Case study
An integrative approach — working through fear — case study of a 10-year-old boy
Abstract
Persistent, excessive fear can be debilitating and a block to all levels of an individual’s growth. Left untreated, permanent alterations in brain chemistry can develop. This is especially of concern when the patient is a 10-year-old boy suffering from increasingly unabated fear, spanning over more than a year, which is deeply troubling and disruptive to him and his entire family. In this case study presentation, we will detail the case history and progress by providing the psychoanalyst’s notes and the direct correspondence received from the patient’s father. The author highlights the methodologies employed and states why they were chosen, comparing their results with the desired objectives.
Patient history, correspondence and updates
Andrew (a privacy pseudonym) is an adorable and otherwise well-adjusted ten-year-old boy who comes from a psychologically informed and supportive family. When his father reached out to me, the situation had been getting progressively worse over a span of more than a year, interfering with his sleep, his home life and social life.
Below is a combination of correspondence and notes that provide background information and progress details on the case:
Information I requested from Andrew’s father prior to our first session:
• How long has this situation been going on?
• Was there an event that triggered the onset?
• Is there a phase he is going through that is challenging, frightening or anxiety-provoking?
• Based on your best assessment, are there fears that he may have, and that he may be projecting onto these imagined creatures?
19.09.16, Notes from Andrew’s father received via e-mail:
Andrew has always been a good sleeper. It started months ago when he started coming into our room, occasionally in the middle of the night, saying he had had a bad dream or couldn’t sleep. As far back as a year ago, he felt afraid to be alone in the dark, or in his room to go to sleep, and so we would lie down with him to help him fall asleep. It has steadily worsened and in the last month it has gotten much worse and reached a point where he feels too afraid to sleep in his room. At first, we occasionally let him sleep in our bed when afraid. In the last month, he began to wake up every night in the middle of the night, afraid. So after being woken nightly, we eventually put a mattress on the floor of our room for him to sleep there in the hopes it was a blip and would pass. We tried that for a week, but even with the mattress in our room, he was too afraid to stay on the mattress on the floor and came into our bed.
Before it really escalated, I had been trying to get to the bottom of the issue. At first he told me that he saw something scary last Halloween and that was the issue. For quite a long time, when we drove by the old J&R building at City Hall (in lower Manhattan) he would look away because he had seen large billboards with frightening costume advertising on the wall, at Halloween last year, and didn’t want to drive down that road. He has complained intermittently about scary advert posters on buses, etc. When it got much worse some weeks ago, he confided that he was playing a kids game online and a zombie advert popped up, with much gore and violence, and it freaked him out. He said that he couldn’t get the images out of his head no matter how much he tried. It was a night-time scene. He now expresses extreme fear of the dark. Right after he saw the zombie clip, he was very afraid of the dark, and whenever we were out and about he would ask to leave and come home so that he would be home before dark, with the doors locked and all lights on. At night he won’t be in a room alone. In the day, he seems fine, and says that he is ok during the day.
I have spoken with him about being with feelings and experiencing them, and know that they will pass. He says he tries to do so, but it is too scary. I have spoken about how it’s not real, and says he knows that, but can’t get the images out of his head and they terrify him. He has said that he needs to occupy his mind so that he doesn’t think about the images and turns on music at night, in order to distract himself and go to sleep. I have tried various approaches, but nothing seems to have helped much.
Last night is a good example of where he is at present. He wouldn’t leave the living room to go to bed unless someone was with him to walk him to his room, and wouldn’t go to bed unless someone lay down with him until he fell asleep. After 30 minutes I tried to get up and he stirred and woke himself and insisted I stay, so I stayed another 30 minutes. Got up to leave and he woke again. I insisted I couldn’t stay any longer, and he needed to go to sleep. After some protesting and trying to get up and crying he eventually stayed. Several hours later when I was going to bed, I found him still awake and looking at the light down the hallway. He said he couldn’t fall asleep. I spoke with him for a while and then insisted that he had to sleep by himself and work through the fears, and went next door to my bedroom, with the doors open. He started whimpering about how afraid he was, which escalated to crying and calling out for mama or dada to stay with him. After a few minutes, that started escalating to panic breathing and louder terrified crying. After 5 minutes of this and some more attempts to talk with him and calm him and find some resolution for him to sleep alone, I gave up and let him sleep in our bed with his mother and I slept in his bed.
