Tales from the therapist's couch: Fear and loathing ? and how to overcome it

A man phones his wife in distress. She hurries home to find him huddled in a chair, shrunk in terror. He jabbers an explanation. A large spider crawled from the cupboard as he went to change clothes. A woman stands by the window.Her body is tense, her breathing shallow. She is visibly shaking as she makes herself leave the house.

A man phones his wife in distress. She hurries home to find him huddled in a chair, shrunk in terror. He jabbers an explanation. A large spider crawled from the cupboard as he went to change clothes. A woman stands by the window.Her body is tense, her breathing shallow. She is visibly shaking as she makes herself leave the house.

Phobias. Most of us know someone with some degree of phobic reaction. Flying, heights, mice, spiders, dogs, bats, enclosed spaces, open spaces, social situations, public speaking, the dark: these are the most common triggers.

For most people, the fear is manageable and can be avoided. Unlike other symptoms that reveal a gap between what the mind wants and how the body behaves, people with mild phobic reactions don't tend to feel any personal responsibility or social shame.

Not everyone is so lucky. For the agoraphobic woman, her phobia came to thwart her life. She lost her job, her marriage fell apart, and her daily, lonely terror was soon accompanied by a severe depression.

There is little theoretical agreement over the origins of phobic terrors. The biological school of thought argues that phobias are leftovers from our evolutionary past: we have inherited the instinctive knowledge to be wary of animals or fear the dark. Another explanation is the trauma theory: a phobia can be tracked down to a specific fright.

I've never been convinced by either theory alone. It is rare that a phobia can be tracked to a specific personal happening, and the genetic approach leaves so many fears unexplained (how does it make evolutionary sense to be terrified of feathers?) Psychoanalytic theory, which looks at how fear is absorbed from the world around us, offers a more convincing explanation.

Working with people troubled by phobic reactions, there is frequently an underlying fear of losing control running through their lives. Many describe how, from an early age, they have avoided situations that make them anxious. Many reel off a litany of phobias that have shape-changed as they grew older. It is as if the phobic object or situation becomes a habitat for all the unnamed feelings of fear. As Freud put it: "phobias have the character of a projection in that they replace an internal, instinctual danger by an external perceptual one."

Freud concentrated on the patient's personal history to track down the origins of fear and avoidance. More recently, psychotherapeutic research has been casting the net into the wider culture. For example, recent studies have persuasively shown the effect that war trauma can have not only upon the victims themselves, but their children and their children's children.

So what is the best way of tackling a phobia? There can be a tug-of-war between different theories – an enormous shame as different approaches can complement each other. Analytic work can help uncover and name unconsciously learned patterns of fear, while cognitive and behavioural techniques can offer practical guidance on confronting and overcoming terror.

Ultimately, recovery involves learning how to trust both ourselves and the world around us, and to endure in our lives what cannot always be controlled.

Elizabeth Meakins is a psychoanalytic psychotherapist in private practice. None of the clinical material above refers to individual cases.