Hypnotherapy for public toilet anxiety

I can never speak for all hypnotherapists, but I can tell you what I would do with hypnotherapy for public toilet anxiety. Usually, the first thing will be to take a case history. A case history is where I find out about you and your problem. What it primarily does is tell the me what approaches are going to suit you best.

Assessing the causes of public toilet anxiety.

From the case history I will look for both the cause of the public toilet anxiety and the factors which maintain it. Typically, a public toilet anxiety is based on one of three things:

1. Social anxiety.
2. Contamination anxiety.
3. Traumatic experience.

Having identified the primary cause, I will decide if that needs to be treated first or if I can move directly to symptom change. If I need to work with the initial cause I can help with approaches like EMDR, systematic desensitisation, parts therapy or a combination of these. This could be sufficient to solve the issue, but more likely some work changing the habitual and behavioural elements of the problem will be required.

Changing habits and behaviours.

Whatever the cause, public toilet anxiety tends to be associated with certain habits of thought and behaviour. Typically, these include:

• Anticipation of negative outcomes from using a public toilet. – This can be anything from being criticised for the sound or smell of bowel movements to experiencing violence. A therapist would look to change such thoughts, by processing old thoughts and introducing new ones.
• Lack of privacy. – Both bowel and balder are tremendously private organs and the awareness of being in public can inhibit their actions. Through a combination of suggestion, visualization and relaxation a hypnotherapist would look to decrease self-consciousness and help relax them into the toilet.

If you would like to begin addressing your public toilet anxiety please get in touch to book a free consultation.

The author

Dr Matt is a hypnotherapist who decades of experience who has a specialism in functional disorders and anxiety issues. He is a member of the BSCH and NCH

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• 14% of participants showed public toilets avoiding behaviours.
• Toilet avoidance was more common amongst women than men.

People who experience public toilet anxiety tend to avoid using public lavatories where possible. They may also adopt specific coping behaviours such as:

• Picking times to visit the toilet to avoid busy periods.
• Holding off bladder or bowel movements to an uncomfortable level.
• Cleaning public toilets with antibacterial wipes.
• Avoiding going to social events or being in public.
• Not travelling.

So why do people develop this phobia?

What causes public toilet phobia?

There are several potential causes and reasons why someone would develop a public toilet anxiety. These include:

• Lack of perceived privacy – Going to the toilet is an instinctually private activity for most people. There’s a reason we call it the privy and sometimes use disguising terms for it like ‘the smallest room’. As we appear to be naturally embarrassed by these intimate bodily functions it is no surprise that sometimes doing them in shared environments become an anxiety problem.
• Abuse experience – A lot of bad things happen to people in public toilets. School toilets are often a place where bullying and other abuse is carried out because there is no adult oversite. This is less common in adulthood and yet people still do have bad experiences in public toilets.
• Traumatic experiences – Loss of bowel, bladder control, excessively pungent movements or any number of upsets which may draw unwanted attention can be traumatising when in a public toilet.
• Contamination phobia – Many people are sensitive to potentially dirty environments and the contaminants and germs they may contain. Few environments are as wildly unpredictable in their cleanliness as public toilets, and sometimes they can be traumatically bad. As a result of this many people with only a mild tendency towards contamination phobia find they develop a toilet phobia. Knowles ( 2023) study found that 21% of avoidance was explained by contamination issues.
• Claustrophobia – public toilets are often poorly lit, poorly ventilated tight little spaces. This can trigger anxiety in people who are prone to claustrophobia and ultimately a wider fear of these spaces.

Can it be treated?

Very little research has been done into treating this condition. However, my experience as a therapist is that generally people who suffer from it make substantial improvements. For more on this topic read my blog – hypnotherapy for public toilet anxiety

The author

Dr Matt Krouwel PhD is a hypnotherapist based in Birmingham (UK) who specialises in treating anxiety and functional disorders. He is a member of both the NCH and BSCH.

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References

Knowles, S. R. (2023). Socio-cognitive processes are associated with parcopresis symptoms and public toilet avoidance in university students. Current Psychology, 42(3), 1762-1772.

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Very little research done into therapy for Shy bladder syndrome. However, a study of 101 people with shy bladder who underwent a weekend course of exposure therapy. These people were found to have significant benefits when followed up a year later (Soifer, Himle & Walsh, 2010).Personally I’ve found that most patients respond well to therapy. So what might I do to help?

