Mark Stephen Schwartz, Ph.D.

What are the Phobia Treatments?
The most common successful treatment methods are behavioral therapies and very successful. This booklet focuses on Exposure Treatments which are the most common.

Systematic Desensitization is the most common type of exposure treatment. Instead of using the term systematic desensitization in this booklet, I call this gradual exposure treatment. The word systematic means organized, orderly, and precise. Desensitize means to end reactions or sensitivity to stimuli. Remember that allergy doctors use treatments they call desensitization to stop or reduce allergic reactions. They put small amounts of allergic substances into the body. The body adapts and develops counter measures to the allergic substances. The body develops ways to reduce or stop the sensitivity. Therefore, the body "gets used to" the substances. This is similar to what exposure treatments do for phobias but without putting substances into the body. Instead, there are methods that allow the body to adapt and develop counter measures to the phobia.

Exposure treatments can help you:
• Uncover the major 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, thoughts, and reducing tension

The timing and amount of exposure can be in small steps as in gradual exposure treatments. The exposures can also be in larger amounts as in a related therapy called flooding. A later section of this booklet discusses flooding. Professionals may use different amounts of exposure and different exposure procedures.

These very successful treatments has some of its roots back centuries but mostly to early in the 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. Your physical reactions can include increased heart rate, queasy feelings in your stomach, shortness of breath, and dizziness. Muscle tension in various parts of the body also can increase. Perspiration on your hands and soles of your feet can also be part of your reaction.

For other people, fear involves mostly thoughts. For example, you might say that you feel afraid or very anxious about your reactions to specific situations. For other persons, fear involves          behaviors such as avoiding specific situations. You might act frightened when you expect to be in these conditions or face the feared situation. The thoughts or physical reactions might not be present but you might arrange your life by avoiding such events. Maybe, you think that if you actually face the situation, you would have fearful thoughts and physical tension. You might not, but you do not want to take a chance. Avoiding the situation shows your phobia.

People with phobias report different blends of physical tension, thoughts, and avoiding behaviors. People do behave, feel, and think differently from each other even when they report a phobia with the same name.

Phobias are very common. 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 you did not suffer a frightening event. Thus, people can learn by seeing or hearing about other people experiencing fear. Some people appear to learn these reactions by simply 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 own fears in front of their children and thereby act as models for fearful behaviors. If you do not know what to expect in a situation, you also might be afraid. If you have no experience with it, thus the unknown, you could become very anxious.  

Physical reactions associated with those events can recur even when thinking about the place, people, objects, or situation. When you face or expect to face the same or similar situations, then you might have similar thoughts and physical reactions.

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 partly 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 influences 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?
In some people there might be some genetic tendency for developing fears and phobias. Even if this is true, we must keep it in perspective. Life experiences are far more important for determining what we learn rather than our genes.

Common Fears And Phobias
There are hundreds of phobias. Among the more common are:

Being alone                                
Feeling rejected        
Airplane flying
Small enclosed places                      
Sexual activities
Shopping malls
Rodents and snakes
Dirt or messiness      
Dentists and physicians
Physical symptoms                          
Public speaking        

Evaluating Fears and Phobias
Evaluation methods involve:
• Interviews
• Questionnaires                        
• Behavior measures      
• Recordings with biofeedback instruments                  

Many professionals use morethan one method. All use an interview and some also use questionnaires. A smaller number use biofeedback instruments and a few use behavior measures such as how close you approach a feared object. All are proper but provide different information. Your specialist will discuss the evaluation methods with you.

Research Evidence Shows That These Treatments Work.
Over the past few decades, extensive good to excellent research studies and huge numbers of cases consistently support the success of exposure treatments. You clearly can have much confidence in these treatments. Exposure treatments are strong. They are 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. They know how to increase the chance of the effectiveness of the treatments. Summaries of the common explanations are below. They are not in any specific order.

