Beating Dog Phobias
Clinical Psychiatry News - Volume 33, Issue 9, Page 22 (September 2005)
You have a patient who is planning to visit a good friend. The patient is looking forward to the visit but with a sense of dread—for reasons that have nothing to do with the friendship.
Why the ambivalence? It's the friend's dog, which is a lovely animal that has never bitten anyone and appears to like the patient. But dread and terror dominate the patient's thinking. What are some of the most efficient ways of treating such problems?
There are probably as many theories about the origin and development of phobias as there are psychotherapies. I have found, however, that we as psychiatrists and psychotherapists can use one of the simplest in vivo techniques to help the dog-phobic patient.
Often, in the context of discussing my learning, philosophizing, and action (LPA) treatment model, I mention in vitro solutions to a problem or disorder. In this case, with guidance, the motivated dog-phobic patient could conquer this problem on his own in the in vivo setting at little or no expense, as would not be the case when addressing in vivo elevator or airplane phobias.
I recall a successful attorney who previously had been in two psychotherapies in an effort to get over his dog phobia: once with a psychiatrist, with sessions that lasted 8 months; and the other with a psychologist, for 3 months' worth of sessions.
Over time, the patient found that many of his adult friends had gotten dogs as pets, as had some of the legal colleagues whose homes he visited. He had spent at least 10 adult years wanting to overcome this phobia. Also, he wanted to conquer his fear so he could get a dog for his family, which included three children.
The psychiatrist had taken the patient back to childhood fears of death by dog bite and rabies. As they proceeded, the patient said he and the therapist examined many fragile aspects of his family relationships in which the possibility of death and dying were overplayed. The patient went along with this approach, even though he had traced his phobia to his mother and grandmother, who had taught him some of their own faulty beliefs.
The patient accepted the tactic for a time. But after 8 months, he gave up, and a year later, he started working with a second psychotherapist. Without much to review, this therapy focused on dog hairs and the patient's fear of choking as being the reasons for this phobia. This, according to the patient, started because when asked about the first phobic response in childhood, the patient reported a lot of coughing during his first anxiety/phobic episode.
He did remember having a bad cold at the time—which the therapist ignored. The patient recalled that he had never found himself coughing again when he felt anxiety-ridden about coming in contact with a dog.
I won't fault the two therapies because they were trying to get to the root of the anxieties that developed into the phobic response. Unfortunately, it may not have been the initial anxiety, coupled with symbolic representations that preceded the phobia, that were inaccurate, but rather, the learned behavior.
The patient's desire to get a dog for his family provided the incentive to seek help for a fear he now believed was irrational.
On our first and only visit, the patient recalled that his memory of fearing dogs appeared directly related to being told repeatedly by his mother and grandmother that dogs can hurt people and their bites can result in rabies. Based on what this man had been taught for years, it seemed natural for him to develop a fear of these animals.
My work with these types of phobias is behavioral, aiming for as rapid a problem resolution as possible. In this case, the patient made clear how he had learned this fear. I accepted his theory in much the same way that we in medicine accept a patient's theories about how they reactivated an old shoulder injury.
With the LPA method, the learning phase was simple; the patient clearly explained it. The philosophizing phase had been done during the two previous therapies. But I added a new consideration—beyond death and dying or choking on dog hairs—the concept of “possibilities vs. probabilities.” That is, yes; it's possible that a dog might bite you, and it is also possible you might get rabies, but what are the probabilities? This patient accepted the probabilities' message. The next phase—action—was an in vivo eight-step program I explained in the one visit we had. Here are the suggestions I gave him:
1. Get a book on dogs with lots of pictures. Each night for a week, you and your family should pore over the book for a half hour and decide which kind of dog you'd like to get. Be sure to look at all the breeds.
2. Pick a person you truly trust who owns a friendly dog and plan your strategy over a 6- to 10-day period.
3. Set up a time to visit with your friend and her dog, which should be on a leash, and be sure to observe this dog from a distance of 20 feet. You can do this indoors or outdoors. On the first day, stay 20 feet away for 20–30 minutes while you and your friend engage in relaxed conversation. The person holding the dog should never approach you or let go of the dog. That is why the person must be a trusted relative or friend; this is serious business.
4. On the following day, do the same thing from 15 feet away.
5. Repeat from 10 feet away the next day.
6. On the fourth day, repeat the process, but this time from 5 feet away. This is a critical time, since you can almost touch the dog. It is important not to change the plan or come any closer than 5 feet.
7. The next day, go back to the 20-foot mark (step 3), but this time, slowly approach the dog while the other person holds the animal. Stop when you are 5 feet away.
8. Repeat step 7, but this time, when you feel comfortable, keep moving forward slowly until you can touch the dog and pat it. Do this for a second, for a minute, or for as long as you want.
A critical point in this in vivo strategy is that the person conquering the phobia controls the situation. The trusted friend keeps the dog leashed and close by, and the patient always knows that he is the one approaching the feared animal, for as long as the strategy progresses, with no exceptions. This level of trust assures the patient that nothing unexpected will happen during the treatment.
The plan can be modified, stretching out the steps if the patient wants to go slower. I also advise that the patient and his family keep browsing the dog book daily.
After each day's trial, I phoned to see how the program had gone. If I felt a certain approach needed to be changed, I offered that suggestion. Throughout the process, I left the door open for the patient to make his own modifications, a strategy that makes success more likely.
The program of in vivo desensitization was successful in this case, and the attorney and his family were able to get a dog.
The expense was a single 11/2 hour visit. I know other therapists who treat this same type of phobia in two to four visits, which seems perfectly right, depending on the behavior modification or cognitive therapy format used and their level of comfort with it.
We can speculate about the two unsuccessful approaches, and why some therapists still use these vague, open-ended, unstructured approaches. The point is that these age-old methods are used too often, when a straightforward, inexpensive single-visit method can be more effective.
If these short-term methods fail, then a more theoretical approach might be employed. My patient ended up questioning what he saw as “harebrained” techniques to resolve his simple, single phobia. He went on to question standards of care as he paid those bills.
Let me know your experience with treating simple phobia disorders, and I'll try to pass them along to my readers.