C8005 (Clinical Psychology): Specific Phobias
Specific Phobias
Diagnostic Criteria
There are three forms of phobia: simple or specific phobia, social phobia and agoraphobia.
Simple phobias are unique within this group in that they appear to be confined to a specific
object or situation. Examples of specific phobias are: Arachnophobia (spiders), ophidiophobia
(snakes), acrophobia (heights), nosophobia (injury/illness), thanatophobia (death) and
pogonophobia (beards), caligynephobia (beautiful women), melanophobia (the colour black),
philophobia (love), and arachibutyrophobia (peanut butter sticking to the roof of the mouth)
(see http://phobialist.com/).
The diagnostic and statistical manual of mental disorders (DSM—IV) characterises
specific phobias as follows:
•
Marked and persistent fear that is excessive or unreasonable, cued by the presence or
anticipation of a specific object or situation
•
Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response
•
The person recognises that the fear is excessive or unreasonable
•
The phobic situation in avoided or else endured with intense distress
•
The avoidance, anxious anticipation, or distress in the feared situation interferes
significantly with the persons normal routine, occupation (or academic) functioning, or
social activities or relationships, or there is marked distress about having the phobia
•
In under 18’s minimum duration = 6 months
•
Not better accounted for by other diagnosis
Theoretical Perspectives
Psychoanalytic theories
Psychodynamic theories are based on the idea that fears are a “defence against repressed id
impulses”. As such, anxiety is displaced onto an object or situation, which helps the individual
avoid dealing with repressed conflicts. One example is that of Little Hans (Freud, 1909) who
developed a phobia of horses after witnessing a fear of horses while with his father.
In this framework, objects of fear are symbolic (e.g. fear of spiders is a fear of bisexual
genitalia and the phallic wicked mother…). As Sperling (1981) put it “most investigators seem
to agree that the spider is a representation of the dangerous (orally devouring and anally
castrating) mother, and that the main problem of these patients seems to centre around their
sexual identification and bisexuality” (Sperling, 1981, p. 493). In the case of little Hans, his
fear was explained in terms of his castration anxiety from his father (because in Freud’s theory
little boys secretly desire their mothers and hence fear retribution in the form of castration
from their fathers). In a 150 page monologue Frued asks Hans a series of leading questions
and after many dodgy connections are made between the horse’s large penis and the various
penis-related anxieties that the child had, Freud concludes that Hans had transferred his fear
of his father to a safe target (i.e. a horse). Of course, the fact that Hans witnessed a very
traumatic carriage accident involving a horse had nothing to do with it … ☺
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Learning Theory and Behaviour therapy
Early Theories and Therapeutic Models
Learning theory’s initial contribution to the treatment of phobias was through the work of
Watson and Rayner (1920). Watson and Rayner initially showed that Albert, a nine month old
‘stolid and unemotional’ child (Watson and Rayner 1920, p.1), exhibited no fear when
presented with animals (e.g. a rat, dog, rabbit and monkey) or inanimate objects (e.g. cotton,
a burning newspaper and human masks). Fear was, however, evoked when a metal bar was
struck with a claw hammer behind his back. Two months after this initial test, Albert was
presented with a white rat (a conditioned stimulus, or CS) paired with a loud noise (the claw
hammer hitting the rod — in conditioning terms an unconditioned stimulus or UCS). After
seven pairings Albert cried and avoided the rat whenever it was subsequently encountered.
Five days later he was presented with a selection of animals and objects (e.g. a rat, a dog,
wooden blocks, Watson’s white hair and a bearded Santa Claus mask) to test the
generalization of his fear. Watson and Rayner concluded that ‘many of the phobias in
psychopathology are true conditioned emotional reactions either of the direct or transferred
type’ (p.14).
