Can the Cognitive Approach Be Used to Conquer Fear - Assignment Example

Can the Cognitive/Behavioural Approach be used to conquer fear? Anxiety can be a difficult emotion to overcome, especially when it arises at inopportune times seemingly over unreasonable issues, such as when one is driving across a high bridge. This fear can sometimes prove quite limiting, as when one is too afraid to cross such a bridge as the only way to reach a destination. To overcome such a fear, a cognitive/behavioural approach was adopted as an attempt to resolve this anxiety for one test subject and remove or reduce the restrictions on movement it imposed. Interaction consisted of the instruction of breathing and other panic control techniques, a progressive series of homework assignments in which the patient crossed over increasingly larger bridges and the discussion of the various components that led to the perpetuation of the anxiety. At the conclusion of the project, the patient demonstrated a much reduced fear of high bridges, indicating that the cognitive/behavioural approach was successful in bringing relief. Can the Cognitive/Behavioural Approach be used to conquer fear? For most people, occasional feelings of anxiety, worry or fear are a normal part of life hardwired into the human system as a means of preparing the body for any kind of reaction that might be necessary, the famed fight or flight response. This reaction is even necessary as “being able to anticipate things that might happen allows us to make plans and to consider the possible consequences of choices we make, enabling us to have better lives” (Anxiety Disorders, 2006). Accompanied by physical responses such as increased heart rate, trembling, dry mouth, sweating, nausea or clammy hands, anxiety indicates our body is ready to do whatever it takes to keep us safe from the negative or threatening situation we are anticipating.  Unfortunately for some people, anxiety has become a significant problem as it becomes applied to issues or objects that are unlikely to cause any harm or present any true danger. This irrational fear has come to be known as a phobia and these phobias can sometimes become so severe that they significantly reduce a person’s quality of life and ability to function within normal society. In determining whether the cognitive/behavioural approach is an appropriate and effective treatment to combat incapacitating fear caused by anxiety, it was determined to use a test subject who suffered from a specific phobia. She experienced significant fear every time it was necessary for her to cross over a high bridge, particularly (but not necessarily only) when she had to cross over water. Because this subject had recently moved to an island, only connected to the mainland by means of a tall bridge designed to allow the passage of tanker ships to cross beneath, this presented a significant barrier to her enjoyment of life. The only other way to reach things as common as the supermarket is to drive several miles and over a lower bridge to another island before getting on a ferry. This roundabout route not only forces additional expenses in terms of fuel and time, but still requires the use of a bridge to accomplish. The subject is a 32-year-old female, married and with two small children. Although she has always been active in her community, her phobia regarding bridges did not present a significant barrier to her activities until the family’s recent move. The subject reported having experienced anxiety when crossing bridges since she’d been young, but could not remember any triggering event. She had never sought help for this phobia because she had previously always been able to reach her destination through reasonable alternative routes. Since their move, the subject indicated that the fear she experienced when crossing bridges frequently prevented her from being able to participate in activities and events held only on the mainland. In discussing this fear, it was recognized that there were several components involved in this experience that would need to be addressed if relief was to be found. The study attempted to address cognitive issues (the thoughts associated with the anxiety), determine behavioural responses (becoming progressively less able to drive over bridges regardless of size), recognize affective experiences, identify associated symptoms and examine the precise situations that triggered the anxious response. Literature review Several studies have been conducted to try to understand the physiological causes of fear and anxiety as a means of curing phobias and other related conditions. These studies have indicated that several areas of the brain seem to be primarily connected to the production of these emotions, particularly the amygdale and the hippocampus (LeDoux, 1998). While the amygdala seems to be the alert center regarding threats, thus retaining emotional memories to some degree, the hippocampus appears to be that area of the brain that translates threatening events into memories, thus playing a significant role in defining what makes an event threatening (Rauch & Savage, 1997). It has been observed that the hippocampus of those individuals who experienced traumatic events as children or who grew