The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 99 - -99
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 - Rating: 99 - -99
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 - Rating: 5
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
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.
Children and Young People - Rating: 5
Research Design & Number of Studies – CYP
High level evidence supports the use of CBT with exposure in CYP with specific phobia. Where possible, evidence for different forms of delivery and long-term outcomes is highlighted.
A meta-analysis by Stoll et al. (2020) (1) evaluated the outcomes of non-pharmacological interventions in childhood anxiety and included 10 RCTs (n=621) that involved brief CBT for specific phobia in CYP.
A second study is an RCT conducted to determine the effectiveness of One Session Treatment (OST) in the management of specific phobias in youth (2). The study included 196 participants, aged 7-16 years, who fulfilled the diagnostic criteria for various specific phobias for a minimum of 6-months. OST was delivered in one 3-hr session. The study was conducted in USA and Sweden.
Another RCT (3) investigated the impact of comorbid anxiety disorders on OST outcomes (n=54).
A systematic review and preliminary meta-analysis of nine studies (4 pre-post studies, 5 randomized controlled trials) investigated internet and mobile interventions (4). Study sizes ranged from 13-351 participants and trials were conducted in Netherlands, Spain, Australia, USA and Sweden.
Outcomes Achieved – Children and Young People
Compared to educational support or wait-list control, the following outcomes were observed;
- Well-established efficacy for in-vivo anxiety for specific phobia and probable efficacy for CBT (1).
- Significantly reduced specific phobia severity at post-treatment, maintained at 6-months follow-up (2) and some maintenance at longer term follow up of up to 4yrs (1).
- Significant improvements in measures of specific phobia at post-treatment, regardless of co-occurring anxiety disorder (3).
- Significant improvements post-treatment in CYP receiving internet and mobile supported interventions (4).
Adults - Rating: 5
Research Design & Number of Studies - Adult
Some of the best available evidence demonstrating the effectiveness of CBT and exposure in the treatment of specific phobia in adults includes meta-analyses and RCTs. The studies below include those that have evaluated CBT (i.e., described as CBT by the authors or that have included both cognitive and behavioural strategies) as well as those using primarily behavioural (exposure) strategies. Five key studies are summarised here.
The most recent study reviewed was a meta-analysis that evaluated the long-term outcomes of CBT on anxiety-related disorders (5). The study included 69 randomised clinical trials with 4118 adult outpatients diagnosed with generalized anxiety disorder (GAD), obsessive compulsive disorder (OCD), panic disorder (PD), posttraumatic stress disorder (PTSD), social anxiety disorder (SAD), and specific phobia. Three studies were specific to specific phobia, and meta-analyses for these studies were reported separately. CBT was delivered in individual, group, or internet formats.
A review of the evidence of CBT for Anxiety Disorders (6) summarised the outcomes from RCTs of CBT with and without exposure for specific phobia.
A meta-analysis (7) investigated evidence for psychological interventions for specific phobia (33 studies, n= 1193) and reported outcomes for exposure and CBT.
An early RCT compared one-session treatment, 5 sessions of exposure or 5 sessions of CBT in 46 people with claustrophobia (8).
A review of virtual reality compared to in vivo exposure for phobic anxiety contained 9 studies (n=371), with 4 specific phobia trials, 2 agoraphobia trials and 3 social phobia trials (9). Results for specific phobia were reported separately.
Outcomes Achieved - Adults
Compared to control conditions (including treatment as usual, pill placebo, supportive therapy, or waiting list), the following outcomes were observed:
- Significantly reduced symptoms of specific phobia at post-assessment (5,6) maintained at 6-7months follow-up (5).
- In vivo exposure-based treatment produced large effects sizes relative to no treatment and outperformed placebo conditions and alternative active psychotherapeutic approaches (7).
- Large, significant effect sizes post treatment for both vivo and virtual reality exposure with a small, non-significant effect size favouring in vivo exposure (9).
- Clinical improvements following one session treatment, exposure treatment or CBT maintained at one year follow-up (8).
- Multi-session treatments marginally outperformed single-session treatments on measures of phobic dysfunction (7).
- Significant improvements post-treatment in adults receiving internet and mobile supported interventions (4).
Need
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?
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
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?
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
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?
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
