Exposure Therapies for Specific Phobias

Status: Strong Research Support


Exposure-based therapies reflect a variety of behavioral approaches that are all based on exposing the phobic individuals to the stimuli that frighten them. From a behavioral perspective, specific phobias are maintained because of avoidance of the phobic stimuli so that the individual does not have the opportunity to learn that they can tolerate the fear, that the fear will come down on its own without avoiding or escaping, and that their feared outcomes often do not come true or are not as terrible as they imagine. Avoidance can occur either by not entering a situation at all or by entering the situation but not experiencing it fully (e.g., because of consuming alcohol before taking a flight for a person with flying phobia). Exposure therapies are thus designed to encourage the individual to enter feared situations (either in reality or through imaginal exercises) and to try to remain in those situations. The selection of situations to try typically follows an individually-tailored fear hierarchy that starts with situations that are only mildly anxiety-provoking and builds up to the most feared encounters, though in some forms of exposure therapy (e.g., implosion therapy), the individual starts out being exposed to a very anxiety-provoking stimulus rather than building up to that point more gradually.

There are a number of variations of exposure therapy that work effectively in the treatment of specific phobias, so to some extent the specific approach selected may depend on the nature of the phobia and therapist and client preferences. Notwithstanding, the research evidence does provide more substantial support for some exposure therapies (i.e., in vivo exposure) over others (e.g., systematic desensitization).

In vivo exposure involves actually confronting the feared stimuli, usually in a graduated fashion (e.g., in spider phobia, a person might first look at a picture of a spider and eventually work up to touching a large tarantula; in flying phobia, a person might first read a story about a plane crash and then work up to taking an actual flight). The treatment usually last a number of hours, and can be administered in one very long session (e.g., one 3-hour session for spider phobia) or across multiple sessions (e.g., three to eight 1-1.5-hour-long sessions). A range of specific phobias respond well to in vivo treatment, although treatment acceptance and dropout can be a problem. Further, treatment gains tend to be well maintained up to a year following the end of treatment, particularly for animal phobias (though follow-up data is less impressive for blood-injection-injury phobia). When the therapist is actively modeling each step of the exposure and teaching the phobic individual how to interact with the feared stimulus, this type of exposure therapy can also be called Participant modeling or Guided mastery.

Applied muscle tension is a special variant of in vivo exposure for the treatment of blood-injection-injury phobia. This treatment uses standard exposure techniques but also incorporates muscle tension exercises to respond to decreases in blood pressure that can lead to fainting.

Virtual reality exposure uses a computer program to generate the phobic situation (e.g., being on a plane that is taking off, encountering a large tarantula, looking over a tall balcony ledge), and integrates real-time computer graphics with various body tracking devices so that the individual can interact in the environment. This therapy appears to be useful for phobias that may be difficult to treat in vivo; namely, flying phobias (where repeated plane flights are impractical) and height phobias, but more studies are needed to demonstrate its efficacy for a broader range of phobia subtypes.

Systematic desensitization involves exposing phobic individuals to fear-evoking images and thoughts (i.e., imaginal exposure) or to actual phobic stimuli, while pairing the exposure with relaxation (or another response that is incompatible with fear) to decrease the normal fear response. Treatment using systematic desensitization tends to take longer than in vivo exposure, and appears to be more effective at changing subjective anxiety than at reducing avoidance. Thus, it is not recommended as the first line of treatment if a client is willing to try in vivo or an alternate form of exposure therapy.

Note that many exposure therapies also include a cognitive component that involves cognitive restructuring to challenge distorted or irrational thoughts related to the phobic object or response (e.g., I am going to fall, The dog is going to attack me, I can't tolerate this fear, etc.). Further, there is some evidence that either adding cognitive therapy to in vivo exposure or administering cognitive therapy alone can be helpful for claustrophobia, and it may also be useful for dental phobia. Evidence regarding the utility of cognitive therapy for flying phobia is mixed, and it is not clear that adding cognitive therapy to exposure therapy for other phobia types improves outcomes.

Key References (in reverse chronological order)

In vivo Exposure Therapy (typically therapist-directed, also termed guided mastery or participant modeling)
Animal phobias
Flying phobia
Water phobia
Height phobia and driving phobia
Virtual Reality Exposure Therapy
Flying phobia
Height phobia
Animal phobia
Applied Muscle Tension for Blood-Injury-Injection Phobia
Systematic Desensitization
Animal phobia
Height phobia and claustrophobia
Cognitive Therapy
Dental phobia
Flying phobia
Treatment reviews of exposure therapy for specific phobias
Future directions in therapies for specific phobias

Advances in therapies for specific phobias are promising, including the use of computer-assisted therapy, and the use of interoceptive exposure therapy (exposure to anxiety-relevant bodily sensations, such as dizziness and shortness of breath) for claustrophobia. Key references for each of these treatment approaches are noted below, though there is not yet sufficient research evidence to list these approaches as well-established.

Clinical Resources

See description of exposure techniques in the following clinical resource/manual:
See description of applied muscle tension in the following clinical resource/manual:
See description of cognitive therapy techniques in the following clinical resource/manual

Training Opportunities

Center for Cognitive Therapy
Cory Newman, PhD, Director
Mary Anne Layden, Ph.D., Director of Education
University of Pennsylvania Medical School
3535 Market Street, 2nd Floor
Philadelphia, PA 19104-3309
Phone: 215-898-4100

Beck Institute for Cognitive Therapy and Research
Judy S. Beck, PhD, Director
One Belmont Avenue, Suite 700
Bala Cynwyd, PA 19004-1610
Phone: 610-664-3020

San Francisco Bay Area Center for Cognitive Therapy
Oakland, CA (Rockridge)
Phone: 510-652-4455

Anxiety Disorders Center
Saint Louis Behavioral Medicine Institute
1129 Macklind Avenue
St Louis, MO 63110
Director, C. Alec Pollard
314-534-0200, fax 314-534-7996

UCLA Anxiety Disorders Behavioral Program
Department of Psychology
405 Hilgard Ave
Los Angeles, CA 90095-1563
310-206-9191, fax 310-206-5895