Specific Phobias
Diagnostic Criteria
There are three forms of phobia: simple or specific phobia, social phobia and agoraphobia.
Simple phobias are unique within this
group in that they appear to be confined to a specific object or situation.
Examples of specific phobias are: Arachnophobia
(spiders), ophidiophobia (snakes),
acrophobia (heights), nosophobia
(injury/illness), thanatophobia
(death) and pogonophobia (beards), caligynephobia (beautiful women), melanophobia (the colour black), philophobia (love), and arachibutyrophobia (peanut butter
sticking to the roof of the mouth)
(see http://phobialist.com/).
The diagnostic and statistical manual of
mental disorders (DSM—IV) characterises specific phobias as follows:
• Marked and persistent fear that is
excessive or unreasonable, cued by the presence or anticipation of a specific
object or situation
• Exposure to the phobic stimulus almost
invariably provokes an immediate anxiety response
• The person recognises that the fear is
excessive or unreasonable
• The phobic situation in avoided or else
endured with intense distress
• The avoidance, anxious anticipation, or
distress in the feared situation interferes significantly with the persons
normal routine, occupation (or academic) functioning, or social activities or
relationships, or there is marked distress about having the phobia
• In under 18’s minimum duration = 6
months
• Not better accounted for by other
diagnosis
Theoretical Perspectives
Psychoanalytic theories
Psychodynamic theories are based on the
idea that fears are a “defence against repressed id impulses”. As such, anxiety
is displaced onto an object or situation, which helps the individual avoid
dealing with repressed conflicts. One example is that of Little Hans (Freud, 1909) who developed a phobia of horses after
witnessing a fear of horses while with his father. In this framework, objects
of fear are symbolic (e.g. fear of spiders is a fear of bisexual genitalia and
the phallic wicked mother…).
As Sperling (1981) put it “most
investigators seem to agree that the spider is a representation of the
dangerous (orally devouring and anally castrating) mother, and that the main
problem of these patients seems to centre around their sexual identification and
bisexuality” (Sperling, 1981, p. 493). In the case of little Hans, his fear was
explained in terms of his castration anxiety from his father (because in
Freud’s theory little boys secretly desire their mothers and hence fear
retribution in the form of castration from their fathers). In a 150 page
monologue Frued asks Hans a series of leading questions and after many dodgy
connections are made between the horse’s large penis and the various
penis-related anxieties that the child had, Freud concludes that Hans had
transferred his fear of his father to a safe target (i.e. a horse). Of course,
the fact that Hans witnessed a very traumatic carriage accident involving a
horse had nothing to do with it.
Learning Theory and Behaviour therapy
Early Theories and Therapeutic Models
Learning theory’s initial contribution to
the treatment of phobias was through the work of Watson and Rayner (1920).
Watson and Rayner initially showed that Albert,
a nine month old ‘stolid and unemotional’ child (Watson and Rayner 1920, p.1),
exhibited no fear when presented with animals (e.g. a rat, dog, rabbit and
monkey) or inanimate objects (e.g. cotton, a burning newspaper and human
masks). Fear was, however, evoked when a
metal bar was struck with a claw hammer behind his back. Two months after
this initial test, Albert was presented with a white rat (a conditioned stimulus, or CS) paired with a loud noise (the claw hammer hitting the rod — in
conditioning terms an unconditioned stimulus or UCS). After seven pairings
Albert cried and avoided the rat whenever it was subsequently encountered.
Watson and Rayner concluded that ‘many of the phobias in psychopathology are
true conditioned emotional reactions either of the direct or transferred type’ (p.14).
Watson and Rayner’s study remained
largely ignored for some 40 years until Eysenck (1960) and Wolpe (1962) used it
as a basis for therapeutic treatment of phobias. Their rationale was that ‘because human neurotic habits of reaction
can often be dated from particular experience that involve stimuli to which the
patient has come to react with anxiety, and because these habits can be altered
through the techniques of psychotherapeutic interviews, there is a prima facie
(at first sight) presumption that neurotic reactions owe their existence to the
learning process’ (Wolpe, 1962). This claim was substantiated by Rachman
(1966a) who showed that a sexual fetish to knee-length women’s boots could be
conditioned in men by presenting them alongside slides of female nudes. This
simplistic account led to the assumption that if fears could be learnt, then it must also be possible to unlearn them.
