The therapeutic approaches to treating phobias

This essay describes Phobias, their symptoms, the different therapeutic approaches to treating phobias, and studies that demonstrate the effectiveness of different treatments. Three key approaches to understanding phobias and their treatment will be evaluated, including the psychodynamic, social, and behavioural approaches. An emphasis will, however, be placed on the behaviourist approach and the successful treatment of phobias via cognitive behaviour therapy (CBT).

Introduction

Phobias are the most common form of anxiety disorder in the UK, with there being an estimated 10 million people living with phobias. Phobias are characterised by irrational and excessive fears of objects or situations. These fears can cause symptoms of extreme panic, sweating, palpitations, fainting, and paralysis (Iris Health, 2006). There are two main types of phobia: specific and social. Social phobias are an excessive fear of embarrassment in social situations, whilst specific phobias are an excessive fear of particular objects or situations. Examples of specific phobias include claustrophobia (i.e. fear of closed spaces) and arachnophobia (i.e. fear of spiders). The Diagnostic and Statistical Manual for Mental Disorders (DSM-IV) criteria for a diagnosis of phobia is that the fear must be excessive or unreasonable and provoked by an object or situation. Furthermore, exposure to this object or situation immediately produces anxiety, and avoidance of this fear interferes with the sufferer’s life (APA, 1994).

Phobias can be treated successfully, although complex phobias can take a significant period of time. Treatments include talking therapies such as counselling or behavioural therapies such as Cognitive Behavioural Therapy. Some of these treatments are discussed next, along with evidence of their effectiveness.

Psychodynamic Approaches

Psychodynamic theories propose that phobias in adulthood are the result of negative childhood experiences (Freud, 1909). In particular, Freud reasons that phobias are the result of sexual repression, as he attempts to demonstrate in his famous case study of Little Hans. Little Hans was a 5-year old boy who had a phobia of being outside with horses, buses, and carts containing baggage. At the same time, Little Hans also showed signs of the Oedipus complex (a young boys desire to be sexually involved with his mother and kill his father), resulting in fear of castration. Freud proposed that horses resembled Little Hans’ father since he wore glasses that were comparable to the horse’s blinkers. Freud further explained that horses (which represented Hans’ father) would bite Little Hans “because of his wish that it (his father) should fall down” (Freud, 1909, p.90). After conversations between Freud, Little Hans, and his father, Little Hans was able to overcome his sexual repression and thus his phobia.

Social Approaches

Social theorists state that life events and styles of parenting can contribute to the development of phobias. According to these theories, people with phobias are more likely to have experienced negative or traumatic life events than people who don’t have phobias. Kleiner and Marshall (1987) found that 84% of individuals with agoraphobia (fear of open spaces) reported family problems in the months before developing panic attacks. Barrett (1979) found that patients reported undesirable life events 6-months before developing panic attack. In terms of parenting style, Silove et al. (2001) found that people with social phobia and agoraphobia experienced less affection from their parents than people without such phobias. It has also been found that children who experience separation anxiety are likely to develop phobias in adulthood (Pincus, Eyberg, and Choate, 2005). Despite evidence suggesting a link between phobias and social factors, there is no treatment that is primarily based on this approach.

Behavioural Approaches

The behaviourist approach to phobias states that there are different ways in which people learn to fear certain objects or situations, including through direct negative experiences, observing fear in others, or through repeated negative experiences. In other words, phobias are the result of ‘classical conditioning.’ Classical conditioning is the term used to describe the process of learning new behaviours or responses based on their consequences. Watson and Rayner’s (1920) research with Little Albert is one of the most cited examples of how the behavioural approach can assist in understanding phobias. Watson and Rayner (1920) showed how a 9-month old boy could be conditioned into fearing a rat. Little Albert originally expressed no fear of the rat, but was fearful of loud noises. By pairing the loud noise with the appearance of the rat, Little Albert gradually started to show fear in response to the rat alone. Not only did he learn the association between the rat and loud noises, but he also learnt that avoiding the rat meant avoiding the noise, which was an important aspect of the development and maintenance of the phobia.

