Combining CBT for specific phobias with logotherapy or hypnosis
Introduction
According to experts, specific phobias are successfully treatable anxiety disorders whose treatment is carried out either by medication (most commonly antidepressants, anxiolytics) or by psychotherapy – most often by applying approaches from the framework of cognitive-behavioral therapy. In the present study, however, we point to the possibilities of a combined approach in the form of supportive therapeutic techniques from the framework of logotherapy or hypnotic therapy. The author chose these therapeutic directions not only because of his personal therapeutic experience with them (when working under supervision), but also because of their methodological intersections and potential to facilitate, through mutual interaction, the course of treatment of specific phobias and to achieve a positive outcome including long-term maintenance of therapeutic gains.
Due to the limitations set for the scope of this study, we will not deal in detail with the etiology or phenomenology of specific phobias and will only point out facts directly related to the proposed combined therapeutic approach. Techniques from the framework of cognitive-behavioral therapy used to treat specific phobias will also be mentioned only indicatively and only in connection with the topic of the contribution, based on the assumption that the methods of CBT, one of the most developed therapeutic directions in the context of the former Czechoslovak Republic, are sufficiently known to specialists at a general theoretical level. Under the leadership of Prof. Kondáš (1930-2002), the issue of CBT in our countries developed in an original way under the name of discent psychotherapy.
1 Specific Phobias – Classification and Manifestations
Specific phobias can be divided into various groups and categories depending on the applied criterion. The American Psychiatric Association separately distinguishes:
- animal phobias (e.g., insects, snakes),
- natural environment phobias (e.g., storms, water),
- blood-injection-injury phobias,
- situational phobias (elevators, airplanes)
- other phobias (e.g., illness, loud sounds, etc.) (APA, 2000).
However, other categorizations distinguish only situational phobias, animal phobias, and injury phobias. In the context of the Czech and Slovak Republics, the use of the International Classification of Mental and Behavioral Disorders (10th revision) is mandatory in healthcare, with specific (isolated) phobias bearing the code F 40.2. In addition to a) avoidance behavior, b) escape from an uncomfortable situation, or c) experiencing excessive anxiety, other symptomatic reactions often appear in the behavior of affected individuals, such as: d) safety-seeking behavior, e) seeking help and reassurance (from family members, friends, medical specialists), f) blaming others for being inconsiderate of the client's condition, or g) neurotic behavioral manifestations (Antony – Barlow, 1998).
In a phobic client, even the mere thought of the phobic object triggers anticipatory anxiety. If they are directly exposed to the phobic stimulus, physiological reactions usually appear, such as palpitations, muscle tension, trembling, hyperventilation, sweating, hot or cold flushes, stiffness, tightness, or pressure in the chest or stomach area. In severe cases, dizziness, vertigo, loss of consciousness, derealization, depersonalization, etc. may also occur.
The exact cause of phobias is not yet known, or rather there is too wide a range of possible origins to address here. From a phenomenological perspective, specific phobias mostly relate either to (latent or manifest) fear of the extinction of the subject – of death (in the sense of the end of human existence due to the effect of the phobic object), further to fear of pain, or to fear of one's own inadequacy – the belief in the inability to cope with confrontation with the phobic stimulus (Ibidem). In this context (feelings of threat, attitudes toward pain), a space naturally opens for therapists to implement tools from the framework of logotherapy, or another direction of existential or humanistic psychotherapy, because successfully dealing with the question of death, or the meaning of life, can significantly contribute to reducing the level of experienced fear in clients. According to research, the neurotic fears the end of his existence precisely because he is largely dissatisfied with his current life and is afraid of dying without ever having authentically lived and enjoyed life (Barlow, 2004, p. 60). At the subconscious level, reduction (elimination) of anxiety in the client can also be achieved by using hypnosis to induce relaxation. As for deficits in self-confidence and self-knowledge, all existing psychotherapeutic directions, including CBT, can be helpful in principle.
2 Treatment Procedures of Cognitive-Behavioral Therapy
In general, it can be stated that the goal of cognitive-behavioral therapy is to interrupt the cycle: trigger (phobic stimulus) → automatic (catastrophic) thoughts → anxious emotions and uncomfortable somatic reactions → avoidance and safety-seeking behavior.