Some believe that relaxation of your nervous system helps replace physical and mental  anxiety with relaxation. This was one of the original ideas and might be one important part of effective treatment for many people. However, deep relaxation probably is not necessary. Anxiety can end by mere exposure to the anxiety-producing stimuli. This happens by adapting or becoming accustomed to the situation, sometimes called habituation. A related explanation is extinction. The anxiety becomes extinct. It vanishes.  You carefully improve and increase fearless behaviors. You approach and contact the fear arousing stimuli. All of this increases your self-confidence, sometimes called self-efficacy. You also develop other stress management skills. You also change what you say to yourself before and during exposures. This self-dialogue or self-statements become more positive. Phobias often develop because of more than one reason and treatments work because of more than one reason. Good treatments consider many of the reasons. Treatment is usually directed 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

Your doctor or other therapist can discuss these with you.

Ways To Change And Manage Physical Reactions
Relaxation treatments reduce physical tension. Physical tension involves your muscles, breathing, and other parts of your nervous systems. These lead to the release of anxiety chemicals, like adrenaline, into your blood.  Relaxation reduces these chemicals and reduces muscle tension, heart rate, blood pressure, and other signs of physical anxiety. It also helps calm anxious thoughts.

Changing And Managing Fearful Thoughts
You can help yourself manage anxiety and fear by changing your attitudes, beliefs, and what you say to yourself. What you think and say to yourself, and what you imagine, affects your bodies and your symptoms. You can develop new and positive thoughts about your fears. Specialists can recommend some methods for you and you can learn about these methods by reading and in office sessions.

The word cognition means thoughts, attitudes and beliefs, expectations, perceptions, and knowledge. These can be accurate or faulty. Cognitive therapies result in enlightenment of thinking.

What is The Relationship between Your Thoughts, Physical Reactions, And Behaviors?
Your thoughts influence body changes and feelings. This occurs because part of your brain affects emotions by releasing chemicals. Thoughts affect this part of the brain. In turn, your behaviors often affect what you do. The reverse is also true. What you do, your behaviors, also influences your thoughts, body changes, and feelings.

Therefore, changes in one part of our thinking and behavior can lead to or affect changes in others parts. Changes in attitude can change behaviors. Changes in behaviors can change attitudes. Changes in body activities can change attitudes. Changes in attitudes can change body activities. If you have questions about this, discuss them with a specialist.

Changing Phobic Behaviors
In addition to changing your cognitions and your physical reactions, you need to actually experience the feared situations, objects, places, or persons. As you do this and learn better ways to manage your fear, you also will develop more self confidence.

Continue To Face Phobic Situations And Experience Some Anxiety.
During treatment you face the conditions and situations that you fear. This is also important after successful treatment. By doing so, this will help you maintain your gains and develop more thoughts of mastery and confidence in yourself. You fortify your feelings of mastery each time you are in a situation that used to be phobic. Each time you reduce and manage a little physical and mental anxiety, you also reinforce your abilities and self-confidence.

When you experience these repeatedly, you feel the beginning of some physical tension. Then, you reduce it with relaxation and positive thoughts. Then, you can say the following to yourself.          

                           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 you that can learn to do it. It is certain that we all will 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.

In fact, anxiety, like stress, is often useful 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 better handle future situations.

As with experiencing stress, managing anxiety can be a learning experience from which we can benefit. So, look at each exposure as another chance to practice, to develop and to maintain skills and to enhance self-confidence.

Procedures For Desensitization And Other Exposure Treatments
Exposure treatments are strong. Your program might accent some aspects and downplay other aspects. Those differences need not affect your success.

• Preparation. The treatment should make sense to you. You need to understand it.
• Relaxation. There are several methods for muscle relaxation, relaxed breathing, and other types of relaxation. Booklets, audiocassette tapes and 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 the use of special electronic instruments that measure and give information about your body's activity. Some professionals use these methods to help them measure relaxation and tension. It gives information about excess tension that often is below your awareness. It shows the therapist when the tension decreases. Biofeedback also can help you increase your confidence in your reduction of tension. A detailed discussion of biofeedback is beyond the scope of this booklet. There are other materials that your health professional can give you and discuss.

