PSYCHOLOGICAL THERAPIES FOR PHOBIC DISORDERS
To read up on the psychological therapies for phobic disorders, refer to pages 500–510 of Eysenck’s A2
Level Psychology.
Ask yourself
 How can the behavioural approach be applied to the treatment of phobia?
 How can the cognitive approach be applied to the treatment of phobia?
 Which psychological therapy do you think will be most effective for phobia?
What you need to know
BEHAVIOURAL THERAPIES
Systematic desensitisation
Exposure therapy
 Evaluation of behavioural
therapies
Behavioural therapies
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COGNITIVE THERAPY
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The effects of cognitive therapy on
social phobia, specific phobias,
and agoraphobia
Evaluation of cognitive therapies
Behavioural therapies are based on the principles of learning and, in particular, the theory that behaviour is
learned through association (classical conditioning). Abnormality is a result of learning maladaptive and
dysfunctional behaviour and so the treatment uses counter-conditioning to replace the maladaptive
(dysfunctional) behaviour with more adaptive (functional) behaviour. Of key importance is eliminating the
patients’ avoidance of their phobic stimuli and situations. This is difficult because the fear reduction, which
is a result of the avoidance behaviour, is rewarding.
Systematic desensitisation
Joseph Wolpe (1958, 1969, see A2 Level Psychology page 501) was a behaviour therapist who devised
systematic desensitisation. This involves an attempt to replace the fear response with a new response
incompatible with fear. Relaxation was considered to be incompatible (can’t be experienced at the same
time) with fear and so this is induced based on the logic that if the patient is relaxed then they cannot
experience their usual fear response. The therapy involves four stages:
 First stage—relaxation training: The first stage is to provide clients with
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relaxation training in which they learn how to engage in deep muscle
relaxation.
Second stage—fear hierarchy: Second, clients construct a fear hierarchy with
the assistance of their therapist. A fear hierarchy consists of a list of
situations or objects that produce fear in the client, starting with those that
cause only a small amount of fear and moving on to those that cause
increasingly greater levels of fear. For example, the first item on the list of a
snake-phobic person might be a small, harmless snake 50 feet away, with
subsequent items featuring larger and more dangerous snakes closer to the
client.
Third stage—imagine feared objects: Third, clients learn how to use their
relaxation techniques while imagining the objects or situations they fear,
starting with those at the bottom of the fear hierarchy. The therapist
describes the object or situation, and the client then tries to form as clear an
image of it as possible.
Fourth stage—experience feared objects: An alternative approach is to
present the actual object or situation itself (known as in vivo desensitisation).
Wolpe used the term reciprocal inhibition (also known as counterconditioning) to refer to this process of
inhibiting anxiety by substituting some competing and incompatible response. For relaxation to inhibit the
client’s anxiety, the amount of anxiety triggered by imagining the phobic stimulus mustn’t be too great.
That explains why systematic desensitisation starts with stimuli creating only a small amount of anxiety.
Exposure therapy
Wilson and Davison (1971, see A2 Level Psychology page 502) argued that the crucial process in
systematic desensitisation is extinction, not reciprocal inhibition. Extinction occurs when there is repeated
non-reinforced exposure to the phobic stimulus, i.e. nothing bad happens through exposure to the feared
stimulus.
This led to exposure therapy, during which phobic individuals are exposed to the object or situation they
fear (often gradually increasing the threateningness of the object or situation) for lengthy periods of time
until their anxiety level is substantially reduced. It differs from systematic desensitisation in that the latter is
more gradual as it involves imaging the fear stimulus first.
Exposure therapy has now been developed into virtual reality exposure therapy, whereby a computer
program produces a virtual environment simulating the phobic situation. Exposure therapy provides
maximal scope for extinction to occur but doesn’t involve muscle relaxation, as this is not necessary if
extinction is key rather than reciprocal inhibition.
EVALUATION OF BEHAVIOURAL THERAPIES
Effectiveness
 Moderate effectiveness. Choy, Fyer, and Lipsitz (2007, see A2 Level
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Psychology page 502) reported that systematic desensitisation was generally
moderately effective in reducing anxiety levels.
Effectiveness on avoidance lacks reliability. Some studies suggest
systematic desensitisation does treat the avoidance behaviour whereas
others suggest it does not, and so research findings lack consistency
(reliability). For example, Rosen, Glasgow, and Barrera (1976, see A2 Level
Psychology page 502) found in a study on animal phobia that clients treated
with systematic desensitisation were as likely as controls to continue to
avoid the feared animals. However, contradicting this, Choy et al. (2007, see
A2 Level Psychology page 502) found the treatment gains (decreased anxiety
and avoidance) present at the end of treatment were maintained at the time
of follow up.
A pioneering treatment that paved the way for further behavioural
therapies. It was one of the first techniques within behaviour therapy to be
developed. The success of systematic desensitisation played some role in the
subsequent development of related techniques such as exposure therapy and
virtual reality exposure therapy.