2.1 Reflection
The role of the initial objectifying distance from the client's phobia is fulfilled in the initial phase of therapy by working with a form of phobic objects and situations. Both CBT and logotherapy share an initial reflective basis (albeit in a different form). A fundamental difference arises only in the subsequent phase, which in CBT leads to working with cognitive schemas and automatic thoughts (i.e., focusing on them), while in logotherapy, conversely, attention is redirected from the client's current (self-focused) needs to broader contexts within their "life story." Within CBT, the so-called confrontation record with the phobic stimulus, containing information about the degree of perceived anxiety, its physiological manifestations, a description of the phobic situation, and a description of the client's behavior (after exposure), also has a reflective nature.
2.2 Cognitive Schemas and Automatic Thoughts
Negative core cognitive schemas concern either the relationship of a person to themselves (I am uninteresting.), the relationship to others (He is smarter than me.), or the relationship to the world (The world is full of dangers.) (Praško et al., 2008, p. 132) Challenging core schemas and working with negative automatic thoughts in CBT is mostly done through logical analysis (including the Socratic dialogue method). We ask the client: How did this assumption arise? What helps maintain it? Did you create this belief yourself or did you adopt it from someone? How does this rule help you in life? How is this assumption harmful to you? For comparison, we note that the logotherapeutic dialogue applies the following sequence of steps: a) expression of recognition, b) help in defining the problem, c) working with alternatives, d) searching for meaning.
We also encourage the client to actively seek evidence that their original core rule does not hold true.
This phase also places high intellectual demands on therapists, because clients offer conscious or unconscious resistance to the challenging of their original core schemas, since in the past they themselves have reinforced these schemas so intensely and, in their opinion, justifiably.
2.3 Setting Goals
The essence of this phase is the definition of specific, realistic, and achievable goals after the completion of therapy, as well as intermediate goals – mostly set by applying the principle of reverse ordering of elements from the initially compiled hierarchy of phobic situations concerning various forms of confrontation (exposure) with a specific phobic stimulus, where the bottom rungs feature the least psychologically burdensome forms and the top rungs feature the most psychologically demanding situations (e.g., "in vivo" exposure). When (jointly) defining treatment goals, the therapist should focus both on specific, carefully set goals, as well as on building and strengthening effective comprehensive (cognitive, behavioral, volitional) competencies of the client to independently manage phobic or other stressful situations.
2.4 Relaxation
The purpose of using relaxation techniques is to eliminate physical and mental tension in the body. Tension release techniques in CBT are generally applied just before exposure to the phobic object, and just after it – with the aim of eliminating the resulting physiological symptoms, based on the assumption that a relaxed state of the organism prevents the creation of the tension that accompanies the fear response. It is precisely with this technique, as well as with the following technique from the CBT framework (breath control), that we see possibilities for enhancing their effectiveness by using some element from the instrumentarium of hypnotic therapy.
2.5 Breath Control
Calming the breath is a strategy that allows for a relatively quick reduction of muscle tension in situations that provoke anxiety. Its effectiveness stems from two factors. The first is the fact that incorrect breathing supports the development of anxiety. The second is the fact that during breath control, attention is redirected from the phobic object to the breathing process itself, thereby secondarily eliminating (reducing) the symptoms of anxiety.
2.6 Systematic Desensitization
The aim of systematic desensitization is to create psychological resilience in the client toward the phobic stimulus through contact with it (exposure), with a deliberate gradation of its difficulty in terms of intensity and frequency. As we have already stated, this technique is usually performed in a relaxed state – first in imagination, then in virtual 3D reality, and finally "in vivo." "In vivo" exposure is the most significant component of CBT for specific phobias and is carried out according to the order of difficulty of graduated contact with the phobic stimulus that the client established when defining the therapy goals (hierarchy of phobic situations). However, a relevant fact in this context is that patients who decided to prematurely terminate the CBT process most often cited the refusal to undergo "in vivo" exposure as the reason (Tolin, 2010), which opens up space for the use of some of the mentioned supplementary techniques, which we will discuss in more detail in the following sections. Finally, a specific form of desensitization is the so-called "flooding" method, where the client is exposed to the feared situation at full intensity and remains in it until the experienced anxiety decreases.
