel works best for them, and it works pretty quick. But any breathing technique, meditation, you need to find what helps you calm down, bring your breathing to normal, decreases your anxiety. Whatever that is for you is great. It's not one size fits all by any means. I always talk about there's lots of tools in CBT. You need to find the ones that are going to work for you. There's lots of breathing techniques. You need to find the one that's going to work for you. There's meditation apps out there you can use. There's lots of things. What's going to help you feel calm and secure and in that moment. So if you're out in public and you start to feel this way, I don't want you to just run home because it's just going to perpetuate the situation.

And it just feeds on the belief I can't handle things. I can't cope. I want you to start knowing you can't cope. The fact that this client left this marriage after 20 plus years with everything she went through, which you can only imagine, right? Obviously, this client is very brave, very courageous, and is definitely a survivor, not a victim. And it's important for all of you to see that you're courageous as well. And you're a survivor from whatever is going on in your life. And you're not going to be a victim to this anxiety and just allow this feeling, even though it's real, to take over your life. You deserve more. Whatever you've been through, you definitely deserve more. So you have to remember, and I always tell people with anxiety that people with anxiety tend to poohpoo any accomplishments they've gone through. Oh, yeah, I went through that, but this is the one time I won't be able to handle it. Oh, I went through that, but this time I won't be able to handle it. And you really dismiss all the excellent tools you've learned. You dismiss how courageous you are. You dismiss how well you've handled things in the past.

Instead, I want you to look at your past and look at them as stepping stones. I've done this for myself. And I know, you know what? I used to dismiss. I used to tell people about when my mom left and they'd be like, Oh, my God, you're only eight years old. And I was like, Oh, I was fine. I was busy. I had a good life. Until later on in years, I'm like, What the heck? That was a big deal. I needed to look at that. I need to address it. And by me dismissing it, I never really got to my issues. I needed to say, Yeah, that was a big deal. And what do I need to do for me to heal from that? So don't dismiss. And then when I've gone through things, I look back at that time in my life, or actually, when I mentioned earlier about having cancer because of the review the woman gave me, leave me, I remember being in my hospital bed saying, Okay, Julie, you've gone through all these other things in your life. You can also get through this. And you have your CBT tools. You're going to be okay.

So it's really important you use your past experience as stepping stones. Right? Like, Oh yeah, I remember I went through that. Oh yeah, I handled that. That was really hard. That was really hard. And if you have a hard time acknowledging your accomplishments and the things you've survived and overcome, using a double standard technique is really helpful. So that means that if your friend, if your child, if your partner, someone you care about and you admire, went through those things, would you dismiss that for them? Or would you say, Wow, you're really brave. You've got to through so much, you can handle this. And if that's your answer for them, that's the answer for you. When I ever ask my clients, What would you tell someone else in this situation? They usually answer me in about two seconds, and I always say that's your answer as well. So that's a good tool also. If you have a hard time giving yourself credit for what you've gone through. And if you dismiss things, it's really important to use those again as stepping stones that I got through those things. I can also handle this, get out of my home, get a bigger life, and now let this agoraphobic control everything.

Also, another tool that I would share with my client I have, we've worked on, again, is those safety features for herself. So is it who can go out with me when I'm feeling nervous? What can I do if I am... Say I'm at the movie theater, so I tell this client, many clients that avoid places like that, You're never trapped. You can get up and leave. You can get up and leave in a situation like that. If you're at the grocery store, you can leave your cart and you can walk out the door. If for some reason they're thinking, Oh, I can't leave, or I'm trapped. You're not trapped. I would say if you're with someone to let them know, if I feel overwhelmed or I need to go out and get some fresh air, that's what I need to do. So they're not like, Where are you going? What's going on? It's already talked about. The person you're with, you can feel safe with and they understand. And you guys can talk about how to handle that situation ahead of time, not in it. Do you want that person to encourage you and say, No, come on, let's breathe, let's stay?

What is it that's going to help you? Maybe just say, Just come out with me. Let me get some fresh air. We'll go back in. Whatever you come up with is fine. But think of a plan and how to handle this. And you take it in steps and you move up. In the Understanding Anxiety chapter in Mind over Mood, there's what we call a fear ladder. It's an exercise. Think of a ladder. You're walking up and up until you get to the top. So maybe the top would be to be comfortable wherever I go. That would be the ultimate goal. So we would start at the very bottom of the ladder, walking around your neighborhood, taking a drive. Then I'm going to go to the grocery store, I'm going to go to the bank, I'm going to go to the post office. Whatever these things that I've been avoiding, what's the most comfortable for me next? And then what's the next challenge and what's the next? So we want to walk up that ladder till we get to the top and it feels more manageable and not so overwhelming. Because if you're overwhelmed, you're not going to do it probably.