I don’t know if there are other fear issues he is projecting onto the zombies; would be good to explore.
19.09.16 Analyst’s notes, session #1:
Andrew recounts that a few months back he was “waiting to watch Mine Craft (computer game) when an ad for zombies popped up on his iPad and it was awfully scary. These creatures are all full of blood and they can eat your brain and turn you into one of them. They can take over the planet and turn everyone into one of them. You have to survive.” (Note to self: Deep underlying fears may be connected to survival, either personally, ancestrally or at the level of the collective unconscious?)
Andrew had a hard time initially articulating what he was experiencing, but with some help he was able to do so. He was rigid and anxious. We did several rounds of relaxation techniques, which included the use of essential oils, EFT, touch and deep breathing. He immediately felt better and looked much more alive. I gave him written instructions on how he could do the EFT exercise on his own before going to sleep.
20.09.16 Progress update received from Andrew’s father via e-mail after session #1:
Thank you so much for seeing Andrew today! The EFT tapping technique is great for him and he feels more empowered.
I don’t have any additional insight. In general Andrew is prone to emotional over-reaction, is very sensitive and has low emotional resilience. He is easily offended and quick to anger and we work a lot on those things.
11.10.16 Analyst’s notes, session #2:
His father more recently reported there had been some initial progress. Andrew had even taped the EFT instructions by his bed wall, but with time he has regressed back to waking up and wanting to sleep in his parents’ room. During our session, Andrew downplayed the regression and said he was doing much better. He reports that he listens to music or tries not to think about them. The fear is that there are zombies circulating the house but they can’t get in because the doors are locked. I asked him to imagine the details and share them with me while I conducted an EFT exercise that consisted of tapping on designated acupuncture points that could help him relax as he continued recounting the details to the questions I asked. I had him repeat the reframe: “Although I Andrew, have fear of these zombies circulating my house and I know it is my imagination, I still have some fear even though I know I am safe and protected and know I am a good kid.” I asked him to continue doing the exercise on his own.
19.10.16 Progress update received from Andrew’s father via email after Session #2:
I think we have seen some improvement with Andrew. He has come into our bed four nights this week, and he tried to come in the other nights during the middle of the night, but we were able to talk him back into staying on his mattress on the floor next to us. Previously he would refuse to stay on his mattress and get panicky at the prospect of not coming into our bed.
We were also in the park one night, and another evening he was comfortable to run down the sidewalk on his own in the dark. Previously he would fixate on wanting to go home before dusk to be locked safe inside the house before dark.
19.10.16 Analyst’s notes, session #3:
Andrew reported that he was much better and that the zombies had only come to mind once during the past week and that he used the oil and was able to get himself back to sleep. We re-imagined the images and the scenes. In his mind’s eye, he saw the scenes from an aerial prospective, overlooking his house, and the zombies are surrounding the house. From that distance, they are small and look like normal people. I sensed there is still residual fear. I asked him to reimagine all the details of the events and to share them with me. I did the relaxation protocol and then EFT on him as he retold the details of the episodes. I continued to ask endless questions about the story. He eventually got bored with the story and automatically switched to telling me “a funny story”, a prank Andrews’s friend’s dad had played on his son. Andrew was able to linger in the humour of the story without being distracted by the zombie phobia. I sense a substantial shift has taken place with Andrew in our session at that moment. We spent the remainder of the session chatting.
In a telephone conversation a few days after session #3, I shared with his father that I had confronted Andrew and asked him why he continued to sleep in his parents’ room if he was so much better? He replied that they were having houseguests for a few weeks and there was no other place for him to sleep. I responded to both Andrew and his father saying “fair enough”, that that was a valid reason. I asked his father to report back once the houseguests had left and things at home had returned to normal.