A number of therapeutic techniques were
subsequently devised around this conditioning paradigm, any one of which could
be used to remit phobic symptoms. The simplest way to eliminate a conditioned response (CR) such as fear to a phobic stimulus is
through extinction. According to
classical conditioning principles this can be achieved in a number of ways:
First, the CS (the fear-evoking stimulus)
can be presented without the UCS (traumatic outcome);
Second, the CS can be reconditioned to a
more acceptable UCS such as relaxation (counter-conditioning), and
lastly;
The UCS can be presented in the context
of new CSs (Davey, 1981).
The later has the disadvantage of
creating new phobias in the place of the old one. One of the earliest
therapeutic techniques incorporated extinction and is called Massing (or in
it’s extreme form flooding). In essence:
The patient is exposed to the CS for long periods of time.
After an initial increase, the anxiety (CR) to the CS extinguishes because
it fails to elicit an aversive UCS.
The success of this technique seems to
depend upon the length of exposure
(i.e. patients must be exposed for long enough for their fear to subside (Rachman,
1966b; Wolpin and Raines, 1966).
Mowrer (1947, 1960) extended this simple
conditioning model to a two factor
theory of learning in which behaviour is acquired in the normal classically
conditioned way but is maintained through operant
reinforcement. In essence:
This model suggests that someone might
well learn to fear a spider (for example) because it has been associated with
some kind of traumatic experience.
Subsequent contact with spiders leads to
heightened anxiety.
Mowrer’s addition to this model was to
suggest that because anxiety is unpleasant,
people will avoid it.
So, having learnt to fear a spider, when
you next encounter one you will ‘run away’ or avoid it because this
reduces your anxiety. As such, avoidant
behaviour is reinforced because it leads to a reduction in anxiety.
This theory underpins implosion / flooding therapy in which
assessments of the critical stimuli associated with the patient’s anxiety are
made. From this an Avoidance Serial Cue
Hierarchy is constructed according to
the degree to which each stimulus is associated with the original fear-evoking
outcome.
The stimulus lowest on the list is
extinguished first before moving on to the next cue. For example:
An arachnophobic might be asked to imagine
a spider standing still
Then the spider moving
Then the spider crawling on their hand
Then its fangs and so on.
The imaginal presentation of the stimuli
should extinguish the response it normally elicits.
Several studies have verified the
efficacy if this approach. Hogan and Kirchner (1967) compared it very
favourably against relaxation therapies whilst Levis and Carrera (1967) found
it more effective than traditional ‘insight’ therapies at relieving patient’s
symptomatology. However, Morganstern (1973) has questioned whether these
results are not just the result of extraneous
variables or down to the patients’
expectations of success. These notions tie in with Bandura’s (1977) notion
of a perceived self-efficacy, which mediates successful symptom remission. Bandura argued that the effectiveness of
therapy will depend not just on exposure but on the patient’s perception of
their ability to cope with that exposure.
Wolpe (1958) developed a series of
therapies based on the principle of counter-conditioning
in which the acquisition of a new
response, incompatible with the occurring response to the stimulus, results
in the elimination of the old response
(Meyer and Chesser, 1970).
Wolpe noted that ‘if a response
antagonistic to anxiety can be made to occur in the presence of anxiety-evoking
stimuli so that it is accompanied by a complete or partial suppression of the
anxiety response, the bond between these stimuli and the anxiety responses will
be weakened’ (Wolpe, 1958).
The resulting procedure of systematic
desensitization is the basis of the most widespread therapeutic approaches
to the treatment of specific phobias. Wolpe identified several responses that
would be incompatible with anxiety, thus fitting the principle of counter conditioning, the most popular
one being muscular relaxation.
In a systematic
desensitization procedure a detailed history of the patient is made with
consideration to which characteristics of the phobic stimulus influence the
intensity of evoked anxiety.
