5.2 Phobias

Most of us are none too eager to confront a spider or to be caught in a thunderstorm, but few of us have such dread as Marianne or Trisha:

Marianne: Seeing a spider makes me rigid with fear, hot, trembling and dizzy. I have occasionally vomited and once fainted in order to escape from the situation. These symptoms last three or four days after seeing a spider. Realistic pictures can cause the same effect, especially if I inadvertently place my hand on one.

(Melville, 1978, p. 44)

Trisha: At the end of March each year, I start getting agitated because summer is coming and that means thunderstorms. I have been afraid since my early twenties, but the last three years have been the worst. I have such a heartbeat that for hours after a storm my whole left side is painful…. I say I will stay in the room, but when it comes I am a jelly, reduced to nothing. I have a little cupboard and I go there, I press my eyes so hard I can’t see for about an hour, and if I sit in the cupboard over an hour my husband has to straighten me up.

(Melville, 1978, p. 104)

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A phobia (from the Greek word for “fear”) is a persistent and unreasonable fear of a particular object, activity, or situation. People with a phobia become fearful if they even think about the object or situation they dread, but they usually remain comfortable as long as they avoid it or thoughts about it.

phobia A persistent and unreasonable fear of a particular object, activity, or situation.

We all have our areas of special fear, and it is normal for some things to upset us more than other things (see MediaSpeak below). How do such common fears differ from phobias? DSM-5 indicates that a phobia is more intense and persistent and the desire to avoid the object or situation is stronger (APA, 2013). People with phobias often feel so much distress that their fears may interfere dramatically with their lives.

Most phobias technically fall under the category of specific phobias, DSM-5’s label for an intense and persistent fear of a specific object or situation. In addition, there is a broader kind of phobia called agoraphobia, a fear of venturing into public places or situations where escape might be difficult if one were to become panicky or incapacitated.

Specific Phobias

A specific phobia is a persistent fear of a specific object or situation (see Table 5-5). When sufferers are exposed to the object or situation, they typically experience immediate fear. Common specific phobias are intense fears of specific animals or insects, heights, enclosed spaces, thunderstorms, and blood. Here Andrew talks about his phobic fear of flying:

We got on board, and then there was the take-off. There it was again, that horrible feeling as we gathered speed. It was creeping over me again, that old feeling of panic. I kept seeing everyone as puppets, all strapped to their seats with no control over their destinies, me included. Every time the plane did a variation of speed or route, my heart would leap and I would hurriedly ask what was happening. When the plane started to lose height, I was terrified that we were about to crash.

(Melville, 1978, p. 59)

specific phobia A severe and persistent fear of a specific object or situation.

Table 5.5: table: 5-5Dx Checklist

Specific Phobia

1.

Marked, persistent, and disproportionate fear of a particular object or situation, usually lasting at least 6 months.

2.

Exposure to the object produces immediate fear.

3.

Avoidance of the feared situation.

4.

Significant distress or impairment.

Information from: APA, 2013.

Each year around 12 percent of all people in the United States have the symptoms of a specific phobia (Kessler et al., 2012). Almost 14 percent of individuals develop such phobias at some point during their lives, and many people have more than one at a time. Women with the disorder outnumber men by at least 2 to 1. For reasons that are not clear, the prevalence of specific phobias also differs among racial and ethnic minority groups. In some studies, African Americans and Hispanic Americans report having at least 50 percent more specific phobias than do white Americans, even when economic factors, education, and age are held steady across the groups (Stein & Williams, 2010; Hopko et al., 2008; Breslau et al., 2006). It is worth noting, however, that these heightened rates are at work only among African and Hispanic Americans who were born in the United States, not those who emigrated to the United States at some point during their lives (Hopko et al., 2008).