Watson and Rayner’s study remained largely ignored for some 40 years until Eysenck (1960)
and Wolpe (1962) used it as a basis for therapeutic treatment of phobias. Their rationale was
that ‘because human neurotic habits of reaction can often be dated from particular experience
that involve stimuli to which the patient has come to react with anxiety, and because these
habits can be altered through the techniques of psychotherapeutic interviews. There is a prima
facie presumption that neurotic reactions owe their existence to the learning process’ (Wolpe,
1962). This claim was substantiated by Rachman (1966a) who showed that a sexual fetish to
knee-length women’s boots could be conditioned in men by presenting them alongside slides of
female nudes. This simplistic account led to the assumption that if fears could be learnt, then it
must also be possible to un-learn them. A number of therapeutic techniques were
subsequently devised around this conditioning paradigm, any one of which could be used to
remit phobic symptoms. The simplest way to eliminate a conditioned response (CR) such as
fear to a phobic stimulus is through extinction. According to classical conditioning principles
this can be achieved in a number of ways: First, the CS (the fear-evoking stimulus) can be
presented without the UCS (traumatic outcome). Second, the CS can be reconditioned to a
more acceptable UCS such as relaxation (counter-conditioning) and lastly, the UCS can be
presented in the context of new CSs (Davey, 1981). The later has the disadvantage of
creating new phobias in the place of the old one. One of the earliest therapeutic techniques
incorporated extinction and is called Massing (or in it’s extreme form flooding). In essence the
patient is exposed to the CS for long periods of time. After an initial increase, the anxiety (CR)
to the CS extinguishes because it fails to elicit an aversive UCS. The success of this techniqie
seems to depend upon the length of exposure (i.e. patients must be exposed for long enough
for their fear to subside (Rachman, 1966b; Wolpin and Raines, 1966).
Mowrer (1947, 1960) extended this simple conditioning model to a two factor theory of
learning in which a behaviour is acquired in the normal classically conditioned way but is
maintained through operant reinforcement. In essence, this model suggests that someone
might well learn to fear a spider (for example) because it has been associated with some kind
of traumatic experience. Subsequent contact with spiders leads to heightened anxiety.
Mowrer’s addition to this model was to suggest that because anxiety is unpleasant, people will
avoid it. So, having learnt to fear a spider, when you next encounter one you will ‘run away’ or
avoid it because this reduces your anxiety. As such avoidant behaviour is reinforced (because
it leads to a reduction in anxiety). This theory underpins implosion therapy in which
assessments of the critical stimuli associated with the patient’s anxiety are made. From this an
Avoidance Serial Cue Hierarchy is constructed according to the degree to which each stimulus
is associated with the original fear-evoking outcome. The stimulus lowest on the list is
extinguished first before moving on to the next cue. For example an arachnophobic might be
asked to imagine a spider standing still, then the spider moving, then the spider crawling on
their hand, then its fangs, and so on. The imaginal presentation of the stimuli should
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extinguish the response it normally elicits. Several studies have verified the efficacy if this
approach. Hogan and Kirchner (1967) compared it very favourably against relaxation therapies
whilst Levis and Carrera (1967) found it more effective than traditional ‘insight’ therapies at
relieving patient’s symptomatology. However, Morganstern (1973) has questioned whether
these results are not just the result of extraneous variables or down to the patients’
expectations of success. These notions tie in with Bandura’s (1977) notion of a perceived selfefficacy, which mediates successful symptom remission. Bandura argued that the effectiveness
of therapy will depend not just on exposure but on the patients perception of their ability to
cope with that exposure.
Wolpe (1958) developed a series of therapies based on the principle of counter-conditioning in
which the acquisition of a new response, incompatible with the occurring response to the
stimulus, results in the elimination of the old response (Meyer and Chesser, 1970). Wolpe
noted that ‘if a response antagonistic to anxiety can be made to occur in the presence of
anxiety-evoking stimuli so that it is accompanied by a complete or partial suppression of the
anxiety response, the bond between these stimuli and the anxiety responses will be weakened’
(Wolpe, 1958). The resulting procedure of systematic desensitization is the basis of the
most widespread therapeutic approaches to the treatment of specific phobias. Wolpe identified
several responses that would be incompatible with anxiety, thus fitting the principle of counterconditioning, the most popular one being muscular relaxation. In a systematic desensitization
procedure a detailed history of the patient is made with consideration to which characteristics
of the phobic stimulus influence the intensity of evoked anxiety. This is similar to the
avoidance serial cue hierarchy described above. Indeed, a graded hierarchy is constructed
from the minimal fear situation (i.e. a small garden spider standing still several meters away
from the patient) to a maximum fear intensity situation (i.e. a huge, black, hairy spider with
visible fangs crawling across the patient’s face). The patient then ranks these situations in
order. During the sessions in which the hierarchy is constructed, the patient is taught how to
relax and is asked to practice the relaxation techniques at home until they can reach a certain
degree of relaxation. In the desensitization stages the patient is asked to relax and told to
signal by raising his or her index finger if (s)he feels at all anxious or disturbed during the
procedure. At first a neutral scene is imagined before moving on to the lowest situation on the
hierarchy. In initial sessions the therapist makes assessments of the patients ability to imagine
the situations presented to them. In subsequent sessions the therapist begins with the highest
situation that could be imagined at the previous session without fear before moving on to the
next situation in the hierarchy. If at any time the patient looks anxious or indicates anxiety,
they are asked to relax or are given a relaxing scenario to imagine. The sessions are ended
when the highest situation in the hierarchy can be imagined without anxiety. Wolpe (1961)
claimed that there was a close relationship between the degree to which desensitization had
been achieved and the abatement of anxiety responses to real stimuli and Leitenberg (1976)
concluded that ‘systematic desensitization is demonstrably more effective than both no
treatment and every psychotherapy variant with which it has so far been compared’ (p.131).
