SPECIFIC PHOBIAS TREATMENT1(Updated / Edited 03/22/24) Mark Stephen Schwartz, Ph.D. What are Phobia Treatments? Behavioral therapies are the most common successful treatment methods. This booklet focuses on Exposure Treatments, which are the most common.
Systematic Desensitization, also called gradual exposure therapy, is the most common type of exposure treatment. The word systematic means organized, orderly, and precise. Desensitizing means ending reactions or sensitivity to stimuli. Remember that allergy doctors use desensitization treatments to stop or reduce allergic reactions. They put small amounts of allergic substances into the body. The body adapts and develops countermeasures to the allergic substances. The body develops ways to reduce or stop the sensitivity. Therefore, the body "gets used to" the substances. This process is similar to what exposure treatments do for phobias but without putting substances into the body. Instead, some methods allow the body to adapt and develop countermeasures to the phobia.
Exposure treatments can help: • Uncover the significant parts of the phobia • Break the phobia into small parts with different intensity • Learn methods such as relaxation that counter anxiety • Face the anxiety with the counter-anxiety methods • Use other methods to aid in learning new skills and thoughts and reducing tension
The timing and amount of exposure can be in small steps, as in gradual exposure treatments. The exposures can be more significant, like flooding in a related therapy. A later section of this booklet discusses flooding. Professionals may use different amounts of exposure and different exposure procedures.
These successful treatments have some roots over centuries, but primarily in the early 20th century. The treatment we are calling exposure became widely acceptable a few decades ago. Mental health professionals provide exposure treatments.
What is a Phobia? A phobia is an unrealistic fear of objects, situations, places, events, people, or living creatures. For some people, fear involves physical feelings of anxiety. Physical reactions can include increased heart rate, queasy feelings, shortness of breath, and dizziness. Muscle tension in various parts of the body also can increase. Sweat on palms and the soles of the feet can also be part of physical reactions.
For other people, fear primarily involves thoughts. For example, one may feel afraid or anxious about reactions to specific situations. For other persons, fear involves behaviors such as avoiding specific situations. One might act frightened when one expects to be in these conditions or face the feared situation. Thoughts or physical reactions might not be present. However, one might avoid such events. One may have fearful thoughts and physical tension if one faces the situation, but one might not; thus, avoiding the situation shows that a phobia is present.
People with phobias report different blends of physical tension, thoughts, and avoidance behaviors. People do behave, feel, and think differently from each other even when they report a phobia with the same name.
Phobias are prevalent. Many millions of adults have at least one phobia. They are not a reason for embarrassment.
People learn phobias. Some people experience frightening events such as car accidents, floods, fires, severe storms, animal attacks, or mugging. Fear also can result even if a person does not suffer a frightening event. Thus, people can learn by seeing or hearing about others experiencing fear. Some people learn these reactions by knowing someone else who suffered such an event. Other people appear to develop their fears from events with family and friends. Parents sometimes show their fears to their children and act as models for fearful behaviors. A person might also be afraid if they need to know what to expect but have no experience with a situation. Thus, the unknown can lead to becoming very anxious.
Physical reactions associated with specific events can recur even when thinking about a place, people, objects, or situation. People might have similar thoughts and physical reactions when they face or expect similar situations.
Going to a psychologist or psychiatrist is one example. Some persons who go to mental health professionals do so with some anxiety about doing so. This anxiety is in part because they do not know what to expect. Some people do not know any mental health professionals. Other people have not talked to anyone about their experiences with mental health professionals. Maybe they heard something that influenced this expectation. Many people get their information about psychologists and psychiatrists from television and movies, very often not an accurate or flattering picture. Some people are very anxious before and when they enter our offices. They are often not tense later in the session.
Are Phobias Inherited? Some people have a genetic tendency to develop fears and phobias. Even if this is true, we must keep it in perspective. Life experiences are far more critical for determining what we learn than our genes.
Common Fears And Phobias There are hundreds of phobias. Among the more common are:
Heights Swimming Being alone Feeling rejected Crowds Airplane flying Small enclosed places Sexual activities Shopping malls Tests Driving Rodents and snakes Dirt or messiness Insects Criticism Dentists and physicians Physical symptoms Injections/needles/blood Surgery Public speaking
Evaluating Fears and Phobias Evaluation methods involve: • Interviews • Questionnaires • Behavior measures • Recordings with biofeedback instruments
Many professionals use more than one method. All use an interview, and some also use questionnaires. Fewer use biofeedback instruments, and a few use behavior measures such as how close a person approaches a feared object. All are proper but provide different information. A specialist can discuss the evaluation methods.
Research Evidence Shows That These Treatments Work. Over the past few decades, extensive good-to-excellent research studies and vast numbers of cases consistently support the success of exposure treatments. A patient/client can have much confidence in these treatments. Exposure treatments are effective, sound, and hardy.
How Do These Treatments Work for Phobia Management? Professionals have different opinions about how these treatments work. Good professionals know about the different explanations and how to increase the treatment's chances of effectiveness. Summaries of the common explanations are below. They are not in any specific order. Some believe relaxing parts of the nervous system help replace physical and mental anxiety with relaxation. This idea was one of the original ideas and might be a critical part of effective treatment for many people. However, deep relaxation is not necessary. Anxiety can end by mere exposure to anxiety-producing stimuli. This process happens by adapting or becoming accustomed to the situation, sometimes called habituation. A related explanation is extinction. The anxiety becomes extinct. It vanishes. The person carefully improves and increases fearless behaviors. They approach and contact the fear-arousing stimuli. All of this increases self-confidence, sometimes called self-efficacy. One also develops other stress management skills. One also changes what one says to oneself before and during exposures. This self-dialogue or self-statement becomes positive. Phobias often develop because of more than one reason, and treatments work because of more than one reason. AppropriateGood treatments consider many of the reasons. One usually directs treatment toward:
• Proper exposure durations • Rates of exposure (i.e., gradual or rapid) • Methods to reduce physical anxiety (e.g., relaxation) • Promoting effective self-talk and other cognitions • Developing realistic positive expectations • Reinforcing steps in the right direction
A patient's doctor or other therapist can discuss these with them.
