For adults and parents
Specific phobias
Specific phobias often respond to a short course of treatment. This page explains how a phobia is kept going and what treatment involves.
What a specific phobia is
A specific phobia is an intense, persistent fear of a particular thing or situation, out of proportion to the danger, which you either avoid or endure with real distress. Common examples are needles and blood tests, vomiting, dogs, flying, heights, choking, enclosed spaces, motorway driving and dentists, and in children also the dark, loud noises, hand dryers and toilets away from home. Almost everybody with a phobia already knows the fear does not match the risk, which is why being told the statistics on aeroplanes does not help. The fear changes through direct experience of the feared situation, and that is what treatment provides.
How avoidance keeps it going
When you avoid the thing, the fear drops immediately, and you are left believing both that the situation was dangerous and that you got away just in time. Repeated many times, this makes the fear stronger, because nothing ever contradicts it. Avoidance is rarely total. Flying only with a drink and a particular seat, looking away during the blood test or walking the long way round the park in case of dogs all get you through, but they stop you learning that you could have managed without them, which is why somebody can fly regularly and still be terrified.
- Trigger: A dog on the path, or a blood test booked
- Fear and a prediction: “It will bite me” or “I’ll faint”
- Avoid or leave: Crossing the road, cancelling, or looking away
- Relief: The fear drops, and the prediction goes untested
- Then back to the first step, and the loop runs again.
- Other situations that now set it off too: Walking in the park, hospital scenes on TV, friends who have dogs, A dentist’s appointment.
Where treatment steps in. You meet the feared thing in small planned steps, starting with a manageable one, without leaving early or looking away. You learn that you can cope with the fear while it is there, and you also see what actually happens.
New triggers. Over time, more situations become linked to the trigger and start the loop off too.
What treatment involves
The psychological treatment with the most trial evidence for specific phobias is graded exposure (Wolitzky-Taylor and colleagues, 2008), which means approaching the feared thing in planned steps. First we work out exactly what is feared. For someone afraid of dogs that may be the sudden movement, the noise or being jumped at, and for someone afraid of flying it may be turbulence, being unable to get off, or the sensations in the body. Each step then tests the specific prediction you are making.
We build a list of steps, from something you could do today to the thing you cannot yet imagine doing, and use it to choose a starting point rather than as a fixed order. In each situation you stay long enough to learn something and gradually drop the small things you do to feel safer, because doing the thing while gripping the armrest leaves you believing the armrest saved you. The fear does not have to drop during the practice for it to count, though it often does. What you learn is that you can handle the fear and stay where you are, and you also find that what you expected, to faint, be bitten or be sick, does not happen or is something you can cope with. That is what changes the fear. Varying the steps, rather than always following the same sequence, may help the learning last, and the exposure planner is built around this.
Needles, blood and fainting
Blood-injection-injury phobia is the one exception to the usual physiology. Most anxiety raises heart rate and blood pressure, but this fear produces a brief rise and then a sudden drop, which is why some people faint at the sight of blood or a needle and why their fear is based on real experience. Treatment includes applied tension, which means tensing the large muscles of the arms, legs and body to raise blood pressure and prevent fainting, alongside graded practice with the actual equipment.
Phobias in children, and what parents can change
Children develop fears as a matter of course, and most fade. A fear is more likely to stay when family routines change around it, such as the route altered, the party skipped, the room checked first or reassurance given every night. As with other anxiety in children, much of treatment is helping parents reduce those changes and support the child in approaching the feared thing. With younger children the steps are built as a game with rewards, and with teenagers the work looks much like adult treatment.
When it is not a simple phobia
Some fears look like a phobia but behave differently. Fear of vomiting spreads across food, travel, alcohol and other people, and there is a separate page on emetophobia. Fear of choking can narrow the diet until it becomes ARFID, and fear of enclosed spaces is often closer to panic and agoraphobia. These take longer and need a different order of steps, so working out which applies matters from the first session.
Sources
- Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021-1037. doi.org (opens in a new tab)
- Öst, L.-G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27(1), 1-7. doi.org (opens in a new tab)
Common questions
How many sessions does a specific phobia usually take?
There is no fixed number. A single, well-defined phobia in someone who is otherwise well can be treated in a small number of sessions, and there is a research tradition of treating one phobia in a single long session (Öst, 1989), though most people need more than one. Phobias present for decades, involving several feared situations, or alongside panic or depression take longer. The habits built around the fear, such as holidays not booked, can also take time to change. I give you an estimate by the end of the first session, and sometimes further assessment is needed before I can.
Will you make me do something I have not agreed to?
No. We build the list of steps together, you know what each session involves before it starts, and you decide when to take on a harder step. Surprises would not help anyway, because they teach you that the situation is unpredictable. Treatment is a stretch, but it starts with a manageable step, it is planned with you in advance, and it becomes easier with practice.
My child is terrified of needles and has vaccinations coming up. Can you help in time?
Often yes. Needle fear responds well to graded practice with the actual equipment, and where there is a risk of fainting I also teach applied tension, which raises blood pressure briefly to prevent it. If there is a date in the diary, tell me at the free call and we will plan around it, and it is worth starting early.
Free 20-minute call
Not sure whether this is the right fit?
Start with a free 20-minute call. We talk through what is going on, I answer any questions you have, and I tell you whether I think I can help. If I cannot, I will try to point you to someone who can. The call is free and there is no obligation to book.
Weekdays, 9am to 5pm. No GP referral needed.