Postgrad Med J: first published as 10.1136/pgmj.53.615.28 on 1 January 1977. Downloaded from Postgradiuate Medical Journal (January f977) 53, 28-32. Simple techniques to treat medical phobias C. B. TAYLOR JAMES M. FERGUSON* M.D. M.D. BRUCE M. WERMUTHt M.D. University of Utah Medical School, Salt Lake City, Utah, * University of California, San Diego Medical School, La Jolla, California, and tStanford University School ofMedicine, Stanford, California Summary and Beech (1971), representative of the learning Participant modelling, a behaviourally-orientated theorists, view phobia as learned and have described treatment technique, is an effective method of treating various ways in which this could occur. The treat- phobias associated with minor medical procedures or ment of phobias has ranged, in accordance with the apparatus such as needles or intravenous catheters. theoretical persuasion of the therapist, from long- The steps in this technique are described and two term analysis to rapid behaviourally orientated cases of severe needle phobias successfully treated interventions. In several controlled studies, the with participant modelling are presented to illustrate behaviourally orientated therapies have been demon- further its application. strated to offer a quicker, cheaper and more effective treatment for phobias in patients with no other PHOBIAS associated with minor medical procedures psychiatric pathology than other therapies. Thus, in a by copyright. or apparatus such as needles and intravenous hospital setting, the behavioural techniques offer the catheters can be a nuisance and even life-threatening most reasonable approach to treat phobias. when they present an obstacle to a necessary surgery The behavioural therapies for phobias are gene- or diagnostic procedure. In an epidemiological study rally classified as either 'flooding' or 'desensitization'. of common fears and phobias, Agras, Sylvester and The difference between these approaches is primarily Oliveau (1969) found a prevalence of reported one of degree of exposure to the feared situation. In injection phobias of 140/1000 population at the age flooding, the individual is directly faced with the of 20 years. The prevalence sharply declined after situation that provokes the distress and continues to this age suggesting that these phobias are relatively face the situation or object until the fear is elimi- short-lived in the general population. From the nated, while in desensitization, the individual is http://pmj.bmj.com/ response to questions concerning treatment obtained gradually exposed to the feared situation or object, from the study, they found that an estimated 57/ taking one step at a time and usually not facing the 1000 individuals had seen a physician about a severe feared situation until he has mastered and feels fear or phobia of a medical procedure. The actual comfortable with the preliminary steps. Other related incidence of phobias of medical procedures requiring techniques that share the common element of psychiatric intervention is unknown but most con- exposing the patient to the feared situation include sultation services see several such cases every year. implosion, a variation of flooding in which the on September 28, 2021 by guest. Protected There is a paucity of literature on the aetiology of patient faces his feared situation in a series of ima- medical phobias in general. In his classic analysis of gined situations; therapist modelling, in which the Hans, a child suffering from multiple phobias, Freud therapist interacts with the feared object or situation (1919) described what has become the standard and gradually encourages the patient to do the same; psychoanalytical viewpoint on the origins of phobias. and shaping, usually using social reinforcement, in Freud stated that phobias arise from anxiety dis- which the therapist reinforces the patient's gradual placed from an internal drive and a realistically approach to the feared object or situation. All of threatening external stimulus on to an otherwise these techniques have been applied to medical neutral phobic object. On the other hand, Eysenck phobias or phobias that would appear to be analo- gous treatment problems to medical phobias. For Correspondence and reprint requests: Dr C. B. Taylor, Department of Psychiatry, University of Utah Medical instance, in less than five sessions, Katz (1974) used School, 50 North Medical Drive, Salt Lake City, Utah systematic desensitization to treat a haemodialysis 84132, U.S.A. phobia, Wijesinghe (1974) used flooding with Postgrad Med J: first published as 10.1136/pgmj.53.615.28 on 1 January 1977. Downloaded from Simple treatment of medical phobias 29 hypnosis to overcome a vomiting phobia, Turnage feared behaviour. These sub-steps or response (1975) used in vivo systematic desensitization to treat induction aids can be increased length of time of a hypodermic needle phobia, and others have used a exposure to the feared object, inclusion of protective combination of these methods rapidly to treat other devices, e.g. gloves, and exposure to a series of phobias (Nesbitt, 1974; Mahoney, 1971; Naud, related but much less fear-inducing objects, e.g. Boisvert and Lamontagne, 1973; Nimmer and Kapp, smaller needles. 