Humans are wired to avoid vertiginous places, but if this fear gets in the way of life then exposure therapy can help
by Poppy Brown
The American photographer Margaret Bourke-White (1904-71) on the Chrysler Building, looking out across New York in 1931. Photo by Time Inc/The LIFE Picture Collection/Getty
is a DPhil student in the Department of Psychiatry at the University of Oxford.
Edited by Lucy Foulkes
Some people might think that the consequences of having to avoid heights are minimal. But imagine you’re invited to a job interview on the 16th floor of a city office block. Or that your kids are pleading for a family trip to go high-roping. Or that your friends decide it would be fun to hike all the way up to a beautiful viewpoint. For people with a phobia of heights – an extreme, persistent, irrational fear of being high up – these scenarios can become real problems. What do you do in such a situation if you have a fear of heights? Do you miss out on that job? Do you make excuses to your kids? Do you disappoint your friends?
Many of the symptoms of acrophobia, to use the technical term, are shared with other anxiety disorders. These include physical symptoms such as shaking, sweating, a racing heart, difficulty breathing, nausea and a dry mouth. Individuals with acrophobia typically feel intense fear and distress around heights, and tend to avoid them as a result. There are also symptoms more unique to acrophobia, including vertigo and the desire to drop to the knees or clutch on to something.
Some degree of caution is common and sensible when it comes to heights. Many animals and human infants show an innate avoidance of a sharp drop, even before they’ve had any real experience of heights. Evolutionary accounts argue that we are all born with this fear because avoiding heights helps to keep us safe. A problem arises only when this unease around dangerous heights starts to generalise to other, less risky situations, and begins to interfere with daily life.
An intense fear of heights might develop for several reasons. First, a traumatic or frightening event, such as falling out of a tree or off a ladder. This could trigger a phobia of heights because the distressing experience gets paired with heights in the person’s memories – particularly in individuals already predisposed to feeling anxious. They then start to avoid all heights, believing that they might lead to a similar scary experience. The more such people avoid heights, the fewer opportunities they have to learn that heights are generally safe, and so the fear remains and intensifies.
However, you can’t always trace your fear back to a specific traumatic event – many people with acrophobia can’t link their fear to a particular experience. It’s also possible that some people just never have the repeated safe exposure to heights that enables most of us to manage this innate fear. Finally, individuals with height phobia show subtle differences in their ability to maintain their balance, compared with those without height phobia, even when not exposed to heights. This is partly because they have more difficulty integrating perceptual information from their visual system. It is now thought that a combination of factors come together to cause acrophobia.
Estimates suggest that as many as one in three people experience some degree of ‘visual height intolerance’, where looking at something high up can cause them to fear they’ll lose balance and fall over. If your fear of heights starts to interfere with your daily life, getting in the way of the things you want to do, then you might want to try to do something to reduce it. Cognitive behavioural approaches are an effective treatment for many phobias, including acrophobia, and below are some general principles you can try yourself.
Recognise and understand the symptoms of anxiety. The human anxiety response is a natural part of healthy functioning. When we detect a threat, our sympathetic nervous system activates and starts preparing our body for action. This is known as the fight-or-flight response, and it works to protect us. Many of the unpleasant symptoms of anxiety arise because our body is trying to pump more blood towards our muscles, to prepare us to fight or run away. For example, our heart beats faster and we breathe more quickly to get more oxygen to our muscles, and we get a dry mouth and ‘butterflies’ in our stomach as energy and blood are diverted away from these regions towards our muscles.
Hyperawareness and misinterpretation of these bodily sensations is a common problem in many anxiety disorders, including phobias. In acrophobia, for example, a person who feels nauseous and dizzy when up high might believe that these are signs of an imminent catastrophic fall. This can exacerbate anxiety, because the fear of falling will likely make the physical symptoms even worse.
To avoid misinterpretation and to help you tolerate the anxiety, try to familiarise yourself with the physical symptoms of anxiety. This will help you to see your symptoms for what they are: nothing more than your body’s natural fight-or-flight response. Although we can’t simply decide to switch off this system, the anxiety response doesn’t last forever. Remember: the anxiety will always pass.
Gradually build your tolerance of these symptoms around heights. Graded exposure therapy makes use of the transient nature of anxiety, helping you to tolerate and ride out your body’s anxiety response. The idea is to gradually expose yourself to the thing you fear, starting small and slowly working up to more difficult situations. You practise each step until your anxiety subsides, and this helps you create new memories of experiencing the feared object or situation without feeling anxious. As you practise and become more confident, you overwrite your association between the stimulus and fear in your mind. In time, the once-feared scenario begins to evoke less anxiety.
To start, make a list of situations that trigger your phobia and put them in order from least to most anxiety-provoking. For the easiest steps, you could begin with looking at pictures of heights, or creating mental images of heights. The important thing is to start with things that provoke a small but manageable level of anxiety. You could then move on to include standing near heights (such as an escalator in a shopping centre), then actually using an escalator, and then visiting a tall building.
Try out the easiest situation you have chosen, and stay in that situation until your anxiety subsides and you feel more comfortable. Try to stay focused on the features of the situation or image, engaging with the surroundings rather than focusing on your anxiety. For example, if you’re standing in front of a tall building, how many floors does it have? What colours and textures can you see? Remember that any physical sensations are just the body’s natural response and don’t necessarily mean that you’re in danger. For each step, you might find it helpful to rate your anxiety out of 10 in the first minute, and notice how the rating drops over time. Practise this several times until your anxiety for that particular situation has reduced. You can then try the next step on your list.
Practising relaxation exercises before, during and after exposure can be helpful. For example, try using mindfulness or counting your breath. More information on these can be found in the resources section.