Ways To Change And Manage Physical Reactions Relaxation treatments reduce physical tension. Physical tension involves muscles, breathing, and other parts of the nervous system. It leads to the release of anxiety chemicals, like adrenaline, into the blood. Relaxation reduces these chemicals and muscle tension, heart rate, blood pressure, and other signs of physical anxiety. It also helps calm anxious thoughts.
Changing And Managing Fearful Thoughts One can help oneself manage anxiety and fear by changing attitudes, beliefs, and what one says to oneself. What one thinks and says to oneself and what one imagines affects one's body and symptoms. People can develop new and positive thoughts about their fears. Specialists can recommend some methods, and one can learn about these methods by reading and in-office sessions.
Cognitions Cognition means thoughts, attitudes, beliefs, expectations, perceptions, and knowledge. These can be accurate or faulty. Cognitive therapies result in the enlightenment of thinking.
What is The Relationship between Thoughts, Physical Reactions, And Behaviors? Thoughts influence body changes and feelings. These changes and feelings occur because a part of one's brain affects emotions by releasing chemicals. Thoughts affect this part of the brain. In turn, behaviors often affect what one does. The reverse is also true. What a person does, thus behaviors, also influences thoughts, body changes, and feelings.
Therefore, changes in one part of our thinking and behavior can lead to or affect changes in other parts. Changes in attitude can change behaviors, changes in behaviors can change attitudes, and changes in body activities can change attitudes.
Changing Phobic Behaviors In addition to changing cognitions and physical reactions, one must experience the feared situations, objects, places, or persons. As one does this and learns better ways to manage fear, one also will develop more self-confidence.
Continue To Face Phobic Situations And Experience Some Anxiety. During treatment, a person faces the conditions and situations that they fear. This experience is also essential after successful treatment. Doing so will help the person maintain gains and develop more thoughts of mastery and confidence. The person fortifies their feelings of mastery each time they are in a situation that used to be phobic. Each time one reduces and manages a little physical and mental anxiety, they also reinforce their abilities and self-confidence.
When experiencing these repeatedly, a person feels the beginning of some physical tension. Then, one reduces it with relaxation and positive thoughts. Then, they can say the following to themselves.
I can do it. I am doing it. I can do it again. It is getting easier. I feel in better control.
Exposure and re-exposure to the situations and anxiety show that the person can learn to do it. We all will undoubtedly experience some anxiety. Like stress, anxiety is a part of daily living. Some of it will always be present. Anxiety can be healthy. It is not a disorder by itself. We do not cure anxiety or completely stop it. It is not the problem. Anxiety can be our partner.
Anxiety, like stress, is often helpful and needed. In moderation, anxiety can be healthy. It can motivate us to act, react, solve problems, make judgments, change, and grow. Successful management of anxiety helps us to handle future situations better.
As with experiencing stress, managing anxiety can be a learning experience from which we can benefit. So, consider each exposure another chance to practice, develop and maintain skills, and enhance self-confidence.
Procedures For Desensitization And Other Exposure Treatments Exposure treatments are potent. The program accents some aspects and downplays others, but those differences need not affect success.
• Preparation. The treatment should make sense to the client. They need to understand it. • Relaxation. There are several methods for muscle relaxation, relaxed breathing, and other types of relaxation. Booklets, audiocassette tapes, CDS, and DVDs are available to help. Some professionals prefer to provide relaxation procedures without aids such as tapes, CDs, and DVDs. • Biofeedback. Biofeedback involves using special electronic instruments that measure and give information about the body's activity. Some professionals use these methods to help them measure relaxation and tension. Biofeedback gives information about excess tension that often is below awareness. It shows the therapist when the tension decreases. Biofeedback can also help increase confidence and reduce tension. A detailed discussion of biofeedback is beyond the scope of this booklet. There are other materials that a health professional can provide.
Biofeedback is not a necessary part of successful treatments for phobias for most persons. Most successfully treated persons have not used these methods. However, some professionals with special training and experience find the information from feedback instruments helpful.
• Making an Anxiety Ladder. An anxiety ladder is a list that briefly describes events, situations, objects, places, or people connected with phobias. It has layers or levels, ranging from minimal discomfort at the bottom to much anxiety/fear at the top.
The order of some anxiety ladders is according to physical distance or time dimensions. Examples are the time before exposure or the distance from a feared object. Other examples include:
• Time before a test • Distance from an insect or animal • Floor number of a building • Time before going to a dentist • Distance from an injection needle • Depth of water one is standing in • Distance driven from home • Number of persons in the audience to whom one is going to speak • Time before an airplane flight • Distance from an airport and airplane
We often need to consider other ideas when treating some phobias. Two examples show the need to include other topics.
• If the fear is airplane flying, it would be a mistake to include only distance and time items in the ladder. A therapist might ask about other factors of potential importance. These include feelings and thoughts about the following:
• Not being in control • Beginning to feel one's heart beat faster • Being in a restricted space • Being strapped in a seat • Crowds • Body sensations in rough weather with the plane buffeted about or in an air pocket • Height
The hierarchy might contain items reflecting one or more of these additional factors.