Therapy approaches for pee shy / Shy bladder syndrome?

There are a few technique which I’d consider for Shy bladder syndrome. I would  take a case history from the patient and based upon this make some decisions as to what techniques to use. Sometimes a patient identifies a starting point to the problem or identifies that their internal voice is pressuring them. In these cases I consider what are called psychodynamic approaches.

Psychodynamic approaches in hypnotherapy for shy bladder syndrome

These are approach to resolve an internal conflict or address an unhelpful early life learning. This type of work could include such techniques as:

• Inner child work.
• Parts therapy.
• Regression to childhood.
• Eye movement desensitisation and reprocessing (EMDR).

Sometimes the original cause of the problem is no longer relevant, but the behaviour has become habit. When this is the case, a therapist can move to techniques which help to retrain the mind and body.

Therapy for direct change to habitual behaviours for pee shy patients

Such techniques may include:

• Systematic desensitisation – this is an approach in which the patient is mentally walked through going to pee in a public place whilst the therapist induces deep physical relaxation. In effect this retrains the body to be relaxed in a previously tense situation. This is similar to the graduated exposure therapy used by Soifer, Himle & Walsh, 2010 in their research, but many consider systematic desensitisation superior as it actively looks to retrain the body to be relaxed.
• Relaxation cues – A hypnotherapist may give suggestions to be relaxed as soon as you get in to position to wee.
• Flow visualisations – there are various visualisations which a hypnotherapist may use or teach. Typical examples may include such things as mentally seeing the urine flowing comfortably. A visualisation may be more abstract such as picturing the flow of a gentle mountain waterfall as its flows downhill.
• Amnesia suggestions – Light amnesia may be given for peeing so that you forget that you are in public or that there are people around you. These will be carefully crafted to fit the specific circumstances which affect you.
• Privacy visualisations – The therapist will come up with imagery specific to you which will allow you to feel more private when in public toilets.

Homework for Pee shy clients

Homework is likely to be a large part of therapy. Typically, homework would be negotiated with the patient. Mostly homework would involve:

• Practicing relaxation and self-hypnosis techniques.
• Using public toilets.

I hope this guide has helped you to understand what sort of things you may encounter if you presented to a therapist for hypnotherapy for shy bladder syndrome. To find out more or book in a free consultation please contact Dr Matt.

The author

Dr Matt is a hypnotherapist based in Birmingham (UK) with a specialism in functional disorders. He is a member of both the NCH and BSCH.

References

Soifer, S., Himle, J., & Walsh, K. (2010). Paruresis (shy bladder syndrome): a cognitive-behavioral treatment approach. Social Work in Health Care, 49(5), 494-507.

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• A specific form of public toilet anxiety.
• More common in men than women.
• Frequently accompanied by another anxiety issue.

How many people have shy bladder syndrome remains unclear. However, some studies have found that severe pee shy effected as many as one-in-seven of the people they asked. What is known is that it can impact people’s quality of life and even their physical health.

Negative effects of pee shy / Shy bladder syndrome

There are many ways in which people’s lives are affected by living with pee shy / Shy bladder syndrome.

Adopting coping strategies

The most common coping strategies include:

• Finding quiet or secluded toilets where the chances of being alone are higher.
• Using public toilets at quiet times.
• Men will often avoid urinals and use cubicles to gain a sense of privacy.
• Reducing intake of liquids so that don’t need to go so frequently.
• Avoiding unfamiliar environments where other coping strategies may not work due to lack of familiarity of the expectation to drink (pubs and cafes).
• Holding off on urination until they are very full to minimise the number of toilet visits and have the benefit of biological pressure to overcome shyness.

The major drawback for most people living with pee shy / Shy bladder syndrome is that they find themselves thinking about it all the time. This prevents them from relaxing into situations and enjoying themselves. Many people will experience emotional consequences, such as:

• Shame / embarrassment.
• anxiety / panic.

Further, Pee shy / Shy bladder may limit access to social situations due to concerns about being unable to use toilets facilities in unfamiliar locations. This can lead to a reduction in:

• Socializing and dating.
• Work opportunities.

Leading to social isolation, which can cause or worsen issues with anxiety and depression. Although relatively uncommon, over the long-term biological consequences can occur, such as:

• Urinary tract infections (UTI) – These can result from urine sitting for too long in the bladder thus allowing bacteria to grow, or persisitent dehydration due to drinking too little.
• Bladder damage – This can result from excessive holding of urine in the bladder over a prolonger period.
• Kidney problems – Resulting from prolonged dehydration.