The impact of a specific phobia on a person’s life depends on what arouses the fear (Costa et al., 2014; Gamble, Harvey, & Rapee, 2010). People whose phobias center on dogs, insects, or water will keep encountering the objects they dread. Their efforts to avoid them must be elaborate and may greatly restrict their activities. Urban residents with snake phobias have a much easier time. The vast majority of people with a specific phobia do not seek treatment (NIMH, 2011). They try instead to avoid the objects they fear.

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MediaSpeak

The Fear Business

By Beth Accomando, NPR, October 6, 2013

Every job requires a special skill set.

In this business, screaming is one of those skills. Also, being certified on a chainsaw.

“We’re always looking for folks who have a passion for wielding a chainsaw while wearing makeup and costume and just scaring the heck out of people,” says Jennifer Struever.

Streuver is the event manager for Scream Zone at the Del Mar Fairgrounds in San Diego County, Calif. Haunted houses are part of the multibillion-dollar business of Halloween—and they need employees.

Streuver is conducting interviews inside the Scream Zone’s tented maze, in a room that could be Leather-face’s kitchen. It has a slab of meat hanging from the ceiling and impressive cutlery on the wall.

Yikes! Phobophobia, a Halloween show at the London Bridge Experience in London, brings the worst and most typical phobic objects to patrons and has them handle the creatures. Here, a patron confronts a clown, a big spider, and a snake simultaneously.

“We do ask people if they have any problem with chainsaw fumes, moving floors, strobe lights, loud noises,” Streuver says. “We need to know if they’re allergic to stage blood or latex, because they will be experiencing that in their costumes and makeup.”

Over at the haunted castle end of the Scream Zone tent, a huge green demon salivates over potential victims—ahem, applicants—as they wait to be called for their interview. It’s so hot that the multiple fans do little to help, and the heat feels like it could melt the flesh off the living dead.

Geraldo Figueroa could get into that. “I’d like to be a zombie,” he says. “It seems like it’d be really fun, especially with the new attraction”—zombie paintball safari.

That interests Autumn Maize, who’s eager to display her undead expertise. “Well, since zombies can’t really breathe or anything, there’s not really much sound that they make except for maybe some guttural gasps,” she says before giving an example of what that sounds like. “But you can make some great sounds with your mouth like chewing sounds that don’t require breathing—so I get a little technical.”

Maize is exactly the type of person Struever is looking for. “We’re looking for folks who have a passion for Halloween and any theatrical or athletic experience,” Struever says.

Or, lung power—as Samantha Topacio demonstrates. “I mean, I haven’t screamed in awhile because no one really recreationally screams just for fun,” she says.

Topacio performed better at her audition. “I did one that was a victim-type thing,” she says, “and then the other one was more like a creepy antagonist-type character.”

The screams landed her the job and got her a high-five from Ashley Amaral, who’s been working at the Scream Zone for years. The petite, perky blond takes wicked delight in her job.

Might people who enjoy producing fear in others be grappling with their own anxiety issues? Which model(s) might support this view of such individuals?

“It is so awesome to see big burly men crumble to the ground,” she says. “You think they’re so tough. They come in like, ‘Oh, you’re just a girl, please.’ And they just crumble. They will run out of this and say, ‘Oh, blank, no, I’m out of here.’”

Each time someone flees for an emergency exit, it’s a bloody feather in her co-workers’ cap. There’s a scoreboard where they keep a tally of victims who don’t make it through the House of Horror. Last year it was 523. It gives a whole new meaning to customer satisfaction.

The Fear Business. Source: In This Business, Scaredy Cats Need Not Apply by Beth Accomando, NPR October 6 2013 (from KPBS).

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Agoraphobia

People with agoraphobia are afraid of being in public places or situations where escape might be difficult or help unavailable, should they experience panic or become incapacitated (APA, 2013) (see Table 5-6). This is a pervasive and complex phobia. In any given year, 1.7 percent of the population experience agoraphobia, women twice as frequently as men (Kessler et al., 2012). The disorder also is twice as common among poor people as wealthy people (Sareen et al., 2011). At least one-fifth of those with agoraphobia are currently in treatment (NIMH, 2011).

agoraphobia An anxiety disorder in which a person is afraid to be in public situations from which escape might be difficult or help unavailable if panic-like or embarrassing symptoms were to occur.