up in military situations had a much smaller hippocampus than others (Bremner et al, 1995). It is hoped that further research may bring to light various ways in which this region of the brain can be enhanced through medical means and provide a cure for anxiety disorders (Gould et al, 1999). However, these medical advances have not yet been accomplished, so an understanding of these disorders from a psychological perspective remains necessary. Available literature suggests that phobias such as the gephyrophobia experienced by the test subject are quite prevalent among the general populace. A phobia is defined as the experience of excessive fear brought on by proximity to a specific object or a certain type of situation (Beck, Emery & Greenberg, 1985). One characteristic that remains relatively common is that the fear experienced is both exaggerated and, depending upon life conditions, can be significantly disabling. “The person is able to recognize the fear is exaggerated but is unable to eliminate the fear or reduce the avoidance (Beck, Emery & Greenberg, 1985). Even when these characteristics are present, however, “diagnosis is appropriate only if the avoidance, fear or anxious anticipation of encountering the phobic stimulus interferes significantly with the person’s daily routine, occupational functioning, social life or if the person is markedly distressed about having the phobia” (DSMIV, 1994). The determination for most people regarding whether they seek help to overcome their phobias typically depends on exactly how difficult it is to avoid the phobic object. Because many individuals who suffer from phobias are able to find ways of avoiding their phobic situation, to varying degrees of success, it is estimated that less than one quarter of all adults who experience phobias actually seek help (Boyd et al, 1990). Studies regarding the prevalence of phobias among the world’s adult populations have shown wide differences in the estimates. In 1990, it was reported that phobias were among the most common psychiatric disorders to be found in the United States, with an average prevalence of 6.2 per cent with fluctuations as low as 4 per cent and as high as 11 per cent (Boyd et al, 1990). A study conducted by Kessler et al (2005) indicated that as many as 19.2 million American adults suffered from some sort of specific phobia. However, rates reported in the United Kingdom indicate that as many as 18 per cent of adults suffer from some sort of phobia (Singleton et al, 2001). Extrapolations made based upon 2004 census figures and statistics from the National Institute of Mental Health (NIMH) suggest a far lower rate – below half of a per cent – in the UK (“Statistics by Country for Phobias”, 2005). The Singleton (2001) study further examined the phobia rate according to gender, showing that while approximately 13 per cent of the male population reported some sort of phobia, approximately 22 per cent of phobia sufferers were women. This finding was supported by another study that concluded specific phobias were nearly twice as likely to occur in women as they were in men (Bourdon et al, 1988). In addition, specific phobias such as these typically emerge in adolescence and continue throughout adulthood unless treatment is sought (Boyd et al, 1990). According to the [U.S.] National Institute of Mental Health (Anxiety Disorders, 2006), specific phobias usually respond quite well to cognitive/behavioural therapy. This form of therapy is also recognized by the British United Provident Association (BUPA, 2006) as the most effective approach. It is believed the reason for the effectiveness of this treatment is because of its dual focus on both cognitive aspects of the fear as well as the behavioural actions taken in response to this fear. “The aim of treatment is for the client and therapist to work in partnership to identify patterns of thought and behaviour which are causing problems, and to plan a structured way forward with agreed practical objectives” (BUPA Health Team, 2004). While the patient takes on a great deal of responsibility for healing, the therapist offers guidance in relaxation techniques, analysis and behaviour modification practices such as gradual exposure to the phobic object. “When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties” (Anxiety Disorders, 2006). Thus, following initial consultation and treatment plan development, the patient is given a series of ‘homework assignments’ that will help them eventually help themselves (BUPA Health Team, 2004). Assessment A clinical interview with the test subject almost immediately revealed strong indications that she was suffering from a specific phobia. During the conversation, the subject listed several common characteristics of a specific phobia. A specific phobia is defined by Phillip Long (2005) as a “marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation.” In fact, the fear of crossing over bridges has been officially recognized by the medical profession under the term gephyrophobia or gephysrophobia (Culbertson, 2004). According to Long (2005), before diagnosis of specific phobia can be reached, three specifications must be fulfilled. These include determining whether the symptoms experienced are