What can be done about it?

Pee shy / Shy bladder syndrome are under researched areas of therapy. However, early research is with CBT by Soifer Himle and Walsh looks positive, and my own experience as a therapist has been very positive.

For more on this topic see hypnotherapy and pee shy / shy bladder syndrome.

The author

Dr Matt Krouwel PhD is a hypnotherapist from Birmingham (UK) who specialises in functional and anxiety disorders. he is a member of both the BSCH and the NCH.

Key sources

Hutchings, H. A., & Kehinde, A. (2024). Exploring paruresis (‘shy bladder syndrome’) and factors that may contribute to it: a cross-sectional UK survey study. BMJ open, 14(11), e086097.

Soifer, S., Himle, J., & Walsh, K. (2010). Paruresis (shy bladder syndrome): a cognitive-behavioral treatment approach. Social Work in Health Care, 49(5), 494-507.

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• How important is an initial trauma?
• How much is learnt thinking?
• How much is the anxiety a habit?

How important is the initial trauma?

Whilst choking you may fear for their life. This can set up a trauma which then causes you to become tense whenever eating. Overtime, the repeated anxiety caused by the trauma sets up a pattern of behaviours which maintain the choking anxiety: The question is how much is the trauma is still active, or is the problem now one of belief and habit?

Treating an active trauma.

An active trauma will be can be addressed in a number of ways:

• Eye movement desensitisation and reprocessing (EMDR). – This is a well-established trauma protocol with a strong evidence base.
• Regression – In this context, regression is the act of mentally going back into your personal history to the trauma. You then reexperience it with the perspective of the survivor. Reexperiencing something which felt awful at the time but that you now know you survived can allow you to emotionally reappraise it.
• Various dissociative approaches – There are a number of approaches which allow a person to approach an emotionally powerful event whilst disengaged from it. These allow them to experience the memory at a level of emotion which allows for healthy processing.

Trauma work is challenging as such the therapist will do foundational work . Foundational work ensures that the patient is in the best position they can be.

Learnt thinking and beliefs in choking anxiety

Our beliefs about things shape our world; if you believe you are going to choke on a piece of food you will find evidence to support this belief. With choking anxiety this commonly happens in a couple of ways:

• We become hyperaware of evidence for choking. This can be food in our throat taking time to go down, but not actually doing any harm.  Or we may become aware of cases of people choking in the media.
• Our anxiety causes the throat to constrict making swallowing harder. Anxiety can also make us take control of swallowing, turning something automatic (unconscious) into a deliberate action (conscious) which makes it clumsy, causing further catching of food.

Learnt thinking is almost always present at some level with choking anxiety. Usually, these beliefs immediately to eating and might be something like:

• “I could choke on this!”
• “One tough bit could choke me to death!”
• “What if its too big a mouthful; it could choke me!”
• “If I eat when I’m alone there is no one there to save me if I choke.”

The question for the therapists is how much to focus on belief change when using hypnotherapy for choking anxiety. but generally they will do some work on it.

Approaches for belief change in choking anxiety.

There are many ways in which a hypnotherapist may work for belief change, these include:

• Direct suggestions for a new focus. – Focusing the patient on an appropriate level of chewing, how much they enjoy food. These thoughts can then take up the space once occupied by the unhelpful beliefs.
• Amnesia suggestions – These can be used for the unhelpful beliefs or actions and will often be combined with the suggestions for a new focus.
• Belief change visualisations – There are various visualisations which can be used to help change or rewrite beliefs. An example is imagining writing the belief on a whiteboard  and rubbing sections out and writing in new words and phrases.
• Eye movement desensitisation and reprocessing (EMDR) – is a helpful technique for processing strong beliefs.

Habitual choking anxiety

The choking anxiety may have started as a trauma, but by the time use processed the trauma habits have been established. This is usually connected to the development of learnt beliefs (see above) but may present as entirely automatic. Often, the person automatically tenses up in relation to food and in so doing constricts their pharynx and oesophagus / Esophagus making swallowing harder.

