Psychotherapy for phobias
(Note: This article is selected from my series of courses "Psychoanalytic Treatment of Neurosis")
The duration and effect of treatment for phobias vary depending on the nature and degree of fear and the individual's underlying circumstances, such as personality quality, motivation for seeking help, perception, etc. A more complete course of therapy consists of three phases: confronting the fear symptom and the corresponding patterns associated with the symptom, understanding the deep motivation of the fear, and confronting, that is, accommodating the reality of the fear.
(1) Handling of fears
We know that phobias tend to have a fixed object of fear as a trigger for stress, while anxiety disorders do not. Excessive fear itself can hinder normal thinking. Therefore, for patients with phobias, it is necessary to consider dealing with fear at the initial stage.
(1) Face the symptoms head-on and improve the attitude of rejection towards the symptoms
◎ The degree of fear can be judged based on the influence of real function, sleep status, symptom scale test, etc.
◎ All means of cognitive behavioral therapy are effective in relieving symptoms, including drugs. In severe fear, taking an anti-anxiety medication such as alprazolam can relieve excessive tension.
◎ During the period of fear control, the release of emotions is achieved through somatic therapy, such as autologous therapy, music or dance therapy, reasonable emotion therapy, breathing relaxation therapy, etc.
◎ Insist on facing the fear scene through imagery therapy in the context of meditation and relaxation. Mechanism: When people imagine, their thoughts and emotions are synchronized, that is, psychological reality, and the psychological touch of trauma, although it is imagination, is also a terrible and uncontrollable imagination. Therefore, through imagination training, 1) the tolerance to cope with the loss of control can be enhanced, and 2) the "facing the fear" obtained by revisiting can change the unstable sense of loss of control in the past and stimulate the inner positive strength.
(2) After the fear has been alleviated, the following can be clarified and understood through dialogue:
◎ What is the common response pattern to symptoms, and what is the effect?
◎ What are the psychological feelings during the process of responding to the fear, and the emotions afterward?
◎ What is the mental attitude towards the symptoms, such as complaining, self-blame, suppression, elimination, or anything else?
◎ Clarify the reality and imagination of the object of fear: Is the object of fear objectively or subjectively existing, is it the reality of the past, or the reality of the current imagination?
◎ The clarification and understanding of the object of fear is a preliminary work to be able to get close to the deep psychology of fear and analyze the nature of fear. All tangible technical routes are aimed at understanding the unconscious, so that the unconscious can be conscious to the greatest extent.
(3) Precautions
◎ The fear targeted in this article is neurotic, not the fear caused by major trauma. The latter are those that cause partial damage to the neurodefense system (the panic system located in the lower brain tissues) in the event of a major emergency, and treatment is only suitable for "stabilization treatments" that provide physical care and emotional support, and are not suitable for those treatments described above.
◎ Psychodynamic analysis of fear, considering the emotional feeling as the starting point. For example, phobias are the same as anxiety disorders, and behind the behavior is mainly the fear of things, and the emotions are anxiety and fear. Depression, like obsessive-compulsive disorder, is mainly something hateful behind the behavior, and the emotions are anger and depression.
◎ Identifying the nature of emotions and the difference in psychological motivation can help us deeply understand the unconscious world of different neuroses.
(2) Defense analysis of fear
(1) Tasks and objectives of the analysis
◎ What is the "secondary conditioned response" and what are them? What does the awareness of the "secondary conditioned response" defend against?
Psychoanalytic psychotherapy focuses on the primary conditions of the internal and external conditions for the emergence of mental illness, that is, the most primitive psychological or external traumatic events. The formation of phobias does not depend solely on the initial conditioned response, but also on secondary conditioned responses. Secondary conditioned responses refer to the attitudes and behaviors reported in response to the initial conditioned responses.
◎ Secondary conditioned reaction, which is the secondary cause of the disease. Just like the formation of certain "cases", there are masterminds and accomplices. However, in the formation of "psychological cases", accomplices and masterminds are often adherent, and their roles and functions are interchangeable.