• If the fear is public speaking, it would be a mistake to include only times before a presentation on the ladder. It would also be best to consider thoughts and feelings. • What does one think about the number of people in the audience? • Does the type of audience matter? For example, is the anxiety the same if the audience consists of peers or those in more professional or higher business positions than the speaker? • Does the size of the room matter? • Does the topic matter? For example, is the anxiety different when you, as the speaker, have limited knowledge compared to the audience? • Does the number of times one presented on a topic affect the anxiety? • If one's hands begin to sweat, heart beats faster, or one starts to have shortness of breath, does that worsen the anxiety? • If one makes a mistake, does it affect the anxiety? • Does it increase anxiety if one cannot answer a question from the audience? • What happens when one gets lost in one's notes? • How does one, as the speaker, react to a disagreement or criticism from the audience? The hierarchy might also contain items reflecting some or many additional factors.
The Number of Items in Anxiety Ladders Anxiety ladders often consist of up to about two dozen items, sometimes more. Each item is often a slight variation of other items. The parts one can change include the length of time, the number of people in the scene, and differences in the description of the places. Then, rate the intensity of each item from the least to the most discomfort.
On the first try, developing a hierarchy might result in only a brief list with few details. Then, add descriptive and helpful details. The items in the hierarchy should show a fair sample of the conditions one will or could experience in real life.
Rating Discomfort for the Items A standard rating procedure is to use a scale from 0 to 100. 0 means comfort, and 100 means the most discomfort. One rates the items at the extremes and between the extremes. The differences in ratings for the items usually are close. Some professionals suggest dividing the items into low, medium, and high groups. For example, develop items for the lower third, 0-33; the middle third, 34-66; and the upper third, 67-100. For example, do not rate one item as 30 and the next as 55. That could mean a jump too far in one step. Like in a ladder, the rungs are reasonably close together and evenly distributed. For example, consider how one would feel if one feared swimming in the ocean. Imagine walking into the ocean at low tide. If the water gradually becomes slightly deeper, you would feel more comfortable than if suddenly there was a drop of a foot or more. Think of how you would feel if you feared heights on a ladder. You would be more comfortable gradually climbing the ladder than missing rungs requiring more significant steps. Not all anxiety ladders require this degree of precision. However, logically proceeding is proper and might be more comfortable. The critical point is that the hierarchy represents the feared stimuli, and you want the ascent to be comfortable.
Writing The Items The original procedures involved putting each item on a separate 3 x 5 card. This procedure makes rearranging items, adding new items, and having space for elaboration and notes easier. Using these cards is still acceptable. A therapist might prefer this method. Another option is writing and rewriting all the items in the hierarchy on paper. That is my preferred method. Early efforts to write the items could result in some anxiety and even a tendency to write very brief items. Writing them repeatedly on a series of papers and rewriting the descriptions can be therapeutic. Writing can lessen anxiety as one develops the hierarchy further. As one writes more and more, it is like progressing up a hierarchy of writing about the feared words and ideas. The professional working with you will help develop the items, the ratings, and the descriptions.
Developing New And Positive Cognitions What one says to oneself before, during, and after exposure to phobic stimuli is essential. These thoughts can maintain the fear and interfere with overcoming it. A specialist might ask their patient to think about and write down several negative and positive statements about some or all the items before, during, and after imagining or experiencing each item; your therapist might ask you to repeat some positive statements. A few examples will illustrate this point. Ask our doctor or therapist for other examples.
What can you say in the preparation phase before exposure? This phase is an opportunity to practice new and better ways to manage. This situation could upset me, but I now know how to manage it better.
What can I say when the first impact occurs? I am staying calm and relaxing my breathing. As long as I keep calm, I am in control. It is still very early in the process. I can still manage it and keep myself calm. What can I say when feeling some physical tension? It is time now to focus on relaxing. Wait for a second! I will short-circuit this right now! Let me pause for a few moments and relax my muscles and breathing.
During reflection, what can you say? * When you reduce your anxiety, make positive statements. I am proud of myself for how I handled it. It was easier than I thought it would be. It sure feels good to be in better control of my feelings. I made a significant step on the road to managing my symptoms.
* When you do not reduce the anxiety, you can say negative statements. It is not a setback; there is only one event. The next time, I can do better. Keep my positive self-statements and relaxation flowing. I can still use the relaxation now and quiet my body. I will use this opportunity to reflect upon what went wrong and help myself manage better the next time.
Do You Have to Believe Your New Thoughts? The more you believe in your new thoughts, the better you will feel. However, you do not need to believe in them when you start. You can learn to believe them with increased confidence with revisions and practice. You can discuss these procedures for developing new and positive thoughts with your doctor or other therapist.
Progressive Exposure to Items with Mental Images Gradual exposure in imagery is the original procedure and is still in everyday use. One imagines an item for several seconds, about 10 seconds or longer, and then stops. Then, insert periods of relaxation for about a minute or two. Do this until feeling reasonably relaxed. Then, repeat the scene until anxiety no longer occurs during at least two or more repetitions. This process continues with a few items, up to about five in a session.
The next session starts by repeating the last item from the previous session. Some sessions are during therapy sessions with a professional. Sessions also occur at least three times each week at home or elsewhere. Each session preferably ends with completed scenes. One climbs or proceeds up the ladder until completed.
Gradual and Real-Life Exposure Specialists sometimes call real-life exposure in-vivo exposure. The term "real-life exposure" is used in this booklet. Research shows that real-life exposure is more effective than imaginal exposure alone. For some phobias and some people, specialists recommend starting with real-life exposure instead of imagery exposure. For some phobias and some people, one only needs real-life exposure without any preceding imagery phase. Suppose the phobia permits this, and the doctor or other therapist recommends it. In that case, it can speed up the treatment program.
