BEST THERAPIES FOR PHOBIAS
There are three therapies that have proven highly effective against phobias: systematic desensitization, flooding, and modeling. All three were developed within the framework of the behavioral analysis. Historically, the first is systematic desensitization.
Systematic Desensitization
In the 1950s, Joseph Wolpe, a South African psychiatrist, classically conditioned
cats to fear a chamber in which they had been shocked. Using this
animal modeJi of phobias, Wolpe developed the therapy of systematic desensitization.
First he cured his cats oftheir acquired fear, and then he successfully
applied the therapy to human phobias.
Systematic desensitization is effective and brief, usually lasting at most a
few months. It involves three phases: training in relaxation, hierarchy construction,
and counterconditioning. First the therapist trains the phobic patient
in deep muscle relaxation, a technique in which the subject sits or lies
with eyes closed, with all his muscles completely relaxed. This state of relaxation
will be used in the third phase to neutralize fear, since it is believed that
individuals cannot be deeply relaxed and afraid at the same time (that is,
fear and relaxation are incompatible responses). Second, with the aid of the
therapist, the patient constructs a hierarchy of frightening situations, in
which the most dreaded possible scene is on the highest rung and a scene evoking some, but minimal, fear is on the lowest rung.
For example, a hierarchy constructed by a woman with a phobia of physical deformity (from Wolpe, 1969) might be as follows (from minimally feared situations to maximally feared situations):
1. Ambulances (minimally feared)
2. Hospitals
3. Wheelchairs
4. Nurses in uniform
5. Automobile accidents
6. The sight of somebody who is seriously ill
7. The sight of bleeding
8. Someone in pain
9. The sight of physical deformity (maximally feared)
The third phase removes the fear of the phobic object by gradual counterconditioning;
that is, causing a response that is incompatible with fear to
occur at the same time as the feared CS. The patient goes into deep relaxation,
and simultaneously imagines the first, least-arousing scene in the hierarchy.
This serves two purposes. First, it pairs the CS, ambulances, with
the absence of the original traumatic US. (You will recall that presenting the
CS, without the original US, is an extinction procedure that will weaken the
fear response to the CS.) Second, a new response, relaxation, which neutralizes
the old response of fear occurs in the presence of the CS. This is repeated
until the patient can imagine scene 1 of the hierarchy without any fear at all.
Then scene 2, which provokes a slightly greater fear than scene 1, is paired
with relaxation. And so the patient progresses up the hierarchy by the
graded extinction procedure until she reaches the most terrifying scene.
Here the patient again relaxes and visualizes the final scene. When she can
do this with no fear at all, the patient may be tested in real life by being confronted
with an actual instance ofsomething at the top of her hierarchy-in
this case, with a real physical deformity. Therapy is considered successful when the patient can tolerate being in the actual presence of the most terrifying
item on the hierarchy.
Eighty to ninety percent of specific phobias improve greatly with such
treatment. These gains are usually maintained over follow-ups of a year or
two. Follow-up studies universally report that new symptoms rarely, if ever,
develop to replace the phobia. (For a sample ofsuch studies, see Paul, 1967;
Kazdin and Wilcoxon, 1976.) This absence of "symptom substitution"
argues that Freud's theory of phobias, as anxiety displaced from deep intrapsychic
conflict onto an innocent object, is mistaken: characteristically,
the psychoanalytic view of phobias claims that the phobia is merely a superficial
symptom of a deeper, unresolved conflict, which is the genuine
disorder. The psychoanalytic view maintains that removingthe symptomsby
desensitizing the phobic object cannot resolve the underlying conflict, and
that therefore a new phobia or some other disorder will arise to bind the anxiety
that can now no longer be displaced onto the newly desensitized object.
This has not been shown to be the case.
Flooding
Recall that behaviorists believe that phobias persist because phobics will
avoid the phobic object if at all possible, and if forced into its presence, they
will escape rapidly. This failure to find out that the phobic object no longer
predicts the original traumatic event will protect the phobia from extinction.
What happens when a phobic is forced or volunteers to be in the presence
of a phobic object? What happens when rats, who are avoiding shock by
escaping the tone in two seconds, are forced to sit repeatedly through the
ten-second tone and find out that shock no longer occurs? Such «flooding
or reality-testing procedure in rats reliably brings reduced amount of fear
and eliminates future avoidance (Baum, 1969; Tryon, 1976). The success of
eliminating tear in animals by a flooding procedure encouraged behavior
therapists to try, with caution, flooding in real phobic patients (Stampfl and
Levis, 1967).
