Travel, trauma, and phobia: Treating the survivors of transport-related trauma

Abstract

Travelling by public and personal transport is an important part of modern life. Travel phobia is a common and disabling problem characterized by strong fear and avoidance of travel. It can interfere severely with the individual's occupational and social functioning. In clinical settings, fear of travel may present either as the main problem (i.e., as a specific phobia) or as part of another anxiety disorder (e.g., agoraphobia, claustrophobia). It may also develop as a response to experiencing a traumatic event when travelling (e.g., assault, terrorist attack, or severe accident). Whereas the phenomenology of travel fears shares many features among these subgroups of patients (Blanchard & Hickling, 1997; Ehlers, Hofmann, Herda, & Roth, 1994), the concerns that lead people to be afraid of travel may be quite different. Travelling can activate social concerns, such as concerns about behaving in a way that would be embarrassing, thus overlapping in relevant concerns with social phobia. Cognitive behavioural therapy of travel phobia will thus need to be informed about the idiosyncratic cognitions that drive a patient's avoidance behaviour. As this chapter will show, treatment techniques that were developed for the treatment of panic disorder and post-traumatic stress disorder are often helpful in addressing the patient's relevant concerns. This is especially relevant for patients whose travel phobia was triggered by a traumatic event. In order to treat travel phobias after traumatic events, the therapist will need to map the patient's concerns in order to choose the appropriate methods of challenging them and may need to draw on recent advances in treating trauma memories. We will illustrate how a cognitive formulation that takes into account cognitive elements of panic disorder and posttraumatic stress disorder (PTSD) helps direct treatment of travel phobia after traumatic events, drawing on cases from the tragic events in London on 7 July 2005. Mindful of the potential overlap in PTSD and specific phobia symptoms in the context of this large-scale trauma, the authors sought to develop a treatment protocol for individuals presenting with travel fear and avoidance based on existing specific phobia (Davey, 1997) and PTSD treatments. This chapter describes the treatment of two survivors of the London bombings from within a series of patients referred for treatment of fear and avoidance of transport situations; one with a primary diagnosis of travel phobia, the other with a primary diagnosis of PTSD. Both exhibited fear and avoidance of transport situations. Both exhibited some symptoms of re-experiencing and arousal. However, the differential diagnoses, formulations, and treatment protocols illustrate the importance of a range of interventions to treat both PTSD and phobias following trauma.