However, Kazdin and Wilcoxon (1976) have questioned the control conditions used in
systematic desensitization research claiming them to ‘generate less expectancy for
improvement on the part of the clients’ and to be ‘less credible’ (p. 729).
The Cognitive Revolution and Its Effect on Learning Theory and Behaviour Therapy
More recently, behaviour therapy has come under fire for developing without a synchronous
development in underlying theory (Wilson, 1982). The main contention stems from certain
features of phobic reactions that seem contrary to the conditioning account of acquisition.
There are four main criticisms of learning accounts of phobia acquisition (see Field & Davey,
2001):
1. Some phobics cannot remember an aversive conditioning experience at the onset of
their phobia: some phobics have no memory of an aversive conditioning event at the
onset of their phobia. In addition, for a particular feared stimulus some individuals may
remember an associated traumatic event while others who fear the same stimulus have
no such memory (Withers and Deane, 1995).
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2. Not all people experiencing fear or trauma in a given situation go on to develop a
phobia: Lautch (1971) showed that not all people who experience pain or a traumatic
event whilst at the dentist go on to acquire a phobia. Likewise, most of us have
experienced violent and scary thunderstorms yet are not phobic of these situations
(Liddell and Lyons, 1978). The simple contiguity based model espoused by the early
behaviourists simply does not have the power to predict when an individual will acquire
a phobia and when they will not.
3. Incubation (Eysenck, 1979): Incubation is a phenomenon in which fear increases over
successive non-reinforced presentations of the CS (for example, when a spider phobic
subsequently comes into contact with spiders, each spider is unlikely to be paired with a
traumatic event, yet the phobic becomes more fearful of spiders).
4. Uneven distribution of fears (Seligman, 1971): Pavlovian models of conditioning predict
equipotentiality of stimuli which in this context simply means that all stimuli are equally
likely to enter into an association with an aversive consequence. So, fears and phobias
should be evenly distributed across stimuli and experiences. This is clearly not the case
because phobias of spiders, snakes, dogs, heights water, death, thunder, and fire are
much more prevalent than phobias of hammers, guns, knives, and electrical outlets yet
the latter group of stimuli seem to have a high likelihood of being associated with pain
and trauma.
These observations coupled with an increasing interest in cognitive processes led to a reduced
interest in behavioural theories. Nevertheless, behavioural theories have developed in a
number of ways. First Rachman (1968, 1977) noted that in addition to direct learning
experiences, fears could also be learnt through observing the responses of others to fearevoking stimuli, and through acquiring information about a stimulus. Mineka, Davidson, Cook,
& Weir (1984) demonstrated that laboratory-bred rhesus monkeys exhibited fear responses to
toy snakes after watching a video of a fellow monkey exhibiting fear to the same snake.
Recently, Field, Argyris & Knowles (2001) have shown that information about previously unencountered stimuli changes children’s fear-beliefs about those stimuli.