2.7 Reservations
Part of the client and professional community tends to perceive the cognitive-behavioral approach as overly focused on elements of logic (knowledge) and automaticity (behavioral conditioning) in the context of such a complex phenomenon as human existence. It is evident (and CBT takes this fact into account to some extent) that besides the rational component, the human psyche is also composed of its irrational component (including instincts, emotions, intuition, and the like), which becomes particularly important in the case of specific phobias. An inseparable part of the human psyche is also its noetic (spiritual, not necessarily religiously understood) dimension, manifesting primarily in the form of volitional mechanisms. Examples from practice that could support the indicated reservation include clients who, after completing CBT, experienced a temporary remission of (specific) phobic manifestations, but a new type of anxiety appeared, related to the very "being of man in the world," existential crises, or moral conflicts – a so-called noogenic (Greek nous – spirit) neurosis. This phenomenon could, in a certain sense, reflect the (currently minority) opinion that some specific phobias are (merely) a manifestation or accompanying symptom of much more severe mental disorders and diseases.
Another reservation, partially challenging the presumed extremely high effectiveness of CBT, concerns a numerically non-negligible group of patients who had successfully undergone the CBT therapy process in the past, but after several years experienced a relapse (Tolin, 2010). In some cases, this relapse took the form of a different type of specific phobia after the successful completion of therapy for the first phobia.
Also confirmed was the fact that in several quantitative studies focused on the success rate of CBT and presented in scientific circles over the past decades, the numbers of patients who prematurely terminated the therapeutic process (dropouts) were not critically considered (Ibidem). Since the interruption of (voluntary) therapy within any therapeutic direction is not a rare phenomenon, this fact interests us primarily in connection with the need for the correct choice of an appropriate therapeutic framework (after completing the diagnostic process and based on mutual agreement with the client). In our countries, this fact can cause significant practical problems because state therapists are usually bound by insurance companies and trained in only one or two therapeutic directions, and thus attempt to "fit" diverse clients into the adopted therapeutic framework.
The last known reservation toward the principles of CBT from former patients concerns the requirement to regularly expose oneself to the original phobic stimuli even after the completion of therapy. In the case of many specific phobias, however, this is not possible without seriously disrupting the client's healthy daily functioning schedule (for example, fear of flying, visiting the dentist, and the like). Moreover, in a planned exposure situation toward the phobic stimulus, the factor of randomness and spontaneity in the client's reaction to it is fundamentally absent, and thus also the factor of limited time to prepare for coping with it. These agents would accompany every real-life situation of encountering an authentic phobic stimulus.
3 Logotherapy
For logotherapy, the theoretical basis is an explanatory system built on three supporting pillars: the will to meaning, the meaning of suffering, and the freedom of will (Tavel, 2004: 19). In therapeutic practice, this means striving to discover the meaning of the client's suffering and to take a stance toward it by applying or developing the will to meaning. Subsequently, through the freedom of will, the client decides to choose one of the recognized options that the newly arisen situation offers and implements it (Ibidem).
The founders of logotherapy – Viktor Frankl and Elisabeth Lukasová – were convinced that "inner focus on meaning in the surrounding world stabilizes a person's affectivity. This in turn stabilizes their immunity and prevents the onset of psychosomatic illness" (Lukasová, 2009, p. 190).
We are interested in the question of meaning in connection with the topic of this article on three levels: 1) the awareness of meaning as an effective motivating force in the effort to achieve the elimination (or reduction) of the phobic disorder, for example, also in the form of the client's willingness to undergo in vivo exposure, 2) the personal meaning of life as an interpretation of life events (including phobic situations) in a meaningful context [Note: According to Längle, "to understand meaning means to grasp the whole – to give what appears as unrelated a context that challenges us to engage with it. Meaning always points to the current state, points to further contexts" (Längle, 2002, pp. 41-42).] 3) a change in the individual's value hierarchy – a transition from excessive focus on oneself and the satisfaction of needs (including a "safe" living environment where phobic stimuli are absent) to the realization of socially significant values (altruism, solidarity, empathy, and the like).
According to V. E. Frankl, the meaning of life is connected to the feeling of living for someone or for something. Focusing attention on a target point in the future creates a "psychological support" that helps a person not to succumb to the (de)forming forces of the social environment (Frankl, 2006, p. 104). In a meaningful human life, therefore, there should not be a missing reference point that meets three criteria: a) it should relate to the future, b) it should be distinct from the person, c) it should be unattainable (Lukasová, 2006, p. 10).