Real-life exposure is typically necessary for those who start with imagery in the next phase. Professionals often recommend progressing to real-life situations during the latter part or at the end of the imagery phase. Preceding real-life exposures with imagery could better prepare one for real-life exposures, which makes sense from the following viewpoints.
• It can help to rehearse complex tasks in one's mind. • It could help better understand the feared thoughts, feelings, and behaviors. • It permits more chances for estimating each item's physical and mental anxiety. It helps decide the order of items before real-life exposure. • It provides more chances for developing positive cognitions.
For example, a college-age woman discovered her fear of pigeons in a city away from her home. She was walking in an area with many pigeons. There were no pigeons in her home city. However, she planned to attend college in a city where she needed to walk through areas with many pigeons. Luckily, many pigeons were available for research in her home city, and her therapist gained access to them. After an imagery phase, a limited real-life phase resulted in successful treatment.
However, some persons might experience very little anxiety or no anxiety during an imagery phase. They might experience anxiety only during the real-life phase. Therefore, some people and some professionals prefer to start with the imagery phase because of this. Some fears and phobias lend themselves easily to both gradual exposure to imagery and real life. Other fears and phobias do not lend themselves to gradual real-life exposure. For example, an anxiety ladder for a phobia of thunderstorms is workable in imagery but not for real-life exposure. Nature provides what one gets. However, there is still room for gradual exposure. Consider the questions below.
• Does one stay in the house or go out in a car? • Does one turn up a TV, radio, or video player during the storm to block the sounds of the storm? • Does one close the curtains to shut out, reduce the visual effects, or stay in a room without windows?
Much about storms is out of our control. For example, the intensity and duration of the storm, the number of lightning events, the distance of the lightning, and the loudness of the thunder are out of our control. Despite all of this, one can alter the real-life impact. For example, one can gradually turn the radio lower. One can gradually open the curtains.
For some phobias, it is challenging to create gradual real-life exposure. Examples are public speaking, fires, criticism by others, taking exams, and sometimes animals, snakes, or insects. Most therapists cannot easily access natural animal, snake, or insect stimuli. Magazine pictures, slides, and fake snakes, insects, or animals might help. Such procedures are sometimes called in-vitro exposure. It is between imagery and real-life exposure.
For most phobias, one can find ways to arrange for gradual exposure, at least for some items. At first, it might not appear possible. However, with some reflection, one might create something worthwhile. For example, for fear of funerals, arrange to be gradually closer to a funeral home. Walk in one when there are no activities. Briefly attend a stranger's funeral and then for extended periods.
For some phobias, professionals can use slides, cassette videotapes, and films in their offices to simulate real-life situations. Your therapist can discuss the use of such simulated materials. These innovations may help some people. However, for others, one needs a real stimulus.
Duration of Exposure To Each Item The exposure for each item can be brief or prolonged. Most of the above information focuses on gradual exposure methods with brief exposures. In imagery procedures, the exposure times are usually seconds or a minute. In real-life procedures, the exposure times are usually longer. Expect a few minutes or up to hours in some situations. In gradual exposure treatment, stop imagining a scene as soon as anxiety starts. In a real-life situation, leave it when anxiety begins. Then, regain a reasonable and desired degree of relaxation or calmness. The next step is to re-imagine the scene or re-enter the situation again. Discuss the length of exposure time.
In some real-life situations, you cannot simply leave. Examples are giving a speech, being on an airplane, taking a test, or being in a storm. You will need to use a variety of self-management procedures while continuing to be in the stressful situation.
In addition to relaxation and cognitive methods, humor is a helpful procedure for reducing anxiety. Preparing for phobic situations is also advisable. Later sections discuss these other methods of reducing phobic anxiety.
Flooding and Implosive Therapy. Your specialist might consider using other exposure treatments, like flooding or Implosive Therapy. In this booklet, we have discussed gradual exposure treatments. Even real-life exposures are gradual whenever possible. As soon as you experience anxiety, your therapist encourages you to stop imagining the scene or leave the situation.
However, other types of exposure treatments involve continuing to imagine or staying in the situation despite the anxiety. Some professionals use the term flooding to refer to these procedures that expose a person to a continuous stream of feared stimuli. Flooding is an intense exposure. However, it does not involve overflowing or overpowering, as one might think, based on some of the meanings of the word flood. One does not drown!
The intent is to experience the anxiety and remain there until it decreases significantly or stops. You do this regardless of how long it takes. It may surprise you to hear about such treatments. Maybe you even fear taking part in such a treatment. However, specialists advise these approaches for some people and some phobias, and they can be very successful. They need not be as upsetting as they might first appear.
There is simply plenty of stimuli and time exposure. You continue to imagine a scene or remain in a phobic situation. You continue to experience anxiety until the bonds or associations between the stimuli and the anxiety diminish or stop.
Medical students and nurses face naturally occurring flooding experiences that successfully reduce and stop their anxiety about everyday medical stimuli. They often experience intense anxiety when first exposed to surgery, serious injuries, and corpses. Their exposure is in large doses. Natural flooding occurs, and they usually become accustomed to the stimuli. Later, they do not suffer intense reactions or feel neutral reactions. Other natural flooding examples are combat soldiers, emergency medical technicians (EMTs), and morticians.
