Cognitive Fears and Psychoanalytic Phobias
Karon, Bertram P., Widener, Anmarie J., Ethical Human Psychology and Psychiatry
Today, most psychologists and psychiatrists diagnose any excessive fear as a phobia. But psychoanalysts make an important distinction: True phobias must be inconsistent with the conscious learning experiences of the individual, that is, they involve unconscious mean- ings. Severe fears that are not true phobias respond well to cognitive behavior therapies, for example, deconditioning or exposure. But true phobias do not respond to decondition- ing alone; they do respond well to psychoanalytic therapy which makes conscious their unconscious meaning.
Keywords: phobias; fears; psychoanalysis; psychoanalytic psychotherapy; cognitive therapy
Today any unreasonable or excessive fear is diagnosed as a phobia. That is very dif- ferent from the original psychoanalytic definition of a phobia. This difference in terminology leads to confusion and a clear difference in recommended treatments.
In the words of the American Psychiatric Association's (2000) Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR), a specific phobia is a "marked and persistent fear that is excessive or unreasonable, cued by the presence or anticipation of a specific object or situation . . ." (p. 449).
For many psychiatrists, a judgment of excessive or unreasonable in terms of objective reality makes sense because dieir treatment will be a medication diat diminishes the capacity to experience anxiety. The source of the anxiety is irrelevant. However, for most psychotherapists, both psychodynamic and cognitive, medication is not an adequate treat- ment except as a temporary palliative. Given diat cognitive therapy is, to some extent, a historical development from behavioral therapy, it is not surprising that the judgment of "unreasonable" or "excessive" for many cognitive therapists tends to be made in terms of objective reality. But for psychoanalysts and psychoanalytic therapists, a phobia has a more specific meaning. The fear must be unreasonable or excessive given the conscious life experiences of die individual.
Thus, unusually dangerous or painful experience that leads to an unusual fear does not produce a phobia in psychoanalytic terms. Neidier would a lifetime of being told by a par- ent that something was dangerous, even though objectively it was not dangerous, lead to a phobia nor would identifying with a parent who had an unreasonable fear. These would all be considered fears, not phobias. Most of what is currently being described as phobias are actually fears. And fears respond well to cognitive therapy (e.g., desensitization).
The Psychodynamic Diagnostic Manual (PDM), on the other hand, states that "to be considered a phobia in the traditional sense, there must be evidence that the exaggerated fear (symptom) expresses the way die individual organizes internal experience" (PDM Task Force, 2006, p. 104). Even more clearly, in die section on child and adolescent symp- toms, it states ".. . die individual with the phobia is usually not able to explain how he or she became afraid of this benign object, which we assume may unconsciously symbolize anxieties about separation, change, time, or death. We assume diat this process is held in unconscious memory by psychological defenses" (PDM Task Force, 2006, p. 241).
This is important because a statement is often made that cognitive therapy rou- tinely and quickly is effective for phobias and is the empirically validated treatment of choice (e.g., Craske, Antony, & Barlow, 2006; Gersley, 2001; Mayo Clinic Staff, 2011; Winerman, 2005). In fact, desensitization (which has been given several names) and its variants is a learning-based treatment which is empirically effective bodi in clinical work and in laboratory research and is very effective for fears that are consistent with the conscious learning history of die individual. In psychoanalytic words, it is very effec- tive for fears. Psychoanalytic therapists also recommend it for fears. …