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Phobias are treated by exposing the affected person to the phobic situation a little at a time and for a long enough time for the fear of that situation to go away. Some examples:
A driving phobia. A young woman came to me with a history of not being able to drive for a period of a few years. She was driven to my office by her father. Over the next few months she progressed through various stages in her recovery. First, her father drove her again to my office. Then she drove him. Then she drove him with him sitting behind her and not talking, but visible in the driver’s mirror. Then he sat directly behind her, silent and not readily visible. Then he followed behind her in another car while she drove alone. Then he met her half-way at a gas station. Then she drove the entire way alone. Each practice session took about forty-five minutes.
A phobia for shopping centers. A woman who had achieved considerable success at work was, nevertheless, unable to shop in large shopping centers. She had to start treatment by driving in and out of mall parking lots, then on a subsequent occasion parking and coming to the entrance to the mall, then entering a few feet in and walking about very close to the exit, then walking through the first floor of the shopping center, keeping in mind the location of all the exits. Finally, she stayed in a mall for three hours. Then another mall. It was only when she had learned to feel comfortable in the first two or three malls, that she was able to go to a new mall without feeling hesitant.
A phobia for restaurants. This man started treatment able to stay briefly in certain stand-up eating places, but was uncomfortable in any relatively formal restaurant. He started practicing by entering and walking through a restaurant, without making a commitment to remain. On the next occasion, he was able to sit in a booth, but got up from time to time to go to the bathroom or make a telephone call. Finally, he progressed to sitting at a table at the center of the restaurant. His practice sessions ranged from an hour to two hours.
Of course, what all of these patients really feared was having a panic attack in these places and being unable to leave immediately. In treatment, they are told that they are expected to have a panic attack from time to time. They cannot not get over a panic disorder without having panic attacks; but particular phobic circumstances lose their ability to terrify with repetition.
Ideally, practice sessions should be every day, or at least as frequent as possible. And they should last at least an hour, which gives the phobic person time to calm down if he/she has had a panic attack. It is better to have one practice session that lasts two hours, rather than two one hour practice sessions. The patient is more likely to calm down and experience the phobic situation for a longer period of time without being upset.
An easy phobia to treat (relatively speaking:)
A phobia for heights can be treated by going out on a terrace a little bit at a time. It is straightforward to treat because the terrace is always available. It is possible to sit and inch forward a little at a time, and then stand and inch forward a little at a time. One prolonged practice session can end with the phobic person way out on the terrace looking comfortably over the edge.
Hard phobias:
- An elevator phobia, (The elevator ride does not last enough for the phobic person to calm down.)
- A bridge phobia. (You are either on a bridge or not on it. It is hard to get on a bridge a little at a time.)
Treating an elevator phobia: I had a patient once who used to be phobic for many different places and circumstances. Without treatment she had overcome all of these fears—except her fear of being stuck in an elevator. To overcome that phobia, we had to practice in the evening when we had exclusive use of an elevator. We started by standing outside the elevator and repeatedly preventing the doors from closing. After a while, we stood inside the elevator and prevented the doors from closing. This lasted for about an hour. The next few visits we proceeded through different stages: of pushing buttons and preventing the door from closing, letting the door close, allowing the elevator with the two of us inside to go up one floor, then, more floors. In a matter of weeks, the patient was in the elevator by herself with me outside the door, then calling down to her from the next floor, then, finally, meeting her on the ground floor when she went up and down the elevator repeatedly. She had to stay in the elevator almost continuously for at least 30 minutes before calming down. She went on, then, to other elevators. Each new elevator was difficult even when the old ones had become easy. I told her she would probably feel comfortable in all elevators after she had mastered four or five. I was wrong. She had to practice in 26 elevators before she was no longer afraid of any elevator.
Treating a bridge phobia: In some places there are small bridges a patient can practice with initially; but most of the time there is no bridge of an appropriate size. Walking across an overpass hardly ever causes anxiety, and crossing a big bridge always causes anxiety. However, for some reason, just looking at a bridge works to an extent to de-sensitize a phobic patient. There is a big bridge near my office which used to allow cars to pull up on a shoulder in front of the toll booth. Sometimes a patient and I would park in front of the bridge and watch the cars uneventfully driving back and forth; and, then, on impulse almost, the patient would drive across the bridge. Of course, being on a bridge does not usually last long enough to calm down. I think a typical bridge phobia evaporates only after twenty or so trips back and forth. And then the next bridge may still be somewhat difficult.
I had a patient who overcame his bridge phobia. He used to have panic attacks every time he went across the Tappan Zee Bridge. When he was better, he took an automobile ride across the country and back and did not have any panic attacks until he came to the Tappan Zee Bridge, where, once again, he became panicky. Old associations die hard.
Incidentally, for similar reasons, I often suggest to an airplane phobic that he/she should go to an airport just to hang around for an hour or so. Watching passengers disembark is helpful. Their calm is contagious, just as in other contexts fear is contagious.(c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog
