Phobias, CBT and CBH: From Fear to Freedom
- neilgsaunders
- Apr 23
- 6 min read
Phobias from Ancient to Modern
What do spiders, flying, public speaking and heights all have in common? You’ve probably guessed it - these are common phobias. According to an NHS definition, a phobia is ‘an overwhelming debilitating fear of an object, place, situation, feeling or animal’. The word phobia derives from the Greek word ‘Phóbos’, from the Greek god of panic and fear. Benjamin Rush, one of the US founding fathers, is first believed to have used this word in its modern psychological context in 1786 and it is now well established in the modern lexicon.
The DSM-V (the state-of-the-art American manual of psychological disorders) defines phobias by five distinctive categories: animals; natural environment (e.g. height, blood/injections, thunder); situational (e.g. being on a plane, enclosed spaces, lifts) and ‘others’. Interestingly, it lists social anxiety as an entire separate category. At the current time, there are over five hundred recognised phobias and, given our rapidly changing world, it is hardly surprising that new phobias are constantly being defined. Nomophobia anyone? (Fear of being separated from one’s smartphone!) The potential for future phobias seems limitless.
According to the DSM-V, a diagnosis of a phobia requires it to generate excessive fear which is considered disproportionate, to have lasted for at least six months and to lead to behaviour that interferes with normal functioning. There is currently a very strong evidence base that CBT for phobias is the most effective treatment and I will argue that a combination of CBT and hypnotherapy can make the treatment even more successful.
CBT, Conditioning and Phobias
CBT (Cognitive Behavioural Therapy) is based partly upon a school of psychology known as behaviourism, the idea that we often act and think in particular ways because of the ‘conditioning’ we experience, particularly during our early years of life, when we learn to associate certain situations with certain feelings, thoughts and behaviours. For example, maybe at a formative event in our childhood, we encounter a particular stimulus, for example a dog, which prompted a strong emotional fear response, activating the fight or flight response in our autonomic nervous system. Maybe we were particularly small at the time and, never having encountered such a creature before, the dog appeared very large and threatening to us. Perhaps we had a number of similar experiences. Our growing minds become very much programmed by these formative experiences. This might lead any future contact with dogs to trigger this same response of fear and so we become conditioned.
This process often becomes stuck on a loop when we tend to avoid situations which make us afraid (as is perfectly natural). However, this means that we may end up avoiding situations that could be beneficial to us, because of our fear of dogs and this might start to get in the way of our living our life. For example, what if we met a new romantic partner who happened to have a dog? The irony, of course, is that this avoidance is actually the main thing that maintains our phobia, as we never allow our conditioning to change.
Why do some people develop phobias and others not? Scientific evidence shows that, like many other character traits, our individual tendencies to develop phobias may have both a genetic and environmental element, so some of us may inherit a greater predisposition towards developing phobias than others. Parents may end up unintentionally passing on their fears onto their children through learnt behaviour. Other environmental factors, such as early childhood adversity, leading to a heightened sense of threat, can also be a contributing factor. Some phobias may be more cognitive-based, when a thought or idea first creates the fear response, for example when young children first learn about germs and infection.
Blame the Ancestors
Some phobias tap into the deep-seated evolutionary biases of our species, leading to avoidance of things that symbolized danger for the many generations of humans that came before us, so here a fear of blood or heights makes perfect sense, as does, the avoidance of animals that were often venomous, such as snakes or spiders – all of which kept us safe for thousands, or even millions of years. Social phobias such as public speaking can be linked to our heritage as a highly social species, as standing out from the crowd could invite ridicule and social rejection. Such social phobias, linked to being judged by others, could also be linked to our experiences of highly critical parents or experiences of bullying. Many phobias may have a strong social humiliation element attached. Aerophobia (fear of flying), can have a social fear component if it is linked to the fear of a loss of control in public, and therefore a sense of public shame.
Wolpe and Behavioural Therapy
The treatment of CBT for phobias has a strong evidence-based history that dates back to the 1960s, with the use of a technique called systematic de-sensitization. This technique was developed by psychologist Joseph Wolpe. The idea is that a client overcomes their avoidance of the source of their phobia by initially learning how to dial down their fight or flight response using relaxation techniques.
Next, the client learns to combine this relaxation with a very gradual repeated exposure to the feared stimulus, until a new conditioned response is created. This exposure process is discussed collaboratively with the client beforehand, empowering them and allowing for some creativity in the procedure. This is done using a hierarchy. For example, with the example of a dog phobia, the client may begin by looking at an image of a dog whilst using relaxation skills and then repeating this until they encounter no fear. They may then repeat this process with a video of a dog, then allow themselves to be in the general proximity of a dog, eventually working up to being in close proximity to a dog, or even stroking one. These gradations of exposure can be created as slowly and as gradually as the client wishes. Eventually, through this exposure therapy, the fear is removed and replaced by a feeling of relaxation, indifference and even enjoyment.
Although Wolpe is credited with this particular use of this CBT for phobias, there is evidence that folk wisdom understood how exposure therapy worked long ago. The philosopher, John Locke, in 1690 wrote the following about overcoming a fear of frogs (know clinically referred to as batrachophobia):
‘If your child shrieks and runs away at the sight of a frog, let another catch it and lay it down at a good distance from him; at first accustom him to look at it; when he can do that, to come nearer to it and see it leap without emotion; then to touch it lightly, when it is held fast in another’s hand; and so on, until he can come to handle it as confidently as a butterfly or sparrow.’
(John Locke, ‘Essay Concerning Human Understanding’)
...Plus Hypnosis
There is evidence that Cognitive Behavioural Hypnotherapy (CBH) for phobias can be even more effective than just CBT alone. This is because the integration of hypnosis exploits our human tendency towards suggestibility, giving us greater leverage in terms of changing unwanted patterns of behaviour. Hypnosis is sometime described as imagination therapy, as it is almost like using a form of virtual reality to allow clients to imagine experiencing threatening situations, whilst combining these with the relaxation techniques taught by the therapist. In this way, a degree of the systematic desensitization process of the exposure hierarchy, as mentioned above, can be done in the therapy room.
Another element of CBT for phobias is the cognitive element, the challenging and changing of irrational thoughts, and here hypnosis and the use of suggestion can help reinforce change.
So, in summary, CBT for phobias is the most recommended evidence-based treatment and the addition of hypnosis can only enhance this process.
I hope that you found this informative. If you believe you could benefit from CBH for phobias, please contact neil@focusedattention or just click on the button below.
References
Hirsch, J.A. (2018) ‘Integrating Hypnosis with Other Therapies for Treating Specific Phobias: A Case Series’, American Journal of Clinical Hypnosis, 60(4), pp. 367–377
Kirsch, I.; Montgomery, Guy; Sapirstein, Guy (1995). 'Hypnosis as an adjunct to cognitive behavioural psychotherapy: A meta-analysis.' Journal of Consulting and Clinical Psychology, 63 (2), 214-220.
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