Treatment for phobias

By MIKE GROPPER
A dog in the dark (photo credit: INGIMAGE)
A dog in the dark
(photo credit: INGIMAGE)
Josh, 26, came to therapy to get help with a very specific phobia – cynophobia, the fear of dogs.
Josh recalled that when he was seven years old and playing outside with friends, an unleashed dog jumped on him, knocked him over, and licked his face. The owner, who was nearby, ran over to the dog, pulled the dog away and apologized to Josh. Josh recalled that he was not physically hurt, but from that moment on he became terrified of dogs.
Now, as an adult and involved in a serious relationship, Josh was embarrassed to tell his girlfriend about his need to constantly do everything he could do to avoid encountering dogs. Whether alone or with his girlfriend, if Josh saw a dog coming down the street, he would cross to the opposite side of the street. The very sight of dogs would make his heart pound, and if the dog came too close, he would have a full-blown panic attack.
During the days of Freud, psychoanalytic explanations focused on understanding the unconscious meaning of a symptom like a phobia. However, around the middle of the last century, a major paradigm shift occurred with the advent and popularity of behaviorism to explain and treat psychological problems. In the 1950s, behavioral psychiatrist John Wolpe discovered that people suffering from phobias could extinguish their fear responses and relinquish maladaptive coping behavior through gradual and systematic exposure to the feared object.
Fast-forward to today and mental health researchers find that cognitive-behavioral therapy combined with relaxation techniques and exposure therapy is the treatment of choice for many people living with phobia. I will briefly describe how this method helped Josh.
Exposure therapy
In conjunction with learning how to bring about a relaxed state at will, the therapy technique gradually exposes patients to what frightens them and helps them cope with their fears.
Josh was asked to create his own personal fear hierarchy list, which delineated his perceived exposure to dogs from the least fear-provoking to the most fear-provoking situation that he could imagine. For Josh, a very frightening situation would be standing next to a dog and petting the dog. He could not imagine doing this.
I use two types of exposure techniques in my treatment of phobias. The first type is called imaginal exposure, in which I ask my client to visualize each situation listed on his personal fear hierarchy. The goal is to help a client tolerate increased exposure to more difficult identified situations on the imagined situational fear ladder.
Most clients do this well, and Josh was no exception.
As Josh described what he saw with his eyes shut, I also asked him to tell me what he was feeling. Was his breathing getting heavier? Was his anxiety rising? I asked him to also rate each situation on a scale from lowest anxiety 1 to highest anxiety 10.
A dog seen from a distance on a leash with its owner was rated as minimally anxiety provoking. The thought of seeing a rottweiler, a dog with a reputation of being very aggressive, scared him the most.
Relaxation training
An aid to the exposure protocol is to teach the client relaxation skills at each stage in the progression. The objective here is to learn, practice and use relaxation techniques such as meditation, deep breathing, mindfulness and/or progressive muscle relaxation to help the desensitization process.
At each step in the imaginal exposure progression, Josh was desensitized to the imagined phobic scene through exposure while in a state of relaxation. In the office-based imaginal exposure exercises, I saw Josh’s anxiety decrease gradually and significantly.
Cognitive therapy
Cognitive therapy aims to help phobic clients to challenge and examine certain beliefs they have about the feared object and exposure to it.
It is important for me to uncover and explore any negative underlying beliefs and thought patterns that may be influencing and increasing the phobic anxiety and avoidant behavior. People have a lot of misinformation and lack of knowledge about the things they fear.
For example, in Josh’s case, learning about dogs’ behavior and body language was an important step in helping him overcome his fear. Josh was so frightened of dogs that he did not even know that when dogs wag their tails they are in a friendly mode. We covered a lot of things about the behavior of dogs. I also assigned some articles for him to read about dog behavior. Josh found this information to be extremely helpful in decreasing some of his fear. He did not realize how many misconceptions he had about dogs.
In vivo exposure The next stage of Josh’s treatment involved the second exposure technique, “in vivo exposure,” which refers to actual and direct confrontation of feared objects.
Josh and I scheduled several meetings to walk around the community. In real time, I was able to direct him to use his newly acquired cognitive knowledge about dogs and his healthier and more realistic beliefs about them. Once again, I coached him to use the relaxation tools he had learned in the office, as he allowed himself to get closer to dogs. I reminded Josh to try to look at the dog’s body language and to see if the dog’s tail was wagging.
Gradually, he was able to get very close to dogs with little or no anxiety. I knew we had succeeded when Josh asked one owner of a dog if he could pet him. Josh could not previously have believed that he would ever pet a dog.
Medication for phobia
Medications can help control the anxiety and panic responses that result from thinking about or being exposed to the object or situation that induces the phobia.
Antidepressants called selective serotonin reuptake inhibitors are commonly used in the treatment of phobias. If prescribed, they work best in conjunction with psychotherapy.
Children Treatment techniques similar to what helped Josh have been developed for children. They differ in that they take into account the cognitive and emotional developmental factors of childhood, and they utilize parents as full partners in the exposure and desensitization exercises.
The writer is a marital, child and adult psychotherapist, with offices in Jerusalem and Ra’anana. He also provides online videoconferencing psychotherapy. drmikegropper@ gmail.com, www.drmikegropper.weebly.com