This
is similar to the avoidance serial cue hierarchy described above. Indeed, a
graded hierarchy is constructed from the minimal fear situation (i.e. a small
garden spider standing still several meters away from the patient) to a maximum
fear intensity situation (i.e. a huge, black, hairy spider with visible fangs
crawling across the patient’s face). The patient then ranks these situations in
order.
During the sessions in which the
hierarchy is constructed, the patient is
taught how to relax and is asked to practice
the relaxation techniques at home until they can reach a certain degree of
relaxation.
In the desensitization stages the patient is asked to relax and told to
signal by raising his or her index finger if she feels at all anxious or
disturbed during the procedure.
At
first a neutral scene is imagined before moving on to the lowest situation on
the hierarchy. In
initial sessions the therapist makes assessments of the patient’s ability to
imagine the situations presented to them. In
subsequent sessions the therapist begins with the highest situation that could
be imagined at the previous session without fear before moving on to the
next situation in the hierarchy.
If at any time the patient looks anxious
or indicates anxiety, they are asked to relax or are given a relaxing scenario
to imagine.
The
sessions are ended when the highest situation in the hierarchy can be imagined
without anxiety.
Wolpe (1961) claimed that there was a
close relationship between the degree to which desensitization had been
achieved and the abatement of anxiety responses to real stimuli and Leitenberg
(1976) concluded that ‘systematic
desensitization is demonstrably more effective than both no treatment and
every psychotherapy variant with which it has so far been compared’ (p.131).
The Cognitive Revolution and Its Effect on Learning Theory and
Behaviour Therapy
More recently, behaviour therapy has come
under fire for developing without a synchronous development in underlying
theory (Wilson, 1982). The main contention stems from certain features of
phobic reactions that seem contrary to the conditioning account of acquisition.
There are four main criticisms of
learning accounts of phobia acquisition (see Field & Davey, 2001):
1. Some phobics cannot remember an
aversive conditioning experience at the onset of their phobia: some phobics
have no memory of an aversive
conditioning event at the onset of their phobia. In addition, for a
particular feared stimulus some individuals may remember an associated
traumatic event while others who fear the same stimulus have no such
memory (Withers and Deane, 1995).
2. Not all people experiencing fear or
trauma in a given situation go on to develop a phobia: Lautch (1971) showed
that not all people who experience pain or a traumatic event whilst at
the dentist go on to acquire a phobia. Likewise, most of us have experienced
violent and scary thunderstorms yet are not phobic of these situations
(Liddell and Lyons, 1978). The simple
contiguity based model espoused by the early behaviourists simply does not have
the power to predict when an individual will acquire a phobia and when they
will not.
3. Incubation (Eysenck, 1979):
Incubation is a phenomenon in which fear increases over successive
non-reinforced presentations of the CS (for example, when a spider phobic subsequently
comes into contact with spiders, each spider is unlikely to be paired with a traumatic
event, yet the phobic becomes more fearful of spiders).
4. Uneven distribution of fears (Seligman,
1971): Pavlovian models of conditioning predict equipotentiality of stimuli
which in this context simply means that all stimuli are equally likely to enter
into an association with an aversive consequence. So, fears and phobias should
be evenly distributed across stimuli and experiences. This is clearly not the
case because phobias of spiders, snakes, dogs, heights water, death, thunder,
and fire are much more prevalent than phobias of hammers, guns, knives, and
electrical outlets yet the latter group of stimuli seem to have a high
likelihood of being associated with pain and trauma.
These observations coupled with an
increasing interest in cognitive processes led to a reduced interest in
behavioural theories. Nevertheless, behavioural theories have developed in a number
of ways. First Rachman (1968, 1977) noted that in addition to direct learning experiences,
fears could also be learnt through observing the responses of others to
fearevoking stimuli, and through acquiring information about a stimulus.
Mineka, Davidson, Cook, & Weir (1984) demonstrated that laboratory-bred
rhesus monkeys exhibited fear responses to toy snakes after watching a video of
a fellow monkey exhibiting fear to the same snake.
Recently, Field, Argyris & Knowles
(2001) have shown that information about previously unencountered stimuli
changes children’s fear-beliefs about those stimuli.
More recent advances in conditioning
theory have also helped to explain the inconsistencies noted above. The
apparent absence of trauma for many patients can be accounted for through UCS
revaluation, which is based on the notion of ‘behaviourally silent
learning’ (Dickinson (1980).
