Manual for the 1-session treatment

of specific phobias

Lars-Göran Öst, Ph.D.

Department of psychology

Stockholm University

Version 1, December 15, 1997

© Lars-Göran Öst
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GENERAL BACKGROUND
Öst (1989) has developed a rapid treatment method, called 1-session treatment, for specific
phobias in general. The treatment consists of intensive exposure during a single session,
which is maximised to 3 hours. Prior to this session the therapist has carried out a behaviour
analysis, which for an experienced therapist usually takes 1 hr, but which may take longer for
a less experienced clinician.

Behavior analysis
During the screening interview it is important to ask the patient a series of questions in order
to arrive at an individual functional analysis of the subject’s phobic problems. The most
important of these questions concern the factor that maintains the phobic behavior. It is not
very informative to reach the general conclusion that it is the avoidance and escape behaviors
that maintain the disorder. We need to find out what kind of catastrophic beliefs the patient
has when it comes to encounters with the phobic object or situation. This part of the interview
may run something like this as exemplified with a spider phobic.

Therapist: “Imagine that you walk into a room and you see a spider, about 1 inch in size, on
the floor. What thoughts run through your mind then?”
Patient: “I have to run out of the room and cry for help.”
T: “OK, now imagine that you cannot leave the room, for some reason.”
P: “I would cry loudly so that someone could come and rescue me.”
T: “Imagine that you are alone in the house, and there is nobody that can hear you.”
P: “I would get strong panic reactions and then freeze and just stare at the spider.”
T: “What will happen then?”
P: “I don’t know. I can’t think about it. I get panicky just talking about this.”
T: “Please bear with me and continue to imagine that you are in this room with the spider, and
you can’t leave. What do you fear will happen?”
P: “I don’t know because I have always been able to run or get help.”
T: “I fully understand that this is unpleasant to think about, but close your eyes and imagine
that you are in the same room as the spider. What is the worst that you fantasize will
happen?”
P: “The spider will crawl up on my body, and I will not be able to brush it away because I am
petrified by fear.”
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T: “What will happen then?”

P: “It will crawl underneath my clothes and that would be the end.”
T: “How do you mean, the end?”
P: “I would die.”
T: “How would you die?”
P: “I would get a heart attack from the strong panic and die; because the heart can’t stand the
very strong anxiety reactions with palpitations etc..”
T: “OK, let me summarize what we have arrived at with this little thought experiment. The
worst consequence that you believe may happen if you encounter a spider is that you would
die because of a heart attack. Is that correct?”
P: “Yes, I suppose so, but I have never dared to think it through like this before.”
T: “Now I want you to rate, on a scale from 0-100%, how strongly you believe that this
scenario will happen, i.e. if you encounter a spider in a room and can’t leave the situation you
would die of a heart attack. I’d like you to give me two ratings; first when you are in the
actual situation, and second when you are sitting here talking about it.”
P: “I am not sure, but I guess it is high, about 90%.”
T: “And when you sit here and think rationally about it?”
P: “It is lower, say 40%”.
T: “Fine, it is usual that these figures differ a lot.”

Even if this is the interview the therapist may start to dispute the patient’s catastrophic belief
by the following set of questions.