1974). (4) Self-directedpractice. The patient is encouraged Several authors have argued that the crucial to practise his new skills or fearlessness alone and in variable in all of these procedures is length of varied settings to ensure that he can generalize his exposure to the feared object (Marks, 1973; Staub, learning to new situations and that he does not 1968; Leitenberg et al., 1974). Although the pro- attribute his sudden braveness to either the therapist cedure seems to be a useful method of persuading a or the therapeutic situation. phobic subject to encounter the feared situation, the Information alone during the instruction step is particular elements of the procedure, such as sufficient to allow some patients to perform their relaxation in systematic desensitization, may not be feared act. For others, seeing the therapist model or as important as the length of exposure to the feared act out the feared situation will reduce the fears situation (Daniels, 1974). Freud, (1919) stressed the sufficiently for their own participation. Still other importance ofhaving patients experience these feared patients need a battery of response induction aids or situations. 'One can hardly ever master a phobia if sub-steps in the desensitization process carried out he waits till the patient lets the analysis influence him with the help of the therapist to enable them to to give it up ... one succeeds only when he can engage in the feared behaviour. induce them through the influence of the analysis Bandura has used this technique to eliminate snake to . go about alone and struggle with the anxiety phobias rapidly and completely; furthermore, the while they make the attempt'. From this perspective, success in the laboratory situation seems to generalize we now have a battery of procedures that are helpful to other situations. Bandura (Bandura, Jeffery and in encouraging people to 'struggle with the anxiety'. Gajdos, 1975) feels that the overall goals of a treat- While some of these procedures (e.g. hypnosis) ment should not only be to extinguish a fear but to by copyright. require considerable skill and training, a recently have the patient develop a sense of self-competency, developed method called participant modelling offers transfer the extinction to other areas and treatment a simply learned, effective procedure quite suitable settings and acquire a generalizable skill for coping for treating medical phobias. In this procedure, with fear-provoking situations. Although his recent developed by Bandura, Jeffery and Wright (1974), studies have suggested that some subjects do use the the core ingredients are a series of steps that are participant modelling method as a general skill, in a designed to achieve what Bandura considers to be medical setting, the extinction and generalization of the most important vehicle of extinction (or elimi- this extinction to other treatment settings is usually a nation of fears), 'successful performance in presence The two cases illustrate the sufficient goal. following http://pmj.bmj.com/ of the feared object or situation'. use of participant modelling rapidly to extinguish In this procedure, the therapist arranges a learning severe needle phobias. situation for the patient in which he is confronted with aspects of his fears one small step at a time. Case history no. 1 The steps in participant modelling are: A 47-year-old white male with terminal cancer was (1) Instruction. The patient is given information referred to the Stanford consultation service when he about the feared object or situation in a way that reportedly developed bradycardia (pulse <45/min) demonstrates the fear to be unfounded. At the same and hypotension (systolic BP, 80 mmHg), diastolic on September 28, 2021 by guest. Protected time, the desensitization procedure is described and BP, uncertain) when blood was drawn. The referring the positive expectation is given the patient that the physicians kept an electrocardiogram (ECG), procedure will work without inducing undue anxiety. ammonium salts and atropine at the bedside in case He is told to ask the therapist to wait if he is asked to he became hypotensive during a procedure. His encounter a situation that he finds frightening. general practitioner had reported similar episodes (2) Response