Goodwin (1983) states: ‘Anything that is learned can be unlearned’; this view forms the basis of many psychological treatments for phobias. Generally assumed is that the sufferer has, at some point, learnt the association of fear with their feared stimulus through childhood trauma, observational learning or projected fear associations (like Albert’s fear of rabbits). Whether the aim is uncovering subconscious conflicts or challenging illogical thought processes, almost all psychological treatments for phobias have something in common: unlearning through the method of exposure. The first major widely used behavioural treatment was developed by Wolpe (1958). It involved; ‘flooding’ – exposure to the feared stimulus at full intensity; help with social skills for those with social phobia; and modelling – observing another person interacting with the feared stimulus, to see that no harm will result (Marsh & Ollendick, 2004). Because of the success of Wolpe’s ideas, these treatments continue to be used in a variety of formats.
Cognitive-behavioural-therapy (CBT) challenges the negative thoughts that maintain a phobia. Typical treatments include relaxation, education about the feared stimulus, exposure, prevention of immediate responses, and desensitisation. Systematic desensitisation is based on early work in behaviourism and fundamental principles of classical conditioning. The sufferer makes a ‘fear hierarchy’, pairing fear responses with different severities of exposure, before being progressively exposed to their feared stimulus. Literature shows this treatment to be more effective than no treatment, or wait-list control conditions. Other aspects of CBT include contingency-management and cognitive self-control. The former is based on operant conditioning. Instead of avoidance of the fear as a reward, it uses positive consequences following exposure, and negative consequences following fear avoidance. This changes sufferers’ thought patterns; avoiding the feared stimulus is not a positive action. Cognitive self-control tackles maladaptive thoughts, encouraging sufferers to use positive instead of negative statements, and invent constructive coping strategies and reassuring statements to help deal with fearful situations (Davey, 1997).
Amongst these treatments, one boasts particularly astounding success: Ost’s (1989) One-Session-Treatment (OST). This begins with a behavioural analysis of the sufferer so treatment can be tailored specifically, before a single three-hour session exposes them to a high intensity of their fear stimulus. During those 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. Despite claims that sufferers can walk out of treatment practically cured, Ost, Svensson, Hellstrom, & Lindwall (2001) emphasise the need for continued exposure post-treatment; an issue requiring further research.
Jacobson et al., (1984) offer two criteria for judging treatment efficacy. Firstly, the before-after change must be statistically reliable, and secondly, the post-treatment level of phobic anxiety must be within the range of the normal population, or: “outside the range of patient population, defined as the mean +- 2SD in the direction of functionality” (Jacobson, et al., 1984, p. 501). CBT has most empirical support: Kendall et al., (1997) achieved success rates of 71%, compared with 5% success in waiting list conditions. Perhaps the most impressive treatment, however, is Ost et al’s (2001) OST, claiming a 90% success rate, and ensuring maintenance in a follow-up study a year later. By comparison, rates for self-exposure range from 18-33% (Goodwin, 1983). These statistics suggest that it is not the nature of phobias itself that results in successful treatments: they are not easily cured; rather, some aspect of psychological treatment enables sufferers to reduce their anxiety. Conversely, it cannot simply be the treatment, as very similar treatments are used for a host of mental disorders; depression shares the same maladaptive negative thinking as phobias, but it would be absurd to imagine a three hour successful treatment existing. An interaction between the nature of phobic anxiety and the nature of psychological treatments may explain the efficacy of these treatments.
One aspect of phobic anxiety that differs from many other mental disorders is the infrequency of the symptoms. Specific phobias only become a problem when the sufferer is in contact with the fear stimulus; social phobia and agoraphobia differ in this, and several other, senses. Specific phobias relate to one isolated situation or object. Therefore, if the fear response can be removed from that stimulus, the phobia should logically be cured, whether learnt through trauma or association. Social and agoraphobia are not isolated fears, and are therefore harder to cure. They revolve around a multitude of associated fears less easily identifiable, and cannot be treated in the same way as specific phobias. To cure a phobia the conditioned stimulus has to lose strength (extinguish), which occurs when the response no longer receives rewarding behaviour. As mentioned earlier, avoidance itself works as a reward, so this feature must be tackled as part of treatment; with continued avoidance, the sufferer has no chance to ‘unlearn’ the fear (Goodwin, 1983): another reason why exposure is such a successful treatment.
Another aspect that sets phobias apart is the apparent ease with which phobias are acquired, and can even be deliberately conditioned. Watson and Rayner’s (1920) Little Albert demonstrated this, along with a multitude of others since, including Seligman (1971), who claimed to be able to condition a phobia with only two to four shocks paired with spiders or snakes. It seems logical that if a phobia’s cause is conditioning, the reverse could be the cure. If CBT can train a sufferer to replace their negative associations with positive ones, this explains why success rates are so high. Social phobias, agoraphobia, and even conditions such as depression, are not focused on simple association, and thus successful treatments are inevitably going to be as complex as their aetiology. Although various psychological treatments are highly effective, this area of psychology is by no means without problems. As discussed, social phobia and agoraphobia treatments are not included in these success rates, and individual differences still play a huge part. Even with seemingly the most simple phobias, tried and tested treatments can fail to yield results. Conversely, many people have childhood traumas that never lead to a phobia, so a definite answer is still far away. Research does suggest the nature of conditioning to be central to why such therapy as CBT works so well, but issues like spontaneous recovery and follow-up studies should be ignored. Ost (1989) claims success even a year later, but a large proportion of phobia treatments do not have sufficient post-treatment measures (Goodwin, 1983), certainly an issue that needs resolution.
The above criticisms highlight the complex nature of phobias and their treatment. Such a common mental disorder clearly needs much attention, and a huge amount of progress has been made over the last century. Conditioning is now widely believed to be not only the cause, and quite possibly the most promising cure, but also the very reason why CBT and others are so effective. However, without further work on follow-up studies, the success rates may only be a measure of temporary alleviation, and therefore not hugely more beneficial than pharmalogical treatments. Without a doubt, however, progress made in phobic anxiety treatment is comforting; valuable lessons and principles can be extended to other mental disorders, giving hope and support to the millions of anxiety sufferers who are yet to find a cure.
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