In animal studies this takes the form of
two neutral stimuli being paired together (CS1 and CS2) resulting in no
behavioural change. If the animal is then presented with CS2 and a UCS the
subsequent presentations of CS1 elicit CRs appropriate to the UCS. This implies
that there was behaviourally silent learning in the initial stage. This has
been reliable found in human subjects (White and Davey, 1989) and UCS
revaluation has a directly modifying effect on the strength of the human CR
(Davey, 1987). In clinical terms this means that a patient could, for example,
witness someone collapse from a heart attack whilst hiking at the top of a mountain.
The man dying being CS1 and the mountain being CS2. The CS1 does not cause the patient
anxiety and (s)he thinks nothing more about it. However, (s)he has silently
learnt to associate the two events and ensuing hikes up mountains elicit a
memory of the stranger’s heart attack, but no anxiety. Subsequently, a close
friend of the patient dies of a heart attack
thus increasing the aversiveness of heart
attacks in general, which in turn results in acute anxiety when he climbs
mountains. The patient will, however, not remember a direct pairing of
mountains and trauma.
Davey, De Jong and Tallis (1993) present
several cases studies that illustrate this process. Failure to acquire phobias
after a traumatic event can be explained through latent inhibition in which
earlier presentations of the CS (e.g. dental treatment) in the absence of
trauma, inhibit the acquisition of a CR (fear) when the CS is paired with a UCS
(pain) at a later date (Davey, 1988).
In addition the patient’s evaluation of
the UCS will affect the CR and so a patient might see the pain as negligible against
the benefit of having healthy teeth (Davey, 1992).
Incubation could simply be the result of
patients rehearsing the trauma in their minds after the initial event causing
an inflation of the UCS before subsequent encounters with the CS (Davey, C8005
(Clinical Psychology): Specific Phobias Dr. Andy Field Page 5 29-Mar-2002 1989).
Jones and Davey (1990) have produced
these effects in the laboratory, which had only previously been achieved when
the UCS was extremely aversive, such as succinylcholine induced paralysis (see
Campbel et al. (1964). Recent work also indicates that ruminating about the
consequences of a phobia-related encounter can increase both self-reported
fear, heart rate, and catastrophic thoughts about future consequences (Field,
St. Leger & Davey, 2000).
This suggests a possible mechanism
through which incubation might occur.
The uneven distribution of fears
criticism was tackled by Seligman (1971) who proposed that humans had an
inbuilt disposition to associate certain stimuli with aversive events because they
had been phylogenetically relevant to our ancestors (such as spiders, heights
and snakes). However, this preparedness theory does not predict what stimuli
would have been relevant to our ancestors and despite much laboratory support
(see Öhman, 1979) others have explained these findings in terms of subjects’
prior expectations of the experiments (see Davey, 1992, 1995).
Contemporary conditioning models (see
Davey, 1997; Field & Davey, 2001) represent a blend of behavioural and cognitive
ideas. Although based on basic conditioning theory, the factors that influence
the relationship between a stimulus, the outcome associated with it, and the response
to that stimulus involve numerous cognitive elements. Some have already been touched
upon (for example Field et al.’s demonstration that rumination influences the perceived
future threat of a phobia-related stimulus), but there are many others such as
a person’s coping style, personality characteristics and so on. These offer a
number of possibilities for informing future therapeutic techniques.
Purely Cognitive Approaches
The central theme of cognitive approaches
is that disorders result from maladaptive thinking.
Therefore, if you treat the cognitions,
the behaviour will vanish; it assumes that behaviours (such as avoidance) are
caused by thoughts. As such, if we challenge people’s dysfunctional thoughts
then we should be able to remove their fearful behaviour.
The limitations of behavioural
explanations led Beck (1976) to formulate a theory of anxiety based on
cognitive factors. He emphasized Information-processing biases: biases
in attention, memory, thinking, judgments. These biases can take on many forms:
• Attention: anxious/depressed
people attend to threat-relevant material more than nonanxious/ depressed
people. Anxious people show a bias towards material related to their fear.
