Fear of feeling powerless: Case study Kofi

Nobody likes going to the dentist. But for some people, the problems run deeper and form a phobia. The causes of dental phobia can be many and varied. This case study is of a patient whose dental phobia stemmed from how powerless he felt in the dentist chair.

The Patient

Kofi had not been to the dentist for over a decade. His phobia arose from the fact that he did not feel comfortable allowing himself to be treated. A large part of that was because of particular personality traits that allowed him to be successful in other areas of his life. For example, his career as a successful businessman was largely due to his ability to take ownership of projects and control of situations. Placing himself totally in control of the dentist was an idea that was totally alien to him.

People who are accustomed to controlling their environment and making their own decisions often fail to realise that they can become difficult patients. At the same time, a dentist who is treating a patient who is worried about feeling powerless also has to be aware of how clearly they communicate and how quickly they react to patient requests. Often, the fact that the patient has a controlling personality is only part of the problem. They may also be nervous and covering their fear by making excessive demands.

The Scenario

An important aspect of Kofi’s phobia was that it was specifically connected to certain aspects of treatment. So while he was a successful businessman who gave the impression of being unfazed by most things life threw at him, there was a deeper issue.

His phobia was not simply regarding a lack of control. It was also heightened at points where loss of control was at its most visible, for example during anaesthesia. This indicated that it was not simply a case of a clash of personalities with his dentist. It was a phobia based very much on fear.

The result was that Kofi had clashed regularly with his dentist when visiting for regular check-ups. His dentist had failed to understand that his behaviour was phobia-related and had struggled to treat Kofi effectively. Finally, when more complex work was required that involved anaesthesia, the patient-dentist relationship broke down and the patient had refused to carry on with the treatment. Obviously, this was detrimental to the patient’s health in the longer term.

Ultimately, the longer that dental treatment is left without being completed, the more urgent is becomes. Therefore, people suffering from dental phobia are often only delaying the inevitable. This heightens the fear, makes their symptoms more visible and puts extra strain on the patient-dentist relationship.

The Symptoms

It is relatively easy for a dentist to spot a patient who is phobic if that patient understands their own fear. However, in this case, the primary symptom of Kofi’s phobia was a tendency to become more argumentative, more demanding and more challenging of the dentist. This is part of the reason why some patients are often labelled ‘difficult’ or ‘controlling’, when in reality they are just trying to relax themselves and cope with the situation that they are in. They don’t seem to show the classic symptoms of fear; but that isn’t to say that their unwillingness to be treated is not phobia-related.

For Kofi, his more argumentative personality became more pronounced as he became more agitated. This was partly because the physical symptoms of his phobia also contributed to making him feel more and more uncomfortable. Additional symptoms such as palpitations, shortness of breath and tension all added to the sense of anxiety.

The Solution

In a case like this there are a number of options for treating the phobia. However, one of the most important aspects of the treatment is not to do with the patient at all. It is to do with the dentist.

For many dentists, dental phobia is a relatively new phenomenon. While it is easy to spot when someone is nervous or frightened, it is another thing entirely to have the skills, assurance and empathy to be able to put them at ease and complete the treatment. Ongoing training and professional development is therefore crucial for dentists and over the last decade or so, more and more dental schools have started offering courses in behavioural sciences, and there is a much greater emphasis on chairside manner. For many patients, simply finding the dentist with the right skills, personality and intuitive approach can go a long way to resolving their condition.

Unless the condition is chronic and the patient needs to move on to counselling (or even hypnosis techniques which have been used successfully by some), most patients will be treated with what is broadly called Behaviour Management. Essentially, this involves the dentist working with the patient in a way that helps to create a positive experience. It should start from the moment you enter a surgery. In a well-run practice, the atmosphere will be calming, the waiting times short and the reception welcoming. How your dentist talks to you, what sorts of questions they ask, how much time they spend with you – all of these factors can make a significant difference to your overall patient experience. 

Finally, if a Behavioural Management approach does not help the patient to relax enough, there is another option that suits some cases: sedation. There are two types of sedation. Firstly, you can be completely unaware of where you are or what is happening. Secondly, you can be sedated just enough to enable you to relax and allow the dentist to complete the procedure. Clearly, sedation techniques have their benefits. But it should be the last option when other, simpler routes have been explored.

In Kofi’s case, sedation was not an option as his phobia was about feeling powerless. The solution for him was a combination of dental consultations and counselling, which eventually enabled him to agree an approach to dental work that he was comfortable with and that allowed him to feel as though he remained in control of the process.

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