Successful Treatment with Quick REMAP
By Annette Harmuth-Vollbehr
A needle phobia can be cured! The Quick REMAP treatment was developed by Dallas area psychotherapist, Steve B. Reed, LPC, LMSW, LMFT and is utilized by German psychologist Annette Harmuth-Vollbehr and many other therapists to treat needle phobias and other anxiety issues. In this article, Annette provides a wonderful case example of successfully treating a man whose needle phobia had been preventing him from obtaining needed medical and dental care. After treatment with Quick REMAP, he is successfully able to get the medical help that he requires.
For more information about treatment for phobias with Quick REMAP or to schedule an appointment, call Steve B. Reed, LPC at 972-997-9955.
Needle Phobia Case Summary
Needle phobias can produce intense symptoms and extreme avoidance behavior. This case study illustrates outpatient therapy for a client with a severe needle phobia. The client’s psychosocial history suggested a number of past events that appeared to be very traumatizing and to contribute to his phobia. None of those events had been treated sufficiently. The client’s experiences resulted in his increasing avoidance of needles, which soon extended to doctor and dentist visits as well as to medical treatment in general. The client's generalized fear of getting an injection and having to consult medical doctors resulted in constantly elevated anxiety levels, extremely cautious behavior and severe avoidance behavior.
At the beginning of treatment, the client received psycho-educational information about fear, trauma, and symptoms related to these conditions. Then the situations that were traumatizing for the client were treated with Quick REMAP. The client experienced an impressive reduction of his distress levels fairly quickly. The next step was a brief behavioral intervention in the form of gradual exposure to needles and injections. Interestingly, the exposure therapy was much easier, took less time, and caused much less fear and fewer symptoms than before the application of Quick REMAP. The client was gradually exposed to needles and injections during two sessions. Then, the client’s family doctor performed an immunization. Later, after a follow-up booster injection had been given, appointments were made for a blood-draw and a dentist visit. The client was then able to face and calmly deal with the triggers that formerly used to induce a major fear response. Therefore, the treatment could be terminated within a short time. While the Germany health insurance authorizes 25 therapy sessions, only ten sessions were needed. During a follow-up, the client stated that all the medical and dental treatments that he had required had been successfully performed without any major problems.
Needle Phobia – diagnosis and differential diagnosis
Needle phobia falls into the category of Specific Phobia (ICD 10 F40.2, DSM-IV-TR 300.29). According to the ICD 10, the most important criterion to differentiate phobia from common intensive fear is marked and persistent fear that is triggered by the presence or anticipation of a specific object or a specific situation. Examples for such triggers are seeing blood or injuries, doctor or dentist visits, certain animals (such as snakes or spiders), heights, darkness, thunder or storms, and the fear of exposure to certain illnesses. Needle phobia is also a specific phobia. Clients know that their fear is excessive or unreasonable, but they are rarely or not at all able to control their fear and endure the situation. When clients are confronted with the phobic situation (imaginary or in real life) they almost always experience emotional discomfort (such as fear or helplessness) and physical responses (accelerated heart rate, shortness of breath, a feeling of choking, muscle tension, trembling, sweating, dizziness, nausea, hot flushes or chills etc.). In general, clients develop anxious anticipation of, intense distress in, and partial or entire avoidance of the feared situation. This avoidance increasingly limits and interferes with the client’s functioning and quality of life. This again increases the client’s distress about merely having the phobia. The extent of the distress that a client experiences in daily functioning depends on how well they manage to avoid the phobic situation. A specific phobia often develops in childhood and young adulthood and can persist for a lifetime if untreated.
Needle Phobia diagnosis requires the following criteria to be met:
The emotional and physical symptoms are due to fear and not due to psychosis or compulsive thoughts.
Only the presence or anticipation of a specific phobic object or a specific situation triggers the fear. The phobic situation is avoided whenever possible.
Agoraphobia and Social Phobia are not the cause of the needle phobia. Phobias triggered by seeing blood, needles and injuries differ from other specific phobias because they lead to bradycardia (decreased heart rate) and sometimes fainting rather than tachycardia (accelerated heart rate). The anxiety response can have a biphasic autonomic pattern: at first the activity of the sympathetic nervous system increases briefly, then the parasympathetic nervous system kicks in too much, resulting in a lower pulse and blood pressure, which is often accompanied by nausea or fainting.
Needle Phobia symptoms experienced by the client
The client, a 24-year-old male, needs outpatient therapy for a severe needle phobia. His phobia is limiting his daily functioning substantially. For example, he has not had any vaccinations for some time, and he has not had any treatment by doctors or dentists for many years although he requires them urgently. In addition, when the client has larger injuries that need stitches, he always dresses them himself. He has been doing so since his teenage years in order to avoid doctor visits. This avoidance behavior has resulted in a number of unsightly scars over the years. During the first session, the young man reports that he has not seen his doctor in many years, although he has a trusting relationship with her. Dental treatments are also unbearable for him, so that he has not had a dentist visit in years as well. There is clearly an extreme avoidance behavior – for example, he is also unable to accompany friends to see the doctor even if he merely waits in the waiting room. When confronted with objects or stimuli which appears threatening to him (such as the image of a syringe, needle, or a scene on TV showing a doctor or dentist visit) the client responds with extreme physical symptoms. Those symptoms include heart palpitations, dizziness, a feeling of smothering, weakness and trembling in his knees, moist hands, and chills. Even though he has never fainted, in such situations he often feels as if he is just about to faint, the fear of which increases his anxiety even more.