Example: An 18-year-old girl with social phobia presents with a fear of her facial twitches when she meets a stranger (which can be regarded as facial fear). After understanding and analysis, it became clear that the original psychological facts of her expression of fear were: when she was in the first year of junior high school, she introduced herself in class, and she mistakenly said her gender as "male", which caused the audience to laugh, and when she looked in the mirror when she returned home, she found that her expression was stiff and her mouth twitched, which was extremely ugly. The shyness and shame caused by this incident and the incident in her heart are the main cause of the girl's interpersonal fear, i.e. the primary condition of the illness, and the repeated mirror looks that the girl has since then - fear of looking in the mirror, frequent avoidance of school, complete avoidance of group activities, etc., as well as the reactions that make her report that "I really can't speak, my expression is really ugly", "I don't want others to know that I have an interpersonal barrier", "I can't imagine what it will be like if I am laughed at again" and other subjective thoughts, which are secondary conditioned responses to the formation of interpersonal phobias, that is, secondary causes of the disease.
◎ The above case is understood with symbolism. The original psychological trauma fact is that the girl suffers from interpersonal fear, and the girl's precautionary intention of fear of being hurt again is the complicit of the girl's fixation of interpersonal fear.
Extended understanding: A knife cut has a single main cause - accidentally being cut by a knife is at best a pain of a cut, and the wound can heal itself, and only the practice of sprinkling salt on the wound, such as squeezing with dirty hands, scrubbing with dirty water, bandaging with dirty cloth, etc., will suppurate and become infected and cause lesions. Corresponding to a child's mistakes, making mistakes is not a problem, and the practices adopted by parents to make mistakes to children, such as scolding, scolding, negative personality preaching, and "bad self-identity" in the child's heart, these secondary causes lead to the child's habitual mistakes, or other psychological problems.
◎ Secondary conditioned response acts as a feedback mechanism, which in turn reinforces the fear feeling of phobia. From this point of view, secondary conditioned reactions become the masterminds of phobias.
◎ Secondary conditioned reactions can be described as various defensive reactions to anxiety. It is said that it is the mastermind of phobia because it is really guarding against "anticipatory fear". It is precisely the anticipatory fear that causes the patient to have infinitely overlapping fear illusions, thus forming a vicious circle in which the more worried, the heavier the worry.
◎ The goal of defense analysis is to make the fearful person understand how this vicious circle is caused by his defensive conditioned response. Then, the patient can be expected to: 1) consider changing the pattern of response to fear. For example, he may consider shifting his anxiety and rejection of symptoms to acceptance of symptoms. 2) Covert defense mode will be further visible.
◎ Explicit forms of defense, which refer to running away, dodging, talking and doing things non-stop, etc., and covert defense modes refer to suppression, isolation, excessive rationality, rationalization, etc.
(2) A common covert defense in phobias is the externalization of imagery
◎ Conceptual explanation of image externalization: a subjective image becomes an objective reality.
The common phobias include hypochondriacal fear, terminal illness fear, fear of heights, fear of crossing the road, cardiac phobia, fear of accidents, etc., all of which unconsciously externalize the inner fear image.
For example, the fearful person who is afraid of cancer is the symbol of death whose concept of death activates his early life-threatening fear experience, and externalizes this primary fear image, death, into cancer. In patients who are afraid of crossing the street, the scene of crossing the street evokes the loss of fear of being in danger (such as being present or witnessing a car accident, robbery, bereavement, etc.), and externalizes this primary fear image, "danger", into crossing the street.
◎ The primordial fear of neurosis, preserved in its symbolism in the depths of his memory, forms symptoms. When symptoms reappear, they are always expressed in a transformed form.