Hypnotherapy approaches for habit change with choking anxiety

When using hypnotherapy for choking anxiety the therapist is likely to use any number of strategies, most of which promote relaxation to counter the tension:

• Systematic desensitisation – The therapist guides the patient through a series of food situations whilst helping them to relax.
• Relaxation suggestions – These can be used to promote a counter response.
• Eye movement desensitisation and reprocessing (EMDR). – This can sometimes be used to process bodily responses.
• Anchoring techniques – A hypnotherapist using various approaches can establish a conditioned response for relaxation. This can be used by the patient to relax themselves whenever they are engaged with eating.
• Various visualisations – There are many different visualisations which can be used to encourage the relaxation and dilation of the throat.

Hopefully this blog has given you an idea of how a hypnotherapist might approach helping someone with a Choking anxiety.

The author

Dr Matt Krouwel PhD is a hypnotherapist who works in Birmingham (UK) and has memberships of both the NCH and BSCH. He has extensive professional experience with functional disorders of all kinds, especially those relating to eating, such as; IBS,  Emetophobia, ARFID and Choking anxiety.

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Systematic desensitisation – Key features and terms

Trigger.

In this context, a trigger is anything which initiates an emotional or state change. The trigger could be;

• External, like seeing or hearing something,
• Internal, such as imagining or remembering something.

The change induced by the trigger is perceived as swift and automatic.

Relaxation.

In systematic desensitisation relaxation is a deliberately created state. It is common for a therapist to teach relaxing exercises or use a guided relaxation technique to produce relaxation. This kind of relaxation allows the patient to retain a sense of  control and personal agency.

Reciprocal inhibition.

Reciprocal inhibition is the idea that a person can only really experience a single emotional/physical state at one time. This means that if you are anxious you will experience things as anxious. eventually you will come to associate everything experienced with anxiety. Conversely, if you experience something in a relaxed state you will begin to associate that with being  relaxed. So, if relaxation is induced by a therapist and then the anxiety inducing trigger experienced, a new relaxed response will be learnt. This new response will override (inhibit) the previous one.

Graded exposure.

Also called graduated exposure, graded exposure is a process of gentle exposure to trigger stimuli. The triggers are organised in a progressively more challenging way. Normally to achieve this a hierarchy of disturbance is created which is then worked through.

Hierarchy of disturbance.

This is a list of all the elements of a trigger which a person can identify. These are organised from leash difficult to most challenging. An example for a spider phobic might look like this;

1. Knowing there is a small spider in an adjacent room. (least difficult for this hypothetical patient).
2. Seeing a small spider on the far wall (staying still).
3. Seeing a small spider on the far wall (moving slowly).
4. Seeing a medium sized spider on the far wall (staying still).
5. Seeing a medium sized spider on the far wall (moving slowly).
6. Seeing a large spider on the far  wall (staying still).
7. Seeing a large spider on the far wall (moving slowly).
8. A large spider on the floor about 1.5 metres away (staying still).
9. A large spider on the floor about 1.5 metres away (moving slowly).
10. A large spider on the floor about 1 metre away (moving slowly).
11. A large spider on the floor about half a metre away (moving slowly).
12. Touching a spider whilst wearing a thick gardening glove.
13. Touching a spider whilst wearing a plastic glove.
14. Touching a spider. (Most challenging for this hypothetical patient) .

The job of the therapist is then to help create a list of situations of progressively more intense triggers to be worked through.

In life / In the imagination.

The exposure to triggers which is required for systematic desensitisation to work can be done in two ways;

• In real life with the trigger stimulant being either; present in the therapist office or by going out into the world to encounter it.
• In the imagination of the patient.

Both methods have their strengths and limitations. Desensitization in real life is almost certainly the best way but the resources to do it are expensive, time consuming, often specific and difficult to manage. The imagination by contrast is usually very good at conjuring up the required resources but at some point this will have to be consolidated into real life with some real world practice.

Systematic desensitization – uses and limitations.

Systematic desensitization is frequently used by therapists for anxiety responses where the trigger is specific and the reaction is disproportionate to the level of threat. A typical example of this would be a phobia or anxiety induced response like psychological erectile dysfunction or vaginisimus  like . However, frequently the anxiety trigger will have a reason to have come into existence, which may limit progress with systematic desensitization alone. Typical reasons for this are;

• The fear is secondary to another fear. For example a fear of insects can sometimes be a fear of contamination or a fear of heights will often be the result of having the wooziness caused by  vertigo.
• The fear is related to post traumatic stress disorder (PTSD). At some point a powerful experience resulted in an anxiety, it may be that the originating experience needs to be treated before the anxiety can be desensitised.
• Neurological sensitivity to the trigger. Not every bodies sensory experience is the same, substantial numbers of people have a visual or auditory sensitivity which results in apparently normal situations being uncomfortable. Over time the effect of this, combined with other people’s lack of awareness or comprehension of the problem, result in a build-up of tension around it. Overall this means that at best systematic desensitisation will help deal with the build up of tension.