12.11.16 Progress updates received from Andrew’s father via email 3 weeks after Session #3:
I would like to give you a progress report on Andrew. He has started to sleep in his bed again! After all of the houseguests left and I returned from a weekend away, he resolutely moved back to his bed, and has been staying there through the night. He slept there all last week without coming in and waking us up. This weekend he is at a sleep-away with one of his friends at their house.
So, beautiful progress, thank You!!!
Methodologies applied in case study
Classical Depth Psychology approach: determining the patient’s defence mechanisms
As we read Andrew’s father’s initial description of the situation, we suspected that a major defence mechanism that Andrew used to cope with his fears was ‘Avoidance’. As his father noted:
“He has said that he needs to occupy his mind so that he doesn’t think about the images, and turns on music at night, in order to distract himself to go to sleep.”
In session Andrew himself stated, “I listen to music or try not to think about them.”
What further confirmed the hypothesis of an avoidance defence mechanism was the observation that Andrew tended to avoid answering any questions related to the zombies with any details. Rather, he dodged the topic and spoke in vague and minimal terms. It became apparent that in order to eliminate his fear we needed to make his fear concrete and present, rather than vague and distant. Increasingly, we focused on this approach, asking Andrew endless questions about the zombies.
Employing Relaxation Techniques — Aromatherapy, EFT, Deep Breathing and Touch
Since having Andrew revisit the fearful episodes might activate the fear response and deepen his trauma we employed various relaxation techniques. Firstly, we placed a few drops of essential oils in the palm of his hand, asked him to rub his hands vigorously together and inhale very deeply several times. We then employed EFT (Emotional Freedom Technique), which consists of tapping with one’s finger pads on particular acupuncture points on the face and upper torso that activate the relaxation response. We tapped on him, gently touching acupuncture locations on his face and torso as he recounted the same scary story he had told himself countless times. From our experience, this approach, which is a combination of aromatherapy, deep breathing, EFT, which makes use of physical touch, has demonstrated to be highly effective in the consulting-room in eliciting the relaxation response and facilitating a positive shift in the patent’s prospective. Perhaps the shift is assisted through a process where the patient experiences the story through a different sensational context, downloading the episode, if you will, in a more relaxed and calm manner, breaking the chain of a fear-based fight or flight autonomic response.
Determining the patient’s defence mechanisms — continued
Another defence mechanism that Andrew seemed to employ was ‘Minimisation’. At the start of both sessions #2 and #3, he reported he was doing much better whereas his father had reported some improvement but with still some fear. We suspected Andrew was experiencing discomfort and shame relative to his fear. We addressed this in several ways. One was in the EFT re-frame where we added “And I’m a good kid”. We also confronted him directly, asking why he continued to sleep in his parents’ room if he was so much better. This question later proved beneficial on many levels since it clarified the issue in his father’s mind as well as set a plan and target that we could later validate.
Employing other Depth Psychology modalities
To help strengthen his pre-existing intellectual understanding, that all of this was in his mind and a product of his own imagination, we did not deny, dismiss or minimize his visions when he was gripped by them, but rather, tried to enter into his reality. We encouraged him, through ‘Mirroring’, to articulate the scary story in a rather matter of fact manner. We continued to dialogue with Andrew in a tone and with a presence that validated his experience. This approach, coupled with the continued focus on the story, moved the fear projection out of a conceptual — mental state and more into an actual concrete reality state, where he was later able to disconnect from his imagined fears.