For example, there is a young man who has compulsive vomiting (traumatized by humiliation in his childhood) who is afraid of both his vomiting and his inability to control it. But he didn't know that vomiting was already a symbol of his moral and mental nausea, because he unconsciously needed to "vomit" in order to continue to excrete and soothe the resentment in his heart. In fact, in the personality of many OCD patients, there is a powerful superego, often in the form of somatic symptoms or somatic punishment, in other words, to express the subject's repressed emotions.
◎ The therapist's analysis of defense requires the person to interpret how his inner fear has become an external terrible thing on the premise of presenting his fear situation and fear experience, or how his inner fear has become a completely different external fear.
(3) Dynamic analysis of fear
As mentioned earlier, phobias, like anxiety, have something to fear behind their behavior, while obsessive-compulsive disorder, like depression, has something to hate behind their behavior. What's different behind it is the mental motivation behind the neurotic retention symptoms, which is what makes us understand the underlying reasons behind the patient's symptoms.
◎ For example, behind the phobia behavior is fear... , a metaphor for his relationship with the person or thing to whom his fear referres, is a dissociative relationship, and behind the obsessive-compulsive behavior is disgust... , which is a metaphor for his relationship with the person or thing to whom he is averse, as a tangled sexual relationship.
◎ The psychological mechanism of dissociative relationship at the unconscious level is mostly the loss of traumatic memory, the emotional experience is mostly nervous, fearful, and melancholy, and the defense mode is mostly denial, replacement, and external projection. At the level of consciousness, with sensitivity and vigilance to the object of fear, they will always be on the defensive.
The direction of treatment is to enable the phobia (excluding dissociative phobias) to be able to face the object of his fear, and eventually to maintain an appropriate distance from the object of the fear, or a relationship of connection.
◎ Tangled sexual relationship, the unconscious level of motivation is attachment defect, loss of love and hatred emotional experience, defense mode is mostly repression, splitting, external projection, etc. At the level of consciousness, relying on super willpower, he compulsively pursues an absolutely safe relationship that he can never achieve.
The direction of treatment is to realize the unconscious fear and jealousy of intimate relationships one by one, and learn to connect and live with others and oneself.
◎ The deep motivation of phobias comes from two major anxieties: death anxiety and castration anxiety. The latter (i.e., loss of presence, deprivation of sexual experience) is at the heart of the fear of neurosis.
"Humanity proceeds from fundamental nothingness. He had to learn to light the wood and not to go deep. To use Lacan's classical language to understand the source of motivation for fear, the child's past, in which he had to rely on external forces to grow, was the experience of satisfaction or lack in various behavioral experiences, and in this way gained control over his desires.
◎ If in early childhood, experience risk coercion, such as life threat, abandonment, rape, abuse, etc., these fear experiences will be stored in the child's sensory memory as a fear-filled image, once the threatened message appears again, the fear containing the memory image will be evoked, and will try to resist the fear in the feeling. In particular, those children who have experienced the feeling of abandonment for a long time will be full of dark, small, victimized, and helpless feeling materials in their psychological structure, so their attention is inclined to preserve the safety of life, and the basic motivation of life is how to "not have an accident".
◎ Fear itself is energy and motivation, it depends on where it pushes you?
Perhaps: 1) You are afraid of nothingness, and this fear can either be an excuse for you to avoid your pursuits and deceive yourself, or it can also become a motivation for you to fill in yourself and pursue your own goals. 2) Your fear of marriage may be a destructive force in your marriage, or it may be the motivation to make you happy and single. 3) You have a fear of defects, which may be the reason for you to avoid others and responsibilities, or it may be the motivation for you to have extraordinary talents in some area.
...... Too much, perhaps, showing the double-edged magic of fear.
◎ When we calmly feel the relationship between life and the world, you will find that the biggest fear of phobias is not the fear of death, but the fear of premonition of death before death. The biggest fear of ordinary people is not death, but the fear of loneliness and meaninglessness when they are born, or what people fear most is not to die, but not to live well before death. So, it is necessary for us to ask a question worth pondering: how to fill our own lives is the law of reconciliation of fear?