3.1 Self-Knowledge
An essential condition for any therapeutic work oriented toward meaning within logotherapy is self-knowledge. It reveals what already exists in a person's personality – unconscious instinctual needs, genetic predispositions, temperamental and personality characteristics, traits and abilities acquired through upbringing, as well as one's own volitional interventions from previous periods. A prerequisite for any effective change in psychotherapy or in everyday life is therefore knowledge of what is to be changed, what our task concerns.
3.2 Self-Management
The prerequisite for effective self-management is, in turn, the creation or development of the ability for inner control – the ability to distance oneself from the currently experienced mental content and the subsequent realization of inner growth.
3.3 Logotherapeutic Methods Usable for Treating Specific Phobias
1) Paradoxical intention allows the client to create distance from psychogenic triggers (activators), thereby rendering them ineffective. These are usually negative expectations and fears that can secondarily trigger the so-called self-fulfilling prophecy effect. Paradoxical intention teaches the patient to ironize the neurosis or its symptoms and consists of a therapeutic challenge for the patient to paradoxically wish for precisely what they fear. In a certain way, this method can be perceived as a "stepping beyond" and extremization of the "in vivo" exposure technique from the CBT framework, but instead of a primary focus on feelings (stress, fear of fear, etc.), in this case the client's attention is concentrated on the execution of a given cognitive task (where to find the snake, how much time is available, how to protect themselves in the process, etc.). The emotions at that moment are secondary or of a completely different nature than during exposure, e.g., excitement arising from a sense of adventure, joy from a felt sense of perspective over the situation, a feeling of adequacy to handle the situation, etc. Fear and desire collide with each other, inhibit each other, and thus cancel each other out – they reciprocally inhibit each other – the minus of fear and the plus of desire neutralize to zero (Lukasová, 2009, pp. 101-102).
2) Dereflection. Based on its formal linguistic structure, this technique from the framework of logotherapy is often incorrectly likened to the metacognitive position (defusion) from the CBT framework. Dereflection, however, presupposes redirecting thinking to other objects, not monitoring one's own thinking from a metacognitive position.] It aims to reduce egocentrism and hyperreflection in the client, based on the finding (and assumption) that hyperreflection is closely linked to extreme egocentrism, because the one who continuously deals with their own problems and unsatisfied wishes is not at all capable of perceiving anything other than themselves and, after a while, quite naturally becomes a "captive" of their own need for undisturbed well-being and health. If mentally unstable people suppressed their problems in the past, they later tend to hyperreflect on them, i.e., to attribute to them a higher degree of significance than would be appropriate from the perspective of maintaining mental health. In this context, logotherapy also includes two key anthropological features: self-detachment and self-transcendence. Self-detachment allows a person to realize their situation, to perceive individual life events from a different perspective, as if from the viewpoint of an observer, and to evaluate them objectively. Self-transcendence means focusing attention on something or someone else, different from "oneself," for example, on loved ones, work, society, nature, or God. Self-transcendence brings mental stability, because if a person constantly looks only at their own well-being, they live in permanent tension. They incessantly worry about themselves because their "self" is constantly under threat.
3) Modulation of attitude closes the triad of key logotherapeutic methods. In principle, it implies a change in the client's attitude toward irreversible life circumstances or phenomena. In practice, it is realized by pointing to: a) the value, b) the meaning, c) the possibilities, d) the perspective of the arisen situation. (Frankl, 2006, pp. 93-96) For the therapy of specific phobias, we recommend this method only rarely, as it could affect the treatment outcome counterproductively. We indicate its use only in cases where complete elimination of accompanying physiological manifestations upon encountering the phobic stimulus (pain from needle insertion during blood draw or vaccination, discomfort in the form of airplane turbulence during flight) is not possible (for example, phobias of necessary medical procedures).
3.4 Limits of Logotherapy
Humanistic directions in principle reject the concept of psychological measurement and quantification of therapeutic outcomes due to the reductionist, impersonal, unnatural (clinical environment), illusorily objective evaluative, and intellectualized nature of such research (Friedman – MacDonald, 2006). They hold the view that the client's inner experience cannot be quantified or objectified. In practice, this means that the professional community does not have sufficient data (experimentally obtained and processed research data) to assess treatment effectiveness even in the case of the logotherapeutic approach as a whole. On the other hand, many experimental studies have been conducted focusing on individual, isolated techniques from the framework of logotherapy, for example, investigating the correlation between life meaning and emotional stability.