Öhman & Soares (1994) found that snake phobics exhibited a fear response to
pictures of snakes masked with another stimulus (so the snake could not be consciously
perceived), non-phobics did not exhibit fear. The emotional stroop task
involves naming the colour of words when some words are threat-relevant and
others are threat irrelevant (Williams, Mathews & MacLeod, 1996 review the
evidence). Find that anxious subjects take longer to process threat-relevant
words than non-threatening words, for controls there is no difference.
• Memory Recall Bias:
anxious/depressed people have a bias towards recalling negative memories.
Anxious people have selective recall of negative memories. This may be because
anxious people attend more to threatening material and so will have more numerous
and stronger threat-related memories (encoding is improved — think to your lectures
on memory). This can be shown by memory tests of normal words (e.g. box, farmer),
positive words (e.g. excited, glad) and threat-related words (e.g. morgue, trembling,
cancer). Anxious people will recall more threat-related words and less positive
words than control subjects (recall of neutral words is similar) Cloitre &
Liebowitz (1991).
• Misinterpretation: Information
can also be misinterpreted: We’ve all done this in real life.
For example If I walked into the lecture
theatre and heard someone say ‘oh, that George is a shit ….’ I would interpret
that as being the end of the sentence, however it’s possible that they were
going to say ‘oh that George is a shit-hot lecturer’ before I interrupted.
These sorts of biases happen all the times (have you ever thought that people
were talking about/laughing at you? Well, in reality they probably weren’t).
Eysenck, Mogg, May, C8005 (Clinical Psychology): Specific Phobias
Richards and Mathews (1991) carried out a
study in which anxious, recovered anxious, and non-anxious individuals were
shown 32 ambiguous sentences: ‘The two men watched as the chest was opened’ and
‘The doctor examined little Emma’s growth’. Later on, subjects were presented
with both a positive and negative interpretation of each sentence and they had
to identify which sentence they had read earlier on: ‘The doctor looked at
little Emma’s cancer’ (Negative) and ‘The doctor measured little Emma’s height’
(Positive). They counted the percentage of negative interpretations chosen.
Anxious individuals chose many more negative statements than non-anxious.
• Estimating the Likelihood of
Negative Events: Butler and Mathews (1983) asked people to estimate the
probability of nasty and nice things happening to them and to other people. They
found that for positive events the groups did not differ. However for negative
events, anxious/depressed people overestimated the likelihood. This was
especially true when they estimated the likelihood of the negative event
happening to them (rather than someone else). However, Dalgleish et al. (1997)
found that anxious children overestimated the likelihood of negative events to
others and not themselves.
• Rumination: Rumination
(cognitive rehearsal) is repeatedly thinking (or churning over) thoughts in
your mind. Negative rumination involves repeatedly thinking about negative aspects
of a situation (or problem). Although there are several theories of ruminative
Field et al. (2000) has noted that they all have a common theme: rumination is
seen as a normal and adaptive part of a problem solving process, however, if the
problem is not (or cannot) be solved then this rumination becomes maladaptive.
Rumination is seen in OCD (Salkovskis, 1999), GAD (Marks, 1987), stress (Roger
and Najarian, 1997) and can enhance the retrieval of negative memories
(Lyubomirsky, Caldwell & Nolen-Hoeksema, 1998).
Field et al. (2000) have shown that in
phobics, rumination can lead to the enhancement of self-reported anxiety. This
is not true in non-phobics. Therefore, rumination about something that already
evokes fear leads to greater anxiety. This could explain incubation.
The problem with the cognitive approach
is that it doesn’t explain why some people have these maladaptive thoughts.
It’s a chicken-egg situation: does the disorder come from the thoughts or do
the thoughts come as a result of the disorder? It is possible that mental
disorders are learnt but that cognitive biases act to maintain or exacerbate
the feelings of anxiety. There is little evidence that pure cognitive therapy
alone is good for specific phobias (in which sufferers fully acknowledge the
irrationality of their thoughts). Therefore, treating thoughts does not always
lead to a change in behaviour.
A blend of cognitive and behavioural
techniques is usually best. This approach addresses both the behaviours and the
cognitions that maintain them. Cognitive-behaviour therapy blends exposure to
the fear-evoking situation with cognitive techniques to help ‘cope’ with the situation
(and not, for example, ruminate about it afterwards).
