A successful treatment for specific phobias should decrease the fear-driven avoidance behavior. Coupled with reducing the avoidance are two related problems. First, some phobics do not avoid feared situations, but endure them with distressingly high levels of anxiety. More recent etiological accounts have suggested that some specific phobics fear the anxiety (and its imagined consequences) as much as others fear the phobic object (and its imagined consequences). The second difficulty in decreasing avoidance is that specific phobics typically exhibit anticipatory anxiety; either worrying about an inevitable contact with the feared object or situation or worrying about the possibility of contact with what is feared. Therefore, a successful treatment will also reduce the amount of anxiety experienced during exposure and in anticipation thereof. In summary, an effective treatment will reduce (1) the level of anxiety triggered by exposure to feared objects, (2) the level of anticipatory anxiety, and (3) the extent of avoidance.
Nondrug treatments of the specific phobias can be divided into two categories: behavioral and cognitive treatments. Before discussing these empirically-validated treatments, it is worth addressing a treatment that has appeared recently in the literature. Eye Movement Desensitization and Reprocessing was initially developed in the context of Posttraumatic stress disorder, but it has been applied to specific phobias. Muris and Merckelbach have conducted three controlled trials of Eye Movement Desensitization and Reprocessing. Despite some methodological concerns the strongest conclusions that can be supported from these studies are that exposure is an effective method for reducing self-reported fear and avoidance behavior, Eye Movement Desensitization and Reprocessing shows no evidence of being able to reduce avoidance behavior and there is occasional support that Eye Movement Desensitization and Reprocessing reduces self-reported fear. Thus, outside a research context, it would seem negligent to attempt a trial of Eye Movement Desensitization and Reprocessing for specific phobias before a comprehensive attempt at in vivo exposure has been conducted.
Returning to the behavioral and cognitive treatments, in clinical practice both components are combined to varying degrees. However, in order to evaluate the unique and combined contributions of each, it is useful to discuss the interventions separately.
A learning-based etiological model suggests that treatment should involve extinction or exposure to the feared stimulus in the absence of the feared consequences. Such exposure has been widely demonstrated to be a rapid and effective treatment of specific phobias. Exposure should be repeated as frequently as possible. Chambless (1990) suggested that sessions should be scheduled between daily and weekly, although Ost (1989) has found that treatment retains its efficacy if sessions are prolonged. The research literature also suggests that exposure exercises need to be clearly specified and of sufficient duration for anxiety to decrease substantially. Exposure in vivo is probably more effective than in imagination, but both can reduce phobic concerns. It is also preferable to use exposure exercises that are organized into a hierarchy of increasing difficulty, with each item being attempted as it becomes challenging but not overwhelming. Although outcome studies comparing graded exposure and flooding (ungraded exposure) indicate similar effectiveness, clients appear more comfortable with graded exposure and are more likely to complete treatment.
Of the behavioral techniques available, each can be organized on a dimension reflecting the degree to which anxiety buffering is available. At one extreme is flooding. Flooding involves presentation of the most anxiety-provoking object or situation, usually with the therapist present. This is continued until anxiety has dissipated. Implosive therapy can be considered similar to flooding except that it occurs in imagination. In practice, the therapist describes the feared scene as dramatically and vividly as possible, continuing until anxiety dissipates. A technique involving greater buffering of anxiety is participant modeling. The therapist demonstrates approach and contact with the phobic object and subsequently encourages the patient to do likewise. The exposure tasks are ordered in a graduated manner. Finally, at the other end of the continuum to flooding, is systematic desensitization. The client is taught progressive muscle relaxation, hierarchy construction, and graduated imaginal presentation of scenes. The patient then engages in graduated imaginal exposure to feared situations, using relaxation to keep anxiety at minimal levels. Thus, potentially effective exposure-based treatments can be organized in terms of the amount of anxiety buffering included. A thorough assessment prior to hierarchy construction will indicate the amount of anxiety buffering necessary to optimize client participation and therefore which form of exposure to use.