Table 5.6: table: 5-6Dx Checklist

Agoraphobia

1.

Pronounced, disproportionate, and repeated fear about being in at least 2 of the following situations: • Public transportation (e.g., auto or plane travel) • Parking lots, bridges, or other open spaces • Shops, theaters, or other confined places • Lines or crowds • Away from home unaccompanied.

2.

Fear of such agoraphobic situations derives from a concern that it would be hard to escape or get help if panic, embarrassment, or disabling symptoms were to occur.

3.

Avoidance of the agoraphobic situations.

4.

Symptoms usually continue for at least 6 months.

5.

Significant distress or impairment.

Information from: APA, 2013.

People typically develop agoraphobia in their 20s or 30s, as Veronica did:

For several months prior to her application for treatment Veronica had been unable to leave her home…. “It is as if something dreadful would happen to me if I did not immediately go home.” Even after she would return to the house, she would feel shaken inside and unable to speak to anyone or do anything for an hour or so. However, as long as she remained in her own home or garden, she was able to carry on her routine life without much problem…. Because of this agoraphobia, she had been unable to return to her position as a mathematics teacher in the local high school after the summer vacation.

… [Veronica] stated that she had always been a somewhat shy person who generally preferred keeping to herself, but that up until approximately a year ago she had always been able to go to her job, shop, or go to church without any particular feelings of dread or uneasiness. It was difficult for her to recall the first time … but it seemed to her that the first major experience was approximately a year before, when she and her mother had been Christmas shopping. They were standing in the middle of a crowded department store when she suddenly felt the impulse to flee. She left her mother without an explanation and drove home as fast as she could…. After the Christmas vacation she seemed to recover for a while and was at least able to return to her classroom duties without any ill effect. During the ensuing several months she had several similar experiences, usually when she was off duty; but by late spring these fears were just as likely to occur in the classroom…. In thinking further about the occurrence of her phobia, it seemed to Veronica that there was actually no particular stress which might account for her fear.

(Goldstein & Palmer, 1975, pp. 163–164)

It is typical of people with agoraphobia to avoid entering crowded streets or stores, driving in parking lots or on bridges, and traveling on public transportation or in airplanes. If they venture out of the house at all, it is usually only in the company of close relatives or friends. Some insist that family members or friends stay with them at home, but even at home and in the company of others they may continue to feel anxious.

In many cases the intensity of the agoraphobia fluctuates, as it did for Veronica. In severe cases, people become virtual prisoners in their own homes. Their social life dwindles and they cannot hold a job. People with agoraphobia may also become depressed, sometimes as a result of the severe limitations that their disorder places on their lives.

Many people with agoraphobia do, in fact, have extreme and sudden explosions of fear, called panic attacks, when they enter public places, a problem that may have first set the stage for their development of agoraphobia. Such individuals may receive two diagnoses—agoraphobia and panic disorder, an anxiety disorder that you will read about later in this chapter—because their difficulties extend considerably beyond an excessive fear of venturing away from home into public places (APA, 2013).

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What Causes Phobias?

Each of the models offers explanations for phobias. Evidence tends to support the behavioral explanations. Behaviorists believe that people with phobias first learn to fear certain objects, situations, or events through conditioning (Cherry, 2014; Field & Purkis, 2012; Gamble et al., 2010). Once the fears are acquired, the individuals avoid the dreaded object or situation, permitting the fears to become all the more entrenched.

Behavioral Explanations: How Are Fears Learned?Behaviorists propose classical conditioning as a common way of acquiring phobic reactions. Here, two events that occur close together in time become strongly associated in a person’s mind, and as you saw in Chapter 3, the person then reacts similarly to both of them. If one event triggers a fear response, the other may also.

classical conditioning A process of learning in which two events that repeatedly occur close together in time become tied together in a person’s mind and so produce the same response.

