LAYERS OF IRRATIONAL FEARS
When affected persons come to me for seeking my help in the resolution of their irrational fears they describe their problems according to their own conceptualizations. If they are aware of diagnostic labels, they would mention that. But most of the time an affected person is not aware of the diagnostic labels, to the extent that he/she thinks that no other person in the world has the same problem. It is only he/she who is affected by it.
I would simply ask tell me your problems. In response to this question, they will narrate their problems. I conceptualize the problems narrated by the affected person into Two Layers (1) Top Layer (2) Bottom Layer. While the patient narrates, I keep on sorting the narrated problem according to this conceptualization. It is a simple method of making sense of the problems of the patients. A patient may have more than one phobia like claustrophobia, social anxiety, phobia of pointed objects and so on. The layers of each problem are identified separately.
Top Layer: This is also called as surface structure or conscious structure. It consists of comprehensive bulleted lists of (a) Objects of Fear (b) Body Mind Reaction (c) Safety Measures
Bottom Layer: Also known as underlying fear structure, feared cognitions, imagined feared consequences or sub-conscious structure.
A person came to me with following problems (a) Trait anxiety (b) Claustrophobia (c) Social anxiety (d) Interpersonal problems in the family. Originally, he had requested me treatment of claustrophobia. In claustrophobia, a person has irrational fear of closed places like lift, car, metro, caves etc. I specifically told him that I shall deal with each of his problems in a sequence, one by one. We agreed to initiate the treatment of claustrophobia. He had this phobia since childhood. While he was describing his problems, I classified it into two layers and recorded on a piece of paper. The final output of one hour discussion of his problem is reproduced below:
Top Layer: consisting of objects of phobia, body-mind reactions and safety methods.
Objects of Fear: The objects of fear can be any object, situation, person, place, event, body sensations, thoughts, images and urges. Exposure to or an anticipation of exposure to these objects of fear trigger fear reaction in the affected person. Some objects activate severe fear, others moderate or low. If any object/situation does not trigger fear reaction in the affected person, that will not be listed under objects of fear. From his description of claustrophobia, following objects were identified: (i) closed type lift (ii) alone in the car with closed glass (iii) closing eyes while taking bath (iv) basements (v) sleeping in a dark room (vi) swimming pool (vii) imagery of getting sealed in a jute bag (viii) imagery of electricity failure in metro (ix) imagery of getting trapped in a trunk (x) sitting on the backseat of car (xi) airplane (xii) crowded lift (xiii) news items displaying people getting trapped in closed places.
Body-Mind Reactions: Exposure to or an anticipation of an exposure or just images of objects of fear trigger body mind reactions in an affected person. Essentially, the objects of fear signify some kind of danger or threat to life. The systems of body react to this perceived danger and prepare the affected person to deal with the situation. This person reported following body-mind reactions (i) accelerated heart beats (ii) sweating (iii) blank mind (iv) thoughts of escaping (vi) Difficulty in breathing (vii) irritability (viii) fearfulness.
Safety Measures: Since the affected person perceives a danger or threat to life when exposed to the objects of fear, he/she either avoids the exposure or tries to escape from the situation as early as possible. This person makes himself safe by adopting following measures: (i) avoids lift if alone and uses staircase in multistory buildings (ii) keeps lights switched on in the night (iii) takes someone with him when he is about to get exposed to the objects of fear.
Bottom Layer: The bottom layer is the foundation on which the Top Layer rests. The affected person remains dimly aware of the bottom layer; hence it is called as subconscious structure. Most of the content of the bottom layer is usually accessible to the conscious mind when directed to do so. Since, the conscious mind can extract the content that lies buried into deeper layers of the mind, it is termed as subconscious. At times, it becomes a little difficult to dig deeper into the psyche and extract the bottom layer. With persistent query it can be brought to the conscious awareness. I usually ask the patients to tell me what scares you in that object of fear? What can happen to you? What kind of danger or threat to life is involved? What can be the outcome by being in the proximity of the object of fear?
The bottom layer should be identified accurately. I use following criteria to determine and list the bottom layers. (a) Bottom layer consists of feared cognition/thinking (b) It represents consequences of being exposed to the object of fear (c) It involves future orientation or use of future tense (d) objects of fear are antecedents and the underlying fear structure is triggered by the objects.
I insist on comprehensive listing of underlying feared cognition. An elaborate list is the key and should be aimed at mandatorily. I enlist underlying fear structure in either of the two ways or a combination of both. (a) recording of future tense statement verbatim e.g. I will become unconscious (b) in terms of fears such as fear of becoming unconscious. It does not make much difference how do you record the underlying feared cognition. Following underlying fear structure was identified in above person:
1. Fear of oxygen deficiency
2. Fear of death
3. Fear of suffocation
4. Fear of breathing difficulty
5. Fear of becoming unconscious
6. Fear of losing eyesight
7. Unknown fear.
The partition of the problems of the patient in this manner provides a wealth of data in an organized manner. It makes the entire gamut of the problem comprehensible and communicable. This framework can easily be communicated to the affected persons. This two layer partition sets in the systematic application of drill therapy. I am presenting partition of some more problems.
I am quoting an interaction with a person on facebook on 17th November 2015
C: I am a claustrophobic
Me: are you able to identify the underlying fear structure, i.e. of what you are scared of in closed places?