T: “Obviously, you have not experienced this consequence of an encounter with a spider
yourself, since you are sitting here today. But, do you know of someone, a friend or a relative,
who has died from fear or panic in a similar situation?”
P: “No I don’t.”
T: “Have you read in a newspaper, journal or psychiatric book about a person where there is
no doubt that the individual died from a heart attack caused by fear?”
P: “No, but it is what everybody says.”
T: “Yes, it is a popular myth that is part of our folklore, nonetheless it is wrong. There is no
such case reported in scientific journals or books. If it were possible to die in this way there
would be many reports about it, since about 15% of the population has a specific phobia
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sometime during their lives, and most of them encounter their phobic situations many times a
year.”
P: “Yes, you are probably right.”
This transcript gives only a part, but probably the most important part of the issue of what is
maintaining the patient’s phobia: The strong belief in the catastrophe maintains the avoidance
and escape behavior. Since the patient is so convinced that a prolonged encounter will lead to
a premature death it is quite natural that she/he avoids and escapes. This means that she/he
doesn’t get any new information that can correct the false belief, and the phobia is unchanged.
It may even be advantageous to tell the patient that his/her phobia is logical given how
strongly they believe in the possible catastrophe. If I believed, for example that there is a 90%
chance that I would get run over by a car and die when crossing a busy street at a pedestrian
crossing while the WALK sign is lit, it would be rational to avoid this. Instead I would walk a
long distance to find a bridge across or a tunnel under the street.
During the treatment session the therapist will ask more detailed questions to get the
patient to predict what will happen if different things are tried with the spider, e.g. putting
your hand in the plastic bowl. By testing these predictions in different ways the patient will
obtain new information which gradually will change his/her belief.

Rationale for the treatment

As in all instances of working with cognitive-behavioural treatments it is necessary to give
the patient a rationale for the treatment method. In doing this, one should tailor the
description of the treatment to the individual patient's problem behaviours so that she/he can
understand more easily why the selected treatment method should work in his/her case. The
purpose of the 1-session treatment is to expose the patient to the phobic situation in a
controlled way, thus enabling him/her to realise that the consequences one feared would
happen do not occur. Finally, the one-session treatment should be seen as a start, and the
patient must continue exposing him-/herself to phobic situations in everyday life after the
therapy. It is not to be expected that a specific phobia of 20-30 years duration should
completely vanish after only one therapy session. However, the single session enables the
patient to continue on his/her own with exposure in natural situations, e.g. by following a
voluntary maintenance program (Öst, 1989b), so that within a few months the remaining
phobic behaviour will disappear.
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Pre-treatment instructions
At the end of the behaviour analysis interview the therapist gives the patient some instructions
concerning what will happen during the treatment session. First of all, the patient is told that
team-work is important in carrying out the treatment, and both the therapist and the patient
have equal responsibility for achieving a good result. This kind of therapy is hard work and
can only be successful if the patient fulfils his/her part in the team-work.
Most patients fear that some kind of "shock treatment" may be applied, e.g. that the
therapist suddenly takes out a spider and throws it in the patient's lap. Thus, it is important to
inform the patient that the therapist will never do anything unplanned in the therapy room, but
will describe to the patient what will happen, then demonstrate it, and finally will get the
patient's permission to do it.
Another fear that many patients have is that they will be subjected to such a high level
of anxiety and during such a long time (3 hours) that they will not be able to cope with it,
mentally or physically. They believe, for example, that they may suffer a heart attack and die
from anxiety. Here it is important that the patients think back on the most anxiety-arousing
situation they have ever experienced in relation to the phobic stimulus, and calling this 100 on
the 0-100 Subjective Units of Disturbance (SUDs) scale. The therapist then informs the
patient that even if the treatment will mean that he/she will be exposed to much more than
they ever have been in natural situations this will not "break their personal record" of anxiety
in the phobic situation. The reason being the planned, gradual, and controlled way the
exposure is carried out.
Finally, the patient is told that a high level of anxiety is not a goal in itself for the 1-
session treatment, but can be considered a side effect. If the patient can achieve the treatment
goal with a maximum anxiety level of 40-50, instead of 80-90, it is quite all right as long as
no cognitive avoidance goes on and the necessary emotional processing can take place.
Immediately before the treatment session starts the patient's understanding of the
rationale and the pre-treatment instructions is checked by letting him/her describe them to the
therapist. Any misconceptions can easily be corrected and you have a patient better equipped
to fulfil his/her part in the team-work.
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The 1-session treatment