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. These vary from those with very little discomfort at the bottom to those with 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 you are standing in
• Distance you drive from home
• Number of persons you are going to speak to
• Time before an airplane flight
• Distance from an airport and airplane

We often need to consider other ideas in treating some phobias. Two examples show the need for including other topics.

• If the fear is airplane flying, it would be a mistake to include only distance and time items in the ladder. Your therapist might ask you about other factors of potential importance. These include your feelings and thoughts about:

• Not being in control
• Beginning to feel your heart beat faster
• Being in a restricted space
• Being strapped in your seat
• Crowds
• Body sensations in rough weather with the plane buffeted about or in an air pocket
• Height

The hierarchy might well contain items reflecting one or more of these additional factors.

• If the fear is public speaking, it would be a mistake for the ladder to contain only times before a presentation. You also should consider your thoughts and feelings.
• What do you think about the number of people in the audience?
• Does the type of audience matter? For example, is your anxiety the same if the audience is peers or those in higher professional or business positions than you?
• Does the size of the room matter?
• Does the topic matter? For example, is your anxiety different when you have limited knowledge; much knowledge?
• Does the number of times you presented on a topic affect your anxiety?
• If your hands begin to sweat, your heart beat faster, or you start to have shortness of breath, does that worsen your anxiety?
• If you make a mistake, does it affect your anxiety?
• Does it increase your anxiety if you cannot answer a question from the audience?
• What happens when you get lost in your notes?
• How do you reach to a disagreement or criticism from the audience?

Here too, the hierarchy might well contain items reflecting some or many of these 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 you change can include length of time, number of people in the scene, and differences in the description of the places. You then rate the intensity of each item from the least to the most discomfort.

Your first try developing a hierarchy might result in only a brief list with few details. Then, you will add descriptive and helpful details. The items in the hierarchy should show a fair sample of the conditions that you will or could experience in real life.

Rating Your Discomfort for the Items
A common rating procedure is to use a scale from 0 to 100. The 0 means comfort and 100 means the most discomfort. You rate the items at the extremes and between the extremes. The differences in ratings for the items usually are not far apart. Some professionals might suggest that you start by dividing the items into three groups, low, medium and high. For example, develop items for the lower third, 0-33, the middle third, 34-66, and the upper third, 67-100.
For example, you would not rate one item as 30 and the next as 55. That could mean that you would jump too far in one step. Like in a ladder, the rungs are fairly close together and evenly distributed. For example, consider how you would feel if you feared swimming in the ocean. Imagine you are walking into the ocean at low tide. If the water gradually become deeper, then 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 real ladder. You would be more comfortable with a gradual climb up the ladder than with missing rungs requiring big steps. Not all anxiety ladders require this degree of precision. However, proceeding in a logical order is proper and might be more comfortable. The important 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 makes it easier to rearrange items, put in new items, and have space for elaboration and notes. This is still acceptable and your therapist might prefer this method. Another option is writing and rewriting all the items in the hierarchy on a piece of paper. That is my preferred method.
Your early efforts to write the items could result in some anxiety and even a tendency to write very brief items. Writing them over and over on a series of pieces of paper and rewriting the descriptions can be therapeutic. This can lessen your anxiety as you further develop the hierarchy. As you write more and more, it is like progressing up a hierarchy of writing about the feared words and ideas.

The decision as to which method you use will be up to you and your therapist. The professional working with you will help you develop the items, the ratings, and the descriptions.


Developing New And Positive Cognitions
What you say to yourself before, during, and after exposure to phobic stimuli is important. These thoughts can maintain the fear and interfere with overcoming it. Your specialist might ask you 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 of these 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 is an opportunity to practice new and better ways to manage.
This situation could upset me, but I now know some ways to better manage with it.

What can I say when the first impact occurs?
I am staying calm and relaxing my breathing.
As long as I keep calm, I'm 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 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.  
This was one major 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, 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.