primary or secondary responses, ensuring that the anxiety is only experienced when the subject is in the presence or immediate anticipation of the phobic object or situation and observing whether the phobic situation is avoided whenever possible. The particular fear experienced by the test subject used in this report was associated with a specific object or activity that actually posed little to no actual immediate threat to her well-being. While she recognized this fear to be quite irrational, she could not rid herself of the anxiety. At times, this anxiety response was severe enough to prevent her from crossing any bridge, forcing her to remain in her home rather than participate in the activities of her family and friends. Even when she was able to overcome her fear, she said she never crossed the bridge without feeling some form of distress. In reporting these symptoms, the test subject typifies four of the principle characteristics of a person suffering from a specific phobia. In this sense, she represents an almost textbook case of a specific phobia as defined by Long (2005). To determine the extent of the phobia, the subject was asked to describe some of the thoughts she associated with bridges and the idea of crossing them. The subject indicated that her primary fear was of driving off of the edge of a bridge and having a horrific accident. She indicated her thoughts regarding driving off the bridge did not only included picturing herself accidentally falling off the bridge, as in a vehicular accident, blown tire or other mechanical issue, but also a fear of deliberately driving off of the edge. Although she was unaware of it, this feeling is quite common among those individuals who experience this anxiety (Katz, 2003). Other associations included thoughts of the bridge collapsing underneath her vehicle, the conception of the length of the fall and the probable outcome upon reaching the bottom. When crossing over water, the subject indicated she also imagined herself trapped within the vehicle as it sank, leading to her eventual drowning. When the subject approached a bridge while driving or even contemplated the idea of crossing over a bridge, she indicated she experienced a wide variety of symptoms that served to increase her anxiety. The physical reactions to facing a bridge often included hyperventilation and heart palpitations that would occasionally leave her feeling dizzy and faint. These symptoms served to increase her fear while driving over bridges as she felt she might faint or experience a heart attack while operating a vehicle. This vicious cycle contributed additional thoughts of death associated with bridges, causing her to avoid them as often as possible. While her fear had originally been relatively confined to the idea of crossing over high bridges or bridges over water, her avoidance had reached such a point that she often found herself avoiding even flat bridges over marshy areas and occasionally experiencing symptoms when crossing over simple freeway overpasses. The subject was beginning to confine herself to her home as the only means by which she could avoid the unpleasant feelings caused by the bridges around her home. Because she realized her fears were irrational and unfounded, she continuously blamed herself for her own confinement and experienced frequent bouts of loneliness and depression as a result of this isolation. Further discussion with the subject indicated that she wished to gain the ability to cross even very tall bridges over channels on her own, even if she had to battle her fear every step of the way every time. She did not wish to pass her fear on to her children and she wished to become an active member of her new society. In addition, performing daily activities necessary to the care and well-being of her family could not be completed without overcoming this fear. Determining that such a large step would be unlikely in a short amount of study time, the intervention method included a great deal of ‘homework’ to the patient accompanied by a crash course in relaxation techniques. In addition, discussion was held in which thoughts regarding the probability of bridge-related threats were examined in closer detail, acknowledged and accepted. Intervention The cognitive approach taken to treating this test subject focused upon the concepts proposed through the Institute of Psychiatry (“Specific Phobias”, 2005). The idea was that the patient may best be able to gain control of some of the negative thoughts that engendered her fear of bridges by accepting them. “The anagram AWARE can help sufferers to cope better in the phobic situation” (“Specific Phobias”, 2005). This anagram provided the subject with an easy-to-remember sequence of cognitive thoughts to follow whenever she felt negative thoughts and symptoms rising. The first step is to ‘A’ccept the anxiety by reassuring herself that it was okay to be feeling the way she was feeling, but that she didn’t need to allow it to overwhelm her. Keeping it in mind that these feelings were acceptable allowed the patient to stay in the moment, rather than anticipate the next step in her developing panic. ‘W’ stands for ‘watch your anxiety’, and served as a reminder that the subject is not the