Synopsis of psychotherapy
The client’s psychosocial history shows without a doubt that he experienced various events during his childhood and teenage years which were clearly traumatizing for him and which he has never processed effectively. The client had surgery at one year of age. He had several sports injuries and witnessed friends being injured in sporting activities. When his grandfather suffered a stroke, the client found him and had to call the ambulance in order to make sure that he received first aid. He was confronted with doctors, emergency rooms, and hospitals repeatedly in this manner. A total of seven events were identified that continued to feel very emotionally charged. These events were treated one-by-one with Quick REMAP. The client also received psycho-education as part of therapy, which included information about fear, trauma, and symptoms related to these conditions. Emotional and physical responses and processes, as well as escalating spirals of fear, thoughts, emotions, and behavior were explained.
In order to determine the effectiveness of treatment, behavioral interventions in form of exposure and systematic desensitization were used. Before treatment, the client experienced even a pin as a threatening object. He ranked the contact with one or more pins on a scale measuring fear from 0 to 100 at a level between 50 and 67. He ranked a sealed syringe that was placed two meters away from him at 85, and a syringe that was unwrapped but still at a clear distance he ranked at 94. When the object was moved closer, he ranked his fear at 98 to 100 and as “not acceptable or unable to even imagine tolerating”. It was interesting that exposure to needles after the treatment with Quick REMAP went well and without any major problems. On a scale from 0 to 10, he did not rank his fear higher than 5 in any situation and his fear was mostly at a 2 or 3 then. While the client could barely endure seeing a sealed syringe lying on a table at a distance of two meters at the beginning of treatment, he was able to take real syringes and needles out of their packages and handle them in person after the treatment with Quick REMAP. He could also go through a brief practice session with pictures of syringes and immunizations successfully. By working in this way, the exposure hierarchy that was developed at the beginning of treatment could be worked through in an impressively short time.
Then an appointment with the client’s family doctor was made to give a primary course of immunizations, which would be followed by a booster injection after the required time had elapsed in order to build up adequate protection. The doctor was informed about the client’s course of therapy. He was also given suggestions regarding how to make the immunizations easier for the client. Other appointments were then made for a blood-draw to perform a complete blood count and for a dental visit.
Treatment with Quick REMAP
The Quick REMAP method was explained, as well as what it was supposed to accomplish. The client ranked the seven events that he identified as being emotionally charged on a Subjective Units of Distress (SUD) Scale from zero to 10 (with zero being no emotional charge at all and 10 being the highest emotional charge possible).
At first, the situation the client ranked as least emotionally charged (a level three on the SUD scale) was treated with the Quick REMAP 4-point Protocol. (Nine years ago a friend suffered a concussion and a meniscus tear during a soccer game and the client had to give first aid. When the doctor arrived, he gave the soccer player a painkiller injection before he was transported to the hospital.) The REMAP Eye Circle helped the client to focus on the situation. After acupressure on the first two acupoints, Large Intestine (LI) 4 and Stomach (St.) 36, the client visibly experienced stress relief. He still remembered the situation clearly and in every detail, however, there was no emotional charge left on it. After the stimulation of Extra Point (Ext. Pt.) 1 located between the eyebrows and activation of the Ear Relaxation Point the client did not feel any more stress. Therefore, it was possible to move up to the next, more emotionally charged event in the hierarchy during the same session. Four more points were added to the Quick REMAP 4-point protocol, which are recommended for the treatment of fear, trauma, panic, and anxiety. These are, in addition to the four previously mentioned points: Liver (Liv.) 3, Spleen (Sp) 6, Bladder (B) 67, and Kidney (K) 3, 4, and 5.
The second situation had a distress level of five. (The client was nine years old when he had a severe bicycle accident, in which he suffered several lacerations and abrasions on his knees. The doctor cleaned and dressed his wounds, and one of them needed stitches for which he was injected with a local anesthetic.) The treatment of this specific memory with Quick REMAP brought further stress relief. The client was able to report a complete resolution of stress related to this incident after treatment on the acupoint known as Liver (Liv.) 3. This was the fifth acupoint to be stimulated during that treatment.
In the next session (which was the second Quick REMAP treatment session), an interesting domino effect could be observed: the distress levels of the various traumatic events were all somewhat lower than at the beginning of the previous session, even the levels of the events that had not yet been treated. The client then felt encouraged to move up to the next, more emotionally charged event in the hierarchy and to treat it.