You Have to Believe Your New Thoughts?
The more you can believe in your new thoughts the better you can feel. However, you do not need to believe the new thoughts when you start. With revisions and practice you can learn to believe them with increased confidence. 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 still in common use. You imagine an item for several seconds, about 10 seconds or longer, and then stop. You then insert periods of relaxation for about a minute or two. You do this until you feel fairly relaxed. Then, you 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 with repeating the last item from the prior session. You can have some sessions in a professional's office. They also occur at least three times each week at home or elsewhere. Each session preferably ends with successfully 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. I call it real-life exposure in this booklet. Research shows that real-life exposure is more effective than imaginal exposure alone. With some phobias and for some people, specialists recommend starting with real-life exposure instead of imagery exposure. For some phobias and for some persons, one only needs real-life exposure without any preceding imagery phase. If your phobia permits this and your doctor or other therapist recommends it, then it can speed up the treatment program.

For those who start with imagery, real life exposure typically is necessary at the next phase. Professionals often recommend progressing to real life situations during the latter part or at the end of the imagery phase. The reason for preceding real-life exposures with imagery is that it might better prepare you for the real-life exposures. That makes sense from the following viewpoints.  

• It can help rehearse difficult tasks in your mind.
• It could help develop better understanding of the feared thoughts, feelings, and behaviors.
• It permits more chances for estimating the physical and mental anxiety for each item. 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 while 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, there were many pigeons 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 persons and some professionals prefer starting with the imagery phase because of this. Some fears and phobias lend themselves easily to both gradual exposure in 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 for thunderstorms is workable in imagery but not for real-life exposure. Nature provides what you get. However, there is still room for gradual exposure. Consider the questions below.

• Do you stay in your house or go out in your car.
• Do you turn up a TV, radio, or video player during the storm to block the sounds of the storm.
• Do you close the curtains to shut out or reduce the visual effects, or do you stay in a room without windows.

Obviously, much about storms is out of our control. For example, the intensity and duration of the storm is out of our control. So is the number of lightening events, the distance of the lightening, and the loudness of the thunder. Despite all of this, you can alter the real-life impact. For example, you can gradually turn the radio lower. You can gradually open the curtains.

For some phobias it is difficult to create gradual real-life exposure. Examples of these are public speaking, fires, criticism by others, and taking exams, and sometimes animals, snakes or insects. For animals, snakes or insects, most therapists do not have easy access to the real stimuli. Magazine pictures, slides, and fake snakes, insects, or animals might help. This is sometimes called in-vitro exposure. It is between imagery and real-life exposure.

For most phobias, one can usually find ways to arrange for gradual exposure at least for some items. At first, it might not appear possible. However, with some reflection, you might create something useful. For example, for a fear of funerals, you could arrange to be gradually closer to a funeral home. You also could walk in one when there are no activities. You also could attend a stranger's funeral briefly and then for longer periods.

For some phobias professionals can use slides, cassette videotapes and films in their office to simulate real-life situations. Your doctor or other therapist can discuss the use of such simulated materials. These innovations may help some persons. However, for others, one needs the real stimulus.  

Duration of Exposure To Each Item
The exposure for each item can be brief or long. Most of the above information focuses on gradual exposure methods with brief exposures. In imagery procedures the exposure times usually are seconds or a minute or so. In real-life procedures the exposure times are usually longer. You can expect a few minutes or up to hours in some situations.  
In gradual exposure treatment you usually stop imagining a scene as soon as anxiety starts. If you are in a real-life situation, you leave it when anxiety begins. You 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. Your doctor or other therapist will discuss the length of exposure time.

Obviously, in some real-life situations you cannot simply leave the situation. 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 useful 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 such as flooding or Implosive Therapy methods. So far in this booklet we discussed gradual exposure treatments. Even the 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, there are other types of exposure treatments that involve continuing to imagine or staying in the situation in spite of the anxiety. Some professionals use the term flooding to refer to these procedures that expose a person to a continuous stream of the feared stimuli. This is an intense exposure. However, it does not involve overflowing or overpowering you as you might think by some meanings of the word flood. One does not drown!