Every individual will vary in the exact scenarios they find most challenging, and how quickly they can move between steps. Try to take small steps that are challenging but manageable. Take your time: leaving the situation before your anxiety has subsided might be counterproductive as you will continue to associate that situation with fear.
For a lot of people with a fear of heights, you can try these principles on your own or with the help of a friend. However, if this is too difficult or your fear is particularly severe, you should attempt these principles only with the support of a trained therapist.
Understand and then challenge your beliefs about heights. While exposure therapy focuses on reducing feelings of anxiety, cognitive therapy exercises focus on a person’s beliefs about heights. Many people with height phobia think something bad will happen when they are up high. For example, you might fear that you will fall over, that the structure will collapse, or that you might throw yourself off. In cognitive therapy, the goal is to help you learn that you are safer than you think, and that your feared outcome about heights won’t actually happen.
Ask yourself some questions. What do you believe might happen when you expose yourself to your fear? How likely do you think it is (on a scale of 1-10) that this would happen? What would be the outcome of it happening? For example, you might believe that if you go up a tall building the structure will collapse: you feel certain that this will happen, and that you would be seriously injured when it does.
Once you’ve answered the above questions about the likelihood of your fears manifesting themselves, you can try some ‘behavioural experiments’. These are a type of exposure activity where you test out your beliefs. For the above example, you could try a behavioural experiment where you go up high and see what happens: whether the structure indeed seems unstable, or whether you do indeed fall. Again, you can start small with your experiments, using relaxation exercises to help you. The idea is that, once you test out your fears, you see that the worst doesn’t actually happen – or that, if something difficult does happen, it’s not as bad as you feared.
Try to spot the safety behaviours you use. During these experiments you might also want to identify any safety behaviours you resort to. These are behaviours that we use because we think they help to keep us safe. The most common safety behaviour is avoidance: simply not going anywhere that requires being up high. More subtle examples include closing your eyes, not looking down or over the edges, tightly holding on to something, or focusing your attention on repeating a certain phrase. While these can be helpful in the short term – for example, holding on tight to the railings makes us feel steadier – such behaviours actually act as barriers, preventing us from really engaging with the height. As a result, we’re unable to learn that we are, in fact, safe and able to cope without them. Holding on to the railing, for example, means that we don’t get to learn that we can stand, all on our own, without falling, and so our anxiety persists. Try to identify what defences you use, and then repeat the behavioural experiments without using them.
It is important to note that safety behaviours are very different from helpful coping mechanisms. The former get in the way of us learning that we’re safe without them, while adaptive coping mechanisms (such as relaxation exercises) simply help us to face the difficult situation and to tolerate our anxiety.
Following each behavioural experiment, think about what you’ve learnt. The following questions might be helpful: what happened? Did any of your anticipated fears that you wrote down beforehand happen? What happened instead? What went through your mind – and was that accurate? What happened when you did or didn’t use your defences? What can you learn from this experience? What does it mean for the future?
As with the graded exposure exercise, these exercises can be attempted on your own or with the support of a friend. However, if your fear is severe or you’re struggling to identify your beliefs about heights or the defences that you use, then having the support of a trained therapist is recommended.
I once watched someone standing in front of a narrow wooden plank suspended over a vast drop. Before she began to edge on to it, I could see her hands trembling, her body gripped with terror, battling her desire to both conquer her fear by taking a step forward – but also to run away. And all this unfolded within the safe confines of a small carpeted room at the University of Oxford, the plank and drop merely simulations seen through a virtual reality (VR) headset.
VR is an immersive, interactive, computer-generated environment. It creates the sensation of actually being in real-life situations, and is an ideal tool for treating phobias. VR allows individuals to repeatedly practise how to feel confident in scenarios that they find difficult. Simulated situations can be personalised and graded in difficulty. While testing them out, individuals can receive guidance and encouragement from an automated virtual coach who is in the VR environment with them.
VR makes it easier for people to engage in therapy, particularly cognitive behavioural therapy, because it’s easier to try out things that we find difficult when we know it’s only a simulation. Crucially, however, individuals respond in the same way in VR – psychologically, emotionally and physiologically – as they do in corresponding real-world environments. This combination of knowing that we’re safe, yet feeling as though the simulations are real, makes VR a powerful tool. Any learning that occurs in VR appears to transfer to the real world, and VR therapies for anxiety disorders (including phobias) have been found to be at least as effective as real-life exposure therapies.
I was one of a team of researchers who recently tested the effectiveness of VR therapy for height phobia. In the study, 100 participants diagnosed with fear of heights were randomly allocated to receive either VR therapy (delivered in six 30-minute sessions over a two-week period) or to receive no therapy. In the VR therapy, an automated virtual character called Nic guided the individuals to try out different tasks, such as looking over a balcony or helping a cat down from a tree. During the tasks, Nic encouraged participants to test out their beliefs concerning heights, and to try dropping their defence behaviours.
Those who received VR therapy experienced significant reductions in their fear of heights, compared with those who received no intervention. These benefits were maintained when the participants were tested again four weeks after the end of the treatment. In the UK where I work, VR therapy for height phobia is now available in some NHS services, and might become available in other countries in the near future.
At the end of the study, we asked participants what they thought about the therapy. Here are some of the things they said:
‘It definitely pushed the limits in terms of what I thought I would be able to achieve, and then got me to go past that.’
‘The difference in my mental capacity to deal with heights was amazing.’
‘I’ve had three sessions of VR and I’ve already surpassed everything that I imagined I could.’
The idea of attempting treatment might feel daunting, particularly given that this requires facing your fears. However, psychological treatments for phobias have consistently been shown to be highly effective and long-lasting. With the help of a friend or therapist and by starting small, you could surprise yourself with what you can achieve. Tackling your fear of heights can ensure that you never miss out on a job, never have to make excuses to your kids, and never get left out of a fun activity.