In the 1920s, a clinician described the case of a young woman who apparently acquired a specific phobia of running water through classical conditioning (Bagby, 1922). When she was 7 years old she went on a picnic with her mother and aunt and ran off by herself into the woods after lunch. While she was climbing over some large rocks, her feet were caught between two of them. The harder she tried to free herself, the more trapped she became. No one heard her screams, and she grew more and more terrified. In the language of behaviorists, the entrapment was eliciting a fear response.

EntrapmentFear response

As she struggled to free her feet, the girl heard a waterfall nearby. The sound of the running water became linked in her mind to her terrifying battle with the rocks, and she developed a fear of running water as well.

Running waterFear response

Eventually the aunt found the screaming child, freed her from the rocks, and comforted her, but the psychological damage had been done. From that day forward, the girl was terrified of running water. For years family members had to hold her down to bathe her. When she traveled on a train, friends had to cover the windows so that she would not have to look at any streams. The young woman had apparently acquired a specific phobia through classical conditioning.

New best friends? Is a mouse’s fear of cats a conditioned reaction or genetically hardwired? Scientists at Tokyo University used genetic engineering to switch off this rodent’s instinct to cower at the smell or presence of cats. But mouse beware! The cat has not been genetically engineered correspondingly.

In conditioning terms, the entrapment was an unconditioned stimulus (US) that understandably elicited an unconditioned response (UR) of fear. The running water represented a conditioned stimulus (CS), a formerly neutral stimulus that became associated with entrapment in the child’s mind and came also to elicit a fear reaction. The newly acquired fear was a conditioned response (CR).

US: EntrapmentUR: Fear

CS: Running waterCR: Fear

Another way of acquiring a fear reaction is through modeling, that is, through observation and imitation (Bandura & Rosenthal, 1966). A person may observe that others are afraid of certain objects or events and develop fears of the same things. Consider a young boy whose mother is afraid of illnesses, doctors, and hospitals. If she frequently expresses those fears, before long the boy himself may fear illnesses, doctors, and hospitals.

modeling A process of learning in which a person observes and then imitates others. Also, a therapy approach based on the same principle.

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Why should one or a few upsetting experiences or observations develop into a long-term phobia? Shouldn’t the trapped girl see later that running water will bring her no harm? Shouldn’t the boy see later that illnesses are temporary and doctors and hospitals helpful? Behaviorists believe that after acquiring a fear response, people try to avoid what they fear. They do not get close to the dreaded objects often enough to learn that the objects are really quite harmless.

Behaviorists also propose that learned fears of this kind will blossom into a generalized anxiety disorder if a person acquires a large number of them. This development is presumed to come about through stimulus generalization: responses to one stimulus are also elicited by similar stimuli. The fear of running water acquired by the girl in the rocks could have generalized to such similar stimuli as milk being poured into a glass or even the sound of bubbly music. Perhaps a person experiences a series of upsetting events, each event produces one or more feared stimuli, and the person’s reactions to each of these stimuli generalize to yet other stimuli. That person may then build up a large number of fears and eventually develop generalized anxiety disorder.

stimulus generalization A phenomenon in which responses to one stimulus are also produced by similar stimuli.

How Have Behavioral Explanations Fared in Research?Some laboratory studies have found that animals and humans can indeed be taught to fear objects through classical conditioning (Miller, 1948; Mowrer, 1947, 1939). In one famous report, psychologists John B. Watson and Rosalie Rayner (1920) described how they taught a baby boy called Little Albert to fear white rats. For weeks Albert was allowed to play with a white rat and appeared to enjoy doing so. One time when Albert reached for the rat, however, the experimenter struck a steel bar with a hammer, making a very loud noise that frightened Albert. The next several times that Albert reached for the rat, the experimenter again made the loud noise. Albert acquired a fear and avoidance response to the rat.

