418: Phobias, Be Gone!

Today, we feature Werner Spitzfaden, LCSW, a Level 3 certified TEAM-CBT therapist who recently treated Rhonda, who's driving phobia returned during the pandemic because she did very little driving at that time. After you overcome any fear or phobia, it has a way of returning if you don’t continue confronting your fear. Werner describes his skillful and compassionate work with Rhonda!

Werner is a dear colleague and friend with over 35 plus years of clinical experience treating phobias, such as the fear of flying, claustrophobia (the fear of being trapped in small places), and driving (especially over bridges and overpasses). He also treats depression, panic and other forms of anxiety, and works in corporate environments to improve communication and teamwork.

Let's dive right in, Please take a look at Rhonda’s completed Daily Mood Log,

As you can see, the upsetting event was thinking about driving over an overpass, and she rated her initial anxiety cluster at 100%, indicating extreme anxiety. She was also 90% ashamed, and 80% Inferior, worthless, inadequate, defective, and incompetent. She was also feeling 99% embarrassed, foolish, humiliated, and self-conscious, and 85% hopeless, despairing, frustrated, stuck, angry, annoyed, irritated, upset, and devastated. Her sadness was only modestly elevated at 25%.

There are several teaching points. First, most of Rhonda’s negative feelings were severely to extremely elevated. Second, although she is asking for help with a phobia, anxiety often goes hand-in-hand with a wide variety of negative feelings, including shame and inadequacy. This is because anxious individuals often feel like there’s something terribly and shamefully wrong with them.

Rhonda's feelings of shame are not unusual. Shame is a central feature of anxiety, whereas a loss of self-esteem is a central feature of depression. Werner added that the fear of driving often goes along with the fear of heights as well as claustrophobia.

Rhonda admitted to engaging in many “safety behaviors” which typically make anxiety temporarily better but worse in the long run. Rhonda's "safety behaviors" included  going out of her way when driving to avoid scary overpasses as well as asking her husband to drive her many place. As you can see, these totally understandable “safety behaviors” relieve your anxiety in the here-and-now because they are forms of avoidance, but that’s why they makes anxiety worse in the long run. The urge to avoid of the thing(s) you fear is universal among individuals struggling with all forms of anxiety.

Werner emphasized the importance of empathy in the initial phase of treatment, and throughout the treatment, since trust and the courage to face your fears is so central in the treatment of all forms of anxiety and, of course, depression as well.

Rhonda invited Werner and another TEAM-CBT colleague, Lee Flowers, to stay with her in Berkeley during the recent TEAM intensive that David and Jill Levitt directed at the South SF Conference Center near the airport. She drove the group to and from the workshop to face her fears and get some motivation and support at the same time.

You can see many of her negative thoughts about driving on Rhonda’s completed Daily Mood Log, including these:

1. The bridge will collapse. 95%
2. Other cars will make the bridge unstable. 100%
3. I’ll have a heart attack. 95%
4. I’m so dumb for not driving on this overpass. 1005
5. I’m an ass. 100%
6. I can’t do this. 100%
7. I’ll die. 100%
8. Lee and Werner will see me at my worst. 100%
9. I need to study the exact route before I start. 100%
10. I’ll get into an accident. 100%

As you can see, the list includes a mixture of fear-inducing thoughts as well as self-critical thoughts and shame-inducing thoughts, like "Lee and Werner will see me at my worst."

Whenever you are working with anyone with anxiety, you have to emphasize first, to create trust, warmth, and understanding. This won't cure anyone of anything, but will give your patients the courage to face their fears when you get to the M - Methods portion of your TEAM session.

After you get your A in empathy, you can move on to A = Paradoxical Agenda Setting. That where you bring Outcome and Process Resistance to conscious awareness. Then you melt them away using a variety of TEAM-CBT techniques. Outcome Resistance means that Rhonda may have mixed feelings about a “cure” for her driving phobia. In other words, although she WANTS to get rid of this fear, she may subconsciously NOT want to get rid of it.

Can you think of why? Take a moment to think about it, and make a guess. You’ll find the answer at the end of the show notes.

Process Resistance means she may WANT a cure for her driving phobia, but may not be willing to do what it takes to defeat this fear.

What will she have to do? Take a moment to think about it, and make a guess. You’ll find the answer at the end of the show notes.

Werner and Rhonda described a number of TEAM-CBT M = Methods that they used to reduce Outcome Resistance, including

• The Miracle Cure Question
• The Magic Button
• Positive Reframing
• The Pivot Question
• The Magic Dial.

To put this phase in a nutshell, Werner highlighted how Rhonda's intensely negative feelings helped her and revealed many positive things about her core values as a therapist and human being. This is a shame-reducing technique and you can use the Magic Dial to ask your patient what they would like to dial each negative feeling down to, without reducing them all the way to zero. You can see Ronda's goals on Rhonda’s completed Daily Mood Log in the Emotions Table

Next, Werner worked on Process Resistance, bringing the work on Paradoxical Agenda Setting to closure.

At the start of the M = Methods portion of their work, Rhonda identified the distortions in two of her thoughts (“I’m dumb,” and “I can’t do this.”). See how many distortions you can find. Wrote them down on a piece of paper and when you're done you can see the answers at the end of the show notes.

Werner pointed out that Rhonda’s anger, directed against herself, had become a springboard for agitation which intensified her anxiety.

Werner and Rhonda challenged some of her negative thoughts with Examine the Evidence, Externalization of Voices (illustrated live during the podcast),Double Standard Technique and the Paradoxical Double Standard Technique as well as a Fear Hierarchy, which you can see if you click here.

The also did Cognitive Flooding (also called Imaginal Exposure) three times, and by the third time Rhonda could only increase her negative feelings into the mild range, whereas they had started out in the extremely elevated range.

They also used breathing exercise plus getting into the here-and-now to calm herself while driving over overpasses.

All of this was background work for actually driving during the intensive, and the highlight was driving home in the dark on the third evening of the intensive. For Rhonda, this was the most fearful thing of all!  She said at the start her anxiety was "greater than 100%," but she felt triumphant when she arrived home.

Werner gave her specific homework, like driving over a specific overpass four times, and also encouraged Michael, Rhonda’s husband, not to give in to her requests to do the driving on a planned trip to visit friends in Sacramento.

I am deeply grateful to Rhonda for giving us such a raw and real glimpse into her courageous and victorious win over her intense driving phobia, and a big thanks also to Werner for being such a kind and powerful TEAM-CBT therapist, teacher!, and beloved friend!

Thanks for listening today,

Rhonda, Werner, and David

Solution to puzzles above

• Outcome Resistance: If she’s “cured,” she’ll have to start driving much more, and that will include driving over overpasses and bridges. This concept will freak her out now, because she’s still afraid something horrible might happen if she stops avoiding them.
• Process Resistance: To overcome her fears, she’ll have to face them and experience some fairly intense fear along the way. Werner can support her, and drive with her, as he did, but she will still freak out at first when driving on overpasses and bridges.
• The distortions in those two negative thoughts included All-or-Nothing Thinking, Overgeneralization, Mental Filtering, Discounting the Positive, Mind-Reading, Magnification and Minimization, Emotional Reasoning, Hidden Shoulds, Labeling, and Self-Blame.