As for the typology of the client base, it was found that non-directive logotherapeutic techniques are preferred mainly by motivated, verbally and introspectively skilled individuals (Melton – Schulenberg, 2008), which implies a significant narrowing of their general therapeutic applicability in practice.
Finally, due to the nature of its predominantly existential orientation, this type of treatment preferentially focuses on complex therapeutic goals such as self-knowledge, self-awareness, self-actualization, or other forms of personal growth, which many clients may perceive as an unwanted psychological burden exceeding the necessary framework, or as an unengaging and time (financially or otherwise) demanding activity, especially if their current pragmatic priority is the "immediate and effective removal of experienced discomfort" – in our case, a specific phobia.
4 Hypnosis
Suggestive and hypnotic psychotherapy do not act directly on the client's psyche but attempt to "bypass" their logical thinking. The conscious human mind operates on the principles of rationality, linearity, and causality. Persons under hypnosis, however, tend to connect their experience with a different logic than they use in the waking state. Unconscious thinking is more associative, metaphorical, and concrete (visual). Trance logic means that a person ceases to have the need to objectify the experience and unites consciousness and unconsciousness within themselves (Zíka, 1992, p. 39).
The main tools of hypnosis are the client's temporarily altered mental state (altered state of consciousness) and the therapist's authority – including effectively delivered suggestions aimed at achieving desirable attitudes and behavioral changes. The altered state of consciousness is characterized by: increased suggestibility, a trust relationship between the hypnotist and the hypnotized subject, as well as manifestations of relaxation, drowsiness, or inhibition (Kratochvíl, 2009). A decisive factor when considering the use of hypnosis in therapeutic practice is the so-called hypnotizability – the client's ability to enter a certain depth of the hypnotic state. Another significantly effective factor in the use of hypnotic therapy may also be the so-called placebo response effect, i.e., influencing the effectiveness of the therapeutic intervention by positive expectations on the part of the patient. In this context, clients are usually divided into so-called placebo reactors and placebo non-reactors.
4.1 Suggestions
Suggestion is usually understood as the verbal influence of one person on another (or on oneself), the result of which is an unconscious reaction. For a statement to be considered a suggestion, it must meet an important criterion – the reaction to it must be spontaneous, automatic.
Therapeutic suggestions are usually created according to the symptoms the therapist wishes to address. Inappropriate habits can be linked with aversion and indifference, or hypnotic suggestion can be used to strengthen motivation toward overcoming an undesirable habit. In practice, we distinguish between so-called direct (You will feel relaxed. You feel relaxed.) and indirect suggestions. The indirect form uses a short story, joke, metaphor, or talking about a third person. It can also take the form of an image suggestion, where we mentally transport the client to a place (most often in nature) where they carry out instructions given by the therapist. Created suggestions should be positively formulated, short, and understandable. Their rhythm is often an effective factor as well.
4.2 Anchoring
Another widespread method used in hypnotic practice is so-called anchoring. This involves linking a certain physiological or psychological state with some somatic or mental stimulus. In practice, this can mean either linking a state of relaxation during hypnosis with a certain verbal construction, for example, Whenever you say the words 'Peace, relax!', you will feel peaceful and relaxed as you do at this moment. It is also possible to link the state of relaxation with some action, for example, touching a certain place on the patient's body (somatic stimulus). In that case, the therapist asks the client to simultaneously press a certain place on their body, such as the wrist or the back of the hand, while experiencing deep relaxation. It is usually recommended to choose a body part that does not come into regular contact during the day (for example, during work, hygiene, exercise).
5 Case Studies of Specific Phobias
This part of the contribution contains two case studies from clinical practice. The time elapsed since the completion of therapy is, in each respective case, eight and five years.
Male, age 25, phobia of contracting HIV. Anamnesis. A young, single man J. K. lives in a common household with his mother and sister, with whom he has an exceptionally strong and close relationship. After experiencing several emotional disappointments, other women seem unreliable and cruel to him, so he spends most of his free time with his family at home, or at various cultural, sports, and entertainment events with friends.