A related type of treatment is Implosive Therapy (IT). Here, too, a literal dictionary definition is misleading. Implosive therapy does not involve a partial vacuum or "bursting inward." Implosive therapy procedures are all in imagery. They involve continuous exposure to a variety of intense details about the phobia. One significant difference from flooding is that there is exaggeration or elaboration of the stimuli based on the therapist's hypothesis, theory, or assumption about some of the underlying fears in IT.
For example, the exaggeration might involve imagining much more filth and garbage in your house than would ever realistically be present. A person who says their fear is flying might be harboring a fear of going berserk on an airplane. A person who says their fear is giving a speech might be harboring a fear of seeing people in the audience laughing at them, making challenging and attacking comments, or going blank and leaving the podium. A person who says their fear is bugs or frogs might be harboring a fear of them jumping on them by the hundreds. Well, assume you get the point without more examples.
The selection of imagined scenes can be initially gradual. However, the therapist continues to present each until the anxiety tapers off a lot or stops. If one can experience an exaggeration of the phobia, the real-life situation will not appear so bad.
It is like holding something heavy, followed by something much lighter but still heavy. The second object feels much lighter because of the prior experience with the much heavier object. Flooding treatment does not involve the exaggeration or elaboration of implosive therapy.
Research shows that implosive therapy can be successful, but not more so than flooding and graduated exposure treatments. Some professionals still prefer to use implosive therapy. I have successfully used both methods many times.
How Do Flooding And Implosive Methods Work? Here, too, there are different explanations for why these treatments work. Some professionals believe that the treatment somehow extinguishes the anxiety on a physiological or neurological level. The bonds break between the stimuli and the resulting anxiety. Other professionals focus on changes in beliefs and self-statements during and after exposure. Still, others believe that we get accustomed or habituated to the stimuli. Here, too, there are multiple reasons. Your therapist will discuss with you the decision to use or not to use flooding or implosive procedures.
SELECTED GUIDELINES and CONSIDERATIONS in GRADUATED EXPOSURE TREATMENTS
Relaxation. Consider the following when learning relaxation.
• Start each session with relaxation for at least several minutes. • Longer periods, up to about 20 minutes, are standard and suggested earlier in treatment. • Some therapists use deep relaxation before starting imagery, artificial exposure, or real-life exposure. Other therapists suggest general relaxation and express less concern with deep relaxation. Research supports both, but your therapist has preferences based on training, experience, and judgment. • In the therapist's office, you might be shown how relaxation and other anti-anxiety methods can reduce anxiety.
Anxiety Ladder. Consider these items when making your anxiety ladder.
• Make the items specific and detailed, which can help understand them. Repeating images on different days will then be more consistent. • Items should include stimuli you have not yet experienced. These include those you avoided in the past but probably would face without the phobia. • Whenever possible, include items under your control in real life. • You can mix different themes within one anxiety ladder.
When you imagine the scenes, review the following two ideas.
• Involve yourself in the scenes. Thus, imagine the scenes vividly and in detail. View them as if you are participating rather than just seeing yourself.
As one moves through an anxiety ladder, remember the ideas below.
• Some professionals will recommend waiting to proceed with new items until one has mastered or successfully managed prior ones. • One might repeat the last item from the last session. • Do not rush through the hierarchy. • Do not reduce the exposure times when repeating imagined items. • Remember positive self-statements during and between scenes. • In some variations of gradual exposure treatment, it is more important to manage the physical signs of anxiety. Focus on those signs rather than just the scene.
What do you do between office sessions?
• Attend to anxiety between office sessions. When one feels anxious or has anxious thoughts, ask, "What is going on that could be making me anxious?" • Take responsibility for practicing often, ideally daily but at least three times a week.
Will You Need Other Treatments? Gradual exposure treatments might be all that you need. However, other methods and stress management procedures can be helpful and sometimes necessary. Brief discussions of these will help in preparation.
• Medication • Social skills training • Other skills training (e.g., study habits, time use management) • Matching capacities and abilities with tasks and jobs • Caffeine reduction or elimination • Assertiveness • Humor • Modeling or observing others
Medicine Many published studies support the use of certain medicines in the treatment of some phobias. A physician, usually a Psychiatrist or Family Practice physician, may recommend and prescribe a trial of certain medicines. Medicine can be helpful alone or with psychological methods such as the exposure methods discussed in this booklet. Your physician can discuss the potential advantages and disadvantages of the medicines.
One possible reason some medicines work for some phobias is that they reduce some of the physical symptoms. Medication can help one be more confident about entering and remaining in feared situations where one experiences less discomfort. When one uses medication alone, these exposures are typically not gradual or orderly.
Several repetitions can break the bonds between the stimuli and the anxiety. Negative thoughts can change into positive thoughts. Physicians often decrease or stop medicines after several exposures. A detailed discussion of medicine is beyond the purpose of this booklet. You can discuss this with your therapist or physician.
However, note that medications are not usually needed to treat specific phobias successfully. The decision whether to use medication or not is tailored to the individual.
Social skills training Some persons who fear social situations could benefit from learning specific social skills. Treatment with exposure treatments, with or without medicine, might not be sufficient. Do you know how to apply specific social skills? Do you have confidence in applying what you know? If you need help understanding one reason, you expect and are tense when facing certain social situations. Does your phobia involve the need for improved social skills? If so, a more detailed discussion of social skills training will interest you more. Ask your therapist or other appropriate healthcare professional where to find more information and get help. Social skills training is beyond the scope of this booklet.
Other skills training Suppose you suffer much discomfort before and during school tests. Your therapist must learn about study habits and learning skills in that case. If you do not study for exams, or if you study very little, or if you procrastinate and try to do all or most of your studying the day before, you have good reason to be very anxious. That is not a phobia. Learning better study habits is needed and could solve most or all of the problems. If the anxiety remains despite proper studying, then exposure treatments might still be helpful.
