Specific Phobia (VCE SSCE Psychology): Revision Notes
Evidence-Based Interventions and Their Use for Specific Phobia
Introduction to evidence-based interventions
Evidence-based interventions are treatments that have been demonstrated to be effective through valid and reliable research studies. When addressing specific phobia, these interventions must be considered within the biopsychosocial framework, targeting the biological, psychological and social factors that contribute to the development and maintenance of the condition.
A holistic approach using multiple evidence-based interventions is most likely to be effective, as it addresses the various contributing factors of specific phobia rather than focusing on just one aspect. This comprehensive approach recognises that different people with various types of phobias may respond differently to different treatments.
The biopsychosocial approach to managing specific phobia includes biological treatments (GABA agonists and breathing retraining), psychological treatments (systematic desensitisation and CBT), and social treatments (psychoeducation).
Biological interventions
Biological interventions target the physiological mechanisms that contribute to specific phobia. Rather than addressing underlying causes, these interventions focus on eliminating or reducing the symptoms of the disorder. Two main biological interventions for specific phobia are GABA agonists and breathing retraining.
Short-acting anti-anxiety benzodiazepine agents (GABA agonists)
Benzodiazepines are a class of sedative or depressant medications used to manage insomnia and anxiety. They work by slowing down activity in the central nervous system, which reduces physiological arousal and promotes relaxation. This makes them effective for managing the anxiety symptoms associated with specific phobia.
How benzodiazepines work:
Benzodiazepines function as agonists – drugs that mimic or enhance the action of neurotransmitters. Specifically, when a benzodiazepine binds to a GABA receptor site on the post-synaptic neuron, it increases the inhibitory effects of GABA. This makes the post-synaptic neuron less likely to fire, which reduces feelings of anxiety.
Example: Using Benzodiazepines for Blood/Injection Phobia
Someone with a blood/injection phobia might take a benzodiazepine before receiving an immunisation injection to feel calm during the procedure. The medication enhances GABA's inhibitory effects, reducing the physiological arousal that would normally trigger their fear response.
Limitations of benzodiazepines:
While generally safe, benzodiazepines can have several side effects:
- Reduced alertness, coordination and reaction time, increasing accident risk
- Lowered inhibitions, particularly when combined with alcohol or other drugs, potentially leading to more impulsive behaviour
- Risk of addiction with long-term use
- Withdrawal symptoms including anxiety, agitation, insomnia, sensory disturbances and potentially seizures if stopped suddenly
Due to these risks, benzodiazepines are typically prescribed for short-term use only.
Breathing retraining
When facing a phobic stimulus, people with specific phobia often experience abnormal breathing patterns. This may involve hyperventilation (rapid, shallow breathing), which creates an imbalance of oxygen and carbon dioxide in the blood. Low carbon dioxide levels can trigger symptoms such as dizziness, light-headedness, blurred vision and pins and needles, which further increases already heightened anxiety.
How breathing retraining works:
Breathing retraining is an anxiety management technique that teaches people how to control their breathing when facing their phobic stimulus. The technique aims to slow breathing and maintain regular breathing rhythms.
Worked Example: Breathing Retraining for Cat Phobia
A therapist might teach someone with a fear of cats to consciously control their breathing by:
- Breathing slowly in through the nose
- Focusing on breathing out slowly from the diaphragm
- Maintaining this pattern whenever they see or think about a cat
When breathing is controlled, this restabilises the balance of oxygen and carbon dioxide in the bloodstream, which helps to reduce heart rate and respiration, lower stress hormones, and increase feelings of calm and control.
Advantages of breathing retraining:
Benefits of Breathing Retraining:
- Can be taught in a single session with a therapist
- Can be used in public settings without drawing attention
- No side effects or risks
- Provides the individual with a sense of control
However, breathing retraining needs to be well practised, especially in the absence of the phobic stimulus, to become a habit that can be effectively used when experiencing anxiety.
Psychological interventions
Many clinical psychologists believe that learned behaviours and environmental triggers are the most important causes of phobias. They argue that a phobia is a learned response to a stimulus, and 'unlearning' this response can cure the phobia. Psychological interventions using psychotherapy aim to achieve this, with evidence suggesting these methods are as effective as (or more effective than) biological interventions. Consequently, psychotherapy and biological interventions are often used together.