In fact, the intent is to experience the anxiety and remain there until the anxiety decreases a lot or stops. You do this regardless of how long it requires. 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 persons and for 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 diminishes or stops.

Medical students and nurses face natural occurring flooding experiences that are successful in reducing and stopping their anxiety about common 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 they 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 major difference from flooding is that in IT there is exaggeration or elaboration of the stimuli based on the therapist’s hypothesis, theory, or assumption about some of the underlying fear.

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 really be harboring a fear of going berserk on an airplane. A person who says their fear is giving a speech might really be harboring a fear of seeing people in the audience laughing at him/her or making very challenging and attacking comments, or totally going blank and having to leave the podium. A person who says their fear is bugs or frogs might really be harboring a fear of them jumping on them by the hundreds. Well, I 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, then the real life situation will not appear so bad.

It is like holding something very 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 in my career.

How Do Flooding And Implosive Methods Work?
Here too, there are different explanations 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 that happen during and after exposure. Still others believe that we get accustomed or habituate to the stimuli. Here too, there are probably multiple reasons. Your doctor or other therapist will discuss with you the decision to use or not to use flooding or implosive procedures.  


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 common 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 his or her 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. This can help you and your therapist understand the items. Repeating images on different days will then be more consistent.  
• Items should include stimuli you haven’t yet experienced. These include those that you avoided in the past, but probably would face without the phobia.
• Whenever possible, include items that will be under your control in real life.
• You can mix different themes within one anxiety ladder.  

When you imagine the scenes, review the next two ideas.

• Involve yourself in the scenes. Thus, imagine the scenes vividly and in detail. View them as if you are actually participating rather than just seeing yourself.  

As you move through your anxiety ladder, remember the ideas below.

• Some professionals will recommend that you wait to proceed with new items until you have mastered or successfully managed prior ones.
• You 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 your 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. You might focus on those signs rather than just the scene.

What do you do between office sessions?

• Attend to your anxiety between office sessions. When you feel anxious or have anxious thoughts ask yourself, "What is going on that could possibly be making me anxious?"
• Take responsibility for practicing often, ideally daily but at least 3 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 prepare you.

• Medication
• Social skills training
• Other skills training  (e.g. study habits, time use management)
• Matching your capacities and abilities with tasks and jobs
• Caffeine reduction or elimination
• Assertiveness
• Humor  
• Modeling or observing others  

There are many published studies supporting 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 useful either alone or together 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 that some medicines work for some phobias is that they reduce some of the physical symptoms. This can help you to be more confident to enter and remain in feared situations where you experience less discomfort. When you use medication alone, these exposures are typically not gradual or orderly.

After several repetitions, the bonds between the stimuli and the anxiety can be broken. Negative thoughts can change to 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 in most cases, medications are not needed for successful treatment of specific phobias. This decision is tailored to the individual.  

Social skills training
Some persons who fear social situations could benefit from learning certain social skills. Treatment with exposure treatments, with or without medicine, might not be enough. Do you know how to apply certain social skills? Do you have confidence in applying what you know? If not, then you understand one reason you expect and are tense when you face certain social situations. Does your phobia involve the need for improved social skills? If so, then a more detailed discussion of social skills training will be of more interest to you. Ask your therapist or other appropriate health care professional for where to find more information and get help. This is beyond the scope of this booklet.

Other skills training
If you suffer much discomfort before and during school tests, then your therapist must find out about study habits and learning skills. Obviously, 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 exams, then you have good reason to be very anxious. That is probably not a phobia. Learning better study habits is needed and could be most or all of the solution. If the anxiety remains despite proper studying, then exposure treatments might still be useful.

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 of school.  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 with professionals who are trying to accomplish more in life than is reasonable. If there is a chance that this might be the case then consider proper assessment of your abilities. I have seen this mismatching many times in my professional career.