Matching capacities and abilities with tasks and jobs Be sure that your abilities match your goals. For example, expect problems if your abilities do not match the difficulty level. This is not a phobia. That is realistic. This mismatch between abilities and tasks occurs in more than school examples. It occurs with persons in a variety of work and other life situations. It also occurs when professionals try to accomplish more in life than is reasonable. If this is the case, then consider proper assessment of your abilities. I have seen this mismatching many times.
Caffeine reduction/elimination Caffeine stimulates parts of your nervous system and causes or worsens many physical and mental symptoms, including:
• Heart rate • Vascular headaches • Blood pressure • Cold hands • General anxiety • Sleep onset insomnia
Caffeine is in coffee, sodas, tea, chocolate, and many medicines. Most people's caffeine intake is from coffee. Stopping caffeine is often only enough if you are consuming large amounts. Caffeine intake should be minimal for relaxation methods to be more effective. For example, the amount of caffeine in only a few ounces of drip coffee is enough to increase your heart rate. Consuming much larger amounts can be a significant problem. Fortunately, stopping caffeine is accessible to nearly everyone. Your doctor might discuss the amount of caffeine you consume and the reasons for seriously considering decreasing or stopping it. See separate references, booklets, and websites for more information about caffeine.
Assertiveness The word assertive means appropriate expressions of oneself in interpersonal relations. It is not aggression or anger. It is not passive. Assertiveness is something very different. Consider viewing a triangle with assertiveness as separate, at the apex, and above the other options of aggressive and passive. Examples of applications are:
• Expressing, supporting, or defending your opinion • Honestly and comfortably expressing feelings • "Standing up" for oneself • Starting conversations • Asking for help You can do all of this and more without interfering with the rights of others. When you avoid expressing your feelings, it often is because you might fear a reaction from others if you express yourself poorly or feel discomfort regarding what you say. You also might fear feeling the physical tension that can accompany expressions of feelings.
If your common ways of interacting with others are suppressing or burying your feelings, then learning assertiveness will be helpful. Do other people see you as aggressive in what you say or in the tone of your voice? Do you think you appear aggressive? If so, then consider learning to be assertive.
Avoidance of some interpersonal situations and discomfort in many interpersonal situations are partly due to suppressing certain feelings. For example, one could suppress the thoughts that expressing feelings will result in adverse effects. It does not make sense to arrange only graduated exposures to such situations. You also need to know how to express yourself appropriately. You must have improved and adaptive beliefs about expressing your thoughts and feelings in these situations. A few sample questions will be enough to make this point.
a. Might a fear of crowded places include anxiety about someone getting in front of you in a line? b. Might a fear of some social situations include a perceived or actual inability to speak without discomfort in a discussion with other people? c. Might a fear of public speaking include a perceived or actual inability to disagree appropriately with someone who criticizes what you said or asks a question for which you are unsure of the answer?
A detailed discussion of assertiveness is beyond this booklet. Available books can be helpful. See the bibliography.
Humor You know that you usually are not anxious and genuinely laughing simultaneously. Some health professionals suggest using humor and laughter as another means of reducing anxiety.
Using humor and laughter is insufficient, and good research still needs to be done on the therapeutic value of laughter for managing phobias. Do not laugh at everything that one fears. However, laughter can lead to less anxiety for some people. Humor might be helpful in phobia management treatment. Many of us take many events in life far too seriously. The psychological distance often achieved with humor and laughter can be valuable.
If time is unavailable to learn good relaxation, consider using humor. Consider including it in some scenes to aid in reducing anxiety. (Ventis, 1987)
Funny hierarchy items make one at least smile and preferably laugh. Humor can result in new and less anxious thoughts and help reduce physical tension. Remember the humorous items when you are in anxious situations.
Here are some examples of humor in anxiety ladder items:
• When facing an injection, imagine the nurse or doctor wearing clown makeup. • Imagine the teacher wearing funny clothes to help reduce test anxiety. • In a crowded elevator, imagine other people cracking jokes and making funny faces. The patient and therapist might incorporate humor and laughter into the treatment program. Consider Jimmy Durante's words.
"It dawned on me then that as long as I could laugh, I was safe from the world, and I have learned since that laughter keeps me safe from myself too. All of us have schnozzles --- they are ridiculous in one way or another, if not in our faces, then in our characters, minds, or habits. When we admit our schnozzles, instead of defending them, we begin to laugh, and the world laughs with us" (Peter & Dana, 1982).
Modeling or Observing Others They were seeing other people doing what they fear can be very useful. Modeling, or what some professionals call Guided Participation, is sometimes on film but usually in real life in therapists' offices and elsewhere. A more detailed discussion is beyond the intent of this booklet. However, the following discussion provides some discussion and examples.
The therapist might model relaxation, new thoughts, humor use, engaging in the feared activity, and handling the feared object (e.g., animal, insect). This procedure can be beneficial for some patients.
One patient I treated had a long and gradual series of imagined and actual exposures to dead insects and a live frog. I then held a frog and encouraged the patient to take the frog herself. I did this first by having her surround my hands, holding the frog. Gradually, I eased the frog into her hands. This process occurred while teaching relaxation, new self-statements, and a little humor. After that session, treatment progressed more rapidly, and she could manage real-life experiences in her life. She could go to lakes and camp with her husband, a primary reason for seeking treatment.
Modeling occurs naturally in our lives. We learn much from seeing others and imitating them. For example, have you ever watched preschool children on a beach with small waves rolling in? Some children fear going near the water but want to play in the water. Other similar-age children often play in the shallow part of the water. They are jumping and showing that they are having fun. Seeing that, the fearful child might be bolder in getting closer to the water and going in.