C: I need fresh air all the time, so I feel when I am at closed places like a lift for instance I get cut off from oxygen, so I refrain from using lifts. I feel I get suffocated and that makes me restless
Me: Exactly these were the issues in other person who was having claustrophobia and used to avoid lifts
C: I feel very uneasy. I start to sweat at times; at times I feel my heart starts to sink. I rush out for fresh air. I can't be at any place which does not have proper ventilation
Me: Since when you are having this problem?
C: It's been quite long now. I think 10 years or so, but never had too much problem, so never consulted anyone.
Me: do you have any past traumatic experience related to this problem?
C: I don't think so. I think I developed this only after once my BP was quite low, so I had to take medication for that. I don't remember any traumatic incident related to it as such
Me: What closed places you are avoiding?
C: Lifts for sure, or any room which has no doors or windows or if doors and windows are closed. Or any place which I think I will not be able to rush out for air easily. Even at movie theatre I take corner seat, because no one will be on one of my sides.
Me: Do you get anxious simply by imagining yourself in a lift?
C: Depends on what floor I have to go. One or two floors don’t matter much, but if more than that, then probably I get anxious at the very idea of getting into a lift. I then use stairs, no matter how much I will have to climb. I simply can't be surrounded by people I get suffocated in a crowd as well.
Me: Have you tried any method to overcome it?
C: Not as such. I just avoid all this.
Me: Do you want to overcome it now?
C: Yes of course sir!
Me: alright, we have two layers conceptualization for claustrophobia. Fear of closed places like lifts, crowd etc is the surface structure. The fear of suffocation and decreased oxygen level constitute the underlying fear structure. We need to correct this underlying fear structure through Cognitive Drill Therapy. When this underlying structure will get resolved the surface structure will also disappear.
C: OK sir. What will I have to do for this?
Me: So you need to work directly on fear of suffocation
Structure of Social Anxiety: In social anxiety the person is distressed and wants to avoid exposure to social situations such as speaking in public, interview, group discussion, debate, giving lectures and presentations, performing before an audience, interacting with superiors and authorities. This is a surface structure which consists of social situations as stimuli and fear as reaction. The underlying fear structure consists of following fears:
a. Fear of humiliation
b. Fear of embarrassment
c. Fear of devaluation
d. Fear of negative evaluation
e. Fear of non-specific outcomes
f. Fear of negative impression on others
g. Fear of ridicule
h. Fear of losing trust of others
i. Fear of letting others down
j. Fear of rejection
k. Fear of loss of self-esteem
l. Fear of being ashamed
m. Fear of going blank
n. Fear of somatic symptoms such as trembling, stammering
An adult male came to me with significant distress in social situations involving boss, persons in authority, group of people or girls. The distress is somatically represented primarily on face and feelings of discomfort. He tries to deal with the distress by avoiding the situations both at Cognitive level or if possible at behavioral level. When he is not able to avoid, he becomes absorbed in anxiety reaction and mentally get focused over the sensations and feelings on face. This entire pattern exemplifies the top layer (also called as surface structure or conscious structure).
A brief interview quickly led to the identification of following underlying fear structure (also called as bottom layer, sub-conscious structure).
i. fear of humiliation,
ii. fear of ridicule,
iii. fear of devaluation,
iv. fear of negative view by others,
v. fear of nonspecific outcomes,
vi. fear of negative impression on others,
vii. fear of embarrassment,
viii. fear of increased distress with passage of time
He is engaged in behavioral and cognitive avoidance of social situations. His strategies of cognitive or behavioral avoidance would not change the underlying fear structure. Cognitive Drill Therapy acts directly on the underlying fear structure to modify the top layer structure.
Acquired associations between Exogenous/Covert Conditioned Stimuli and anxiety response, for examples, seeing dirty objects, touching dirty objects, thoughts of getting dirty leads to severe anxiety response.
The patients are struck in this surface structure in the form of avoidance of dirty objects and repeated cleaning of self or objects. This focus on avoidance and cleaning is negatively reinforced by temporary reliefs obtained through cleaning and avoidance. The patient remains struck in this elusive state for years.
This is the foundation of the surface structure. We can dig deeper into the psyche of the patients and can discern the underlying fear structure. This underlying imagined fear structure gets reflected in following future orientations such as
i. Fear of spreading contamination to other household objects,
ii. Fear of inhaling germs,
iii. Fear of contamination of religious objects,
iv. Fear of being blamed in case something happens due to contamination,
v. Fear of punishment by god if religious objects get contaminated,
vi. Fear of jeopardizing safety and security of family members due to contamination.
This underlying fear structure can be destroyed through Cognitive Drill Therapy or any other methods. The patients' surface structure will get collapsed proportionate to the destruction of underlying fear structure and there will be rapid significant improvement in the contamination OCD.
A senior faculty member met me in a conference in November 2015. He reported that he was having a fear of snake for a long time. He had participated in one of my lectures on Cognitive Drill Therapy about two years back. He applied the concepts to this problem. His fear disappeared within a few days which is still maintained.
Two Layers Conceptualization of such phobias (1) the surface structure consists of exposure to snake or thoughts, images of snake leading to anxiety reaction (stimulus-response association). (2) Underlying fear structure such as fear of snake bite, fear of death due to snake bite etc. This underlying fear structure can conveniently be destroyed through Cognitive Drill therapy leading to fast or even instant relief in such irrational fears.
The underlying fears in examination phobia include - fear of going blank, fear of forgetting, fear of failure, fear of embarrassment, fear of humiliation, fear of loss of self-esteem, fear of humiliation of parents, fear of career loss, fear of not able to manage things after failure, fear of ridicule by the rival etc. This fear structure can be processed through Cognitive Drill Therapy.
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