The Author

Dr Matt Krouwel PhD is a hypnotherapist in Birmingham (UK) with over 25 years experience of working with anxieties, panic and related disorders. He is a a member of the BSCH and NCH.

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What is Choking anxiety?

Choking anxiety is the experience of fear when eating and when approaching meals, that you will choke. Clinically choking anxiety is classified as a specific presentation of ARFID. Many people with this fear find themselves behaving in unusual ways, such as:

• Restricting foods to those perceived as easily swallowable.
• Excessive time spent cutting up food into swallowable pieces.
• Extreme chewing.
• Unusual amounts of time spent thinking about and planning food intake.
• Avoiding social eating situations due to the risk of being criticised as a picky eater or because you cannot plan what you eat.
• An overall reduction in food intake, possibly resulting in unwanted weight loss.

So how does someone develop a choking anxiety?

How does choking anxiety develop?

There are several common ways in which a person develops choking anxiety.

Single event traumatic learning.

A person has a choking experience in which they are scared for their life. This may mean that they feel that they nearly died or that they feel that their life has been changed forever. For many people it is a single occasion when a piece of food gets stuck in their throat and they are unable to swallow and breathing was restricted. Sometimes a piece of food gets lodged in such a way that they can still breath, but it restricts eating and leaves them in discomfort for an extended period. This latter example gives time to worry that they may be slowly dying (starving or dehydrating) or that all eating will now be uncomfortable.

Multiple event traumatic learning.

A person experiences several choking events in relatively quick succession. This embeds the fear caused by the initial choking event and convinces them that they are at risk of choking. Commonly choking  will have occurred due to a temporary medical issue, or because they are anxious already due to the first event. However, a choking event can reactivate the memory of a bad experience from years before.

Build up of anxiety due to multiple mild events.

A person may experience food catching in their throat, but not full choking, which draws their attention to the possibility of choking and overtime the concern about this grows into a pattern of anxiety.

Anticipated anxiety

With stressed people or high anxiety personalities the knowledge that you can choke may be sufficient to develop this anxiety without substantial experience of choking. For most people who experience this it will pass on as they focus on something else or general stress reduces. However, should they begin to experience food catching in their throat, often as a result of the concern itself interfering with normal swallowing, choking anxiety can develop.

Choking anxiety, what can be done about it?

A therapist is likely to assess the patient for;

• Initial trauma – how much of an ongoing problem this is?
• Beliefs – are they holding unrealistic beliefs about choking?
• Habit – How much are they automatically tensing and questioning both their swallow action. This can occur both at the point of swallowing and in anticipation of swallowing?

They will then put a programme of therapy together to address the elements, typically using techniques like;

• Graded exposure OR Systematic desensitisation.
• Cognitive re-evaluation of and reconstruction of beliefs around swallowing.
• Trauma treatment protocols like EMDR.

For more on Hypnotherapy for choking anxiety click here!

The author

Dr Matt Krouwel PhD is a hypnotherapist who works in Birmingham (UK). He has over 25 years experience as a frontline hypnotherapist and is a member of both the BSCH and the NCH.

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At first panic attacks tend to be triggered by external stimuli, such as an encounter with a phobic trigger, a trauma, or news of a bereavement. But it could be triggered by something almost imperceptible if the person has been in a heightened state of tension for a long time. Typically a panic attack is the pinnacle of an ever more rapidly escalating series of tensions.

The development of a panic attack

There are a number of common elements to the development of panic. Not all may be present in an individuals experience of panic, but several usually will;

1. Long term buildup

The person who has a panic attack has usually been in an elevated psychological and/or physical state for some time. This could be as simple as they have been working hard, or they have not been processing their emotions as they go through life, or any force which allows stress to build.