Cognitive Behavioural Therapy (CBT)
People with specific phobia typically experience both cognitive bias and a disproportionate behavioural reaction to the fear-producing stimulus. This creates a cycle: exposure to the phobic stimulus leads to negative thoughts (memory bias, catastrophic thinking), which causes emotional responses (distress, shame, embarrassment) and biological responses (activation of the fight-or-flight-or-freeze response). The person then alters their behaviour by actively avoiding the object or situation, which perpetuates the phobia.
CBT comprises a range of cognitive and behavioural therapies and learning principles designed to help people identify, challenge and change unhelpful thought processes, feelings and behaviours to ones that are more helpful. It assumes that the way a person thinks about an object or situation influences both how they feel about it and how they behave in response to it.
If someone with a specific phobia can develop a new understanding of the phobic stimulus as not dangerous, they can reduce instances of avoidance behaviour by using coping strategies. For example, if someone with a cat phobia realises that it is unlikely they will be attacked and disfigured by all cats, they will be more likely to expose themselves to situations where they might encounter a cat with minimal fear or anxiety.
Traditional CBT usually requires weekly sessions of 30-60 minutes over 12-20 weeks. Within these sessions, the therapist addresses both the cognitive and behavioural components of the therapy.
Cognitive therapy component
Cognitive therapy focuses on the role of thoughts, beliefs and attitudes in determining emotions and behaviour. The therapist encourages their client to identify which thoughts and feelings related to the phobic stimulus might be cognitive biases or fear-related. The client is then encouraged to gather evidence that both supports and refutes their fear.
Worked Example: Challenging Fear of Flying
Someone with a fear of flying might gather information about the number of plane crashes over the past year. The therapist would then encourage the person to acknowledge that it is unlikely they will crash and die the first time they fly. This evidence helps the person challenge their belief and realise it is false.
Outcome: Once the person has identified and challenged their cognitive distortions, they are more likely to change their thoughts, feelings and beliefs to more realistic and positive ones. This leads to a reduction in fear-related behaviours such as avoidance. For example, a person might now believe they will be perfectly safe if they take a flight (instead of thinking the aeroplane will crash), which leads to reduced anxiety about booking a flight.
Behavioural therapy component
Behavioural therapy deals directly with maladaptive behaviours that can maintain or worsen psychological problems and the associated thoughts and feelings. This could include:
- Teaching relaxation techniques such as breathing retraining or progressive muscle relaxation
- Promoting exercise
- Encouraging engagement in distracting and rewarding activities
These approaches allow dysfunctional ways of responding to be replaced with new, more functional behaviours. For example, a person could be helped to gradually expose themselves to the phobic stimulus while using relaxation techniques to reduce anxiety (systematic desensitisation).
Systematic desensitisation
Classical conditioning plays a role in the development of some specific phobias. Associations developed through classical conditioning can be exceedingly strong, long-lasting and resistant to simple extinction. This has led psychologists to apply classical conditioning processes in developing therapies for treating phobias.
Systematic desensitisation involves progressively introducing a person to their phobic stimulus while using relaxation techniques until their fear is replaced by a relaxation response. This model operates on the principles of classical conditioning and aims to recondition the association between the phobic stimulus and the fear response by associating the phobic stimulus with a relaxation response instead.
The three steps of systematic desensitisation:
1. Learning a relaxation technique
Before exposure to any stimulus, the person is taught a relaxation technique. This may include breathing retraining, progressive muscle relaxation, or the use of visual imagery to reduce the physiological arousal involved in the fear response.
2. Forming a fear hierarchy
After learning a relaxation technique, the person is helped to form a fear hierarchy by breaking down and organising the phobic stimulus into a list of anxiety-inducing situations from easiest to most difficult to confront. The therapist arranges these situations in hierarchical order from least frightening to most frightening.
Worked Example: Fear Hierarchy for Aeroplane Phobia
Someone with a phobia of aeroplanes might have a fear hierarchy that progresses from:
- Driving to the airport (least frightening)
- Checking in at the terminal
- Waiting for boarding
- Getting on the plane
- Taking a flight (most frightening)
Each step represents a progressively more challenging exposure to the phobic stimulus.
3. Gradual exposure to the fear stimulus
After creating the fear hierarchy, the person is progressively exposed to each fear-producing situation. They are exposed to the least-frightening fear on the hierarchy while using a relaxation technique to control the fear response. This is repeated until the stimulus no longer produces a fear response but instead produces a relaxation response.
Worked Example: Gradual Exposure Process
The therapist might first show the client a photo of a plane and help them remain calm and breathe deeply throughout the exercise. Once the client can look at a photo of a plane and feel calm rather than fearful, they tackle the next fear in the hierarchy.