Therapy for Specific Phobias
Despite the early behaviourists’
contention that behaviour therapy should provide a general framework around
which individual therapists could operate, there
is no such strict guideline.
Therapy is a very individual procedure
not only in terms of the patient and symptoms but the therapist as well. It is
extremely hard to describe a behavioural treatment of a phobia in the absence
of an actual patient with whom to work. Not only are there therapeutic
variations between disorders (for example a treatment of agoraphobia can be
somewhat different to a treatment of a simple phobia) but also within disorders
(the treatment of a simple phobia with one patient might be quite different
from the appropriate procedure for a different patient).
First Steps
The first step in any behavioural
treatment is to establish the precise nature of the phobia and its suitability
for treatment (Butler, 1989). A behaviour therapist would carry out a functional
analysis to establish whether:
Patients and clinicians are rarely aware
of all of the important events and so data must be collected over a period of
time through patient diaries or interviews with a third party.
The data should be as unambiguous and
absolute as possible and once established, these factors should be eliminated,
replaced or modified to change the behaviour.
Maintenance factors should be identified
along with secondary gains (reinforcers of anxious behaviour such as people giving
you comfort or sympathy).
It is crucial to get as full a picture as
possible and not to interpret the data and jump to false hypotheses about the
causes of the disorder.
Behavioural therapists are interested
purely in behaviour and not causes or moods.
Goal Setting
By this stage the therapist should have
formed hypotheses that can be tested. Once causal factors have been identified,
the therapist should collaborate with the client to establish the goals of
therapy. The general goal of therapy for phobics is often self-evident but it
is very important that the clinician discuss the precise goals with the client
to avoid any potential confusion. One disparity often apparent in therapy is
expecting miracles; the clinician should always make the client aware that
spontaneous recurrence of symptoms is to be expected.
There are no rules governing what the
goals should be although Öst et al. (1984) suggested that blood phobics should
aim to donate blood regularly, similar goals can be established for other
phobias (i.e. going shopping alone for agoraphobics, removing spiders from the
house for arachnophobics).
Measures
Having established the maintenance
factors and set up mutually agreeable goals, the next stage is to measure the
phobia using easy and sensitive measures that reflect the client’s individual
concerns. Measures are vital in assessing the progress of a therapeutic
technique; it is important to keep in mind that you are testing a possible
hypothesis and so it is necessary to compare the patient’s behaviour against an
initial baseline measure throughout therapy in order to monitor the effects of
any intervention. As you introduce new techniques you should look at its effect
on behaviour to see whether or not it was effective. There are several ways to measure
phobia severity. One way is to use a graded hierarchy (described earlier). The
patient has to think of a number of situations and then rate the anxiety and
avoidance that each situation would provoke (on a scale of 1–10 or 1–100).
Often it is easier for the patient to think of extreme examples and then think
of items that lie in between the two extremes.
Hierarchies are often a lot more
difficult to construct than they first appear because fears may be difficult to
grade into small steps (e.g. fear of flying). In addition, patients often avoid
situations and yet are totally unaware that they are doing so or are oblivious
to the precise nature of their phobia (a spider phobic may not be scared of
spiders per se, it may specifically be their movement). If they find
constructing a hierarchy difficult it may be useful for the patient to read,
talk or write about their phobia and watch relevant films in order to gain inspiration
about what sorts of situations they find most and least anxiety evoking.
A second measuring technique is that of
behavioural tests in which clients do something which they would normally avoid
and rate their anxiety at the time. This is especially useful for looking at
where on the hierarchy you should start working or in situations where the
patient has an extensive pattern of avoidance and hence is merely guessing at
the anxiety experienced.
The patient
should keep records of their
exposure and anxiety.
This self-monitoring is important in
assessing change but also provides evidence against the tendency to
remember failure and forget success. In addition there are several
standardised questionnaires which measure phobic anxiety such as; the
Fear Questionnaire (Marks and Mathews, 1979) and the Fear Survey Schedule
(Wolpe and Land, 1964).