More recent advances in conditioning theory have also helped to explain the inconsistencies
noted above. The apparent absence of trauma for many patients can be accounted for through
UCS revaluation, which is based on the notion of ‘behaviourally silent learning’ (Dickinson
(1980). In animal studies this takes the form of two neutral stimuli being paired together (CS1
and CS2) resulting in no behavioural change. If the animal is then presented with CS2 and a
UCS the subsequent presentations of CS1 elicit CRs appropriate to the UCS. This implies that
there was behaviourally silent learning in the initial stage. This has been reliable found in
human subjects (White and Davey, 1989) and UCS revaluation has a directly modifying effect
on the strength of the human CR (Davey, 1987). In clinical terms this means that a patient
could, for example, witness someone collapse from a heart attack whilst hiking at the top of a
mountain. The man dying being CS1 and the mountain being CS2. The CS1 does not cause the
patient anxiety and (s)he thinks nothing more about it. However, (s)he has silently learnt to
associate the two events and ensuing hikes up mountains elicit a memory of the stranger’s
heart attack, but no anxiety. Subsequently, a close friend of the patient dies of a heart attack
thus increasing the aversiveness of heart attacks in general, which in turn results in acute
anxiety when he climbs mountains. The patient will, however, not remember a direct pairing of
mountains and trauma. Davey, De Jong and Tallis (1993) present several cases studies that
illustrate this process.
Failure to acquire phobias after a traumatic event can be explained through latent inhibition in
which earlier presentations of the CS (e.g. dental treatment) in the absence of trauma, inhibit
the acquisition of a CR (fear) when the CS is paired with a UCS (pain) at a later date (Davey,
1988). In addition the patient’s evaluation of the UCS will affect the CR and so a patient might
see the pain as negligible against the benefit of having healthy teeth (Davey, 1992).
Incubation could simply be the result of patients rehearsing the trauma in their minds after the
initial event causing an inflation of the UCS before subsequent encounters with the CS (Davey,
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1989). Jones and Davey (1990) have produced these effects in the laboratory, which had only
previously been achieved when the UCS was extremely aversive, such as succinylcholine
induced paralysis (see Campbel et al. (1964). Recent work also indicates that ruminating about
the consequences of a phobia-related encounter can increase both self-reported fear, heart
rate, and catastrophic thoughts about future consequences (Field, St. Leger & Davey, 2000).
This suggests a possible mechanism through which incubation might occur.
The uneven distribution of fears criticism was tackled by Seligman (1971) who proposed that
humans had an inbuilt disposition to associate certain stimuli with aversive events because
they had been phylogenetically relevant to our ancestors (such as spiders, heights and
snakes). However, this preparedness theory does not predict what stimuli would have been
relevant to our ancestors and despite much laboratory support (see Öhman, 1979) others have
explained these findings in terms of subjects’ prior expectations of the experiments (see
Davey, 1992, 1995).
Contemporary conditioning models (see Davey, 1997; Field & Davey, 2001) represent a blend
of behavioural and cognitive ideas. Although based on basic conditioning theory, the factors
that influence the relationship between a stimulus, the outcome associated with it, and the
response to that stimulus involve numerous cognitive elements. Some have already been
touched upon (for example Field et al.’s demonstration that rumination influences the
perceived future threat of a phobia-related stimulus), but there are many others such as a
person’s coping style, personality characteristics and so on. These offer a number of
possibilities for informing future therapeutic techniques.
Purely Cognitive Approaches
The central theme of cognitive approaches is that disorders result from maladaptive thinking.
Therefore, if you treat the cognitions, the behaviour will vanish; it assumes that behaviours
(such as avoidance) are caused by thoughts. As such, if we challenge people’s dysfunctional
thoughts then we should be able to remove their fearful behaviour.
The limitations of behavioural explanations led Beck (1976) to formulate a theory of anxiety
based on cognitive factors. He emphasized Information-processing biases: biases in
attention, memory, thinking, judgments. These biases can take on many forms:
•
Attention: anxious/depressed people attend to threat-relevant material more than nonanxious/depressed people. Anxious people show a bias towards material related to their
fear. Öhman & Soares (1994) found that snake phobics exhibited a fear response to
pictures of snakes masked with another stimulus (so the snake could not be consciously
perceived), non-phobics did not exhibit fear. The emotional stroop task involves naming
the colour of words when some words are threat-relevant and others are threat irrelevant
(Williams, Mathews & MacLeod, 1996 review the evidence). Find that anxious subjects take
longer to process threat-relevant words than non-threatening words, for controls there is
no difference.
