Dr Robert London

Finding a Way to Cross the Bridge

Clinical Psychiatry News - Volume 36, Issue 2, Page 17 (February 2008)

Treating phobic responses is therapeutically challenging since they often require a creative spin for different individuals. That's also the case when the therapist uses standard relaxation techniques, systematic desensitization, and reciprocal inhibition. An attorney I treated a few years ago is a good illustration.

The patient wanted me to help her overcome a fear of crossing bridges and going through tunnels. She practiced divorce law and needed to drive to work, usually carrying a large number of documents and traveling between courtrooms and colleagues' offices. She was a tough lady and clearly wanted to solve her phobic disorder.

We all know that the phobic response is described as an irrational, persistent fear of an object, a particular situation, or a type of circumstance. This attorney knew that definition all too well and had sought out a variety of counselors to help her deal with her fears. Her work, economics, and personal dignity were at stake. She was depressed about her inability to overcome this set of fears, despite some understanding of the phobic origins, and felt like a failure.

After taking a history, I learned that she did not become phobic if she rode a bus or train filled with other passengers. She clearly understood that she needed help in overcoming the phobic response she experienced when she herself was driving.

The patient also made it clear that she was not interested in an in-depth analysis of theories relating to abandonment, fear of being alone, or of impending doom when alone—as other therapists had tried to explore with her. She said, “Doc, if you come to the office to fix a broken leg, don't focus on helping the good arm.” After she clarified where she did not want to go, it was easy for me to agree. After all, I wasn't going there anyway.

An important concept of good talk therapy is to listen to what a person is saying rather than insisting, as some would, that she was controlling the situation and that therapy would fail unless the control factor was addressed. Having a range of responses and treatment options is important. Yes, she was controlling the situation to some degree, but she also made clear the approach she did not want to take. Simply put, in this case, her consumer request appeared reasonable.

I thought that developing a behavioral/cognitive strategy would help solve the problem. My approach would be to use the learning, philosophizing, and action (LPA) technique. My plan, however, was to skip the learning part because this patient had spent time with other therapists. In those sessions, the learning aspect, which appeared to be psychodynamically oriented, had failed. That's not unusual.

Over the years, patients have reported that, although they have learned a lot about themselves in psychodynamic psychotherapy, the phobia remained. In this case, the patient did not think that she had learned much she didn't already know.

With this patient, I did not think that the in vivo approach I used in conquering elevator phobias (“Conquering Phobias,” May 2004, p. 43), which requires that a therapist or friend assist with desensitization, was the right one. Taking an elevator in a high-rise building over a period of time takes far less time and energy than routinely crossing bridges and going through tunnels.

After skipping the learning phase of the LPA technique, we began to discuss some philosophical ideas about bridges, tunnels, and people. To begin, I asked the patient who she thought had invented the wheel. Well, she didn't know, and frankly, neither did I. We tossed around some ideas and essentially neither of us knew when the wheel was invented, either. We did agree that it was invented by humans, and that began a philosophical discussion of the attributes, creativeness, and inventiveness of our species.

I began to encourage philosophical thoughts about the family of man, and I encouraged the patient to think of us as a part of each other. We, as a species, have the wonderful capacity to create and invent. In essence, we are part of the wheel.

As we extend this, the idea of bridges and tunnels as creations and inventions of man is processed and the patient begins to see herself as part of this creation. In other words, the patient is part of the building of these bridges and tunnels and, therefore, she drives on the things she helps to create.

It's this type of almost illogic that can be developed into a simple logic in order to define, in a narrow window, a new way of thinking to begin to challenge and overcome the problem.

This illogic/logic was not lost on the patient, and she did like the newness of the concept from a therapeutic perspective. If you do nothing else but offer a new perspective on an old set of problems in talk therapy, that's offering a lot. It gives the person a new view and understanding, with greater options for dealing with troubling situations, and from this new perspective new options on coping can be developed.

This process of discussing how we are a part of the tradition of mankind started this patient on a new way of thinking and a new perspective, even though she knew that she had neither designed nor created bridges or tunnels.

With this new perspective in place, the next phase is to move away from philosophy and start the action phase of resolving the phobic response. For this, I teach a simple method of relaxation that takes about 20-30 minutes for the patient to learn. Then a specific technique is offered to desensitize the patient. The in vitro approach is to have the patient in the relaxed state to visualize a split screen. On the left side of the screen, she can project a series of images developed from a hierarchy in which less stressful images regarding phobias move to the actual driving over a bridge or going though a tunnel. Simply getting into her car and leaving for work, for example, may begin the hierarchy in this desensitization process.

As she goes through this hierarchy, the patient with a phobic/anxiety disorder gets anxious, so it's important to make her aware that she is in an imagery mode and that the visualizations are not really happening. As this goes forward, I like to introduce a new spin in the process by having the patient shift over to the right side of this screen, which has been blank, and start to project any number of pleasant situations that then lead to relaxation. With time and experience the patient is able to easily switch from the anxiety-provoking left side of the screen to the relaxing right side.

When this gets translated into actually going over a bridge or traveling through a tunnel, the in vitro technique gives the patient a coping method for the travel she prefers and wants to do. This patient had become desensitized to the phobia and was able to move toward the feared object or situation in a real-world experience in a more relaxed style. She can have the left-sided screen experience of going to a bridge and mentally shift to a relaxing plan—what was visualized on the right side of the screen—to continue the desensitization process. She can see herself on vacation or listen to music while she is crossing a bridge or going through a tunnel.

This, coupled with a new set of thoughts of how we are all connected to the genius of human invention and creativity, was therapeutically helpful and successful. The patient did well. She did experience anxiety and stress when traveling across a bridge on the first few tries, but she was able to try. After a short time, the success of going over a bridge numerous times carried the day in removing the irrational phobia. A year after seeing this patient, she followed up, and I learned that she was driving over bridges and going through tunnels without using any strategies.

She admitted that she was “uncomfortable” if traffic was heavy and stalled in the process of crossing the bridge or going through the tunnel. This patient regularly traveled, though, so the phobia strategy worked. For those who get desensitized and don't keep the practice up, the outlook is not always so favorable.

Let me know some of your experiences treating phobias, and I will try to pass them along to my readers.

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