Two issues of importance concern the type of exposure used and the duration of exposure. First, considering the type of exposure, systematic desensitization has a demonstrated efficacy in the treatment of specific phobias, although there are suggestions that in vivo exposure is preferred to imaginal exposure. This conclusion is based on studies that have reported a superiority of performance-based treatments. However, these data need to be interpreted in the light of other studies that failed to find such differences. A further difficulty with imaginal exposure is evidence that the transfer of learning to real-life situations is less than perfect. A second important issue is the duration of time spent in the presence of the phobic object or situation. Generally, it is found that longer exposures are preferred to shorter exposures, even though specific phobics’ fears decrease faster than those of people with other anxiety disorders. However, Rachman et al. (1986) compared the outcome of agoraphobics who remained in the presence of their phobic object with a group who were permitted to escape when anxiety reached a certain level. According to an operant conditioning account of the maintenance of phobic avoidance, it would be predicted that the anxiety reduction following escape would negatively reinforce avoidance and therefore be counterproductive. In fact, the escape did not appear to reinforce avoidance behavior, suggesting that alternative or additional mechanisms are operating during exposure. Rachman et al. (1986) suggest that the permission to escape and return provided a sense of safety and self-control that facilitated fear reduction. This process would be similar to systematic desensitization, where the person is allowed to resume relaxation whenever anxiety rises beyond a certain level. However, it is also possible that the exposure (with or without escape) is therapeutic because it serves to enhance self-efficacy. In support of this position, Penfold and Page (1999) found that a distracting conversation reduced within-session anxiety to a greater degree than did a conversation that focused on the feared stimulus, and that the therapeutic effect of distraction during in vivo exposure appeared to operate by enhancing the perceived control over anxiety. Although this effect was limited to within-session anxiety, Oliver and Page (2002) have replicated these effects across multiple sessions and found that the perceived control over anxiety continues to climb when the exposure sessions have been terminated, but only for people in the exposure plus distraction condition.
Dangers of behavioral treatments
There can be dangers associated with behavioral treatments. The chief pitfall, inherent in the procedure, is the possibility of sensitization. A conditioning account suggests that exposure to the feared stimulus accompanied by the reduction in anxiety will decrease the amount of fear experienced in the future. Brief exposure, when the level of anxiety is not decreased, may sensitize the person, thereby increasing future levels of fear. The data of Rachman et al. (1986) suggest that this danger may not be as serious as previously thought. Their data may be taken to imply that the critical danger to avoid is exposure that elicits fear when the person feels an absence of control. It may be speculated that short exposures could be counterproductive if the person tries but fails to remain in the presence of the phobic object because of the intensity of their fear. On the other hand, short exposures may reduce subsequent anxiety when the person faces the feared object and learns that control is possible. A second danger with behavioral treatments is one that is uniquely associated with blood-injury phobia. Sufferers not only experience fear in the presence of the phobic stimuli, but on occasions may also faint. The unsuspecting therapist may find such an outcome frightening, but it can be more serious for the patient who may be injured. This issue and methods for dealing with fear-related fainting will be discussed in more detail below, in the context of blood-injury phobia.
Recently, with the rise of cognitive explanations in clinical psychology, cognitive therapies have been advocated as effective treatments for phobias in their own right or combined with exposure-based strategies. Given the cognitive view of conditioning, it is necessary to modify any cognitions that lead to the perception of possible contingencies and enhance anxiety. Although these conceptual changes could be considered to have blurred the distinction between cognitive and behavioral treatments, Last (1987) concluded that cognitive treatments in specific phobias do not yet have clear empirical support. It was argued that while studies with analogue populations are encouraging, when clinical samples have been examined cognitive techniques initially appeared to be ineffective relative to behavioral interventions and added nothing in combination. These results are unexpected, first, because cognitive theories predict that the modification of maladaptive cognitions would be an effective therapeutic strategy. Second, cognitive therapy appears to augment treatment effectiveness in other anxiety disorders. At this early stage, it would be unwise to rule out the possibility that cognitive techniques enhance exposure-based therapies. Indeed, Marshall (1985) has found that coping self-statements enhanced the efficacy of exposure-based programs. Similarly, Emmelkamp and Felten (1985) reported that training in adaptive thinking (i.e., relabeling and reappraisal of feared situations) enhanced the efficacy of exposure-based programs. Therefore, the principal theories of specific phobias provide reasons why cognitive therapies should enhance behavioral treatments. There are also some data that can be considered preliminary demonstrations that cognitive therapy can enhance exposure-based programs in some instances. For these reasons, it would be premature either to strongly support or to strongly reject cognitive interventions in specific phobias.