•
Memory Recall Bias: anxious/depressed people have a bias towards recalling negative
memories. Anxious people have selective recall of negative memories. This may be
because anxious people attend more to threatening material and so will have more
numerous and stronger threat-related memories (encoding is improved — think to your
lectures on memory). This can be shown by memory tests of normal words (e.g. box,
farmer), positive words (e.g. excited, glad) and threat-related words (e.g. morgue,
trembling, cancer). Anxious people will recall more threat-related words and less positive
words than control subjects (recall of neutral words is similar) Cloitre & Liebowitz (1991).
•
Misinterpretation: Information can also be misinterpreted: We’ve all done this in real life.
For example If I walked into the lecture theatre and heard someone say ‘oh, that Andy is a
shit ….’ I would interpret that as being the end of the sentence, however it’s possible that
they were going to say ‘oh that Andy is a shit-hot lecturer’ before I interrupted. These sorts
of biases happen all the times (how many times haven’t you thought that people were
talking about/laughing at you when in reality they probably weren’t). Eysenck, Mogg, May,
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Richards and Mathews (1991) carried out a study in which anxious, recovered anxious, and
non-anxious individuals were shown 32 ambiguous sentences: ‘The two men watched as
the chest was opened’ and ‘The doctor examined little Emma’s growth’. Later on, subjects
were presented with both a positive and negative interpretation of each sentence and they
had to identify which sentence they had read earlier on: ‘The doctor looked at little Emma’s
cancer’ (Negative) and ‘The doctor measured little Emma’s height’ (Positive). They counted
the percentage of negative interpretations chosen. Anxious individuals chose many more
negative statements than non-anxious.
•
Estimating the Likelihood of Negative Events: Butler and Mathews (1983) asked people to
estimate the probability of nasty and nice things happening to them and to other people.
They found that for positive events the groups did not differ. However for negative events,
anxious/depressed people overestimated the likelihood. This was especially true when they
estimated the likelihood of the negative event happening to them (rather than someone
else). However, Dalgleish et al. (1997) found that anxious children overestimated the
likelihood of negative events to others and not themselves.
•
Rumination: Rumination (cognitive rehearsal) is repeatedly thinking (or churning over)
thoughts in your mind. Negative rumination involves repeatedly thinking about negative
aspects of a situation (or problem). Although there are several theories of ruminative Field
et al. (2000) has noted that they all have a common theme: rumination is seen as a
normal and adaptive part of a problem solving process, however, if the problem is not (or
cannot) be solved then this rumination becomes maladaptive. Rumination is seen in OCD
(Salkovskis, 1999), GAD (Marks, 1987), stress (Roger and Najarian, 1997) and can
enhance the retrieval of negative memories (Lyubomirsky, Caldwell & Nolen-Hoeksema,
1998). Field et al. (2000) have shown that in phobics, rumination can lead to the
enhancement of self-reported anxiety. This is not true in non-phobics. Therefore,
rumination about something that already evokes fear leads to greater anxiety. This could
explain incubation.
The problem with the cognitive approach is that it doesn’t explain why some people have these
maladaptive thoughts. It’s a chicken-egg situation: does the disorder come from the thoughts
or do the thoughts come as a result of the disorder? It is possible that mental disorders are
learnt but that cognitive biases act to maintain or exacerbate the feelings of anxiety. There is
little evidence that pure cognitive therapy alone is good for specific phobias (in which sufferers
fully acknowledge the irrationality of their thoughts). Therefore, treating thoughts does not
always lead to a change in behaviour.
A blend of cognitive and behavioural techniques is usually best. This approach addresses both
the behaviours and the cognitions that maintain them. Cognitive-behaviour therapy blends
exposure to the fear-evoking situation with cognitive techniques to help ‘cope’ with the
situation (and not, for example, ruminate about it afterwards).
Therapy for Specific Phobias
Despite the early behaviourists’ contention that behaviour therapy should provide a general
framework around which individual therapists could operate, there is no such strict guideline.
Therapy is a very individual procedure not only in terms of the patient and symptoms but the
therapist as well. It is extremely hard to describe a behavioural treatment of a phobia in the
absence of an actual patient with whom to work. Not only are there therapeutic variations
between disorders (for example a treatment of agoraphobia can be somewhat different to a
treatment of a simple phobia) but also within disorders (the treatment of a simple phobia with
one patient might be quite different from the appropriate procedure for a different patient).