There are many adult examples. These include surgery, piloting airplanes, driving cars, professional firefighting, police work, and many athletic activities such as gymnastics and downhill skiing. Anxiety and fear often occur at first but are later much less or gone. The process includes observation, guided participation, and repeated imitations.
Solving Problems That One Might Face Every treatment has some problems. Do not worry about that. Most people do not experience serious problems, and those who do can usually overcome them. One can view these as challenges and chances to overcome them and grow. If it were too easy, one would not need professional help. After all, professionals also need variety and challenges. It makes our work more interesting.
1. Suppose the patient does not picture clear images. Assume that the images of the scenes relate to real situations. The instructions are to picture them clearly and realistically. One views each item as if they were really in the situation. Imagining images of real situations, reacting to them, and learning to relax and manage them thus have similarities to real-life situations. Interacting with the stimuli and feeling at least some anxiety and tension sensations is often a part of the process.
However, people differ in their imagination skills and ability to picture hierarchy scenes. There are many reasons that one might not ideally picture some scenes. If they have difficulty, discuss this with the therapist. Some therapists provide special instructions for picturing scenes more clearly as a possible solution, and many persons learn to do this with practice. The therapist might ask the patient to rate how they picture each image. A sample rating is: 1 = I barely saw the details, 2…., 3…., 4 = saw the details very clearly. There are other optional solutions. Remember from earlier in this booklet that the third choice between images and real-life exposures is artificial stimuli exposures, like test tubes in laboratories. In-vitro exposures include photographs, slides, audio CDs or tapes, video CDs/tapes or DVDs, and rubber or plastic models. One might even use artificial stimuli even if one can imagine pictures well. They are helpful when real-life exposures are awkward or not practical.
2. What does one do if some items do not raise any anxiety? This problem is common despite clearly picturing scenes. An item might need to be more accurate in some essential details. Maybe the item does not belong on the list as an anxiety item. The patient and therapist need not assume that such items are inaccurate. Instead, successful exposure, relaxation, and positive thoughts with earlier items resulted in benefits to other items. This benefit can occur by generalizing or spreading forward to other items.
Think of it this way. The ladder example is good to use here. Suppose one were afraid of heights on a ladder. Began to climb it in one's imagination and reality. First, go up and down slowly until one is comfortable up a few rungs - for example, the fifth. Then, imagining or being on the sixth rung does not lead to discomfort or less than it did on the lower rungs. First, stop anxiety on the lower rungs. Then, an item higher on the list is like a lower item before starting. The positive effects of the lower rungs might spread to some higher rungs or items.
3. What does one do if annoying side effects occur during relaxation? Relaxation methods seldom result in adverse side effects. However, some people feel temporary annoying effects (Schwartz, Schwartz, & Monastra, 2003). The more common side effects are distracting thoughts and fear of losing control. Other examples are disturbing sensory experiences, discomfort with sitting still, staying tense, and falling asleep. Fortunately, none of these need to be a source of worry. There are methods to reduce and stop these effects if they occur (Schwartz et al., 2003). Consider a few simple remedies adapted from that chapter for the following problems.
• To avoid distraction by external noises or temperatures, arrange for the place where one practices to be quieter and more comfortable.
• If one gets small jerks in muscles, then stay quiet and still. Muscle jerks often mean that one is deepening the effects of relaxation. They are common and often lessen in a few minutes as one relaxes longer. However, some relaxation procedures use muscle tensing and releasing procedures. Some persons tense too tightly and for too long. This can result in increased tension and muscle cramps. If this happens, reduce the intensity and duration of the tensing. Consider using relaxation procedures that do not use tensing-releasing sequences.
• If one feels restless from prolonged sitting or lying down during sessions, limit sessions to slightly shorter ones.
• If one experiences disturbing or distracting thoughts or images during relaxation, try to shift attention to something pleasant. Try picturing the bothersome thought or image as words or a picture on a movie or TV screen. Gradually, over a few seconds, imagine that the screen is becoming smaller and smaller. Pretend the screen moves farther away until it becomes tiny and no longer bothersome. If the image is "in color," convert it to "black and white."
Think of it this way. You are watching a gory movie in color and on a wide screen. You are sitting in the front row. Now you change the picture to a black and white 3-inch TV screen. You then move it across a large room, about 10 to 15 feet away. You might still see it, but the impact on you would be minimal.
• If one becomes sleepy or starts sleeping during relaxation portions, one may realize they are relaxing well. However, this is not what you want to do. If you need more sleep, then discuss this with your therapist. There are many reasons people do not sleep well, and there are many methods for learning to sleep better and longer. Discuss this with your doctor or other therapist if you want more information.
Resistance to Treatment There are reasons some people resist this treatment.
1. Some people fear failing. They avoid treatment rather than trying and taking the chance of being unsuccessful. This fear of failure might be another phobia theme—one fears trying new tasks that appear challenging. If so, then it might need attention.
2. Some people consider exposure procedures superficial or too similar to mechanical treatment. If this applies, discuss it openly with your therapist.
There are specific parts that appear mechanical. These treatments do have technical aspects that appear mechanical to some persons. However, they are much less mechanical than most medical and surgical treatments. Mechanical-like treatments are acceptable as long as they work. Remember the comparison of gradual exposure with the treatment of allergies; remember that these are robust and very successful treatments.
3. Some people believe this type of treatment does not get to the roots of their problem. However, consider that there is more support for the use of these treatments with phobias than with almost any other type of psychotherapy. Gaining insight can be very valuable for many problems. However, it is not the preferred treatment for phobias.
