The Many Treatment Methodologies for Phobias: Finding the Best Fit
by Annabelle Moore
Elizabeth is diagnosed with a phobia of elevators. She is terrified of elevators; she believes that she will get stuck in one, run out of oxygen and die. Elizabeth’s thinking is disordered because she believes that getting stuck in an elevator will result in death and that elevators get stuck frequently. If she is expected to use the elevator or put in a situation where it is only logical to use an elevator, she will experience severe distress and agitation.
In order to manage their anxiety, phobic people will go to great lengths to avoid the stimulus, which ultimately impedes their normal functioning. Though the etiology of phobias is hotly debated, they are considered to be the most easily treated mental disorder (Adler, 2010). Unlike most mental health issues, the first line of treatment is not psychotropic medication. In order to develop the most beneficial intervention many methods have been created and tested. “The Many Treatment Methodologies for Phobias” will discuss popular treatments, such as psychoanalysis and cognitive behavioral techniques, as well as more recent approaches. All of these treatments have shown different rates of efficacy depending on the population and the phobia. Clinicians should be well versed in all of these methods in order to select the most appropriate treatment for the phobic client.
Freud, the father of psychoanalysis, believed that a phobic stimulus is rooted in a traumatic childhood experience. The memory may be repressed, but the associated stimulus still produces fear and anxiety (Willemsen, 2002). In Elizabeth’s case, her elevator phobia may have stemmed from an experience when she was very young and was trapped in an elevator for hours, eventually wetting. While she may not consciously remember the experience, a psychoanalyst would explore the client’s past to discover and expose these repressed processes. By talking about the experience, the client gains insight and is then able to work towards separating the stimulus from the painful memory. However, in order for psychoanalysis to be affective the patient must be psychologically minded and committed to intense introspection (Jemmer, 2005). In addition to the commitment of the patient, the psychoanalytic process can take years and therefore may not be financially feasible. Other treatment methods developed to provide an alternative for psychotherapy and supplement these shortcomings.
Although Psychoanalysis was the first treatment methodology, the most popular and reliable treatment for phobias is Exposure Therapy (ET), a method created by Cognitive-Behaviorists. These clinicians believe that phobias are evolutionary instincts which, in the modern world, are maladaptive (Willemsen, 2002). The principle behind ET is that avoidance of a feared stimulus reinforces the fear while exposure diminishes it. By slowly exposing the client to the stimulus in a safe and controlled environment, their cognitive distortions are challenged and eventually diminish (Scharfstein, 2011).
The therapist and client first work together to understand where exactly the fear lies, identifying “key barriers.” Next, they construct a list from the least to the most anxiety-producing stimuli and work in phases to conquer the list, a process known as hierarchical systematic desensitization (Beutler, 1991). Returning to Elizabeth’s case, if she were engaging in ET she would start with some CBT visualization and verbal discussion about elevators. While some of the therapy session would be devoted to the desensitization process, a CBT therapist would also address behavioral and cognitive anxiety management techniques. For example, a CBT therapist would teach Elizabeth deep breathing exercises to perform while riding an elevator. The sessions would also be devoted to cognitive restructuring: challenging the misconceptions driving the phobia. Elizabeth would be assigned homework, a hallmark of CBT. An assignment might be to research how frequently elevators get stuck and the basic mechanics of an elevator. She would use her breathing exercises during the research if her anxiety started to feel overwhelming. The key feature of the Cognitive-Behavioral approach is the exposure element. During exposure, Elizabeth and her therapist may progress to entering and later taking a short ride on a relatively nonfrightening elevator (maybe a brightly lit, modern) and slowly working on the more intense stimuli (perhaps an older elevator that makes a lot of noise) as time progresses.
Psychoeducation, much like anxietymanagement techniques and cognitive restructuring, is a quintessential element of CBT. Elizabeth can restructure her thinking and decrease her fear by realizing how she overestimates the frequency by which elevators get stuck, thereby decreasing her fear. During their sessions, Elizabeth would be taught that her elevator phobia stems from an evolutionarily adaptive aversion to both heights and small spaces. The inclusion of systematic hierarchical desensitization is a phobia treatment first used in ET and later was adopted by other methodologies due to its impressive response rate of 80-90% (Adler, 2010). Despite these robust findings, Exposure Therapy presents some limitations. For some phobias (such as flying), traditional ET would be unfeasible (Tortella, 2011). Furthermore, CBT addresses the phobia and behavior, but not necessarily any underlying psychological issues (Barber, 1991). Like any treatment besides psychoanalysis, if a client has a co-occurring mental illness, it may be impossible to engage them in ET before first addressing these issues using another form of therapy. ET is typically the first line of treatment for phobias because it has shown such impressive response rates and is easy to administer. Still, no one treatment fits all clients or phobias, and so alternative approaches emerged.
Hypnotherapy employs the principles of systematic desensitization much like Exposure Therapy, but without ever leaving the couch. The hypnotherapist leads the client through a guided visualization exercise, during which the client imagines encountering the stimulus while maintaining a relaxed state (Jemmer, 2005). It is the hypnotherapist’s responsibility to both lead the visualization exercise and remind the client to use relaxation techniques (such as deep breathing,) to self-soothe (Willemsen, 2002). One drawback of hypnotherapy is that imagination does not fully prepare the client for the real experience, and while a client may complete systematic desensitization in hypnotherapy, he may not be able yet to fully expose himself to the stimulus in vivo. Still, hypnotherapy provides an opportunity for clients for whom traditional Exposure Therapy would not be possible. For example, if a client were afraid of airplanes, hypnotherapy would be a practical method of exposure. Other alternative approaches to Exposure Therapy that are currently undergoing trial include virtual reality exposure therapy, which uses computer programming to virtually experience the stimulus.