What concerns might today’s human-participant research review boards raise about the study on Little Albert?

Research has also supported the behavioral position that fears can be acquired through modeling. Psychologists Albert Bandura and Theodore Rosenthal (1966), for example, had human research participants observe a person apparently being shocked by electricity whenever a buzzer sounded. The victim was actually the experimenter’s accomplice—in research terminology, a confederate—who pretended to feel pain by twitching and yelling whenever the buzzer went on. After the unsuspecting participants had observed several such episodes, they themselves had a fear reaction whenever they heard the buzzer.

And don’t let the bedbugs bite In this public demonstration of their behavior and abilities, adult bedbugs crawl on a piece of paper in a tiny jar. The recent bedbug outbreak in New York reminds us that not all fears of insects are ill-founded. Indeed, a number of bedbugs in the city climbed out of bed and boldly marched to places like the Empire State Building, Bloomingdale’s, and Lincoln Center.

Although these studies support behaviorists’ explanations of phobias, other research has called those explanations into question (Gamble et al., 2010). Several laboratory studies with children and adults have failed to condition fear reactions. In addition, although most case studies trace phobias to incidents of classical conditioning or modeling, quite a few fail to do so. So, although it appears that a phobia can be acquired by classical conditioning or modeling, researchers have not established that the disorder is ordinarily acquired in this way.

A Behavioral-Evolutionary ExplanationSome phobias are much more common than others. Phobic reactions to animals, heights, and darkness are more common than phobic reactions to meat, grass, and houses (see MediaSpeak). Theorists often account for these differences by proposing that human beings, as a species, have a predisposition to develop certain fears (Cherry, 2014; Lundqvist & Ohman, 2005; Seligman, 1971). This idea is referred to as preparedness because human beings, theoretically, are “prepared” to acquire some phobias and not others. The following case makes the point:

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preparedness A predisposition to develop certain fears.

BETWEEN THE LINES

Young Dreams

Studies indicate that infants who are generally anxious or “difficult” are more likely than other infants to later experience nightmares throughout their childhood (Simard et al., 2008).

A four-year-old girl was playing in the park. Thinking that she saw a snake, she ran to her parents’ car and jumped inside, slamming the door behind her. Unfortunately, the girl’s hand was caught by the closing car door, the results of which were severe pain and several visits to the doctor. Before this, she may have been afraid of snakes, but not phobic. After this experience, a phobia developed, not of cars or car doors, but of snakes. The snake phobia persisted into adulthood, at which time she sought treatment from me.

(Marks, 1977, p. 192)

Where might such predispositions to fear come from? According to some theorists, the predispositions have been transmitted genetically through an evolutionary process. Among our ancestors, the ones who more readily acquired fears of animals, darkness, heights, and the like were more likely to survive long enough to reproduce and to pass on their fear inclinations to their offspring (Cherry, 2014; Hofer, 2010; Ohman & Mineka, 2003).

How Are Phobias Treated?

Every theoretical model has its own approach to treating phobias, but behavioral techniques are more widely used than the rest, particularly for specific phobias. In addition, research has shown such techniques to fare better than other approaches in most head-to-head comparisons. Thus we shall focus here primarily on the behavioral interventions.

Flight without fear No, these people are not sleeping, or worse. They are going through relaxation and meditation exercises prior to going on an airplane flight from Kansas City to Denver. They are students in an eight-week course called “Flight Without Fear” that applies the principles of behavioral desensitization to help people overcome their phobic fear of flying.

Treatments for Specific PhobiasSpecific phobias were among the first anxiety disorders to be treated successfully. The major behavioral approaches to treating them are systematic desensitization, flooding, and modeling. Together, these approaches are called exposure treatments because in all of them people are exposed to the objects or situations they dread (Gordon et al., 2013; Abramowitz, Deacon, & Whiteside, 2011).

exposure treatments Behavioral treatments in which persons are exposed to the objects or situations they dread.