In a flooding procedure, the phobic patient agrees, usually with great apprehension,
to imagine the phobic situation or to stay in its presence, without
attempting to escape for a long period. For example, a claustrophobic
will be put in a closet for four hours, or an agoraphobic will listen to a long
and vivid tape recording that describes his going to a shopping center, falling
down, being trampled by crowds, hearing them laugh as they observe him
vomiting allover himself. Usually the phobic isterrified forthefirst houror
two of flooding, and then gradually the terror will subside. When he is then
taken to a shopping center, he will usually be greatly improved, and the
phobia may be gone.
In general, flooding has proven to be equal, and sometimes even superior,
to systematic desensitization in its therapeutic effects. This has been particularly
true of treatment for agoraphobia, which sometimes resists desensitization
but is effectively treated by flooding, Treatment gains are
maintained: four years after flooding, 75 percent ofa group ofseventy agoraphobics
remained improved (Marks, Boulougoris, and Marset, 1971;
Crowe, Marks, Agras, and Leitenberg, 1972; Emmelkamp and Kuipers,
1979). By forcing a patient to reality test and to stay in the phobic situation, and thereby find out that catastrophe does not ensue, extinction of the phobia
can usually be accomplished. This directly confirms the hypothesis that
phobias are so persistent because the object is avoided in real life and therefore
not extinguished by the discovery that they are harmless.
Modeling
The third effective therapy for phobias is modeling. In a typical modeling
procedure, the phobic watches someone who is not phobic perform the behavior
that the phobic is unable to do himself. For example, a snake phobic
will repeatedly watch a nonfearful model approach, pick up, and fondle a
real snake (Bandura, Adams, and Beyer, 1977). Seeing that the other person
is not harmed, the phobic may become less fearful of the situation. However,
if the: phobic thinks that the model is endowed with special powers to
deal with a snake, he may continue to fear the situation. In order to change
this belief about the model, the therapist will attempt to find a model who
resembles the phobic. Then, the therapist will gradually involve the phobic
in the exercises. First, the phobic may be asked to describe aloud what he
sees, then to approach the snake, and finally to touch it. The procedure will
be repeated until the phobia diminishes.
Overall, modeling, when used in therapy, seems to work about as well as
both desensitization and flooding in curing both mild and severe clinical
phobias (Rachman, 1976). This therapy brings about cognitive change, as
well as behavioral change. Once a patient has observed a model, the single
best predictor of therapeutic progress is the extent to which he now expects
that he will be able to perform the actions he formerly was unable to do
(Bandura, Adams, and Beyer, 1977).
A single underlying process-extinction-seems to be the operative element
in all three effective therapies for phobias. In all three treatments, the
patient is exposed, repeatedly and enduringly, to the phobic object in the
absence ofthe original traumatic event. Each technique keeps the phobic in
the presence of the phobic object by a different tactic so that extinction can
take place: desensitization by having the patient relax and imagine the object,
flooding by forcibly keeping the phobic in the phobic situation, and modeling by encouraging the phobic to approach the phobic object as the
model has done. The fact that each of these three therapies works and employs
classical fear extinction supports the view that the phobia was originally
acquired by classical fear conditioning.
Drugs
Antidepressant drugs, particularly imipramine and MAO-inhibitors (which
we shall discuss in Chapter 13) may be very helpful in alleviating phobias,
either alone or when given in concert with behavior therapy and supportive
therapy (Tyrer, Candy, and Kelly, 1973; Zitrin, Klein, and Woerner, 1978;
Klein and Davis, 1969; Marks, Gray, Cohen, Hill, Mawson, Ramm, and
Stern, 1983; Zitrin, Klein, Woerner, and Ross, 1983). But there is an important
distinction between the phobics who will benefit from antidepressant
medication and those who will not. The distinction is between phobics
who do and who do not have spontaneous panic attacks. As we mentioned
earlier, agoraphobics typically have spontaneous panic attacks in which
their heart pounds, they believe the ground is trembling beneath them, and
they think they are going to die. In fact, agoraphobia often develops in early
adulthood following such a panic attack. Specific phobics, on the other
hand, are not as prone to spontaneous panic attacks. The antidepressant
drugs seem particularly useful in quelling the agoraphobic's spontaneous
panic attacks. Once the panic attack is so controlled, the agoraphobic need
no longer fear going into the street, perhaps because the panic attack had
been the traumatic event (the US) that he had feared and that he now knows
will no longer occur. If this is so, the effectiveness of the antidepressants in
curing agoraphobia may also provide us with a fourth type of therapy that
works because fear ofthe CS-fear of the phobic object-is extinguished by
learning that the dreaded US will not occur.