According to the rules of EMDR (Eye Movement Desensitization and Reprocessing), which are also useful for the REMAP process, the first, the worst, and the last emotionally charged situation often need to be treated.
This raised a question that I had to consult with Steve Reed by mail to seek an answer: How should I treat the surgery that the client had at age one? Although this situation is undoubtedly imprinted somewhere in the client’s brain, such memories from early childhood cannot be recalled at all or only in very limited form. In addition, the client had no linguistic ability at that age. Steve Reed advised me to ask the client first, how his parents and other people he was close to had experienced the operation and the event in general at that time and how they talked about it in the present. Based on this information it could be concluded how the client himself had integrated the experience of this event in his own life story. Even though only limited details could be discovered to work with, the client still ranked his distress level at a four. By using the eight Quick REMAP acupoints for treating trauma, we were able to desensitize the emotional charge and successfully provided relief from his distress.
The remaining traumatic events were also treated and processed following the Quick REMAP protocol. The distress level of one event (a dentist visit when the client was 13 years old) was first ranked at a level seven, but after the first Quick REMAP session and after treating other traumas it had gone down to five. (This event involved a tooth that needed to be pulled. The client fought the injection of a local anesthetic and was held down by two assistant. This resulted in feelings of panic, fear, constraint, being forced, utter helplessness, and loss of control. The client feels shame and embarrassment when he remembers how the dentist talked down on him: “Don’t be such a coward. You are a boy after all!” and “This is only a small syringe. Look at this one, there are much bigger ones!” Steve Reed explains that the cortex (or thinking brain) goes “offline” in situations of panic. As a result, it cannot be reached with logic. Therefore, the dentist’s demonstration of a larger syringe may have been well intended; however, it was entirely ineffective. After acupressure on the first acupoint, LI 4, the distress level and the feelings of shame and embarrassment exacerbated. A cognitive intervention was then added to the protocol to counteract the added distress that was actually coming from the client's cortex rather than his mid brain. While continuing to stimulate the LI 4 acupoint, the client was then asked to repeat phrases suggested by the therapist three times: “I am okay, even though I feel scared. And the truth is that the dentist made mistakes and did not treat me well.” After a very short time, the feelings of stress were relieved to a large extent, and the acupressure on the two following points (St. 36, Ext. Pt. 1) reduced the feelings of fear and stress substantially more. After the stimulation of the remaining five Quick REMAP acupoints for trauma, the client’s distress level went down to zero, there was no stress left, and the client was tired but content.
Two events were both originally ranked at a distress level of nine (The client’s last attempt to receive an immunization and his grandfather’s stroke. His grandfather had a stroke when the client was 19 years old. The client found him, and there was nobody else around. It was he who called the ambulance and stayed with his grandfather until the ambulance arrived.) At first, this memory was very emotionally charged at a distress level of nine. When the client talked about this experience, he felt very stressed and tense, he got a headache easily, and he choked. The Quick REMAP protocol reduced the client’s feelings of stress to a distress level of two; however, it could not be reduced further. The client thought that this remaining stress may be due to his fear of losing a relative and his being aware of the fact that he will lose a relative sooner or later (fear of illness and death).
The final stressful event we worked on was the doctor’s last attempt to give the client a shot. (Following the doctor’s advice, the client had taken a tranquilizer right before the appointment. Still, the attempt to give the client a shot failed because the client responded with extreme panic and felt like taking flight.) At that point, the client’s doctor advised him to seek psychotherapy. This incident was “the last” phobic situation the client had experienced. Having treated other events with Quick REMAP, this upsetting event had also been relieved to some extent as well. While the client had originally rated the distress of this event very high, at a level nine at the beginning of treatment, he rated it only at a distress level of five at the beginning of that particular session. The client responded quickly to the stimulation of the now well-known Quick REMAP acupressure points and his distress level went down to a level two. Repeatedly, phrases of self-acceptance needed to be found and used (“I am okay; even though I am scared … even though I panic when I get shots…” etc.). The client’s stress level, however, did not go all the way down to zero, which may be linked to his being aware that he would have to face the real situation again in the near future when he would receive the booster injection. He was not sure at that point whether he would be able to handle another shot.
However, as elaborated above, after a brief behavioral intervention (exposure and systematic desensitization), the doctor could be contacted, the first shot was made possible, and further medical and dental treatments followed.
In the follow-up session, the client reported also that his general anxiety level had gone down; he had become calmer and more relaxed. He also stated that his quality of life had increased considerably since he had solved his problem.
By utilizing Quick REMAP, the original traumas that had been experienced by the client and that led to his needle phobia and his extreme avoidance behavior regarding physicians in general were all resolved. The client experienced enormous stress relief through his treatment with Quick REMAP. This made further exposure therapy and systematic desensitization easier. Quick REMAP treatment made it possible for this man to contact the doctor, get his immunization and other necessary medical treatments after only a brief amount of therapy.