2. Trigger

Something causes them to experience a strong physical reaction. This could be;

• An emotion; fear, anger, or loss, whatever it is it will initiate the release of the hormone adrenalin.
• A stimulant such as caffeine, nicotine or pseudoephedrine, as well as the illegal stimulants, all of which simulate adrenaline release to some degree.
• An attack on the body from a virus or allergen.

As a result they experience;

• Increase heart rate,
• Blood pressure,
• Elevated respiration,
• Elevated body temperature.
• and the muscles and brain may become flood oxygen.

3. Escalation into a panic attack

The person notices the heightened state of their body and begins to worry, typically because it is more elevated than they think it should be. A typical first panic attack follows this trajectory:

1. Worry releases adrenaline, which maintains or increases the heighten state.
2. This in turn keeps the person worried, as their body is not returning to normal.
3. This results in the release of more adrenaline, which maintains the fear, releasing more adrenalin, and so it goes.
4. Eventually the fear of what is going on in their body results in them consulting health care services, who identify it as a panic attack, and thus reassured most people calm down.

At the end of this most people are calm. However, this does not mean for everyone that everything is fine, often there will be a lingering concern that something is wrong, which is one of the main reasons that panic disorders develop.

Thinking about therapy for panic?

The author  – Dr Matt Krouwel PhD is a hypnotherapist based in Birmingham (UK) with over 25 years experience. He is a member of both the NCH and BSCH

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Phobias are often described as irrational. However, as the fears they represent are often founded in deep evolutionary learning, many prefer to describe them as ‘disproportionate fears’, ‘over generalised fears’ or ‘out of place fears’.

Characteristics of phobia

There are several characteristics common to a phobia;

• Disproportionate fear. The fear experienced is notably more than the trigger (object, creature, situation or activity) justifies. The spider which sends you fleeing the bathroom is probably harmless*¹.
• Persisitent. The disproportionate fear of the object / creature/ situation etc has been present in your life for some time (six months or more). Some phobias have a seasonal element, such as those with arachnophobia experiencing an upswing in anxiety due to the tendency for spiders to enter the house and move around more in September and October*¹, but the fear of spiders itself does not change, just the number of encounters.
• Avoidance. The person with the phobia will avoid wherever possible the object / creature/ etc. This avoidance may result in substantial disruption or cost. Avoidance behaviours indicate anticipatory anxiety is present and are what make phobia an anxiety condition.
• Emotional and Physical response. The person with the phobia experiences physical symptoms consistent with the ‘Fight-flight’ reaction such as raised heart rate, fast breath, and possible dizziness. Some people with phobias experience secondary psychological symptoms like panic attack triggered by the physical symptoms.

Causes of phobia.

The causes of phobias are various and hotly debated, frequently more than one of the below elements will have been present in a phobias development;

Learned phobic response.

it is theorised that phobias can be learned in one of four ways;

1. Conditioned response.In this the phobia has been learnt by repeated startle responses in proximity to the stimuli. The traditional example of this is the ‘little Albert’ experiments in which a child (Albert) was exposed to a white rat, which he was initially fine with, until it was paired with the bashing of a very loud gong until the startle from the gong developed into phobic reaction to the rat.
2. Modelled by a family member. When a family member, especially parent,  has a phobia or even legitimate concern about a stimuli it is natural that you learn that response from them. A wasp phobic may have seen their mother, who had a known potentially lethal allergy to wasps, panic when wasps were around and as such learnt to act the same when wasps were around.
3. Taught by wider culture or media. We are impressionable and sensitive when young and being exposed to sensational accounts of the dangers of certain situations, especially when accompanied by pictures or film. Films like ‘jaws’ are responsible for many shark phobias.
4. Trauma.  A single traumatising event can set up associated phobias, this can be from PTSD or the more common traumatic learnings, which don’t always meet the criteria of PTSD. An example of the latter might be; being laughed at by classmates at school due to an inadequate or inappropriate answer to a question, resulting in nervousness about answering questions which eventually generalises (see below) to speaking in public.

Other contributary factors to phobia development

There are a few factors which may well contribute to the development of a phobia, but are unlikely to fully explain it;

Lack of positive exposure to stimuli and cultural acclimatization.

Lots of people simply don’t grow up in environments where they get used to certain animals, or situations. As such, they are always a little intimidated by these things which leaves them open to developing phobias of them. In theory the family with dogs is much less likely to have a child who grows up with a phobia of dog.

 Biological and evolutionary sensitivity.

