Specific Phobias: Clinical Applications of Evidence-Based Psychotherapy
Wells, Adrian, Journal of Cognitive Psychotherapy
Specific Phobias: Clinical Applications of Evidence-Based Psychotherapy Timothy J. Bruce and William C. Sanderson. Northvale, NJ: Jason Aronson Inc. (www.aronson.com). 1998, 264pp., $40.00 (hardcover).
This book is one in a series of evidence-based psychotherapy practical guides on selected clinical disorders. The series editor is William C. Sanderson. The aim of this series is to provide empirically supported psychological treatments with step-by-step accounts of the application of these interventions. This book, as the title suggests, focuses on the treatment of specific phobias and presents, as one might expect, a predominantly behavioral account of exposure-based treatments. Overall there are 10 chapters which cover assessment and the implementation of various stages of the exposure-based treatment process.
Chapter 1 consists of a basic definition of specific phobias and briefly describes subtypes of phobias. There is a useful section here on differentiating specific phobias from more complex disorders such as agoraphobia, social phobia, PTSD, and childhood anxiety disorders. Also included is a brief review of theories of the development of phobias which covers preparedness theory, theories based on aversive conditioning, observational acquisition, and so forth. There is also a brief overview of different forms of exposure-based treatments such as systematic desensitization, flooding, and reinforced practice. The aims of the remaining chapters are to present, as stated by the authors, a "flexible, multi-modal approach that characterizes the exposure-based treatment described in this volume" (p. 21). This approach does incorporate methods that are intended to facilitate cognitive change such as education and the identification of cognitive biases. However, the cognitive modification procedures are not intended to be as extensive as those that may be incorporated in some cognitive behavioral treatment packages.
Chapter 2 covers the content of the first treatment session and emphasizes the need for thorough assessment in treatment planning. The book contains several clinical measures that can be used for assessment, and that are produced in the appendix. These appear to be clinically useful tools, rather than formal assessment instruments with established psychometric properties. Of course, there are other self-report measures that may also be useful in the treatment of particular types of phobias which are not discussed here, and these instruments have more formal psychometric properties such as the Beck Anxiety Inventory, the Marks & Matthews Fear Questionnaire, the Agoraphobic Cognitions Questionnaire, and the Bodily Sensations Interpretation Questionnaire. One of the strengths in this book is the use of a clinical vignette which is used throughout, following the treatment of a patient with height phobia. We are introduced to this vignette in chapter 2. The assessment chapter discusses strategies for identifying individual phobic objects, situations and activities, and for drawing up an initial avoidance hierarchy, elicitation of phobic sensations and fearful thoughts, and assessment of typical coping strategies.
Chapters 3 and 4 concentrate on techniques for conveying the therapeutic model and for introducing general guidelines for the practice of exposure. In these chapters we are introduced to the idea of the phobic cycle. In its basic form this consists of conveying the idea that various forms of safety-seeking maintain phobia by not allowing fears and doubts to be disconfirmed through corrective experiences. This is embellished by patients learning that phobic beliefs overestimate threat and the unmanageability of phobic situations. Patients learn that anticipatory fear is a significant component of phobias. There is an introduction to the fight-flight account of anxious arousal and an emphasis on the fact that an alarm reaction does not mean that threat is real. The authors suggest that the phobic cycle can also be described in terms of Mowrer's two-factor theory in which anxiety is maintained through avoidance and avoidance behavior itself is negatively reinforced. …