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Recovering lost revenues These riders scream out as they experience a sudden steep drop from the top of an amusement park ride. Several parks offer behavioral programs to help prospective customers overcome their fears of roller coasters and other horror rides. After “treatment,” some clients are able to ride the rails with the best of them. For others, it’s back to the relative calm of the Ferris wheel.

People treated by systematic desensitization, a technique developed by Joseph Wolpe (1987, 1969), learn to relax while gradually facing the objects or situations they fear. Since relaxation and fear are incompatible, the new relaxation response is thought to substitute for the fear response. Desensitization therapists first offer relaxation training to clients, teaching them how to bring on a state of deep muscle relaxation at will. In addition, the therapists help clients create a fear hierarchy, a list of feared objects or situations, ordered from mildly to extremely upsetting.

systematic desensitization A behavioral treatment that uses relaxation training and a fear hierarchy to help clients with phobias react calmly to the objects or situations they dread.

Then clients learn how to pair relaxation with the objects or situations they fear. While the client is in a state of relaxation, the therapist has the client face the event at the bottom of his or her hierarchy. This may be an actual confrontation, a process called in vivo desensitization. A person who fears heights, for example, may stand on a chair or climb a stepladder. Or the confrontation may be imagined, a process called covert desensitization. In this case, the person imagines the frightening event while the therapist describes it. The client moves through the entire list, pairing his or her relaxation responses with each feared item. Because the first item is only mildly frightening, it is usually only a short while before the person is able to relax totally in its presence. Over the course of several sessions, clients move up the ladder of their fears until they reach and overcome the one that frightens them most of all.

Another behavioral treatment for specific phobias is flooding. Therapists who use flooding believe that people will stop fearing things when they are exposed to them repeatedly and made to see that they are actually quite harmless. Clients are forced to face their feared objects or situations without relaxation training and without a gradual buildup. The flooding procedure, like desensitization, can be either in vivo or covert.

flooding A treatment for phobias in which clients are exposed repeatedly and intensively to a feared object and made to see that it is actually harmless.

When flooding therapists guide clients in imagining feared objects or situations, they often exaggerate the description so that the clients experience intense emotional arousal. In the case of a woman with a snake phobia, the therapist had her imagine the following scene, among others:

Close your eyes again. Picture the snake out in front of you, now make yourself pick it up. Reach down, pick it up, put it in your lap, feel it wiggling around in your lap, leave your hand on it, put your hand out and feel it wiggling around. Kind of explore its body with your fingers and hand. You don’t like to do it, make yourself do it. Make yourself do it. Really grab onto the snake. Squeeze it a little bit, feel it. Feel it kind of start to wind around your hand. Let it. Leave your hand there, feel it touching your hand and winding around it, curling around your wrist.

(Hogan, 1968, p. 423)

In modeling it is the therapist who confronts the feared object or situation while the fearful person observes (Bandura, 2011, 1977, 1971; Bandura et al., 1977). The behavioral therapist acts as a model to demonstrate that the person’s fear is groundless. After several sessions many clients are able to approach the objects or situations calmly. In one version of modeling, participant modeling, the client is actively encouraged to join in with the therapist.

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Clinical researchers have repeatedly found that each of the exposure treatments helps people with specific phobias (Antony & Roemer, 2011; Rosqvist, 2005). The key to greater success in all of these therapies appears to be actual contact with the feared object or situation. In vivo desensitization is more effective than covert desensitization, in vivo flooding more effective than covert flooding, and participant modeling more helpful than strictly observational modeling. In addition, a growing number of therapists are using virtual reality—3D computer graphics that simulate real-world objects and situations—as a useful exposure tool (Dunsmoor et al., 2014; Antony, 2011).