anxiety, which helped her maintain a certain detachment from her fears. The second ‘A’ encouraged the subject to ‘act with the anxiety’, which encouraged her to focus upon what the ‘normal’ behaviours would be under the particular circumstances. ‘R’ reminded the subject to continue to cycle through these three important first steps while ‘E’ encouraged her to continue to expect the best-case scenario rather than concentrating on the worst (Beck, Emery & Greenberg, 1985). These concepts were discussed often in association with the specific thoughts related to bridges. Prior to assigning the subject to attempt crossing a bridge of any type, a quick course in relaxation techniques was given and the subject was given ‘homework’ to practice these techniques at home. To help increase the effectiveness of short exercises that could be done in the car when symptoms began manifesting, the subject was asked to practice deep relaxation methods at home as time permitted. These included autogenic training, meditation and progressive muscle relaxation (“Integration”, 1995). The patient spontaneously selected an image of floating on a cloud as part of her autogenic relaxation practice, which emerged later as a helpful combatant against thoughts of falling or sudden landings. The subject also selected yoga as a means of practicing meditation while progressive muscle relaxation was practiced just before bed, bringing with it positive associations of rest and pleasant dreams. The practice of sequentially tensing and relaxing major muscle groups also helped the subject achieve a more restful sleep at night which assisted in her thought processes the following day. Although these practices were not perfected during the course of the study, their practice seemed to increase the effectiveness of brief methods of relaxation taught to the patient. To help combat anxiety as it arose, the subject was instructed on paced respiration and deep breathing as possible means of overcoming hyperventilation and self-control relaxation as a means of reducing the experience of heart palpitations. The subject ended up utilizing paced respiration most often in combating her physical symptoms of anxiety as it reminded her to take things at her own pace, including her thoughts and emotions. Exposure therapy was used to work on the subject’s behavioural practice of avoiding bridges as often as possible and of confining herself to her immediate, bridgeless surroundings. “Exposure therapy involves starting to confront the fear and stopping avoiding it. When exposed to the feared object or situation, the person is taught to tolerate their high levels of anxiety” (BUPA, 2006). Because the human body can only sustain high levels of this type of arousal for approximately 30 minutes or so, the fear naturally lessons with increased exposure and it becomes easier for the subject to accept the idea that a catastrophe will not necessarily occur. Because the subject was still able to get herself across small bridges at the time treatment started, she was encouraged to practice the brief methods of relaxation she’d been practicing as a means of discovering what worked best to reduce her anxiety on these bridges. Once it was determined that paced respiration was effective in reducing her physical symptoms as well as reminding her of the cognitive steps we’d discussed in the anagram AWARE, the subject was instructed to try driving over a flat bridge that crossed water. This was accomplished on her third attempt. Following steps included crossing medium-sized overpasses, crossing over medium-sized over-water bridges and finally crossing the high bridges that prevented her from accessing the mainland. While this final step was not accomplished during the course of the current study, the test subject demonstrated significant indications that this step would be accomplishable. Evaluation The process of applying cognitive/behavioural therapy in this test case seemed to be highly successful in assisting the test subject to overcome a long-term and debilitating fear that was preventing her from experiencing an acceptable level of quality of life. Following the process brought forward several unexpected aspects of real-life application versus textbook theory. While the subject exhibited a textbook case of specific phobia, treatment was much more integrated than was previously understood. For example, it was necessary for the student therapist to accompany the test subject frequently during the exposure therapy, during which time cognitive therapy and relaxation techniques were utilized liberally. The close relationship that developed between the test subject and the student therapist, as well as a degree of self-evaluation on the part of the student therapist as each concept was discussed, illustrated the difficulty experienced by those who suffer these types of phobias in trying to live a normal life as well as in trying to combat their fear alone. As was reported by the British United Provident Association (BUPA, 2006), cognitive/behavioural therapy did appear to be exceedingly effective in helping this test subject to overcome her fears to some extent within a very short period of time. 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