Cognitive Behavioural Therapy (CBT) for Specific Phobia

Usability

Core Components

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT, and are used in the treatment of a variety of mental health disorders in children, young people and adults. This therapy recognises the interrelationship between thoughts, beliefs, and behaviours, and how alterations in one domain can impact other domains. CBT therefore identifies, challenges, and modifies unhelpful cognitive structures, facilitating emotional and behavioural changes.

CBT helps people identify and challenge thoughts, beliefs and behaviours that are associated with distress and anxiety as it relates their phobia. In the context of specific phobia, the emphasis may be on behavioural approaches called exposure which target excessive fear or anxiety associated with the phobic situations or things. Exposure can be combined with cognitive restructuring strategies to help to correct unhelpful appraisals of the phobic stimuli, which in turn reduces or removes anxiety responses. Hence, the core components of CBT for specific phobia include:

• Cognitive restructuring: Challenges the range of cognitive processes that result in unhelpful thinking patterns and beliefs that contribute to the maintenance of phobias. The cognitive therapy techniques help to change the perception and thinking processes around the phobia and supports people to generate alternative cognitions that are more balanced and helpful.
• Systematic Exposure: Provides the opportunity for people to test their cognitions and assumptions related to the phobic stimuli. It involves controlled exposure to anxiety-provoking situations in order to help confront fears, address unhelpful associations, and reduce avoidance behaviours. Exposure therapy is continued in a graded manner until habituation (a term meaning becoming less sensitive to the phobic stimulus) occurs. Variations of exposure therapy can include in-vivo exposure imaginal exposure and virtual reality exposure. It can be delivered over a number of weeks or conducted in a single session format, normally lasting a few hours.

CBT for specific phobia also includes homework components which provide opportunities for people to practice building their skills independently in their own environments and increase transfer of learning.

Fidelity

Practitioners delivering CBT for specific phobia should receive training and ongoing clinical supervision. Practitioner competence and fidelity to treatment can be monitored and evaluated using appropriate measures, e.g., via recording of treatment sessions and use of fidelity checklists to determine practitioner adherence against a CBT competency assessment tool, such as the Cognitive Therapy Scale-Revised (Blackburn et al. 2001), or another similar scale.   

Modifiable Components

CBT for specific phobia is typically delivered weekly, over 8-12 sessions, with each lasting about 1 hour. An intensive one session treatment (OST) delivered over 3-hours is also available for the treatment of specific phobias. CBT for specific phobia can be delivered in settings that include outpatient clinic, hospital, or residential treatment settings. CBT for specific phobia can be supplemented by computerised packages or virtual reality but computerised packages without support should not be routinely offered for the treatment of specific phobias in adults. Delivery of CBT to children and young people can include parent components.

Supports

Support for Organisation / Practice

Implementation Support

Implementation support is provided mainly by trained supervisors who support the application of CBT within each therapist’s practice. Support for implementing CBT is available through the NES Psychology Adult mental Health and CAMHS workstreams, including webinars, and supervisor training.

Start-up Costs

There are no start-up costs associated with training provided within university training programmes (if training through an NHS place) or by NES. Costs apply when training is provided by private organisations. 

Building Staff Competency

Qualifications Required

Staff will usually hold an undergraduate degree in a relevant area (e.g., nursing, psychology, medicine) and will have completed postgraduate training in CBT (PG Diploma, MSc or Doctoral level).

Training Requirements

Cognitive Behavioural Therapy (CBT) training is included in the adult and child focused MSc CBT/PTPC programmes and the Doctorate in Clinical psychology training programmes in Scotland. Additional training in CBT is available through the NES Psychology and CAMHS workstreams.

Supervision Requirements

Regular (minimum 1 hour a month) supervision by a supervisor who is a CBT therapist and has completed the following pathway of supervision training:

• NES Generic supervision competences training (GSC) (or equivalent)
• NES Specialist Supervision Training: CBT (adult or child focus)

It is recommended practice in Scotland that this psychological intervention is conducted under regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). There is additional training available that specifically supports CBT supervision skills.