However, we can discuss some general techniques and how they might be applied.
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First Steps
The first step in any behavioural treatment is to establish the precise nature of the phobia and
its suitability for treatment (Butler, 1989). A behaviour therapist would carry out a functional
analysis to establish whether the anxiety is restricted to certain environments or times
(settings), whether any particular events have to occur before the phobic behaviour is
displayed and if so are they specific events or a range of events (triggers), What other events
had preceded the behaviour and does it occur in the absence of these events? (antecedent
events) and finally what meaningful outcome of behaviour was there for the client? (results).
Patients and clinicians are rarely aware of all of the important events and so data must be
collected over a period of time through patient diaries or interviews with a third party. The
data should be as unambiguous and absolute as possible and once established, these factors
should be eliminated, replaced or modified to change the behaviour. Maintenance factors
should be identified along with secondary gains (reinforcers of anxious behaviour such as
people giving you comfort or sympathy). It is crucial to get as full a picture as possible and not
to interpret the data and jump to false hypotheses about the causes of the disorder.
Behavioural therapists are interested purely in behaviour and not causes or moods.
Goal Setting
By this stage the therapist should have formed hypotheses that can be tested. Once causal
factors have been identified, the therapist should collaborate with the client to establish the
goals of therapy. The general goal of therapy for phobics is often self-evident but it is very
important that the clinician discuss the precise goals with the client to avoid any potential
confusion. One disparity often apparent in therapy is expecting miracles; the clinician should
always make the client aware that spontaneous recurrence of symptoms is to be expected.
There are no rules governing what the goals should be although Öst et al. (1984) suggested
that blood phobics should aim to donate blood regularly, similar goals can be established for
other phobias (i.e. going shopping alone for agoraphobics, removing spiders from the house
for arachnophobics).
Measures
Having established the maintenance factors and set up mutually agreeable goals, the next
stage is to measure the phobia using easy and sensitive measures that reflect the client’s
individual concerns. Measures are vital in assessing the progress of a therapeutic technique; it
is important to keep in mind that you are testing a possible hypothesis and so it is necessary
to compare the patient’s behaviour against an initial baseline measure throughout therapy in
order to monitor the effects of any intervention. As you introduce new techniques you should
look at its effect on behaviour to see whether or not it was effective. There are several ways to
measure phobia severity. One way is to use a graded hierarchy (described earlier). The patient
has to think of a number of situations and then rate the anxiety and avoidance that each
situation would provoke (on a scale of 1–10 or 1–100). Often it is easier for the patient to
think of extreme examples and then think of items that lie in between the two extremes.
Hierarchies are often a lot more difficult to construct than they first appear because fears may
be difficult to grade into small steps (e.g. fear of flying). In addition, patients often avoid
situations and yet are totally unaware that they are doing so or are oblivious to the precise
nature of their phobia (a spider phobic may not be scared of spiders per se, it may specifically
be their movement). If they find constructing a hierarchy difficult it may be useful for the
patient to read, talk or write about their phobia and watch relevant films in order to gain
inspiration about what sorts of situations they find most and least anxiety evoking.
A second measuring technique is that of behavioural tests in which clients do something which
they would normally avoid and rate their anxiety at the time. This is especially useful for
looking at where on the hierarchy you should start working or in situations where the patient
has an extensive pattern of avoidance and hence is merely guessing at the anxiety
experienced. Cognitivists might also argue that this method takes advantage of ‘hot cognitions’
as well. However, by its definition it involves exposure and so cannot be used repeatedly as a
measurement of therapeutic change. Patients might also be encouraged to keep accurate
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records of their exposure and anxiety. This self-monitoring is important in assessing change
but also provides evidence against the tendency to remember failure and forget success. In
addition there are several standardised questionnaires which measure phobic anxiety such as;
the Fear Questionnaire (Marks and Mathews, 1979) and the Fear Survey Schedule (Wolpe and
Land, 1964).
