THE SAFETY TRAP
In order to escape and avoid the unpleasant body-mind reactions the patients affected by phobia and OCD in particular get involved into a safety trap to the extent that many affected persons almost lock themselves into their house and become practically non-functional and abandon their occupation and even tend to deny promotions. The condition becomes painful for the patients as well as their family.
Mrs. HR came to see me with more than o8 year history of intense suffering. She was terrified of the possibility of having a heart attack. In order to prevent the possibility of heart attack she had thoroughly changed her life style and made extensive safety arrangements. While taking bath she would not close the bathroom doors for the fear that if heart attack occurred inside the closed bathroom she might not be rescued. She would not leave her house alone. She needed a person with whom she could go outside the home; in the presence of such a person called as phobic companion she felt safe to some extent. Even with the phobic companion she would not go outside the city, on expressways or long distance. She thought that in case there was heart attack the medical facilities would not be available immediately. When away from home within city, she would keep reading the boards and mentally recalling nearby hospital facilities. She worked as a teacher in a well reputed school. She had to travel to attend the school. She resigned from the job due to this terror of heart attack. She would avoid malls, crowded places and far off places in the city even with the phobic companion. She even got admitted in Intensive Care Units and got her cardiac examination done on a few occasions. She was thoroughly reassured by cardiologists about not having any abnormality in the functioning of the heart. Despite reassurance from qualified and experienced heart specialists, she kept on fearing the possibility of heart attack. This demonstrates how the mind can rule over the body and distort the reality within mind.
It was not just a private mental experience for her. She actually felt severely disturbing symptoms in her body which consisted of accelerated heart beats, increased respiration, sweating and heaviness and pain in heart area. For her, she was having episodes that mimicked heart attacks. Periodically, she got terrified to the extent that she literally felt that she is just about to die. This phase of acute distress used to last for a few minutes. She would compel her family members to take her to hospital for medical examination and treatment. When the cardiologist and the family member reassured her for no signs of heart attack; she temporarily got solace from it. But her own acute symptoms were so intense and real that she thought that may be the doctors are missing something in her examination and understanding her condition. She was fully convinced of her symptoms and supported the possibility of having heart attack with the periodic and highly distressing symptoms she was experiencing.
Now she was almost house bound and dysfunctional. She stopped riding her scooter for three years. Now she was not feeling safe going outside home, hence she restricted herself to home. Even at home she did not feel reasonably safe and grounded. Even at home, she felt unsafe. She felt helpless, used to weep and lost all the motivations. She also started feeling sad because of these experiences.
She was also referred for psychiatric consultation, but she did not adhere to the treatment as she was not convinced why she should be taking psychiatric medicines as she thought that her condition was physical in particular a case of heart attack. The possibility of heart attack was perfectly real for her.
A common acquaintance of ours, recommended her to see me. She complied and came to me. Having listened to her story, I considered her to be a case of Panic Disorder and Agoraphobia with secondary depression. I communicated my understanding of her problems and advised her to see a psychiatrist. I told her to take medicines for 2-4 weeks and then report back to me for psychotherapy.
She did not come within the timeframe. But her not coming was haunting my mind, because I knew she also needed psychological treatment for her problems. She appeared to me after three months and reported that she has been taking medicines regularly during this period but there were little gains in her condition. I instantly recommended her to commence psychotherapy with me. She agreed to do it. Without taking any other chance, I started my psychotherapy in the same session.
I sorted out the mess of her problems by partitioning its components. I told her that depression is secondary to the fear of heart attack and it will be healed upon removal of the fear of heart disease. The identified components of her problems were as under:
Objects of Phobia: Any object/situation/place/internal body or mind experience that activates phobic reaction is classified under Objects of Phobia. By listening to her story I identified following objects in her phobia:
1. Taking bath in closed bathroom
2. Shopping malls
3. Travelling on expressway
4. Air travel
5. Riding scooter
6. Living alone in house
7. Being in crowded place
8. Going alone outside house
9. Sensations and heaviness in heart area
10. Coming to my sessions alone
11. Visiting other cities
12. Travelling on highway
13. Using metro in Delhi
14. Places where medical facilities are not available immediately
1. Pounding heart
2. Sweating
3. Weeping
4. Irritability
5. Intense fear
6. Pain in the cardiac region
7. Trembling
8. Difficulty in breathing
Feared Cognition: Also called underlying fear structure and imagined feared consequences.
