****As I predicted would happen again in my very first post for PBB, yesterday I accidentally posted the beginning of this article to the website. I apologize to those of you who received the partial post in your inbox or RSS feed reader. I'm sure that won't be the last time I do that.
by Joye C. Anestis
(due to a loose snake, Monk is standing on a kitchen table.)
Captain Stottlemeyer: I thought you were afraid of heights.
Monk: Snakes trump heights. It goes germs, needles, milk, death, snakes, mushrooms, heights, crowds, elevators.
- from USA's Monk, starring Tony Shalhoub as Adrian Monk and Ted Levine as Captain Stottlemeyer
There are a variety of empirically-supported treatments available to treat specific phobias in both children and adults, including systematic desensitization, modeling, cognitive therapy, and exposure. I recently came across a review article of one-session treatment for specific phobia (Zlomke & Davis, 2008). This manualized, one-session treatment (OST) combines several aspects of the various specific phobia treatments into one short therapy session, and has empirical support for a variety of specific phobias, including spider phobias, small animal phobias, flying phobia, and claustrophobia. OST involves gradual exposure to feared stimuli in a single session. Below, I will cover the various aspects of OST for specific phobia as described by Zlomke & Davis (2008; published in Behavior Therapy). For further information, check out the many studies and papers published by Ost & Ollendick.
Assessment: The first step of OST is a thorough assessment prior to treatment. A functional analysis for each specific phobia is conducted to identify both etiological and maintaining factors of the specific fears. This thorough assessment is necessary to construct a treatment plan. Within the assessment interview, information on the client's catastrophic cognitions about the feared stimuli, avoidant response patterns, and experiences with conditioning are gathered. Self-report measures of anxiety can be taken, and behavioral avoidance tasks can also be used. One of the primary tasks of the assessment interview is the development of a fear hierarchy. This hierarchy will be used to structure the treatment session. To construct a fear hierarchy, the client first makes a list of a variety of feared stimuli within a phobia. They then quantify the amount of anxiety each stimuli induces. Quantification generally consists of subjective units of distress (SUDs), rating the amount of anxiety associated with each stimuli on a scale of 1-100 or 1-10. The stimuli are then ranked in order from least to most anxiety-inducing. For example, a sample fear hierarchy (using a 1-100 scale) for a snake phobia might look like this:
- talking about a snake - 40
- seeing a snake on TV - 50
- seeing a rubber snake - 70
- seeing a live snake -95
- touching a live snake - 100
Presentation of the treatment rationale: Before the treatment begins, the therapist must explain the rationale behind the treatment and instructions for the treatment. The overall purpose of OST is to expose the clients to feared stimuli in a controlled manner in order to learn that the feared consequence does not occur or, if it does, the consequence is not nearly as catastrophic as feared. Other points to cover in this discussion are:
- OST is a collaborative process. Client and therapist will work together to face feared stimuli.
- The massed exposure session is only the start of their recovery. Clients must continue to expose themselves to feared stimuli in their everyday lives for months to maintain and stabilize gains
- The therapist will not progress up the fear hierarchy without the client's permission. This is an important point to make. Exposure does not involve shoving the feared stimuli in the face of the client without them being prepared. Each step is done with explicit permission from a prepared client.
In vivo exposure & modeling: Exposure is done in a hierarchical fashion. Usually, an item from the middle of the fear hierarchy is selected first. Once a stimulus for exposure is agreed upon, the therapist demonstrates the exposure first and then the client carries out the interaction. The client maintains interaction with the stimulus without using any cognitive or behavioral avoidance. The interaction continues until the stimulus no longer causes severe anxiety (i.e., the SUDs rating has decreased by at least 50% or is zero). Once anxiety significantly reduces, the next item higher up on the list is confronted. In OST, exposure is structured similarly to behavioral experiments. Before and during the exposure, the therapist elicits catastrophic cognitions (e.g., "If I see a snake, it will jump at me, bite me, and kill me.") from the client and encourages them to reach more rational conclusions from the interaction with the stimulus (e.g., "It seems unlikely that a snake wants to bite and kill me. This one is has not bitten me."). After each experiment, the client's success or failure is discussed before moving up the list. Other important aspects of exposure in OST:
- Overlearning: Clients are encouraged to interact with stimuli at levels not expected in the natural environment (i.e., snake wrapping around one's neck). It is theorized that going beyond a natural interaction will increase habituation to the stimulus and extinction of the fear.
- Modeling: In this treatment, the therapist models appropriate interactions with the stimulus at each step. This is not only instructive for the client to successfully interact with the stimulus, but it serves as another level of exposure. Seeing a trusted person interact with a feared stimulus without negative consequence provides more evidence against the catastrophic cognitions.
Maintenance: Clients commit to continual exposure in their every day life. Therapists can provide more specific maintenance tasks, based on specific fears. Therapists can also give the client a video or photographs of the treatment session for them to refer to. The key is for clients to continue to not avoid or escape interactions with feared stimuli.
It is evident that most specific phobias can be treated in a single, massed therapy session. This is a very efficient, cost-effective, and empirically-supported method for treating phobias - although there are other, equally effective, variations to this treatment. Exposure techniques allow for a quick remission of severe symptoms.
Joye Anestis is a doctoral candidate in clinical psychology at Florida State University.