Exposure to a phobic stimulus may involve imagining the situation using visual imagery or a real-life experience. Although treatment can be conducted within a therapeutic environment, evidence suggests that the best results occur through real-life exposures.
Application to classical conditioning:
Understanding Systematic Desensitisation Through Classical Conditioning:
- Before conditioning: The phobic stimulus (CS) produces fear (CR), whilst a relaxation technique (UCS) produces feelings of relaxation (UCR)
- During conditioning: Each step in the fear hierarchy (CS) is progressively presented whilst performing the relaxation technique (UCS), which produces feelings of relaxation (UCR)
- After conditioning: The phobic stimulus (CS) alone now produces a relaxation response (CR) instead of fear
Social interventions
Social support is very important in the treatment of phobia. Sufferers often experience their phobia daily but may only see their therapist every one or two weeks. Therefore, they need support from family and friends to help manage their phobia. Social interventions may be used alongside biological and psychological interventions to provide this support.
Psychoeducation for families and supporters
Psychoeducation is the process of providing information to people with a mental illness and their family members or friends to increase understanding of the disorder and possible treatment options. When first diagnosed with specific phobia, people generally do not know much about their condition. Psychoeducation assumes that sufferers and their social supporters cope better if they have a thorough understanding of the illness, its treatment and the challenges sufferers face.
Psychoeducation can take place in individual or group sessions. Group sessions include the person with the phobia and members of their social support network, such as family, partners or friends. It is important that friends and family are included because learning more about the symptoms and difficulties associated with specific phobia can decrease associated stigma.
Example: Impact of Psychoeducation
If someone with a specific phobia of buttons is educated about the characteristics of phobia and treatment opportunities, they may feel less shame and be more likely to seek treatment.
Common topics in psychoeducation sessions:
- Symptoms and causes
- Treatment options
- Support services and networks
- Useful sources of information
- Effects on family
- Work-related issues
- What constitutes improvement
Those in the social support network are educated about two key strategies to help manage phobia:
1. Challenging unrealistic or anxious thoughts
The anxious thoughts characteristic of specific phobia are usually negative and unrealistic. For example, someone with a needle phobia might think that if they have an injection, it could hit a bone or lead to an infection and death. Unrealistic thoughts such as these perpetuate the phobia because they make the individual less likely to confront the stimulus.
Members of a social support network can encourage the person to recognise and challenge these unrealistic or anxious thoughts. Family or friends can do this by using questions to help the person look for evidence that counters their thoughts in a calm, gentle manner.
Worked Example: Challenging Needle Phobia Thoughts
For someone with a needle phobia, family members might ask:
- "How likely is it that you will get an infection?"
- "Do you remember all the times you got an injection and you were OK?"
This helps the person become more able to recognise when their thoughts are unrealistic and replace them with a more rational evaluation of potential exposure to the phobic stimulus.
2. Not encouraging avoidance behaviours
Avoidance can make the person feel better in the short term but perpetuates the phobia. Avoidance behaviour stops a person from facing the phobic stimulus, preventing them from seeing that it is not as dangerous as they believe. The comfort of avoiding the stimulus negatively reinforces the phobia.
Often, members of a social support network encourage avoidance behaviours to reduce the sufferer's distress. However, this is detrimental because it unintentionally inhibits recovery.
Instead, members of a support network should:
- Encourage the person to slowly expose themselves to the fear stimulus
- Use praise and companionship whilst the sufferer does this
- Provide support without enabling avoidance
Example: Supporting Exposure to Medical Settings
A girlfriend might suggest that her partner sit in a doctor's office for a small amount of time and encourage him to remain if he gets distressed. This gradual exposure with support is more helpful than allowing him to avoid medical settings entirely.
Remember!
Key Points to Remember:
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Evidence-based interventions use the biopsychosocial framework, addressing biological, psychological and social factors that contribute to specific phobia
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Biological interventions include GABA agonists (benzodiazepines) which enhance GABA's inhibitory effect to reduce anxiety, and breathing retraining which helps control hyperventilation and restore oxygen-carbon dioxide balance
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Psychological interventions include CBT (which has cognitive and behavioural components to challenge thoughts and modify behaviours) and systematic desensitisation (which uses relaxation techniques, fear hierarchies and gradual exposure based on classical conditioning principles)
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Social interventions focus on psychoeducation for families and supporters, teaching them to challenge unrealistic thoughts and not encourage avoidance behaviours
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Multiple interventions are often used together for a holistic approach, as different people with various types of phobias may respond differently to different treatments