J. K. suffers from a phobia of contracting HIV, therefore he adheres to extreme hygiene principles. He avoids physical contact with both acquaintances and strangers. Unless absolutely necessary, he does not use public toilets. Outside the home, he carries antibacterial gel or other disinfectant with him. During occasional sexual contact, he practices exclusively protected intercourse and refuses any intimate practices that could potentially endanger his health. When asked why his phobia concerns this particular disease, he states that it is the only incurable transmissible infection in the country where he lives.
J. K. considers the home environment safe; both his mother and sister work in the healthcare sector (his mother is a radiologist, his sister works in administration), so thanks to regular health checks at their workplaces, he does not consider the danger of infection from these persons likely.
In February 2007, his sister is hospitalized with a diagnosis of appendicitis. Part of the preoperative examinations includes blood tests, which reveal that the sister is a carrier of the HIV virus. The transmission of the disease likely occurred during unprotected sexual intercourse in the past. The duration of the infection was determined to be 1.5 years based on the stage of the disease.
Therapy. When J. K. learns this information and realizes that he lived with the infected relative in a common household the entire time, where he did not fully apply his extreme hygiene habits, he immediately schedules a blood test. The test results are negative, which only confirms medical statistics, according to which the possibility of contracting this virus by any means other than direct contact with bodily fluids is ruled out. J. K. begins to realize that his concerns about his own health were probably exaggerated and inadequate given the actual circumstances.
After the appendectomy, the sister recovered at home, to which J. K. reacted with ambivalent feelings. Although he loved his sister very much and the siblings were emotionally and mentally close, he simultaneously considered leaving the common household to "be safe" and avoid the risk of infection.
In this dilemmatic situation, he decides to visit a psychotherapist, whom he asks for advice on how to proceed. Although he repeatedly refuses the therapist's proposals for proper psychotherapy, in reality the treatment is implicitly carried out in the form of informal conversations about human life, being in the world, the meaning of life, and right (in the moral sense) conduct.
The therapist non-directively applies the logotherapeutic technique of dereflection and self-transcendence, directing J. K.'s attention to the current needs of his loved ones and the role he could play in fulfilling them. The client suddenly realizes that his relationship with his sister is one of the most positive and meaningful qualities in his life and subsequently rejects the idea of leaving the common household. A key role in the decision-making process was played by his involuntary statement that he would sacrifice even his life for his sister if necessary. At that moment, he realized that he was precisely in such a situation, since living with his original family, in his words, meant sacrificing his life to the risk of potential infection. The symbolic distance from his own "problem" simultaneously helps him see the previously exaggeratedly applied "protective practices" in a more objective light and realize at least partially the extent of their exaggeration and, in some cases, their ineffectiveness.
After realizing these facts, the secondary question remained how to behave in the risky environment so as to avoid possible infection, if possible. At this stage, the psychologist applied techniques from the therapeutic framework of CBT and guided the client toward restructuring the original cognitive schemas as well as adopting selected relaxation techniques. The final recovery of the patient thus occurred based on an overlay of two principles – logotherapeutic and cognitive-behavioral.
From the perspective of logotherapy, the principles of dereflection, self-transcendence, and subsequent reconstruction of the value system played a significant role. The discovery of (partial) life meaning (support and help for loved ones, experiencing authentic interpersonal relationships, focusing on experiential and relational values), in whose realization he could continue regardless of possible infection, was undoubtedly also therapeutically significant for the client. J. K. understood that he could not lose the decisive values in his life in any way, which subsequently freed him from excessive fear of illness and death. From the perspective of CBT, the following strategies proved effective: a) change of cognitive schemas, achieved through increasing awareness of the phobic object, b) relaxation enabled the client to eliminate (control) the habit of anxiety responses, c) the spontaneous long-term "in vivo exposure" in the form of living in a common household with an infected person also had a therapeutic effect.