Unclear why systematic desensitisation is effective. It is not clear
whether systematic desensitisation works because of reciprocal inhibition
(with muscle relaxation inhibiting the anxiety response) or because of
extinction (non-reinforced exposure to the feared stimulus). Systematic
desensitisation with and without relaxation has been used to test this and
findings are inconsistent. Levin and Gross (1985, see A2 Level Psychology
page 503) reviewed the relevant literature. In 10 studies, systematic
desensitisation without relaxation was as effective as desensitisation with
relaxation. However, there were a further 15 studies in which relaxation did
contribute to the success of systematic desensitisation!
Exposure therapy seems to be more effective. Both forms of exposure
therapy are often more effective than systematic desensitisation (Choy et al.,
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2007, see A2 Level Psychology page 503). This supports the role of extinction
over reciprocal inhibition.
Systematic desensitisation and exposure therapy have restricted
usefulness. Both forms of therapy are specifically designed to reduce
anxiety, and so they are only of relevance to anxiety disorders. Even within
anxiety disorders, they can only be used for phobias and so it wouldn’t be
appropriate to use systematic desensitisation with generalised anxiety
disorder, because that condition involves excessive worrying about
numerous, ill-defined situations.
Treat symptoms not causes. They treat only that which is observable and
measurable, i.e. behaviour, and so symptoms not causes. This is a significant
weakness because cognitions and emotions are often the motivators of
behaviour and so the treatment is only dealing with symptoms not the
underlying causes.
Reductionism. The ignoring of cognitive factors limits the effectiveness of
the behavioural treatments because research has shown that cognitive
processes do play an important role in determining the effectiveness of
therapy. Accounting for cognitive factors in a cognitive-behavioural approach
would improve the effectiveness of treatment.
Appropriateness
 Strong theoretical and scientific basis. The behavioural treatments can be
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manipulated and tested experimentally. Consequently, they are based on
solid theoretical grounds, which adds to their appropriateness.
Avoidance behaviours are targeted. Exposure therapy and systematic
desensitisation focus directly on reducing avoidance behaviour, which is
appropriate if the phobia is to be cured, and so anxiety levels are reduced in
the long term.
Highly appropriate for specific phobias. The behavioural treatments are
very appropriate to the treatment of specific phobias as the direct nature of
the treatment lends itself to focusing on the one feared stimulus. They are
less effective for social phobia and agoraphobia, perhaps because these more
serious disorders require a more complicated approach to treatment.
Reductionism—ignore important factors. Individuals suffering from social
phobia often have limited social skills and low self-confidence, which aren’t
treated within behavioural therapy. Behavioural therapy doesn’t focus
sufficiently on changing phobics’ cognitive processes and beliefs. This makes
the treatment too simplistic and so less appropriate than cognitive therapies.
Ethical issues. Exposure therapy creates high levels of anxiety when
patients are initially exposed, which raises ethical issues and so questions
appropriateness. It should be noted that the virtual reality therapy does help
resolve these issues.
Drop-out rate. Exposure therapy, unsurprisingly, has a high drop-out rate.
Systematic desensitisation is less appropriate than exposure therapy.
Recent research suggests exposure therapy is more effective and so this
means systematic desensitisation with the use of muscle relaxation is
unnecessarily complicated, and so not appropriate for the most part.
Cognitive therapy
According to the cognitive approach, phobias are due to interpretive biases and so treatment is designed to
reduce or eliminate these biases.
Social phobia
Cognitive therapy has been used most extensively for social phobia rather than specific phobia or
agoraphobia. Clark and colleagues (1995, see A2 Level Psychology page 505) have devised a form of
cognitive therapy that trains patients to focus their attention externally rather than on themselves in social
situations. The training also involves watching video evidence of themselves in social situations to
demonstrate that their social behaviour is more socially skilled than they believed. Patients are instructed to
avoid using all their habitual safety-seeking (avoidance) behaviours in a social situation.
Specific phobias
Cognitive therapy as applied to specific phobia focuses on eliminating the interpretive biases that patients
have for their phobic stimuli. So patients suffering from a flying phobia would have their bias challenged
by statistics.
Agoraphobia
For most patients agoraphobia arises as a consequence of already having panic disorder and so cognitive
therapy first challenges the biases relating to panic disorder. For example, patients often misinterpret a fast
heart rate as indicating they are going to have a heart attack and may well die. Patients are educated about
their bodily sensations so that they can more accurately interpret them in stressful situations. Patients are
also trained to use distraction coping techniques so that they lose focus on their potentially anxietyprovoking bodily sensations. The symptoms of agoraphobia are generally treated by means of behaviour
therapy involving exposure to public places.
