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. …