Treatments for AgoraphobiaFor years clinicians made little impact on agoraphobia, the fear of leaving one’s home and entering public places. However, approaches have now been developed that enable many people with agoraphobia to venture out with less anxiety. These new approaches do not always bring as much relief to sufferers as the highly successful treatments for specific phobias, but they do offer considerable relief to many people.

Crossing over A fear of heights is one of the most common human phobias. Nevertheless, victims need not be stuck with this phobia. Here dentist Jason Bodnar crosses the finish line and wins the Annual Seven Mile Bridge Run in Florida for the fifth time, a clear victory over his phobia of crossing bridges.

Behaviorists have again led the way, this time by developing a variety of exposure approaches for agoraphobia (Gloster et al., 2014, 2011). Therapists typically help clients to venture farther and farther from their homes and to gradually enter outside places, one step at a time. Sometimes the therapists use support, reasoning, and coaxing to get clients to confront the outside world. They also use more systematic exposure methods, such as those described in the following case study:

[Lenita] was a young woman who, shortly after she married, found herself unable to leave home. Even walking a few yards from her front door terrified her….

It is not surprising … that this young woman found herself unable to function independently after leaving home to marry. Her inability to leave her new home was reinforced by an increasing dependence on her husband and by the solicitous overconcern of her mother, who was more and more frequently called in to stay with her…. Since she was cut off from her friends and from so much enjoyment in the outside world, depression added to her misery….

[After several years of worsening symptoms, Lenita was admitted to our psychiatric hospital.] To measure [her] improvement, we laid out a mile-long course from the hospital to downtown, marked at about 25-yard intervals. Before beginning [treatment], we asked the patient to walk as far as she could along the course. Each time she balked at the front door of the hospital. Then the first phase of [treatment] began: we held two sessions each day in which the patient was praised for staying out of the hospital for a longer and longer time. The reinforcement schedule was simple. If the patient stayed outside for 20 seconds on one trial and then on the next attempt stayed out for 30 seconds, she was praised enthusiastically. Now, however, the criterion for praise was raised—without the patient’s knowledge—to 25 seconds. If she met the criterion she was again praised, and the time was increased again. If she did not stay out long enough, the therapist simply ignored her performance. To gain the therapist’s attention, which she valued, she had to stay out longer each time.

This she did, until she was able to stay out for almost half an hour. But was she walking farther each time? Not at all. She was simply circling around in the front drive of the hospital, keeping the “safe place” in sight at all times. We therefore changed the reinforcement to reflect the distance walked. Now she began to walk farther and farther each time. Supported by this simple therapeutic procedure, the patient was progressively able to increase her self-confidence….

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Praise was then thinned out, but slowly, and the patient was encouraged to walk anywhere she pleased. Five years later, she [is] still perfectly well. We might assume that the benefits of being more independent maintained the gains and compensated for the loss of praise from the therapist.

(Agras, 1985, pp. 77–80)

Exposure therapy for people with agoraphobia often includes additional features—particularly the use of support groups and home-based self-help programs—to motivate clients to work hard at their treatment. In the support group approach, a small number of people with agoraphobia go out together for exposure sessions that last for several hours. The group members support and encourage one another, and eventually coax one another to move away from the safety of the group and perform exposure tasks on their own. In the home-based self-help programs, clinicians give clients and their families detailed instructions for carrying out exposure treatments themselves.

Between 60 and 80 percent of agoraphobic clients who receive exposure treatment find it easier to enter public places, and the improvement persists for years after the beginning of treatment (Craske & Barlow, 2014; Gloster et al., 2014, 2011; Klein et al., 2011). Unfortunately, these improvements are often partial rather than complete, and as many as half of successfully treated clients have relapses, although these people readily recapture previous gains if they are treated again. Those whose agoraphobia is accompanied by a panic disorder seem to benefit less than others from exposure therapy alone. We shall take a closer look at this group when we investigate treatments for panic disorder.