EVALUATION OF THE BEHAVIORAL ACCOUNT
The behavioral model of phobias appears to be adequate-in fact, it is as
good a model of a form of abnormality as any we know. It is consistent with
case history material; it has generated three effective therapies based on
classical fear extinction; and it is supported by a good deal oflaboratory evidence.
However, there are three main problems with this account: selectivity,
irrationality, and lack of traumatic conditioning. We will now examine
these three problems and will look at the theory that has been used to account
for them: prepared classical conditioning.
1. Ambulances (minimally feared)
2. Hospitals
3. Wheelchairs
4. Nurses in uniform
5. Automobile accidents
6. The sight of somebody who is seriously ill
7. The sight of bleeding
8. Someone in pain
9. The sight of physical deformity (maximally feared)
The third phase removes the fear of the phobic object by gradual counterconditioning;
that is, causing a response that is incompatible with fear to
occur at the same time as the feared CS. The patient goes into deep relaxation,
and simultaneously imagines the first, least-arousing scene in the hierarchy.
This serves two purposes. First, it pairs the CS, ambulances, with
the absence of the original traumatic US. (You will recall that presenting the
CS, without the original US, is an extinction procedure that will weaken the
fear response to the CS.) Second, a new response, relaxation, which neutralizes
the old response of fear occurs in the presence of the CS. This is repeated
until the patient can imagine scene 1 of the hierarchy without any fear at all.
Then scene 2, which provokes a slightly greater fear than scene 1, is paired
with relaxation. And so the patient progresses up the hierarchy by the
graded extinction procedure until she reaches the most terrifying scene.
Here the patient again relaxes and visualizes the final scene. When she can
do this with no fear at all, the patient may be tested in real life by being confronted
with an actual instance ofsomething at the top of her hierarchy-in
this case, with a real physical deformity. Therapy is considered successful when the patient can tolerate being in the actual presence of the most terrifying
item on the hierarchy.
Eighty to ninety percent of specific phobias improve greatly with such
treatment. These gains are usually maintained over follow-ups of a year or
two. Follow-up studies universally report that new symptoms rarely, if ever,
develop to replace the phobia. (For a sample ofsuch studies, see Paul, 1967;
Kazdin and Wilcoxon, 1976.) This absence of "symptom substitution"
argues that Freud's theory of phobias, as anxiety displaced from deep intrapsychic
conflict onto an innocent object, is mistaken: characteristically,
the psychoanalytic view of phobias claims that the phobia is merely a superficial
symptom of a deeper, unresolved conflict, which is the genuine
disorder. The psychoanalytic view maintains that removingthe symptomsby
desensitizing the phobic object cannot resolve the underlying conflict, and
that therefore a new phobia or some other disorder will arise to bind the anxiety
that can now no longer be displaced onto the newly desensitized object.
This has not been shown to be the case.
Flooding
Recall that behaviorists believe that phobias persist because phobics will
avoid the phobic object if at all possible, and if forced into its presence, they
will escape rapidly. This failure to find out that the phobic object no longer
predicts the original traumatic event will protect the phobia from extinction.
What happens when a phobic is forced or volunteers to be in the presence
of a phobic object? What happens when rats, who are avoiding shock by
escaping the tone in two seconds, are forced to sit repeatedly through the
ten-second tone and find out that shock no longer occurs? Such «flooding
or reality-testing procedure in rats reliably brings reduced amount of fear
and eliminates future avoidance (Baum, 1969; Tryon, 1976). The success of
eliminating tear in animals by a flooding procedure encouraged behavior
therapists to try, with caution, flooding in real phobic patients (Stampfl and
Levis, 1967).
In a flooding procedure, the phobic patient agrees, usually with great apprehension,
to imagine the phobic situation or to stay in its presence, without
attempting to escape for a long period. For example, a claustrophobic
will be put in a closet for four hours, or an agoraphobic will listen to a long
and vivid tape recording that describes his going to a shopping center, falling
down, being trampled by crowds, hearing them laugh as they observe him
vomiting allover himself. Usually the phobic isterrified forthefirst houror
two of flooding, and then gradually the terror will subside. When he is then
taken to a shopping center, he will usually be greatly improved, and the
phobia may be gone.