Cognitive Behavioural Therapy

The literature suggests that the most effective treatment for phobias is that which is based on the behavioural approach. The underlying assumption of such treatments is that anything that is learned can be unlearned (Goodwin, 1983). The first widely used behavioural treatment based on this assumption was ‘flooding’ (Wolpe, 1958). Flooding involves exposure to the feared object or situation at full intensity in order to see that no harm results from the feared object or situation (Marsh and Ollendick, 2004).  Wolpe (1973) carried out a flooding experiment with a young girl who was scared of cars. By locking the girl in a car and driving her around for hours, until she eventually realised she was safe, the girl transitioned from hysteria to a calmer state. The evidence suggests, however, that flooding cannot be endured by everyone (Jaeger et al., 2009).

Ost’s (1989) One-Session-Treatment (OST) has been shown to be particularly effective in treating phobias. This begins with a behavioural analysis of the sufferer so treatment can be tailored specifically, before a single 3-hour session exposes them to a high intensity of their fear. During those 3-hours, the psychologist guides the sufferer through gradual increases in exposure to the stimulus whilst analysing and challenging maladaptive thoughts. Ost (1989) states that exposure through a series of tests rather than immediate full intensity encourages a faster change in their anxiety and avoidance. Ost, Svensson, Hellstrom, and Lindwall (2001) emphasise the need for continued exposure post-treatment in order for success to be maintained. One-Session-Treatment has been found have a 90% success rate, with continued success at 1-year follow-up (Ost, Svensson, Hellstrom, and Lindwall, 2001).

A more modern example of behaviour treatment of phobias is Cognitive Behavioural Therapy. Cognitive Behavioural Therapy challenges the negative thoughts and cognitions that maintain a phobia, helping the person to reframe their thinking. Aspects of Cognitive Behavioural Therapy include contingency-management and cognitive self-control. The former is based on operant conditioning. Instead of avoidance of fearful objects or situations being a reward (due to anxiety reduction), confronting the fear is followed by positive consequences such as praise or positive reinforcement. This gradually alters an individual’s thought patterns. Cognitive self-control targets maladaptive (or irrational) thoughts, encouraging people with phobias to use positive instead of negative statements to cope, such as not criticising their efforts towards facing the fear (Davey, 1997). In this way, Cognitive Behavioural Therapy is used to train people to replace their negative associations with positive ones. Research suggests that taking into consideration the role of conditioning is central to why Cognitive Behavioural Therapy works so effectively (Goodwin, 1983; Ost, 1989). A large component of treating phobias is the knowledge that specific phobias relate to one isolated situation or object. Therefore, if the fear response can be removed from that object or situation, the phobia should logically be cured, whether learnt through trauma or association. Furthermore, since avoidance of feared objects or situations acts as a reward, this aspect of phobias needs to be addressed in treatment, as is the case in Cognitive Behavioural Therapy, which challenges such avoidance; with continued avoidance, there is no opportunity to ‘unlearn’ the fear (Goodwin, 1983).

Conclusions

Phobias are a complex illness and their treatment is just as complex. Conditioning is widely believed to contribute to the development and treatment of phobias. Therefore, the most promising treatment is a method that incorporates conditioning into the therapeutic process. Cognitive-behavioural therapy does just this, which is why the evidence shows it to be so effective. Of the treatments discussed in this essay, Cognitive Behavioural Therapy has most support. Kendall et al. (1997) achieved a success rate of 71% in the Cognitive Behavioural Therapy treatment of children with a variety of anxiety problems. By comparison, success rates for self-exposure treatments range from 18-33% (Goodwin, 1983). Since Cognitive Behavioural Therapy is a cost-effective, short-term treatment, its use in the treatment of phobias is supported.