Adult Treatment Planner
32: Phobia
Goals
- Reduce fear of the specific stimulus object or situation that previously provoked phobic anxiety.
- Reduce phobic avoidance of the specific object or situation, leading to comfort and independence in moving
around in public environment.
- Eliminate interference in normal routines and remove distress from feared object or situation.
Behavioral Definitions
- Describes a persistent and unreasonable fear of a specific object or situation that promotes avoidance
behaviors because an encounter with the phobic stimulus provokes an immediate anxiety response.
- Avoids the phobic stimulus/feared environment or endures it with distress, resulting in interference of
normal routines.
- Acknowledges a persistence of fear despite recognition that the fear is unreasonable.
- Demonstrates no evidence of a panic disorder.
Objectives and Interventions
- Describe the history and nature of the phobia(s), complete with impact on functioning and attempt to
overcome it.
- Explore and identify the objects or situations that precipitate the client's phobic fear.
- Assess the client's fear and avoidance, including the focus of fear, types of avoidance (e.g.,
distraction, escape, dependence on others), development, and disability (e.g., The Anxiety Disorders
Interview Schedule for the DSM-IV by DiNardo, Brown, and Barlow).
- Complete psychological tests designed to assess features of the phobia.
- Administer a client-report measure (e.g., from Measures for Specific Phobia by Antony) to further
assess the depth and breadth of phobic responses.
- Cooperate with an evaluation by a physician for psychotropic medication.
- Arrange for an evaluation for a prescription of psychotropic medications if the client requests it
or if the client is likely to be noncompliant with gradual exposure.
- Monitor the client for prescription compliance, side effects, and overall effectiveness of the
medication; consult with the prescribing physician at regular intervals.
- Verbalize an accurate understanding of information about phobias and their treatment.
- Discuss how phobias are very common, a natural but irrational expression of our fight or flight
response, are not a sign of weakness, but cause unnecessary distress and disability.
- Discuss how phobic fear is maintained by a "phobic cycle" of unwarranted fear and avoidance that
precludes positive, corrective experiences with the feared object or situation, and how treatment
breaks the cycle by encouraging these experiences (see Mastery of Your Specific Phobia - Therapist
Guide by Craske, Antony and Barlow; Specific Phobias by Bruce and Sanderson).
- Assign the client to read psychoeducational chapters of books or treatment manuals on specific
phobias (e.g., Mastery of Your Specific Phobia - Client Manual by Antony, Craske, and Barlow; The
Anxiety and Phobia Workbook by Bourne; Living with Fear by Marks).
- Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its
treatment.
- Discuss how phobias involve perceiving unrealistic threats, bodily expressions of fear, and
avoidance of what is threatening that interact to maintain the problem (see Mastery of Your Specific
Phobia - Therapist Guide by Craske, Antony, and Barlow; Specific Phobias by Bruce and Sanderson).
- Discuss how exposure serves as an arena to desensitize learned fear, build confidence, and feel
safer by building a new history of success experiences (see Mastery of Your Specific Phobia -
Therapist Guide by Craske, Antony, and Barlow; Specific Phobias by Bruce and Sanderson).
- Learn and implement calming skills to reduce and manage anxiety symptoms that may emerge during encounters
with phobic objects or situations.
- Teach the client anxiety management skills (e.g., staying focused on behavioral goals, muscular
relaxation, evenly paced diaphragmatic breathing, positive self-talk) to address anxiety symptoms
that may emerge during encounters with phobic objects or situations.
- Assign the client a homework exercise in which he/she practices daily calming skills; review and
reinforce success, providing corrective feedback for failure.
- Use biofeedback techniques to facilitate the client's success at learning calming skills.
- Learn and implement applied tension skills.
- Teach the client applied tension in which he/she tenses neck and upper torso muscles to curtail
blood flow out of the brain to help prevent fainting during encounters with phobic objects or
situations involving blood, injection, or injury (see "Applied tension, exposure in vivo, and
tension-only in the treatment of blood phobia" in Behaviour Research and Therapy by Ost, Fellenius,
and Sterner).
- Assign the client a homework exercise in which he/she practices daily applied tension skills; review
and reinforce success, providing corrective feedback for failure.
- Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering
self-talk.
- Explore the client's schema and self-talk that mediate his/her fear response; challenge the biases;
assist him/her in replacing the distorted messages with reality-based, positive self-talk.
- Assign the client a homework exercise in which he/she identifies fearful self-talk and creates
reality-based alternatives (or assign "Journal and Replace Self-Defeating Thoughts" in Adult
Psychotherapy Homework Planner, 2nd ed. by Jongsma); review and reinforce success, providing
corrective feedback for failure.
- Use behavioral techniques (e.g., modeling, corrective feedback, imaginal rehearsal, social
reinforcement) to train the client in positive self-talk that prepares him/her to endure anxiety
symptoms without serious consequences.
- Undergo repeated exposure to feared or avoided phobic objects or situations.
- Direct and assist the client in construction of a hierarchy of anxiety-producing situations
associated with the phobic response.
- Select initial exposures that have a high likelihood of being a successful experience for the
client; develop a plan for managing the symptoms and rehearse the plan.
- Assign the client a homework exercise in which he/she does situational exposures and records
responses (see "Gradually Reducing Your Phobic Fear" in Adult Psychotherapy Homework Planner, 2nd
ed. by Jongsma; Mastery of Your Specific Phobia - Client Manual by Antony, Craske, and Barlow;
Living with Fear by Marks); review and reinforce success or provide corrective feedback toward
improvement.
- Implement relapse prevention strategies for managing possible future anxiety symptoms.
- Discuss with the client the distinction between a lapse and relapse, associating a lapse with a
temporary and reversible return of symptoms, fear, or urges to avoid and relapse with the decision
to return to fearful and avoidant patterns.
- Identify and rehearse with the client the management of future situations or circumstances in which
lapses could occur.
- Instruct the client to routinely use strategies learned in therapy (e.g., cognitive restructuring,
exposure), building them into his/her life as much as possible.
- Develop a "coping card" on which coping strategies and other important information (e.g., "You're
safe," "Pace your breathing," "Focus on the task at hand," "You can manage it," "Stay in the
situation," and "Let the anxiety pass") are written for the client's later use.
- Verbalize the costs and benefits of remaining fearful and avoidant.
- Probe for the presence of secondary gain that reinforces the client's phobic actions through escape
or avoidance mechanisms.
- Verbalize the separate realities of the irrationally feared object or situation and the emotionally painful
experience from the past that has been evoked by the phobic stimulus.
- Clarify and differentiate between the client's current irrational fear and past emotional pain.
- Encourage the client's sharing of feelings associated with past traumas through active listening,
positive regard, and questioning.
- Commit self to not allowing phobic fear to take control of life and lead to a consistent avoidance of normal
responsibilities and activities.
- Support the client in following through with work, family, and social activities rather than
escaping or avoiding them.
- Ask the client to list several ways his/her life will be more satisfying or fulfilling as he/she
manages his/her symptoms of panic and continues normal responsibilities.
- Return for a follow-up session to track progress, reinforce gains, and problem-solve barriers.
- Schedule a "booster session" for the client for 1 to 3 months after therapy ends.
Index