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 caffeine intake for most people is from coffee. Stopping caffeine is often not going to be enough unless you are consuming large amounts. For relaxation methods to be more effective your intake of caffeine should be extremely low. 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 major problem. Fortunately, stopping caffeine is easy for nearly everyone. Your doctors might discuss with you the amount of your caffeine intake and the reasons for seriously considering decreasing or stopping caffeine. See separate references, booklet and websites for more information about caffeine.

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 and 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 expression of your feelings it often is because you might fear reaction from others if you express yourself poorly or 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 expression of feelings will result in negative effects. It does not make sense to arrange for only graduated exposures to such situations. You also need to know how to express yourself appropriately. You need to 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 properly 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 useful. See the bibliography.  

You know that you usually are not anxious and genuinely laughing at the same time. Some health professionals suggest using humor and laughter as another means for reducing anxiety.

Using humor and laughter is not enough and good research does not yet exit for the therapeutic value of laughter for managing phobias. I do not recommend that you laugh at everything that you fear. However, laughter can lead to less anxiety for some persons in some situations. Humor might be useful in phobia management treatment.  Many of us do take many events in life far too seriously. The psychological distance often achieved with humor and laughter can be valuable.

If time is not available to learn good relaxation, then consider using humor. You might include it in some scenes as an aid in reducing anxiety. (Ventis, 1987)

Funny hierarchy items are those that make you at least smile and preferably laugh. Humor can result in new and less anxious thoughts. It also can 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's makeup.
• Imagine the teacher wearing funny clothes to help reduce test anxiety.
• In a crowded elevator imagine other people in the elevator cracking jokes and making funny faces.
     You and your therapist might try humor and laughter as part of your treatment program. Consider the words of Jimmy Durante.

"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 -- are ridiculous in one way or another, if not 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
Seeing other people doing what you fear can be very useful. Modeling or what some professionals call Guided Participation is sometimes on film but usually in real-life in therapist's offices and elsewhere. A more detailed discussion is beyond the intent of this booklet. However, the following discussion provides some discussion and examples.

Your therapist might model relaxation, new thoughts, humor use, engaging in your feared activity, and/or handling your feared object (e.g. animal, insect). This procedure can be very helpful for some patients.

One patient I treated had a long and gradual series of imagined and real 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 that were holding the frog. Gradually, I eased the frog into her hands. This was done 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 are often playing 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.  

Adult examples are many. These include surgery, piloting airplanes, driving cars, professional fire fighting, police work, and many athletic activities such as gymnastics and downhill skiing. Anxiety and fear often occurs at first but is later much less or gone. The process includes observation, guided participation, and repeated imitations.

Solving Problems That You Might Face
Every treatment has some problems. Do not worry about that. Most people do not experience serious problems. Those who do can usually overcome them. You can view these as challenges and chances to overcome them and grow. If it was too easy, you probably would not need professional help. After all, professionals also need variety and challenges. It makes our work more interesting.

1. Suppose you do not picture clear images. I assume that the images of the scenes relate to real situations. The instructions are to picture them clearly and realistically. You picture each item as if you were really in the situation. Imagining images of real situations, reacting to them, and learning to relax and manage them thus has similarities to real-life situations. Interacting with the stimuli and feeling at least some anxiety tension sensations is often a part of the process.

However, people differ in their imagination skills including picturing the hierarchy scenes. There are many possible reasons that you might not ideally picture some scenes. If you have difficulty, discuss this with your therapist. Some therapists provide special instructions for picturing scenes more clearly as a possible solution and many persons learn to do this with practice. Your therapist might ask you to rate how clearly you 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 between images and real-life exposures is the third choice, artificial stimuli exposures. This is like test tubes in laboratories. Examples of in-vitro exposures are photographs, slides, audio CDs or tapes, video CDs/tapes or DVDs, and rubber or plastic models. You might even use artificial stimuli even if you can picture well. They are useful when real-life exposures are awkward or not practical.