EVALUATION OF COGNTIVE THERAPIES
Effectiveness
 Very effective in the treatment of social phobia. Clark et al. (2006, see A2
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Level Psychology page 507) compared the effectiveness of cognitive therapy
with exposure plus applied relaxation in the treatment of social phobia.
There was also a waiting-list control group receiving no treatment. 84%
were cured by the cognitive treatment whereas 42% were cured by the
exposure plus applied relaxation, and 0% recovered in the waiting-list group.
Moderately effective in treatment of specific phobia? In Ost et al.’s study
(2001, see A2 Level Psychology page 507) 80% of patients receiving cognitive
therapy showed strong signs of recovery compared to only 18% of controls
in the treatment of claustrophobia. However, cognitive therapy is often less
effective than exposure therapy in treating specific phobia (Choy et al., 2007,
see A2 Level Psychology page 507). Muhlberger, Wiedemann, and Pauli (2003,
see A2 Level Psychology page 507) found that only 45% of flying phobics
treated by cognitive therapy reported flying when questioned 6 months after
the end of treatment. This figure was only slightly (and non-significantly)
higher than patients who hadn’t received any treatment.
Very effective in treatment of panic disorder with agoraphobia. Comer
(2001, see A2 Level Psychology page 508) found 85% of panic patients given
cognitive therapy had no panic attacks for as long as 2 years after treatment,
compared to only 13% of control patients.
A combined approach is more effective. However, cognitive therapy on its
own is often less effective in the treatment of panic disorder with
agoraphobia than when combined with exposure therapy. This is because
exposure therapy is most effective when it produces cognitive change, i.e.
interpretative biases can be shown not to be true through exposure
Salkovskis et al. (2007 see A2 Level Psychology page 508). Thus, it is better
when exposure therapy takes a cognitive focus like this than either therapy
on its own.
Appropriateness
 Challenging cognitive biases. This is appropriate because phobics
undoubtedly possess the various cognitive biases (especially interpretive
biases) assumed to be of central importance by cognitive therapists.
 Effectiveness of treatment. The appropriateness of cognitive treatment is
shown by the fact that cognitive therapy has proved successful in the
treatment of phobias, perhaps especially social phobia (Clark et al., 2006, see
A2 Level Psychology page 508).
 Doesn’t consider the real-life context. The cognitive approach focuses too
much on the patient’s beliefs and not enough on reality. For example, social
phobics often have genuine reasons for being concerned about their social
behaviour.
 Patients know their fears are excessive. The very fact they are seeking
treatment means that patients know their fears are excessive so the
challenging of faulty thinking is not solely due to the cognitive treatment.
 Does not necessarily effect behavioural change. Cognitive therapy for
specific phobia sometimes produces long-term reductions in subjective
anxiety but has much more modest long-term effects on avoidance
behaviour, as in the case of the flying phobic who still did not fly after
treatment.
 Reductionist. The above point shows that the cognitive approach on its own
is too simplistic and so is not fully appropriate on its own.
So what does this mean?
Any comparisons of the effectiveness of different treatments should be treated with caution as it is difficult
to know if differences are due to the actual therapy or the individual differences of the patient or therapist.
Therapy depends in part on the skills of the therapist and so differences in improvement may be due to such
differences rather than the treatment itself. The fact that patients usually choose their own treatment and so
are a self-selected sample also complicates the comparison of treatments. Moreover, recovery may not be
due to the specific nature of the treatment but due to general factors that underpin all treatments, such as the
effect of having someone sensitive to talk to and being able to express all worries and fears, which is
known as the “general therapy effect”.
Assessing the effectiveness of treatments is further complicated by the “hello-goodbye effect” whereby
patients overestimate their symptoms at the start of treatment and underestimate their symptoms at the end.
Another issue is publication bias whereby significant findings are published more than non-significant
ones. These biases may make therapies appear more effective than they really are. Imagine if all the
findings that a therapy doesn’t work are suppressed, then of course it’s going to appear effective!
Ethical issues raise further concerns as can the patient really give fully informed consent? A number of
things can limit this such as the patient may not be provided with enough information about the treatment,
they may not remember the information accurately, and they may agree just because they respect the
therapist rather than understand the treatment.
However, in spite of all of these issues, it is important to understand as best we can the effectiveness and
appropriateness of therapies because treatment is usually better than no treatment, even if part of the
improvement is a placebo effect. The biological approach is moderately effective for social phobia and
agoraphobia, however is less appropriate for specific phobia.
The psychological therapies for phobias have such high effectiveness that the optimal approach to
treatment is multi-dimensional but perhaps with psychological treatments being combined, in particular
behavioural and cognitive approaches. Perhaps drugs should be avoided as a treatment for phobias because
some research suggests even combining them with psychological therapies reduced long-term outcomes for
the patient, i.e. they are more likely to relapse.
Over to you
(a) Outline one or more psychological therapy(ies) for one anxiety disorder. (9 marks)
(b) Evaluate the therapy(ies) described in (a). (16 marks)