Case History

Background Information
John, a 19 years old male, in good health was enlisted to the army and posted to be a transport operator. There are no records of any family mental health history, drug and alcohol history. He is soft spoken and not very sociable.

Current Status
John display signs of fear when put behind the wheels of a vehicle. His legs are trembling, and he grips the steering wheel of the vehicle extremely tight. He gets into panic attack, suffer breathlessness and breaks down crying.
It was later found out from interviewing him that he suffers from post-traumatic phobia. He was in a vehicle that met with a road accident driven by his father.
His fear of driving is caused by and made worse by his obsessive, negative thoughts. These thoughts can be scary and irrational, such as the concern that he will drive off a road, in to pedestrians, and met with an accident like his father or he may be more focused on his physical feelings of anxiety such as a rapid heartbeat or trembling. These automatic thoughts are often described as the most bothersome symptom of driving phobia and they can be the actual triggers for panic attacks while driving.

Desired Status
Controlling John’s thoughts is critical to success in eliminating his driving phobia once and for all. The challenge is to eliminate John’s driving phobia within a 8 week time frame and for him to pass the military driving test.

Psychoanalytic Theory
Psychoanalytic Theory was founded by Sigmund Freud (1856-1939) in the late 1800’s. Freud believed that people could be cured by making their unconscious thoughts and motivations conscious. The aim of psychoanalysis therapy is to release repressed emotions and experiences. It is commonly used to treat depression and anxiety disorders.
According to Freud’s Psychoanalytic Theory of personality, personality is composed of three elements which known as the id, ego, and superego. These three elements work together to create complex human behaviors.
The id is the only component of personality that is present from birth. It is the most primitive and instinctive structure, functioned unconsciously, operated on the pleasure principle, and sought immediate gratification of all desires, wants and needs. If these needs are not satisfied immediately, the result is a state of anxiety or tension.
The ego operates with reason on the reality principle, and regulates the id by satisfying desires in realistic and socially appropriate ways. According to Freud, the ego develops from the id and ensures that the impulses of the id can be expressed in a manner acceptable in the real world. The ego considers social realities and norms, etiquette and rules in deciding how to behave. The ego functions in the conscious, preconscious, and unconscious mind. The ego also discharges tension created by unmet impulses through the secondary process, in which the ego tries to find an object in real world that matches the mental image created by the id’s primary process.
The last component of personality is the superego. It operates on the moral principle, and regulates the id based on social learning and issues of morality. The superego provides guidelines for making judgments. According to Freud, the superego begins to emerge at around age five. The superego acts to perfect and civilize our behavior. It works to suppress all unacceptable urges of the id and struggles to make the ego to turn to moralistic goals rather than simply realistic ones and to strive for perfection. The superego is present in the conscious, preconscious and unconscious.
Freud believed that these three basic structures were in constant conflict. When these parts are in conflict, an imbalance occurs in the form of psychological distress.
Freud’s psychoanalytic theory of phobias is based largely on the theories of repression and displacement. It is believed that phobias are the product of unresolved conflicts between the id and the superego. The ego attempts to modulate these conflicting goals by using a number of coping mechanisms. Repression is one of such mechanisms. In repression, the ego attempts to “forget” that the conflict exists. Therefore, when John is not driving, he “forgets” the fear however, whenever he is asked to drive, the “fear” emerges and he would recall the accident involving him and his father, causing him to tremble and suffer panic attack as he is afraid that the same accident will recur.

Cognitive-Behavioural Theory

Cognitive therapy is first and foremost a psychotherapeutic approach which attempts to influence human behaviours and dysfunctional emotions. The methodology behind cognitive therapy is to analyse negative emotions and identify inaccurate and dysfunctional behaviours. The method is both goal-oriented and well-organised.
The theory behind this method was formed as a result of merging the works of Aaron T. Beck and Albert Ellis. The two theories that were merged to create this method were behaviour theory and cognitive theory. It is therefore now known as Cognitive Behavioural Theory (CBT). Albert Ellis first originated rational therapy which was a main step in the development of CBT. Aaron T. Buck was inspired by Ellis’ work and this led him to develop cognitive therapy.
In the beginning both of these theories were compared and there was an attempt made to determine which one was the best approach. However they were merged instead into one to form CBT. The creation of this joint theory has led to the development of successful treatments for panic disorders. For example, Exposure therapy is a specific type of cognitive behavioral psychotherapy technique that is often used in the treatment of post-traumatic stress disorder (PTSD) and phobias.
In PTSD, exposure therapy is intended to help the patient face and gain control of the fear and distress that was overwhelming in the trauma, and must be done very carefully in order not to re-traumatize the patient. In some cases, trauma memories or reminders can be confronted all at once (”flooding”), while for other individuals or traumas it is preferable to work gradually up to the most severe trauma by using relaxation techniques and either starting with less upsetting life stressors or by taking the trauma one piece at a time (”desensitization”).