Virtual Reality Exposure Therapy
Virtual reality exposure therapy (VRET) employs modern technology to simulate ET, and is only used in the treatment of phobias. In VRET, a virtual scene is designed to portray a realistic encounter with the stimuli using auditory and visual sensory channels (Tortella-Feliu, 2011). VRET is created from the perspective of the person sitting before the computer, so the interaction is as similar as possible to true ET. Some studies found that VRET shows effect sizes similar to those of traditional in vivo exposure (Tortella-Feliu, 2011). VRET is especially useful in treating flying phobias, and realistic flying experiences have been simulated and are stored for clients to use. Since it can be conducted over the Internet in the client’s home, it may be more appealing to people with social phobias, or other phobias limiting travel. If Elizabeth worked with a VRET clinician, she would meet with them once to learn some basic coping skills, such as breathing techniques, before gaining access to the simulation program. The program would present a realistic-looking elevator from her perspective, and would include the sounds of a normal elevator. Elizabeth would use her computer to “enter” the elevator, select a floor, and ride the elevator. She would maintain contact with her clinician over the phone and over the Internet, and the clinician can monitor her progress through the program. While VRET is very new and requires further research and design, it allows for innovation to enter the therapeutic process by introducing technology (Tortella-Feliu, 2011).
Neuro-Linguistic Programming (NLP) is a form of exposure therapy that typically only requires one session to treat phobias (Jemmer, 2005). NLP is used to neutralize troubling memories and situations, and is unique in that the client is not required to disclose anything about the phobia to the practitioner. The process employs ‘dissociated visualization’, and is commonly encorporated in the treatment of post-traumatic stress disorder. If Elizabeth seeks treatment with an NLP practitioner, she would imagine that in the projection booth of a movie theater. Looking down into the theater, she would “see” herself sitting in the seats below. Elizabeth would then “turn on” the projector. A grainy, black and white film is displayed, depicting herself riding an elevator. Throughout the viewing, Elizabeth must try to remain composed and dissociated while watching herself having a phobic response, and the visualization of herself seeing herself watch a film can help her feel removed, and disconnected. Though the encounter is only imagined, a client with a severe phobia may still experience intense fear and anxiety, and the practitioner must constantly remind her that she is safe, she is in the projector booth, and she is in control of the film. The exercise is done multiple times with the client experiencing less and less anxiety each time. Then the NLP practitioner asks the client to “reassociate” with the film, imagining herself in the scene, which is now pictured in 3-dimensions and in vivid color. She is asked to imagine the sounds, smells, and sensations of the scene. The final stage of the process involves “erasing the phobic memory trace” by imagining the film rewinding very quickly, over and over again (Jemmer, 2005).
If NLP is successful, clients report feeling secure, calm, and detached from the stimulus. The treatment method is limited in that it does not explore subconscious processes like psychoanalysis or teach important coping skills and behavioral techniques like CBT, which may limit the long-term efficacy. Still, NLP is effective in the short term that can be beneficial for some clients.
Eye Movement Desensitization and Reprocessing
Eye Movement Desensitization and Reprocessing (EMDR) therapy is used to treat anxiety caused by a specific memory and is recommended for clients who can readily identify the experience that lead to the phobia. The first three phases work to desensitize the memories surrounding the trauma, much like psychotherapy. In Elizabeth’s case she would work through her memory of the initial elevator memory that led to her phobia, then address the most painful memory associated with the phobia, and lastly of the most recent memory of an encounter with the feared stimulus (De Roos, 2008). For Elizabeth, these first two steps could all involve that first, traumatic experience. The fourth step is the creation of a ‘future template,’ or a mental image of the client interacting with the stimulus paired with a ‘positive cognition’, such as the thought, “I can handle this,” (De Roos, 2008). The fifth step involves visualizing the future encounter and identifying the fear provoking aspects, much like the ‘key barriers’ discussed by cognitivebehaviorists. When anxiety starts to emerge, eye movements are introduced, along with positive cognition, to reduce the fear response. The sixth and final step involves in vivo exposure to explore any remaining dysfunctional thinking. EMDR has been proven to be effective for those with specific trauma-related phobias, providing a cost-efficient and time-sensitive alternative to psychoanalysis.
When deciding which phobia treatment best fits a client, several important factors must be considered. First, the root of the phobia must be identified. If the client does not know when or how the phobia originated, cognitive-behavioral Exposure Therapy would be recommended as it has been shown to be the most effective, well researched treatment. If the phobia were difficult to encounter with the therapist, such as a fear of flying, then hypnosis, NLP, and virtual reality exposure therapy would be worth exploring. NLP also requires very little time and money, and might be ideal if a person must overcome a phobia in a limited amount of time. NLP does not require the client discuss any aspect of the phobia and is recommended for clients who do not know how the phobia began. If the client does connect the phobia to a particular traumatic event, EMDR might be a more appropriate recommendation. However, if the client is contemplative, selfanalyzing, and able to afford an analyst’s fees, psychoanalysis could also relieve these symptoms. Because ET is so successful, these alternative treatments have hardly been researched and more investigation of their effectiveness is necessary. Though each treatment is limited in its own way, all are viable options when confronted with a phobic patient. It is up to the clinician to weigh the costs and benefits of each in order to determine which methodology would be most appropriate, and to employ their intuition and creativity to blend these tools into a treatment approach as unique as the individual before them.
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Annabelle Moore is a senior in the Applied Psychology program, with a minor in American Sign Language. She is a research assistant for Dr. Alisha Ali on the PhotoCLUB project, as well as a Case Worker at New York Foundling: Family Services for Deaf and Hard of Hearing Children and Adults. Her research interests include severe and persistent mental illness, trauma and addiction. After graduation she plans to pursue a PhD in Clinical Psychology.