Mental health articles

Behavioural treatments

The premise underpinning behavioural treatments of phobias involve exposure to the feared stimulus either directly (flooding) or in a series of hierarchical stages (systematic desensitization). These approaches may be augmented by teaching people skills such as relaxation or cognitive strategies to counter negative expectations and fear of catastrophic outcomes. However, the effects of these additions have been mixed – with both treatment gains and losses – indicating that the core of any treatment involves direct exposure to the feared stimulus and staying with it until any fear is extinguished (Wolitzky-Taylor et al. 2008). Systematic desensitization and fl ooding have long been considered the primary interventions to treat phobias, and recent research has involved attempts at fine-tuning the approach and making it cost-effective. One strand of research has focused on the effects of single-session exposure to the feared stimulus. These sessions may be fairly lengthy – sometimes over three hours. In one study of its effectiveness, Hellstrom et al. (1996) reported outcomes of a group treatment of people with a spider phobia. They were randomly assigned into one of two conditions: small groups of 3–4 people and larger groups of 7–8 people. They each received one three-hour session in which the principles of the treatment – based on flooding – were explained to participants. They watched as the therapist was exposed to the spiders and coped with their fear. They were then encouraged to handle four spiders and shown how to cope with this experience. Immediately after treatment, 82 per cent of people in the small groups had made clinically significant improvements, compared to 70 per cent of those in the large groups. By one-year follow-up, the equivalent percentages were 95 and 75 per cent respectively. By 2006, a total of 21 studies had reported this or similar one-session treatment programmes. Even so, in their review of these studies, Zlomke and Davis (2008) were somewhat cautious in their conclusions, stating that the one-session approach is ‘probably effi cacious’ as the quality of many of the studies was not sufficiently robust to allow clear conclusions to be determined. A second strand of research has focused on minimizing contact between client and therapist in programmes of systematic desensitization. The effects of this ‘self-directed exposure’ have varied from being as effective as therapist-led exposure to significantly worse. Öst, Salkovskis and Hellström (1991), for example, compared the effectiveness of a single three-hour therapist-led session with that of a self-exposure programme involving use of a therapy manual given to participants. The single session group did far better than the client-determined therapy, with success rates of 71 per cent in the therapist-led therapy and 6 per cent in the self-directed exposure group. By contrast, Schneider et al. (2005) found a self-exposure programme delivered via the internet to be significantly more effective than a stress management programme without the element of exposure. A third strand of therapy has involved the use of virtual reality. In one study of this approach, Walshe et al. (2003) treated car phobics using a virtual reality exposure programme involving up to 12 one-hour sessions. The participants improved significantly on measures of travel distress, avoidance and maladaptive driving strategies. This approach is clearly more expensive and complex than the treatment for spider phobia described above. However, where exposure to a controlled or safe ‘live’ exposure may be diffi cult to establish, it can be of benefit.

Pharmacological treatments

According toHaywardand Wardle (1996), most clinicians consider pharmacological treatment of phobias to be of little benefit. As a consequence, many major reviews of the pharmacological treatment of anxiety (e.g. Nutt 2005) do not even address the pharmacological treatment of specific phobias.

Tags: phobias, treatment