Treatment
The actual treatment procedure chosen
will depend on a detailed assessment of aetiology (causes or origin of disease).
A traditional behavioural treatment for a simple phobia mediated by anxiety is systematic desensitization.
Some of the difficulties in administering
this therapy.
Difficulties which arise in the
construction of a hierarchy have already been mentioned (above) but there are
also associated problems with relaxation as a counter-conditioning technique.
In some patients (notably children) it
may be extremely difficult to obtain relaxation whilst others may be relaxed
but without the subjective feelings of calm;
Some patients have anxiety about the
relaxation itself (Meyer and Chesser, 1970).
Having established relaxation,
difficulties in achieving graduated exposure can manifest themselves if the
patient finds it hard to imagine items in the hierarchy or if the images do not
evoke anxiety.
A good therapist should encourage the
patient to use all sense modalities to construct each image in order to make it
as vivid as possible.
The critical guidelines for exposure are
that it should repeated, graduated and prolonged with tasks being specified and
agreed upon in advance (Butler, 1985).
However, there are difficulties
associated with these guidelines because of the unforeseeable nature of phobic
stimuli (how do you know when you are going to come across a spider?).
These unpredictabilities interfere with
the repetition, graduation and advance specificity of exposure episodes.
One way to overcome this is to practise
an array of tasks encompassing a range of difficulty in the same week as
opposed to stringently moving up the hierarchy.
The administration of exposure is not
just restricted to the clinical session. One key objective of therapy is to
empower the client with the ability to cope with their phobic stimuli alone. An
important step towards this is to set homework for the client.
Many of the behavioural tasks set by the
clinician can be undertaken outside of the clinical setting in the absence of
the clinician. The patient should be encouraged to undertake home-based
treatment often with a relative or friend who has been informed, in detail,
about the treatment. This has been notably beneficial in agoraphobia (Mathews
et al 1981).
Initial stages of exposure should be undertaken
with the clinician until such a time that the patient feels confident enough to
do homework on his/her own.
Other useful behavioural techniques are;
Role playing, which is especially useful
in treating social phobics
Modelling, where the clinician physically
demonstrates how to approach the phobic stimuli (for example by picking up a
spider)
Rehearsal of appropriate strategies for
dealing with the stimuli.
How successful is Therapy?
Although there is a great deal of good
evidence to indicate that exposure therapy is effective (Marks,1987, Mathews et
al.1981) and long lasting (Munby & Johnston, 1980) there is a problem with
assessing it. By asking if a technique is successful we are imposing
homogeneity (properties are identical
everywhere) where none exists. Patients are not all the
same and so the success rate of any therapy should be judged in its ability to
treat a number of different symptoms in a number of different people and
whether it has the flexibility to address novel symptoms.
One of the major problems in assessing a
therapy is the use of control groups. Any good research should incorporate a
control group with which to compare the therapy group, but how ethical is it to
assign people to a group who receive no treatment?
Despite this, there is some support that
behaviour therapy can have generalizable effects such as improvements in
relationships and increased self confidence and it has been noted that exposure
has cognitive as well as behavioural effects (Butler, 1989).
Stern and Marks (1973) concluded that
anxiety levels during exposure have little effect on the outcome but in general
prolonged exposure is more effective than brief exposure. As such, exposure per
se is not predictive of outcome but duration of exposure can be (in general).
Bandura (1977) proposed that exposure was
non-predictive and that perceived self-efficacy was the important variable in predicting
outcome. He argued that the person’s
belief that they could cope with exposure would predict the remission of
symptoms. Exposure also seems to have a minimal influence on controllability
in that symptoms often return after therapy. Again what seems to determine the control of a phobia is not exposure per se but
a patient’s ability to help themselves should symptoms re-occur. This could
be linked again to Bandura’s concept of self-efficacy in that patients who
perceive themselves as able to cope when a setback occurs will be able to
control their symptoms
Predictability and controllability have a
very close relationship in that if a therapist can predict the outcome reliably
then this gives him more control over the therapy. If predictions indicate that
the outcomes will be poor then the therapist can modify the treatment. This is
the reason for doing multiple baseline analysis of treatments to look for trends
in each variable and then modify the treatment in line with these trends.
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