No psychotropic drug can yet be recommended as the treatment of choice in specific phobias. Bernadt et al. (1980) reported that diazepam decreased anticipatory anxiety and avoidance whereas beta blockers inhibited somatic symptoms of anxiety. However, the results did not generalize to the subjective components of the phobic’s concerns. There are a variety of studies showing some beneficial effects of benzodiazepines and beta blockers, but there is no strong evidence of a long-term reduction in symptoms following such treatment. Further, Zitrin et al. (1983) reported that the tricyclic antidepressant imipramine did not enhance a systematic desensitization program. As Barlow (1988) noted, the absence of clear indications of efficacy for the tricyclics for specific phobias is surprising given the benefits noted in other anxiety disorders. Future research may lead to a different conclusion. However, reviewing the current literature, we find that exposure-based and not pharmacological interventions are the treatment of choice.
Combining drug and psychological treatments
Given that exposure-based programs are the treatment of choice, the next question is “Can pharmacological and behavioral interventions be combined to enhance treatment success?”. Providing initial support, Hafner and Marks (1976) reported that exposure at peak blood levels of diazepam inhibited extinction, but exposure when blood levels were waning was associated with the greater decline in anxiety than exposure among patients given a placebo tablet. However, a more recent study extinguishing conditioned fear in rats found a dose-dependent relationship between levels of benzodiazepines and extinction. The higher the blood levels, the less well extinction transferred to a subsequent test session. Thus, at present, benzodiazepines should be used with caution among those with specific phobias who are concurrently undergoing exposure-based therapies. Nevertheless, the issue is an important one because when they come for behavioral treatment many patients have already been prescribed benzodiazepine tranquilizers.
While discussion of treatment has so far been generally applicable to all specific phobias, concerns about blood and injury warrant separate consideration. Although exposure-based interventions are effective and appropriate, the frequently concomitant fainting requires additional treatment and has led some to consider a separate etiology. Specific phobics during exposure exhibit sympathetic arousal in the form of the flight or fight response. Unique to blood-injury phobia about 80% of sufferers in treatment exhibit initial sympathetic arousal followed by a rapid switch to parasympathetic arousal (the rate appears lower in community samples). The concomitant decrease in heart rate and blood pressure may lead to “emotional fainting” (i.e., vasovagal syncope).
The clinician has a number of options in overcoming the complications that fainting presents. Marks (1988) suggested that exposure should be conducted with the client lying down. Ost and Sterner (1987) have suggested an alternative and much more practical treatment. Assuming that a rapid shift to parasympathetic arousal mediates vasovagal syncope, they train clients to tense various muscle groups in response to the first indication of syncope. They reported success with clients that was maintained over 6 months. In a comparison between applied relaxation and applied tension during exposure, they found similar results at 6-month follow-up but favored the latter because treatment took half the time (Ost et al., 1989). In a process study, Foulds et al. (1990) confirmed that applied tension did increase cerebral blood flow and the mechanism suggested by Ost and Sterner (1987) appeared to have merit.
Specific phobias are characterized by an excessive and distressing stimulus-bound fear reaction that leads to avoidance. Many people have phobias, but relatively few have a phobic disorder (i.e., the avoidance handicaps them in some way). When avoidance produces handicap, treatment is indicated. The treatment of choice will involve exposure to the feared object or situation, in a manner that progresses as quickly as possible while maintaining patient compliance. Anxiety-buffering techniques are useful to achieve this balance. Treatment should then progress rapidly and a successful outcome should be observed within six to eight sessions.