Intervention & Integration

By using Freud’s theory of phobias, John is made to go through the various safety aspect of driving a military vehicle in his head, to picture himself performing the various safety procedures, to get the steps into his subconscious mind. He is advised to play the scenario of him performing the various safety procedures vividly in his head before he goes to bed every night i.e. apply the handbrake and engage first gear whenever the vehicle comes to a complete stop, to check his mirrors before moving off and when coming to a stop. By doing so John’s focus will be on the safety procedures rather than the memory of his father’s accident when he is behind the wheels. He will also be asked to say out each procedure he does when he is driving, thus preventing him to think about his fear. By doing all this we are actually using the ego to “forgets” about the conflicts between his id and superego.
John will also be going through a systematic desensitization CBT developed by Joseph Wolpe. Avoidance can make these symptoms of fear of driving the vehicle stick around longer or even intensify. That is, because a person is avoiding certain situations, thoughts, or emotions, he doesn't have the opportunity to learn that these situations may not be quite as threatening as they seem. In addition, by avoiding thoughts, memories, and emotions, a person doesn't let himself to fully process those experiences. Hence graduated exposure therapy then is to help reduce a person's fear and anxiety, with the ultimate goal of eliminating avoidance behavior and increasing quality of life. This is done by actively confronting the things that a person fears. By confronting feared situations, anxiety and fear will lessen and the person will be more in control.
The steps are firstly: Identification of the anxiety using stimulus hierarchy. This is done through a virtual reality driving stimulator, it allows John to identify a fear hierarchy. The fear hierarchy would list the relative unpleasantness of various levels of exposure to the fear. i.e driving the vehicle on a straight road at various speed, negotiating a bend at various speed and etc.
The second step is the learning of relaxation or coping techniques. One of which is relaxation training in the form of meditation, but due to the circumstances and tight training schedule, a break of 10 mins will be planned for John after every 30 mins of driving, so that he can talk about his experience and fear. Maybe you've experienced this for yourself - Every time I'm stressed and I talk to one of my friends, I find that the solutions for the problems I face make themselves come through. I feel lighter and better and the degree of the tension and stress reduces. It focuses on targeting the post-traumatic stress and tension that John faces. It goes to the root of the problem and helps John face the trauma and find solutions for the same and also help him relax. This provides John with a means of controlling his fears, rather than let it increase to intolerable levels.
The third step would be to connect the stimuli to the incompatible response or coping method. John would be presented with increasing levels of the feared stimuli from lowest to highest—while utilizing the coping techniques and the “saying out of the safety procedures while driving” techniques previously learned.
In this case: we propose a scale of 1-10:
1 is the starting point that will produce the least relative anxiety. A "10" would be at the top and potentially create panic if exposed to it too soon. We would hence propose to set this up in grade intervals, where there are 6 grade intervals in total.
1-2 is letting John drive in a controlled environment for 1 week.
3-4 will be exposing John to driving on public road with little traffic for 2 week.
5-6 will be exposing John to driving on public road with heavier traffic for 2 week.
7-8 will be exposing John to another type of vehicle and letting him drive on public road with light traffic for 1 week.
9 will be exposing John to driving the new vehicle on public road with heavy traffic for 1 week.
10 will be John is found competent to take the test and that he knows he is perfectly safe and in total control of the vehicle, and that the accident with his faher was a one-time accident which will not occur with himself if he practice all the safey procedures taught to him.
By the end of the 8 week training, John’s phobia will be completely cure.

Conclusion

Psychoanalysis is a wide, in-depth area to discuss that we feel restricted in covering all areas that could be applied to John. Most of our ideas have come from Freudian.
"an exciting feature of Freudian psychology was that it promised a methodology for at last studying personality in proper depth and for treating complex human problems with the sophistication they deserved".
Cognitive behaviour therapy is useful restricted to treating certain cases in our opinion. One advantage is the therapist themselves is not so important as a psychoanalyst is for example, which means almost anyone can be taught the theory and techniques. We think it would be most suitable for short-term behaviour changes and best advantage is the examination of belief systems.
In John's case we do not believe Behavioural therapy would be suitable as John has some aspects of his past which we believe he needs to examine and work through for a total change of character. i.e him not being sociable. If John were treated only using behavioural techniques, the trauma he has experienced in his past would most likely surface again in the future. Which is why we choose to combine the Freudian psychoanalytic theory and the Cogntive-Behavioral theory to work on John’s case.

References http://ptsd.about.com/od/treatment/a/ExposureTxPTSD.htm http://www.anxietytreatmentexperts.com/cbt_exposure_therapy.asp http://en.wikipedia.org/wiki/Systematic_desensitization http://www.buzzle.com/articles/cognitive-behavioral-theory.html http://psychcentral.com/lib/what-is-exposure-therapy/0001640 https://www.boundless.com/psychology/personality/psychodynamic-perspective-on-personality/freud-s-psychoanalytic-theory-of-personality/ http://www.simplypsychology.org/psychoanalysis.html http://www.simplypsychology.org/psyche.html
http://psychology.about.com/od/theoriesofpersonality/a/personalityelem.htm