In general, flooding has proven to be equal, and sometimes even superior,
to systematic desensitization in its therapeutic effects. This has been particularly
true of treatment for agoraphobia, which sometimes resists desensitization
but is effectively treated by flooding, Treatment gains are
maintained: four years after flooding, 75 percent ofa group ofseventy agoraphobics
remained improved (Marks, Boulougoris, and Marset, 1971;
Crowe, Marks, Agras, and Leitenberg, 1972; Emmelkamp and Kuipers,
1979). By forcing a patient to reality test and to stay in the phobic situation, and thereby find out that catastrophe does not ensue, extinction of the phobia
can usually be accomplished. This directly confirms the hypothesis that
phobias are so persistent because the object is avoided in real life and therefore
not extinguished by the discovery that they are harmless.
Modeling
The third effective therapy for phobias is modeling. In a typical modeling
procedure, the phobic watches someone who is not phobic perform the behavior
that the phobic is unable to do himself. For example, a snake phobic
will repeatedly watch a nonfearful model approach, pick up, and fondle a
real snake (Bandura, Adams, and Beyer, 1977). Seeing that the other person
is not harmed, the phobic may become less fearful of the situation. However,
if the: phobic thinks that the model is endowed with special powers to
deal with a snake, he may continue to fear the situation. In order to change
this belief about the model, the therapist will attempt to find a model who
resembles the phobic. Then, the therapist will gradually involve the phobic
in the exercises. First, the phobic may be asked to describe aloud what he
sees, then to approach the snake, and finally to touch it. The procedure will
be repeated until the phobia diminishes.
Overall, modeling, when used in therapy, seems to work about as well as
both desensitization and flooding in curing both mild and severe clinical
phobias (Rachman, 1976). This therapy brings about cognitive change, as
well as behavioral change. Once a patient has observed a model, the single
best predictor of therapeutic progress is the extent to which he now expects
that he will be able to perform the actions he formerly was unable to do
(Bandura, Adams, and Beyer, 1977).
A single underlying process-extinction-seems to be the operative element
in all three effective therapies for phobias. In all three treatments, the
patient is exposed, repeatedly and enduringly, to the phobic object in the
absence ofthe original traumatic event. Each technique keeps the phobic in
the presence of the phobic object by a different tactic so that extinction can
take place: desensitization by having the patient relax and imagine the object,
flooding by forcibly keeping the phobic in the phobic situation, and modeling by encouraging the phobic to approach the phobic object as the
model has done. The fact that each of these three therapies works and employs
classical fear extinction supports the view that the phobia was originally
acquired by classical fear conditioning.
Drugs
Antidepressant drugs, particularly imipramine and MAO-inhibitors (which
we shall discuss in Chapter 13) may be very helpful in alleviating phobias,
either alone or when given in concert with behavior therapy and supportive
therapy (Tyrer, Candy, and Kelly, 1973; Zitrin, Klein, and Woerner, 1978;
Klein and Davis, 1969; Marks, Gray, Cohen, Hill, Mawson, Ramm, and
Stern, 1983; Zitrin, Klein, Woerner, and Ross, 1983). But there is an important
distinction between the phobics who will benefit from antidepressant
medication and those who will not. The distinction is between phobics
who do and who do not have spontaneous panic attacks. As we mentioned
earlier, agoraphobics typically have spontaneous panic attacks in which
their heart pounds, they believe the ground is trembling beneath them, and
they think they are going to die. In fact, agoraphobia often develops in early
adulthood following such a panic attack. Specific phobics, on the other
hand, are not as prone to spontaneous panic attacks. The antidepressant
drugs seem particularly useful in quelling the agoraphobic's spontaneous
panic attacks. Once the panic attack is so controlled, the agoraphobic need
no longer fear going into the street, perhaps because the panic attack had
been the traumatic event (the US) that he had feared and that he now knows
will no longer occur. If this is so, the effectiveness of the antidepressants in
curing agoraphobia may also provide us with a fourth type of therapy that
works because fear ofthe CS-fear of the phobic object-is extinguished by
learning that the dreaded US will not occur.
EVALUATION OF THE BEHAVIORAL ACCOUNT
The behavioral model of phobias appears to be adequate-in fact, it is as
good a model of a form of abnormality as any we know. It is consistent with
case history material; it has generated three effective therapies based on
classical fear extinction; and it is supported by a good deal oflaboratory evidence.
However, there are three main problems with this account: selectivity,
irrationality, and lack of traumatic conditioning. We will now examine
these three problems and will look at the theory that has been used to account
for them: prepared classical conditioning.
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