Reliance on the presence and power of intuition
Intuition is a topic amply addressed by Sri Aurobindo in The Life Divine. He writes:
“The sages of the Veda and Vedanta relied entirely upon intuition and spiritual experience. It is by an error that scholars sometimes speak of great debates or discussions in the Upanishad. Wherever there is the appearance of a controversy, it is not by discussion, by dialectics or the use of logical reasoning that it proceeds, but by a comparison of intuitions and experiences in which the less luminous gives place to the more luminous, the narrower, faultier or less essential to the more comprehensive, more perfect, more essential. The question asked by one sage of another is ‘What dost thou know?’, not “What dost thou think?” nor ‘To what conclusion has thy reasoning arrived?’ Nowhere in the Upanishads do we find any trace of logical reasoning urged in support of the truths of Vedanta. Intuition, the sages seem to have held, must be corrected by a more perfect intuition; logical reasoning cannot be its judge (1).”
Intuition is a human state of consciousness, veiled to various degrees to all of us, yet still accessible. Like many disciplines or talents, it can be become an ever-increasing part of our knowing and can be further refined.
In working with patients, Intuition can be a source of razor-like precision, helping us hone directly into the core issues. It can reveal itself to us in a powerful passing thought, a sensation, a feeling or an inclination. It can speak to us in a presentation of facts, circumstances and moments that arise in a gestalt fashion. It can unveil an entire story or situation, like a dewdrop reflecting a vast landscape. This “more comprehensive, more perfect, more essential” state is not arrived at through consecutive logical thought and reasoning. Most of us, I believe, possess this capacity and through a process of awareness, it can be honed and become a powerful instrument in helping us work with patients.
As the 13th century Persian mystic Sufi poet, Jalul-ud Din Rumi articulates in the following poem entitled, ‘Two Kinds of Intellect’:
“There are two kinds of intellect; the first is acquired -
Thanks to it, you learn like a schoolboy
Books, teachers, reflection, concepts, all kinds of sciences.
You learn and your intellect grows superior.
But conserving this knowledge is always a burden.
The other intellect is God’s pure gift;
Its heart is in the breast of the soul.
When the water of divine gnosis jets from the heart
It never becomes stagnant or old or dirty.
And if it can’t flow outside, what does that matter?
It keeps foaming up from within the heart (3).”
Intuition was in place in this case and in particular came at a specific moment in my work with Andrew. Towards the later part of our third and last session, Andrew spontaneously shifted gears. He stopped responding to my endless questions about the zombies and changed the topic. His entire demeanour and energy shifted. I strongly sensed, in that moment, that the fear that had possessed him for over a year had lifted. I no longer felt compelled to have Andrew continue focusing on the story of the zombies but rather allowed the conversation to move to a light and playful place. Subsequent progress confirmed this intuitive knowing.
Reliance on the Presence and Power of Grace
With every encounter in the consulting-room, one knows that the deep and sustaining work is being done through Grace and that our work at hand is to surrender to that Grace.
As Sri Aurobindo advises in Letters on Yoga:
“Put your trust in the grace of the One and Divine which has already touched you and opened its door and rely on it for all that is to come (2).”
In entering the realm of deep therapeutic soul work, one is reminded that one is entering a sacred space, entering a sacred relationship with the other and that even the multiple therapeutic modalities that parade in one’s mind and that one is drawn to apply are a working of Grace. This constant reminder “of trust in the grace of the One and Divine” and the surrender to that knowing, appears to me, to be at the core and the source of the healing. Andrew’s progress appeared remarkably deep and swift. We had started working on September 19th and by October 19th at our third and last session the gripping fear that had possessed him for over a year appeared to have lifted.
To be reassured that the shift continued, on December 12, 2016, I again followed up with Andrew’s father. He gladly reported that Andrew continues to sleep throughout the night in his own bed and continues to show no signs of regression.
References
1. Sri Aurobindo. Birth Centenary Library, Volume 18. Pondicherry: Sri Aurobindo Ashram Trust; 1970, p. 69.
2. Sri Aurobindo. SABCL, Volume 23. 1970, p. 897.
3. Harvey A. A Year of Rumi. [Online] Available from: http://www.dailyom.com/mycourses [Accessed 27th January 2017].
Dorathea Thompson is an integrative psychoanalyst in private practice at New York City.
Share with us (Comments,contributions,opinions)
When reproducing this feature, please credit NAMAH,and give the byline. Please send us cuttings.