Case Study No. 2
Female, age 43, arachnophobia. Anamnesis. A housewife who, together with her husband, cares for their two children – a son aged 19 and a daughter aged 17 – has been aware of a phobia of spiders since childhood. The initial stimulus was supposedly watching a documentary about tarantulas. In her own words, she describes these animals as "big, hairy, life-threatening creatures." She considers even the mere appearance of spiders (long legs, small body) to be threatening. Since that moment in childhood, the client cannot tolerate contact, or even the sight, of any spiders. Even talking about them makes her nauseous. She cannot even write the word "spider" or "tarantula" on paper. Just uttering these words by others gives her goosebumps. She also cannot stand the sight of any depiction of spiders in magazines and books. Before reading them, she always asks her husband to flip through the magazine and possibly warn her about pages with pictures or photographs of these animals. Plush and rubber toys in the shape of spiders cause her significant anxiety and heart palpitations. She describes the emotional states she experiences when seeing spiders as "disgust, revulsion, fear, hatred." When a live spider appears near her, she screams loudly and uncontrollably. Insect screens are installed on the windows throughout the apartment where the family lives. Before going to sleep in the evening, she always checks every corner of the apartment to determine any possible presence of spiders or cobwebs. Mrs. J. also refuses any stay in nature. Only after rain can she go into the forest to pick mushrooms, because according to her, spiders are hidden in damp weather. As she claims, she would most like to live in a country where spiders do not occur at all, because it is always cold and snowy there.
Therapy. At her husband's insistence, and also due to his numerous business trips, when the client finds herself at home without his help, Mrs. J. undergoes a psychodiagnostic examination. Already during the initial interview, she describes herself as an extremely suggestible and sensitive person. After completing the relevant examinations, the therapist, also thanks to the aforementioned statement and a subsequent hypnotizability test, decides to incorporate into the dominant CBT approach a technique for quickly and effectively achieving a relaxed state through hypnosis. He uses the anchoring method combined with direct suggestion: Whenever you touch the wrist of your right hand, you will achieve the same state of relaxation you are experiencing at this moment. Whenever you touch the wrist of your right hand, you will achieve an instant state of relaxation.
During the following two sessions, the therapist reinforces these suggestions and simultaneously guides the client to become aware of cognitive errors and incorrect assumptions regarding the danger of spiders to human life. Furthermore, he draws her attention to the fact that many cultures consider the spider a "symbol of good luck," and that its presence in the home is welcomed and intentionally sought. Since Mrs. J. is not only suggestible but also superstitious and irrationally thinking, perceiving herself as a victim of unfortunate life circumstances, she begins to think about the therapist's remark and, in the sense of the implicitly applied logotherapeutic technique of paradoxical intention, gradually starts to perceive the occurrence of spiders in her surroundings as a phenomenon beneficial for achieving the desired happy life. Spiders remain for her "visually repulsive creatures," but she newly thinks of them as a "necessary evil" that ultimately benefits her life.
During subsequent therapeutic sessions, the therapist and client perform "in vivo" exposure according to the usual levels of difficulty. At the sixth session, the client expresses her calmness and indifference regarding the presence or absence of common spiders in her living environment.
This situation was secondarily aided by the fact that the client's cousin, whom Mrs. J. occasionally helps with raising children, had in the meantime, at the children's insistence, purchased a pet tarantula, and the client thus learned a great deal of details about the life, care, and potential danger of this animal. She also discovered that a tarantula bite cannot be fatal (for her) in any way. Several times a week, she witnessed the children talking to the spider, feeding it, admiring it, and not being afraid of it at all. Moreover, the sight of the vulnerability of the tarantula's physical shell during the period of shedding its exoskeleton even evoked sympathy and curiosity in her. [Note: During this period, the tarantula does not accept food, lies on its back for several days, and barely moves. It cannot be fed or touched, as its body is soft and vulnerable to touch.]
Conclusion
The use of combined therapeutic techniques can be a significant effective factor influencing the course, effectiveness, and duration of treatment, as well as the possibility of maintaining its results permanently.
The functionality of the therapeutic intersection of CBT with logotherapy or hypnosis is also evidenced by the emergence of the so-called third wave of CBT (Metacognitive therapy, Acceptance and Commitment Treatment, Mindfulness-based Cognitive Therapy, Dialectical Behavioral Therapy, Functional Analytic Psychotherapy), within which there is an expansion of "the understanding of disorders and therapeutic help far beyond the original behavioral and cognitive paradigms" (Bažant, 2013, p. 87).
Author: Pavol Štubňa, Mgr. PhD. The author is an assistant professor at the department. In recent years, the focus of his scientific interest has been the intersection of literary studies and cognitive psychology in the form of an interdisciplinary direction called the psychology of literature. Using theoretical models as well as experimentally oriented research, he examines analogies between the principles of narrative psychology, narrative psychotherapy, bibliotherapy, and the structural-content components of literary texts.
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