Some people are more sensitive than others.

• This can be general; they are taking in more information from their environment than others and thus the causes mentioned above happen faster and deeper.
• Sensitivity can also be more specific and possibly have an evolutionary basis. Children appear to have a recognition of animals from a very early age and it has been theorised that this is an evolutionary response to help them avoid dangers, such as venomous spiders and snakes. Some people may have more of this capacity than others and thus retain the sensitivity, making them especially prone to developing phobia to that particular stimuli.

Generalisation and ‘What if?’ thinking.

This is part of the development of a phobia. The process of generalisation is where an initial fear stimuli begins to be associated with similar things which then become stimuli themselves. The example of ‘little Albert’ (see conditioned response above) is once more the traditional example here. Once Albert had developed a phobia of the white rat it began to generalise to a number of furry objects.

The ‘What if?’ question is a cognitive vehicle for generalisation. In this the person asks themselves a  ‘What if?’ question in relation to their phobia. To give an example a wasp phobic may ask themselves ‘what if there are wasps in the park’, and now they have anxiety about going to the park, this can repeat as for numerous situations

Types of phobia

There are a number of ways in which phobias tend to present and be classified, here are two of the most common;

1. Specific. The phobia is limited to a specific object/creature/ situation and doesn’t generalise much beyond that. Animal phobias are very common examples of specific phobias.
2. Social. The fear of negative assessment by people may present as an inability to give presentation, to talk in groups or to strangers, or just being in crowded places.

Hypnotherapy for Phobia

If you would like to book a free consultation with Dr Matt for an in-person or online therapy for a phobia, please contact me on 0778 909 7741 or email mattkrouwel@gmail.com

footnotes

*¹ I’m assuming you are reading this in Britain.

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The ABC model of Cognitive Behavioural Therapy (CBT)

The ABC model is used to understand how thoughts, feelings, and behaviours are interconnected. It helps individuals identify and change negative patterns by examining these components.

Here’s a breakdown:

• A (Activating event): The activating event or trigger is what initiates the chain. This is commonly an external event but can also be a thought (such as suicidal thoughts) or a feeling.
• B (Beliefs): The thoughts or beliefs about the event. This is how we interpret the A (Activating event). We may be aware of these at the time (Thoughts) or they may be deeper ingrained and automatic (beliefs).
• C (Consequence): The emotional or behavioural response resulting from the beliefs about the event.

I describe the relationship between these elements mathematically;

A x B = C

To give an example; Bob has to give a presentation at work (A), Bob believes his colleagues will negatively judge him (B). which makes him very nervous (C).

If Bob held a different belief (B) about the presentation (A), such as ‘I’m great at presentations and everyone is going to think I’m amazing’, he is more likely to feel excitement (C).

By identifying and analysing the beliefs (B) that link the event (A) to the emotional or behavioural consequences (C), individuals can work to challenge and modify unhelpful beliefs, leading to healthier emotional responses and behaviours. However, changing a belief (B) is rarely as simple as just telling yourself a different story, you have to believe in that new belief, so how do we create this change?

Cognitive Behavioural Therapy (CBT) changing beliefs through actions

Unfortunately,  a lot of thoughts and beliefs appear to happen automatically and simply trying to think differently can seem naïve to people who have been attempting to do that most of their life. As such, CBT has adopted and developed a number of tools and approaches to aid in this change.

Realistic new belief

Most unhelpful beliefs don’t come from nowhere, if we find something difficult its often because, for us at least, it is hard, but probably not as hard as we believe. To put it another way, Bob, from the earlier example, probably isn’t one of life’s natural presenters and if he just believes he’s brilliant at presenting he probably won’t suddenly become brilliant. However, probably can, when calm, present to a sufficient degree. So we formulate the belief accordingly, ‘I don’t enjoy presenting, but I can do it, and it’s generally fine’.

Alternatively, we might emphasis coping and survival as part of the new belief formulation. This is based on the idea that we often tell ourselves that something is terrible or a disaster, when in fact the consequences fall a long way short of this. In this instance Bob’s proposed new belief might be, “I prefer to give good presentations, and when I don’t it is disappointing, but it’s not the end of the world and I can cope with not always being perfect”.

The emphasis is upon making the belief realistic, which makes it easier to accept.

Another way to address this is to take practical measures which raise your ability, so Bob might learn more about how to give a good presentation. By learning this his ability to accept that the presentation will be good increases.