Evidence

Theory of Change

Mowrer's classic two-stage model of fear and anxiety can be used to explain the theory of change for psychological interventions that include exposure strategies. The model proposes that fear is established when there is pairing between a single discrete stimulus (i.e. the conditional stimulus) and an aversive stimulus (i.e. unconditional stimulus). Mowrer proposes that phobic stimuli produces fear which results in the adoption of escape behaviours. The model also proposes that imaginary or symbolic representation of the phobic stimuli elicits avoidance behaviours. The avoidance and escape behaviours in turn prevent safety learning, and negatively reinforce the relationship between the feared stimuli and person’s response. Exposure-based CBT therefore applies cognitive restructuring and exposure strategies to correct unhelpful misappraisals of the phobic stimuli, which in turn reduce or remove anxiety responses, and helps people confront fears without anxiety.

Values

Cognitive Behavioural Therapy (CBT) is an encompassing term that includes a range of psychological therapies that apply the standard principles of CBT. In the context of specific phobia, CBT helps people identify and challenge thoughts, beliefs and behaviours that are associated with distress and anxiety as it relates their phobia.

• Does this specific phobia focus align with the requirements of your organisation?

Priorities

CBT applies cognitive restructuring and exposure strategies to correct maladaptive misappraisals of the phobic stimuli. This in turn reduces or removes anxiety responses and helps people confront their fears without anxiety. CBT can be delivered to children, young people and adults, in individual, group or family formats. Computerised CBT for specific phobia is available. CBT can be delivered in multiple sessions, however, an intensive one session treatment (OST) approach is available.  

• Is your service looking to deliver an intervention that is focused on addressing unhelpful appraisals of phobic stimuli and anxiety responses on exposure to the stimuli?
• What population will your service like to deliver this intervention to?
• In what format will CBT be delivered (in-person vs online; individual, group or family; multiple sessions vs OST)?

Existing Initiatives

• Does your service currently deliver interventions to treat specific phobia, or do the interventions address a range of anxiety disorders?
• Do existing initiative show evidence of effectiveness for mental health conditions that could co-exist with specific phobia?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

Cognitive Behavioural Therapy can be delivered by healthcare professionals (e.g., psychologists, mental health nurses) who have undergone training to support its delivery. CBT for specific phobia can be delivered weekly in 8-12 sessions, or as an intensive one session treatment (OST). CBT can be delivered face to face or using computerised programmes.

• Does your service have qualified practitioners who are available and interested in learning and delivering CBT?
• Can your service support the time commitment required for practitioner training, supervision, and intervention delivery?
• Will your practitioners deliver CBT face-to-face or using computerised programmes?
• If delivered face-to-face, is there capacity to support its delivery?

Technology Support

CBT can be delivered without access to technology, however access to methods of recording sessions for supervision will be useful. Computerised CBT programmes for specific phobia are also available.

• Will CBT for specific phobia be delivered as a computerised intervention?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

CBT can be delivered face to face (individual, group, or family) or using computerised programmes. In-person delivery can be held in settings that include outpatient settings, hospitals, and residential treatment settings. CBT for specific phobia in children and adolescents can include parent sessions. Administrative support is needed to manage appointments, collate and input outcome measures and process written reports.

• In what format will CBT be delivered?

• In what setting and venue will CBT be delivered?

• Can administrative supports be provided to deliver CBT?

Financial Support

Scottish Government/NES Psychology routinely funds training programmes in CBT and supervisor training. Training is available from other organisations at a cost.

• Can your service financially support practitioner training costs if accessed outside NES?

Comparable Population

CBT has been shown to be effective when delivered to children, young people, and adults with specific phobia. Comparable populations include, but not limited to, people with acrophobia, dental anxiety, fear of cancer reoccurrence, and intra-oral injection phobia.

• Is this comparable to the population your service would like to serve?

Desired Outcome

CBT for specific phobia is associated with significant improvement in specific phobia symptoms at post-treatment. Significant improvements in measures of specific phobia have also been reported over the long-term (i.e. 0.5 to 4 years).

• Is delivering CBT for specific phobia a priority for your organisation? 
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?