These are all the tools. So again, it's not just I'm going to tell my client, Well, you just need to go to that place. It's like, Well, no, we got some safety issues here because the X is showing up. A lot of times there aren't safety issues except how you feel safe. So we got a plan and make it manageable. So you're willing to go do that. And then, of course, using your thought record. So your thought record is where you're identifying a situation, what are your moods, and then what are your hot thoughts? All your automatic thoughts, what are you thinking that's caused you to feel so anxious for you to be agoraphobic, for you not to maybe leave your home or avoid places that used to bring you pleasure and you enjoyed, so you can have a full life. Because when you don't work through this, you're allowing the situation to control you. So again, it's understandable. It's not like, Oh, that's weird. I don't know why you feel that way. I totally get my client, I would be anxious as well. I just got out of this horrific abusive relationship, and now I go out, I think he's stalking me and he's showing up in places.

Not talking to me, but I see him over there. That is really upsetting. It really can be scary. But I told my client, You found the courage to leave, which was probably the hardest part of ending this relationship, was actually leaving it. So many people are afraid to leave because the threats partners give and all of those types of things. She found the courage to leave. She can handle going out and seeing him from a distance and creating a safety plan. Again, that safety plan can... This one's about a person, but the safety plan can be what's your safety plan if you start to feel this way so you don't just retreat. We know, research shows that when you go through the anxiety, you get over the anxiety. And they say it takes about 90 seconds to really hit its peak. I know sometimes it can feel way longer than that, but 90 seconds is a long time when you feel like your heart is going to pop out of your chest, or you can't catch your breath. 90 seconds 90 seconds, I understand, is a long time, but you will get through it because you need to be out and have experiences so you can say, Oh, okay, that was uncomfortable, but I got through it.

I knew what to do. I had a plan on what I was going to do if I got overwhelmed or if I didn't feel safe. I had a plan. And then you start to believe in yourself again, and you start to see how brave you are and how courageous, and that you deserve to have a full, happy life and not to let anything or any person or any situation control and dictate how you live. So again, agoraphobia is another type of anxiety. It makes sense when we talk about, Oh, this happened here. This happened here. This happened here. I'm not going to go to these places. I can see how it happens. But it's not a way to live your life, obviously. And it's allowing something else to control your life. So if this is something you're going through, if you know somebody, please share this podcast with them. It's a real thing. It's out there. I know people need help. Even going out to the therapist, right? I don't want to leave my house. So there is telehealth, but I would really encourage any client, and I felt grateful this client came to me, just coming to me is going somewhere, right?

And being in a safe environment, and letting... I showed her where the exit is in my office. She wasn't trapped with me either. It's important for all of us. We might not think about it if we're not going through this. But it's important for all of us to know that if I need to leave a situation, I can get up and go. That's empowering. That gives me peace. That makes me feel calm. I know where to go if I need to leave. I think it's something that's just there for most of us. We don't think about it because we're not scared about where we're at. But in reality, that's something that we all have on our mind. I think it's more unconscious, like, I'm going here because I feel comfortable. I know if I have to leave, I can get up and go. It's just there. I share with my clients with anxiety that I don't wake up in the morning and say, Oh, my God. What's going to happen? How am I going to handle it? Subconsciously, I believe in myself that whatever comes my way, I will handle. So I'm not worried about what's going to happen.

Somebody with anxiety wakes up and says, What's going to happen today, and will I be able to handle it? So you already put your brain in fear mode, anxious mode, like, Maybe I can't cope. Instead of just getting up and starting your day and doing what you're planning to do that day or what you want to do. So that's where it's so subtle sometimes, but we really have to be mindful about what we're thinking and how that feeds into our anxiety. So I hope this was helpful. Again, it's many things that my clients working on. It's many things that you can work on. I don't want anyone listening to this podcast going, Oh, my God. I have to just, like I said, jump in the deep end. No, we're taking baby steps. What's the first thing that you can do? What's the first thing you're willing to do for yourself? And who's your safe circle? Who's the people in your life you can reach out to so you don't have to feel alone and willing to go with you wherever you want to go to to feel safe. And then eventually you'll be on your own and you will have the life that you want and you'll have the life that you used to have.

And you will feel powerful and you'll see how important you are and reminding yourself that you deserve to have a full life. So thanks for being with me.

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