Behavioural experiments

It can be hard to change an automatic reaction, but less hard to deliberately enter a situation with a pre-planned belief that you are rehearsing as you enter that situation. By doing this the person disrupts the old belief, giving the new one some chance to embed. Simultaneously, they are learning that the consequence is not what they believed it would be. By repeating this multiple times they may embed the new belief and become more comfortable in those situations.

The aforementioned Bob could volunteer for presentations and in gently reminding himself of his new belief would find overtime that the new realistic belief is indeed true.

Systematic desensitization

Systematic desensitisation is a process in which a patient is moved through a progressively more challenging series of anxiety provoking situations (A’s) whilst in a relaxed state. The move into a relaxed state fundamentally alters the patients experience of the situation allowing them to lay down new beliefs in relation to the trigger (A).

Bob, could be guided into a physically relaxed state and then be taken through the build up to the presentation, and the presentation itself, in his imagination whilst relaxed. At each stage the guiding therapist would endeavor to help Bob obtain a state of relaxation and calm before moving onto the next stage. Subsequently, Bob may be taught to relax himself so that he can enter a relaxed state more effectively himself and reinforce this as he approaches and gives the presentation.

These are mainstream CBT approaches, but how does hypnotherapy help?

Cognitive Behavioural Therapy (CBT) and hypnotherapy

So how do hypnotherapy and CBT interact? There are a number of ways

• Hypnotic relaxation and questioning can make identifying the and problematic beliefs more easily.
• Hypnosis can be used to help integrate new beliefs. Traditional hypnosis can be used to give direct suggestions for the agreed new beliefs. EMDR can be particularly useful at helping with this change.
• Enabling deeper relaxation to aid with processes like systematic desensitisation

What is Cognitive Behavioural Therapy (CBT) helpful with?

In theory CBT can help with any psychological problem, or physical problem with psychological impact. Specifically, CBT is most well researched for anxiety(1), depression(2), PTSD(3) substance abuse(4) anorexia nervosa (5) and coping with cancer(6).  However, there are a wealth of other problems for which it has been successfully applied and has probably the most substantial body of evidence for its effectiveness of any psychotherapeutic intervention.

Cognitive Behavioural Therapy (CBT)

Hopefully this brief overview has helped you get an understanding of what Cognitive Behavioural Therapy (CBT) is and how it could be of use.

A note of caution and final thought

Despite the mass of evidence for its beneficial effects this does not mean that it works equally well for everyone with every condition. Further, the enthusiasm with which CBT has been deployed in health services around the world, often in short interventions, may mean that many people have encountered it do so in less favorable circumstances, leaving them with a poor perception of it. CBT is a therapeutic tool which fits well into the kit of a generalist, but as with any tool it is not right for ever job and an integrative therapist will use it as and when it appears appropriate.

References

1. Bhattacharya S, Goicoechea C, Heshmati S, Carpenter JK, Hofmann SG. Efficacy of cognitive behavioral therapy for anxiety-related disorders: A meta-analysis of recent literature. Current psychiatry reports. 2023;25(1):19-30.
2. Werson AD, Meiser-Stedman R, Laidlaw K. A meta-analysis of CBT efficacy for depression comparing adults and older adults. Journal of affective disorders. 2022;319:189-201.
3. Zainal NH, Soh CP, Van Doren N, Benjet C. Do the effects of internet-delivered cognitive-behavioral therapy (i-CBT) last after a year and beyond? A meta-analysis of 154 randomized controlled trials (RCTs). Clinical psychology review. 2024;114:102518.
4. Boness CL, Votaw VR, Schwebel FJ, Moniz-Lewis DI, McHugh RK, Witkiewitz K. An evaluation of cognitive behavioral therapy for substance use disorders: A systematic review and application of the society of clinical psychology criteria for empirically supported treatments. Clinical Psychology: Science and Practice. 2023;30(2):129.
5. Duggan HC, Hardy G, Waller G. Cognitive-behavioural therapy (CBT) for outpatients with anorexia nervosa: a systematic review and meta-analysis of clinical effectiveness. Cognitive behaviour therapy. 2025:1-46.
6. Xiang L, Wan H, Zhu Y. Effects of cognitive behavioral therapy on resilience among adult cancer patients: a systematic review and meta-analysis. BMC psychiatry. 2025;25(1):204.

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