Treatment
The actual treatment procedure chosen will depend on a detailed assessment of aetiology. A
traditional behavioural treatment for a simple phobia mediated by anxiety is systematic
desensitization. However, a phobia maintained by secondary gains may be treated with
operant conditioning. Having already described the procedural operation of systematic
desensitization it would be repetitious to include the details here. However, I will mention
some of the difficulties in administering this therapy. I have already mentioned the difficulties
which arise in the construction of a hierarchy but there are also associated problems with
relaxation as a counter-conditioning technique. In some patients (notably children) it may be
extremely difficult to obtain relaxation whilst others may be relaxed but without the subjective
feelings of calm; some patients have anxiety about the relaxation itself (Meyer and Chesser,
1970). Having established relaxation, difficulties in achieving graduated exposure can manifest
themselves if the patient finds it hard to imagine items in the hierarchy or if the images do not
evoke anxiety. A good therapist should encourage the patient to use all sense modalities to
construct each image in order to make it as vivid as possible. Nowadays exposure is usually
conducted using behavioural tasks extracted from the hierarchy as well as, or instead of,
imaginal exposure. The critical guidelines for exposure are that it should repeated, graduated
and prolonged with tasks being specified and agreed upon in advance (Butler, 1985). However,
there are difficulties associated with these guidelines because of the unforeseeable nature of
phobic stimuli (how do you know when you are going to come across a spider?). These
unpredictabilities interfere with the repetition, graduation and advance specificity of exposure
episodes. One way to overcome this is to practise an array of tasks encompassing a range of
difficulty in the same week as opposed to stringently moving up the hierarchy.
The administration of exposure is not just restricted to the clinical session. One key objective
of therapy is to empower the client with the ability to cope with their phobic stimuli alone. An
important step towards this is to set homework for the client. Many of the behavioural tasks
set by the clinician can be undertaken outside of the clinical setting in the absence of the
clinician. The patient should be encouraged to undertake home-based treatment often with a
relative or friend who has been informed, in detail, about the treatment. This has been notably
beneficial in agoraphobia (Mathews et al 1981). Initial stages of exposure should be
undertaken with the clinician until such a time that the patient feels confident enough to do
homework on his/her own. Other useful behavioural techniques are; role playing, which is
especially useful in treating social phobics, modelling, where the clinician physically
demonstrates how to approach the phobic stimuli (for example by picking up a spider) and
finally rehearsal of appropriate strategies for dealing with the stimuli.
How Successful is Therapy?
I briefly touched on some of the studies supporting systematic desensitisation but have yet to
comment on the success of exposure treatments as a whole. Although there is a great deal of
good evidence to indicate that exposure therapy is effective (Marks,1987, Mathews et al.1981)
and long lasting (Munby & Johnston, 1980) there is a problem with assessing it. By asking if a
technique is successful we are imposing homogeneity where none exists. Patients are not all
the same and so the success rate of any therapy should be judged in its ability to treat a
number of different symptoms in a number of different people and whether it has the flexibility
to address novel symptoms. One of the major problems in assessing a therapy is the use of
control groups. Any good research should incorporate a control group with which to compare
the therapy group, but how ethical is it to assign people to a group who receive no treatment?
Despite this, there is some support that behaviour therapy can have generalizable effects such
as improvements in relationships and increased self confidence and it has been noted that
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exposure has cognitive as well as behavioural effects (Butler, 1989). Stern and Marks (1973)
concluded that anxiety levels during exposure have little effect on the outcome but in general
prolonged exposure is more effective than brief exposure. As such, exposure per se is not
predictive of outcome but duration of exposure can be (in general). Bandura (1977) proposed
that exposure was non-predictive and that perceived self-efficacy was the important variable in
predicting outcome. He argued that the person’s belief that they could cope with exposure
would predict the remission of symptoms. Exposure also seems to have a minimal influence on
controllability in that symptoms often return after therapy. Again what seems to determine the
control of a phobia is not exposure per se but a patient’s ability to help themselves should
symptoms re-occur. This could be linked again to Bandura’s concept of self-efficacy in that
patients who perceive themselves as able to cope when a setback occurs will be able to control
their symptoms. Predictability and controllability have a very close relationship in that if a
therapist can predict the outcome reliably then this gives him more control over the therapy. If
predictions indicate that the outcomes will be poor then the therapist can modify the
treatment. This is the reason for doing multiple baseline analysis of treatments to look for
trends in each variable and then modify the treatment in line with these trends.
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