Phobia Treatment with the aid of Stress Management – a Case Study

By Angela Scott

Here I am going to undertake a case study approach and perform a critical analysis on the treatment of a client with a dental phobia. In order to achieve this I will briefly discuss phobia theory, management and treatment and the subsequent effects of the treatment given. Client confidentiality is paramount throughout and the client will simply be referred to as ‘Lucy’.

Phobia Theory

It could be argued that a phobia is a fear of a specific situation and may often be connected to a previous traumatic experience. A phobia can also be regarded as an extreme fear and very often no logical or rational basis for the phobia is known. These two different approaches can be summed up by the The Psychodynamic Theory and The Behaviourist Theory of phobia.

The Psychodynamic Theory is that a phobia is the result of “repressed psychic material”. The phobia therefore can represent an unconscious fear which is not readily available. The psychodynamic treatment consists of analysis thereby to bring the repressed material to the surface.

The Behaviourist Theory is that “we learn a phobia” and therefore can “unlearn” it. The behaviourist treatment is either to use a “flooding” technique (confrontation with the phobic object) or “reciprocal inhibition” (desensitisation through gradual introduction to the phobic object).

The Treatment of Phobia

What is often referred to in the jargon as the First Process is treatment of the anxiety by simple positive suggestion and deep relaxation over a number of sessions.

The Second Process can be referred to as “face the tiger” which involves confrontation with the phobic object. This could also could be regarded as the “Behaviourist” approach. In order to achieve this approach another confidant/friend needs to be with the client in order to return the client to a safe environment if the fear proves to be too difficult. By doing this the client is aware that they are in control of the situation at all times. This may be achieved by performing relaxation processing with the client on an individually assessed basis.

The Third Process involves reconditioning the client and placing them in light relaxation. When in this state of relaxation you should ask the client how long they can confront the phobic situation. You then go on to get the client to imagine they are near the situation or experiencing the situation and increase for longer periods of time each session i.e., 1 minute, 5 minutes, 10 minutes, etc. This process can assist the client in facing the fear and overcoming the problem. In order for this therapy to be effective the client needs to be capable of visualisation and seeing a mental image of phobic situation.

The Client

In order to maintain confidentiality the client will simply be referred to as Lucy. Lucy booked in for individual stress management sessions with me in order to overcome her severe dental phobia. Lucy is a professional woman, working in health care, in her mid thirties. She is married with two children. The fact that Lucy works in health care presented a huge barrier for her and she stated that she felt ashamed and embarrassed that she was unable to access dental treatment due to her phobia. (The term “health care” is a deliberately ambiguous statement in order to preserve client anonymity).

At the outset of the session I presented Lucy with my Code of Practice. I also showed her my qualifications and policy for professional and public liability insurance. I informed her that I complied with data protection regulations and then advised her that I would be informing her doctor and her dentist of the sessions and progress as a matter of courtesy and good practice. I then proceeded to take a history from Lucy. When Lucy initially booked the session I did inform her that she would be entitled to a free fifteen minute initial consultation and then it would be up to her whether she wished to proceed. I regard all the aforementioned as being important in promoting good standards for professional practice. Offering a free fifteen minute consultation means that the client can walk away without obligation if they feel that the recommended therapy and treatment is not suitable. (This has never happened to me yet).

Following a long discussion it emerged that Lucy’s dental phobia had begun following traumatic dental experiences as a child. She was given gas on two separate occasions in order to have teeth extracted. On the first occasion she went into what was referred to as “shock” and her mother was informed it had occurred because she had been given too much gas. On the second occasion she had an anaphylactic reaction during the procedure and recollects the experience of floating out of her body (an out of body experience). The Dentist informed her mother that she was allergic to the gas and in future would need any further extractions done under local anaesthetic. Both these traumatic experiences occurred when Lucy was a young pre-school child yet remained easily accessible in her memory. Even talking about these experiences proved very difficult for her and she began sweating and became quite tearful at one stage. She also reported palpitations when talking about these dental experiences.

Lucy was now in a position where she needed dental treatment and her phobia was preventing this occurring. Lucy stated that her sister was willing to assist her in overcoming her phobia. I informed Lucy that it would be of paramount importance to desensitise her at an appropriate level that she could cope with in order to overcome her phobia. I informed her that in my professional opinion at least three sessions would be required. Lucy responded positively to this suggestion and following lengthy discussion a treatment plan was devised.

Given that Lucy’s sister was willing to be an active participant in assisting her to overcome her phobia it was felt that in this instance an “eclectic” approach to therapy would be suitable consisting of the following:-

• Consultation – the Third Process of Phobia Challenging
• Telephone follow up – to discuss progress.
• Facing the phobia with her sister – the Second Process of Phobia Challenging

This was intended to be a cyclical approach that would be repeated over at least three occasions.