4. Another problem that some persons resist treatment is the problem of "secondary gain." For some people, ongoing problems result in some benefits.
This benefit is expected. There are some benefits to most or all lasting problems. The negative features of problems usually outweigh the positive features. However, sometimes, the benefits outweigh the negative aspects. When the latter occurs, there can be secondary gain from the problem. The person receives too much gain from the problem. In this case, the "gain" adds to the problem. We may even want it to continue when we benefit from these behaviors.
Although secondary gains are often present to some degree, they are not a problem for most people with phobias. When they do exist, revealing and realistically dealing with them is essential.
A few examples help one better understand this complex and sensitive issue. Consider the following example. What happens when a person's phobia results in being able to avoid tedious or troublesome chores or tasks or their job?
Also, think of an airline pilot who only flies short hops called "milk runs" between the same small towns. Suppose he feels bored with his job and sees no way of changing. Suppose he is flying in a thunderstorm and clips a few treetops while landing but manages to land safely. He felt intense tension in his nervous system. Over the next several weeks, he gradually develops similar physical anxiety while flying, especially when there is terrible weather present or expected. Then, he might develop these symptoms before flying or getting to the airport. He developed a phobic reaction. Of course, he can no longer fly. He could avoid returning to work because he could get a medical disability. He was also very resistant to treatment. He might not even be aware of these conflicting and complex thoughts. This is not a far-fetched example if the reader "gets my drift."
Now, think of another person's phobia - one that involves intense anxiety in some social situations. It also might keep that person from other awkward activities, such as being with certain people whom she wants to avoid. Of course, such a person did not develop the phobia to avoid certain people or activities. However, the net result is the same. Successful treatment means that the person can attend social events or activities that are boring or otherwise annoying.
Suppose a phobia for crowds and social events gives more time for other desired activities. Successful treatment might mean going places that will take time away from these other preferred activities.
The presence of resistance suggests the possibility of secondary gain. One need not feel embarrassed by the presence of secondary gains. They are not rare, and one expects them in some situations. One must become aware of the secondary gain and deal with it effectively before treatment progresses. Please remember to discuss this and any other concerns with one's therapist.
Summary This booklet describes and discusses many aspects of phobia management treatments used to treat fears and phobias. These are robust and very effective treatments, with extensive research, broad professional support, and usage over many years. One can feel confident in these treatments. Success, of course, also depends on the qualifications and experience of the professional with whom one works. Positive motivation and active participation are both critical. Ask questions and discuss any problems with one's doctor or therapist.
Appendix 1: Topics not covered in this booklet. • Social Phobia • OCD • Medication • Children • Agoraphobia • Eye Movement Desensitization and Reprocessing (EMDR)
Appendix 2: Websites There are a vast number of websites about phobias. The list below is only a few, but it probably will be sufficient to get the information wanted and needed.
[Mayo Clinic] [About Phobias] [AllPsych Online ] [Association for Behavioral and Cognitive Therapy - ABCT] ABCT - phobia pdf document [Anxiety Disorders Association of America - ADAA] ADAA - specific phobia ADAA - phobia ADAA - treatment The Laughter Prescription (book) The healing power of laughter
References and Bibliography • Alberti, R.E. & Emmons, M.L. (1995). Your Perfect Right: A Guide to Assertive Living (25th Anniversary Edition). Atascadero, CA: Impact Publishers.
• Block, K., Schwartz, M.S., Gyllenhaal, C. (2003). Dietary Considerations: Rationale, Issues, Substances, Evaluation, and Patient Education. (Ch. 9, Section on Caffeine pp. 192-200). In Mark S. Schwartz & Frank Andrasik (Eds.). Biofeedback: A Practitioner's Guide (3rd Edition). New York: Guilford Press.
• Bourne, Edmund J. (1998). Overcoming Specific Phobia: A Hierarchy and Exposure-Based Protocol for the Treatment of All Specific Phobias – Client Manual. Oakland: New Harbinger Publications. (Cost about $10.- $13.)
• De Jongh, A. De, Broeke, E. T., & Renssen, M. R. (1999). Treatment of Specific Phobias with Eye Movement Desensitization and Reprocessing (EMDR): Protocol, Empirical Status, and Conceptual Issues. Journal of Anxiety Disorders, Vol. 13, No. 1–2, pp. 69–85.
• Hyer, Lee & Kushner, Bonnie (2007). Eye Movement Desensitization and Reprocessing and Stress: Research, Theory, and Practical Suggestions (ch 21, pp545-578. In Paul M. Lehrer, Robert L. Woolfolk, & Wesley E. Sime (Eds.). Principles and Practice of Stress Management (3rd Edition). New York: Guilford Press.
• Peter, L.J. & Dana, B. (1982). The Laughter Prescription. New York City: Ballantine Books (Random House Publishing Group)
• Phelps, S. & Austin, N. (2002). Assertive Woman (4th Edition). Atascadero, CA: Impact Publishers.
• Schwartz, M.S., Schwartz, N.M., & Monastra, V.J. (2003). Problems with Relaxation and Biofeedback-Assisted Relaxation, and Guidelines for Management. (Ch. 12). In Mark S. Schwartz & Frank Andrasik (Eds.). Biofeedback: A Practitioner's Guide (3rd Edition). New York: Guilford Press.
• Ventis, W. L. (1987). Humor and Laughter in Behavior Therapy. (pp.149-69). In William Fry & Waleed Salameh (Eds.). Handbook of Humor and Psychotherapy. Sarasota, FL: Professional Resource Exchange.
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