2. What do I do if some items do not raise any anxiety? This is common despite clearly picturing scenes. It is possible that an item might not be accurate in some important details. Maybe the item does not belong on the list as an anxiety item anymore. You and your therapist need not assume that such items are inaccurate or incorrect. Rather, it might be that successful exposure, relaxation, and positive thoughts with earlier items resulted in benefit to other items. This can occur by generalizing or spreading forward to other items.

Think of it this way. The ladder example is good to use here. Suppose you were afraid of heights on a ladder. You began to climb it in your imagination and in reality. First, you go up and down slowly until you are 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, you stop anxiety on the lower rungs. Then, an item that was higher on the list is now like a lower item before you started. The positive effects of the lower rungs might spread to some higher rungs or items.  

3. What do I do if annoying side effects occur during relaxation? Relaxation methods seldom result in negative side effects. However, some people do 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 worry you. 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.

• For distraction by external noises or temperatures, arrange for the place you practice to be more quiet and comfortable.

• If you get small jerks in your muscles, then stay quiet and still. Muscle jerks often mean that you are actually deepening the relaxation effects. They are common and will very often lessen in a few minutes as you relax 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 you feel restless from prolonged sitting or lying down during sessions, then limit your sessions to slightly shorter periods.

• If you experience disturbing thoughts or other distracting thoughts or images during relaxation, then try to shift your 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 that the screen is moving farther away from you until it becomes tiny and no longer bothers you. If your image is "in color," then 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 very little or nothing at all.

• If you become sleepy or actually go to sleep during relaxation portions, you will realize that you are relaxing well. However, this is not what you want to do. If you need more sleep, then discuss this with your doctor. There are many reasons people do not sleep well. 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 even be another phobia theme. It could be that you fear trying new tasks that appear difficult. If so, then it might need attention.

2. Some persons think of exposure procedures as superficial or too much like a mechanical treatment. If this applies to you, then you should 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 treatment of allergies, and remember that these are robust and very successful treatments.

3. Some persons believe that this type treatment does not really get to the roots of their problem. However, consider 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 is that some persons resist treatment is the problem of "secondary gain." For some persons ongoing problems actually result in some benefits.  

This is not surprising when you think about it. For most or all lasting problems there are some benefits. Negative features of problems usually outweigh the positive features. However, sometimes the benefits can appear to 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. When we gain some benefits from these behaviors we might even feel a little like wanting it to continue.  

Although secondary gains are often present to some degree, it is not a problem for most persons with phobias. When it does exist it is very important to reveal it and realistically deal with it.

A few examples might help you better understand this difficult and sensitive issue. Consider the following example. What happens when a person's phobia results in being able to avoid boring 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 very bored with his job and sees no way of changing. Now suppose he is flying in a thunderstorm and clips a few tree tops during a 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 bad weather present or expected. Then, he might develop these symptoms even before flying, before even 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 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 who 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 might then mean that the person can attend social events or activities that are boring or otherwise annoying.  

Suppose that a phobia for crowds and social events results in providing you with more time for other desired activities. Successful treatment might be seen as meaning that you to go places that will take time away from these other preferred activities.

The presence of resistance suggests the possibility of secondary gain. You need not feel embarrassment by the presence of secondary gains. It is not rare and is expected in some situations. You must become aware of the secondary gain and deal with it effectively before treatment starts or progresses very far. Please remember to discuss this and any other concerns with your therapist.  

This booklet describes and discusses many aspects of phobia management treatments used in the treatment of fears and phobias. These are robust and very effective treatments with extensive research and broad professional support and usage over many years. You can feel confident in these treatments. Success, of course, also depends on the qualifications and experience of the professional working with you. Your positive motivation and active participation are both important. Ask questions and discuss any problems with your doctor or therapist working with you.  

Appendix 1: Topics not covered in this booklet.
• Social Phobia  
• Medication
• Children
• Agoraphobia  
• Eye Movement Desensitization and Reprocessing (EMDR)

Appendix 2: Websites
There are a huge number of websites about phobias. The list below is only a few but probably will be sufficient for you to get the information you want and need.

[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)
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.

  1© (pending) Mark S Schwartz PhD Endeavors