1. Fear of heart attack
2. Fear of death
3. Fear of non-availability of emergency medical help
Safety Mechanisms: The phobic person perceives a danger to his/her life in one or the other forms. All fears get zeroed down to a threat to life for the objects which are either 100% safe to non-phobic or cause minimal risk. There is an exaggeration of this danger perception. The affected person makes elaborate safety arrangements to prevent the occurrence of the dangerous consequences. Mrs. HR was no exception. She also took so many safety measures which consisted of:
1. Not leaving home alone
2. Rushing to ICU as soon as there were indications of potential heart attacks
3. Restricting herself to home
4. Avoided being in crowded, shopping malls, closed places.
5. Avoided travelling far away, expressway, other cities, even distant places in her city of residence
Despite extensive safety measures to prevent the danger of heart attack, she did not feel safe even inside her own house. This is because her phobia was inside her own mind. The danger of heart attack was not present anywhere in the outside world. Hence, wherever she would be, her phobia in her own mind accompanied her. Precisely, this is the reason that safety mechanisms do not eradicate the phobia instead they create an illusion in the mind by giving temporary relief. The avoidance of objects of phobia and imposing restrictions in life provide temporary and fleeting relief and expand the scope of phobia.
A Million Dollar Question: The phobic condition is so painful and problematic to the affected person, even then why it persists specifically after taking so many counter measures? The answer to this question is simple and straightforward. The phobic person does not attempt to eradicate the underlying fear structure. Avoidance-Avoidance-Avoidance are the solutions executed by such person. He/she does not acknowledge and deal directly with the feared consequences. All thinking and behaviors are centered on the avoidance of those consequences. The safety measures offer no solution to heal the phobia. Instead, the affected person should comprehensively identify all aspects of underlying fear structure and deal with them head on. It may appear as if things ‘said easier but difficult to do’. Cognitive Drill Therapy has made it possible to do the seemingly difficult task very easily. Now it is “easier to do”.
Drill & Daring: Based upon my conceptualization of conversion of feared cognition into past tense and their verbal repetition in bulk for each object of phobia one by one in sequence, I commenced drill therapy with her. This is a very powerful procedure which acts directly on the underlying fear structure and removes the fears associated with the feared cognition. During the course of Cognitive Drill Therapy, I prescribe home work of drill & daring. I ask the affected person to expose himself/herself to the objects of phobia in real life situations as far as possible and sub-vocally keep doing the drill. First perform the drill in imagination and then expose to the real objects while mentally doing the drill; and the magic happens. I did following drill on her in my sessions and prescribed the daring as home work.
While performing the drill, I ask the person to mentally imagine the objects of phobia and verbally repeat the feared cognition by changing its tense to past or present. She did the following drills:
1. Imagine yourself in a closed bathroom and keep verbalizing ‘heart attack ho chukka he’ (I have had a heart attack).
2. Imagine yourself in a closed bathroom and keep verbalizing “main heart attack se mar chuki hun” (I have died of a heart attack)
3. Imagine yourself in closed bathroom and keep verbalizing “heart attack ho chukka he, koi hospital bi pas me nahi he” (I have had a heart attack and there is no hospital nearby)
4. Imagine yourself in closed bathroom and keep verbalizing “heart attack ho chukka he, pas me hospital bi nahi he, main mar chuki hun” (I have had a heart attack, there is no hospital in a nearby place, and I have died of heart attack)
At the commencement of drill, merely by repetition of above statements, she showed extreme emotional reactions, she cried, cried and cried. Literally wept, tears in her eyes. It was very painful. It was managed by giving pauses and drill dilution. In drill dilution, sometimes, I speak for the patient. I repeated verbally for her “mera heart attack ho chukka he” (I have had a heart attack). She had lots of vibrations and sensations in her body. She subjectively felt as if lots of negative energy was flowing out of her body. As usual, within 5-10 minutes her reactions to drill were getting subsided. But for each change in object of phobia or feared cognition, she had emotional bursts of equal intensity. As and when she had overwhelming anxiety experience during drill, I managed it by giving pauses of a couple of minutes and drill dilution.
Within 10 sessions, she processed all objects of phobia and the feared cognition. Each session lasted for about 60 minutes. She also started going for daring in real life situations. She was now comfortable in repeating all identified objects of phobia and feared cognition. She started going outside home alone. She started riding her scooter. She visited shopping malls. She started visiting to distant places in the city. She began to forget to scan the boards/hospitals in nearby places which she was doing earlier. She was no longer avoiding crowded places. She became at ease in most places in the city. I also enquired her to mentally scan all the places in the city and consider if there could be any place associated with phobic reaction. She was not able to mentally access any such place now. Her affect improved. Her sadness got lifted away. She was now cheerful. She was happy and contented. She did not take a job instead she set up her own coaching. She is being liked and appreciated by her students and their parents. She got fully occupied. She helped a few other patients known to her to get into the psychological treatment. Her husband used to keep worrying about her even at his workplace as distress calls were coming to him unexpectedly. Her husband also got relieved and now devoting full time to his occupation without the fear of distress calls.
She began to experience bliss and joy in her life and along with her me too felt joyous for seeing her so much improved with 10 sessions of Cognitive Drill Therapy. This extra-ordinary improvement in her boosted my self-esteem and self-efficacy. I looked forward to formalize this procedure more and more in order to heal the persons affected by phobia and OCD; also to train professionals on this novel form of psychological treatment.
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