SESSION 1 – It was felt that the suitable treatment for Lucy in this instance would initially be the third process of phobia challenging. Lucy was aware that she would be placed in light relaxation and asked to visualise driving to the dentist and actually booking an appointment to view the dentist’s treatment room. Lucy was informed that she would remain safe throughout the session and that the mental pictures produced would create no uneasiness at all. She was aware that she would be in control of her feelings at all times.

Prior to commencing the relaxation I practised breathing techniques with Lucy. I asked her to breath in through her nose and out slowly through her mouth. This was performed in order to enable her to concentrate on her breathing slowly thereby preventing her hyperventilating and giving her something else to concentrate on whilst producing the mental images of the dental experience. The background music Lucy chose for the relaxation session was “Ocean Waves at Sunset” as she thought this would help her create a positive mental picture. Lucy responded well to this technique of light relaxation. I kept reminding her to remain in control of her breathing and reiterated the fact that she would remain calm and relaxed throughout the session (which she did). The power of suggestion is very positive on the mind.

Lucy responded well throughout the session and remained silent. I asked her to imagine driving to the dentist, going inside and booking an appointment to view the treatment room. Lucy stated that she felt calm and relaxed throughout the session. The session was taped in order for Lucy to practice at home. When preparing taped sessions for clients I always make sure that I mention their name many times on the tape – this renders it useless for anyone else to use (why should anyone have free therapy at my expense).

Telephone Follow-Up – Lucy’s sister was willing to participate in her recovery. It was agreed that Lucy would continue listening to the tape for one week and then have a telephone discussion with me. This discussion revealed that Lucy was responding well to the therapy and felt more relaxed about the whole dental experience. She now felt ready to take the next step.

Facing the Tiger – It was agreed that sometime over the following week Lucy would actually go to the dentist with her sister and book an appointment. This is known in the jargon as process two (facing the tiger). The Dentist was aware of her phobia which could only assist further in this instance in helping Lucy overcome her fears. Lucy did telephone and inform me that this session went very well indeed. She remembered to perform her breathing exercises when she felt stressed and stated that the dentist was absolutely fantastic and very kind and patient. This shows the importance of maintaining good interpersonal skills and maintaining inter-professional relationships in order to benefit the client.

SESSION 2 – The next consultation occurred three weeks later and Lucy looked much more relaxed about the whole situation, very different from the initial consultation whereby she was sweating and experiencing palpitations. The third process of phobia challenging was felt to be suitable to use again. Lucy was placed into light relaxation and reminded to concentrate on her breathing. She was asked to imagine attending the dentist and having a look inside the treatment room. The session was tape recorded again and Lucy responded well and remained very relaxed throughout. I informed Lucy that I would undertake a telephone follow up with her in one week’s time to check her progress. Lucy was also aware that she could contact me in the interim period if necessary.

Telephone Follow-Up – This follow-up revealed that Lucy was doing really well with the therapy and relaxation tape. Her sister was willing to accompany her to the dentist for a visit in the treatment room. I agreed to see her three weeks after this or sooner if required.

Facing the Tiger – Lucy’s sister accompanied her to the dentist to visit the treatment room. Lucy was slightly apprehensive about undertaking this visit but continued practising with the relaxation tape and breathing techniques. The visit to the dentist went ahead without any problems. The dentist was aware of the situation anyway and was particularly sensitive. Lucy felt that her fears of the dentist were somewhat illogical and also felt very embarrassed given that she did work in health care anyway.

SESSION 3 – Lucy was much more talkative at the commencement of this session and felt rightly proud of having been able to visit the dental surgery. The third process of phobia challenging was felt to be a suitable treatment once again given the success achieved at this time. Lucy was placed into light relaxation and asked to visualise attending the dental surgery, having an examination and a scale a polish. Lucy was reminded to concentrate on her breathing technique and remained calm throughout this session. A tape was given to Lucy and I informed her that I would undertake a telephone follow up the following week.

Telephone Follow-Up – This call revealed that Lucy felt reasonably confident in attending the dentist for treatment and stated that she would book an appointment and ask her sister to attend with her for morale support. At this point she did not feel the need to book any further sessions with me but had my telephone number for support if needed.

Conclusion

I heard from Lucy some six weeks later saying that she had been able to attend the dentist but that it had taken a lot of courage. He sister had accompanied her to dentist for support. The dentist was very sensitive to her needs and had ensured that she was relaxed. The relaxation tape of Ocean Waves at Sunset was played throughout the session which Lucy found to be of enormous benefit.

Lucy was extremely pleased that she had confronted her phobia after all those years. I never expected to hear from her again but she rang six months later informing me that she now attends the dentist alone, without the aid of her sister, but still uses the relaxation tape. She was so deeply relaxed at her last dental visit that she had a filling without any local anaesthetic.

From this I realise that an individual assessment of the client’s circumstances is paramount. In this instance an eclectic approach was utilised in treating Lucy utilising process two the and third process. This could be achieved due to the time and commitment that Lucy’s sister was able to give.