When the treatment is applied for animal phobics it consists of a combination of exposure in-
vivo and participant modelling, while for other specific phobias the modelling component
doesn’t seem to be necessary.
Exposure in-vivo. The guiding principle for the exposure situations is the cognitive
analysis of the patient's catastrophic cognitions concerning the phobic object/situation
described above, and the exposure is set up as a series of behavioural tests, instead of a
straightforward exposure focused only on what the patient avoids. My clinical impression is
that there is a more rapid shift in avoidance behaviour and subjective anxiety by doing the
exposure this way. An analogy may clarify this; if you are a big game hunter you use a rifle
and not a shotgun in order to bring down e.g. a moose at a 100-200 yard distance.
Furthermore, the general principles for exposure in-vivo are followed; the patient
makes a commitment to remain in the exposure situation until the anxiety fades away, he/she
is encouraged to approach the phobic stimulus as much as possible, and remain in contact
with it until the anxiety has decreased, and the therapy session is not ended until the anxiety
level has been reduced with at least 50%, or completely vanished.
Modelling. The principles developed by Bandura and his co-workers are followed,
which means that the therapist first demonstrates how to interact with the phobic object. At
this step it is important to get the patient to continuously observe what is happening, and not
close the eyes, or look away. After doing this for a while the therapist helps the patient
gradually to approximate physical contact with the phobic object, e.g. by first holding the
patient's hand, then the arm, and gradually reducing the physical assistance. At this stage the
therapist may have to reduce and increase the physical help a number of times before the
patient is ready to proceed to the next step. This means that the patient interacts with the
animal on his/her own, only with the help of the therapist's instructions.

Goals for the 1-session treatment

There are two types of goals in connection with 1-session treatment. The first is what the
patient should be able to manage in natural situations after completing the treatment.
Examples of this goal are that a spider phobic should be able to catch a spider with a glass and
a postcard and throw it out of the house, or an injection phobic being able to have an injection
or give a blood sample with no more discomfort than people in general.
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The second goal is what the therapist wants the patient to achieve during the therapy
session. For the spider phobic the therapist wants the patient to be able to have two spiders
walking on his/her hands at the same time. Concerning the injection phobic, the therapist
wants him/her to have their fingers pricked several times (10), subcutaneous injections (5-10),
and a few venipunctures (2-4). However, the therapist does not inform the patient about this
goal because this knowledge will be detrimental when it comes to the patient's performance
during the session. First of all, a large majority (90% of my patients) would never have
presented for treatment had I told them about this goal during the screening-interview.
Furthermore, knowing what the therapist has planned as the final step will lead to the patient
ruminating about this in a negative way which will prevent him/her from focusing on the task
at hand, i.e. carrying out the step they are at. It may be considered unethical not to inform the
patients about the second goal before starting the therapy, but so far, after 9 outcome studies
and numerous clinical patients, no single patient has complained about this. On the contrary,
they are grateful that the therapist helped them to realise that they could achieve much more
than they had ever imagined. Since withholding the second goal actually helps the patient I do
not consider it unethical not to inform the patient about if beforehand.
However, it should also be pointed out that the treatment outcome can be very good
even if the goal of the therapist has not been reached during the session. Since the patients’
expectations usually are much lower than the therapist’s goal they will be very satisfied with
a less achievement. What is very important in this respect is to end the session on a positive
note, i.e. you should not push the patient to attempt things that he/she may fail to accomplish
and thus running the risk of experiencing a failure at the last step.

How the 1-session treatment differs from natural encounters with the phobic situation
Some patients may have tried to expose themselves to their phobic stimuli, but failed, and
may be a bit sceptical concerning the possibility of changing their phobic reactions, which
most of them have had for 50-75% of their lives. In order to demonstrate these differences the
graph depicted in Figure 1 can be shown to the patient.
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The anxiety curve

Catastrophe

What the patient

fears will happen
100
Anxiety level

Escape
What the therapist
predicts will happen

0
Exp. starts Time ends

In fig.1 two important things are shown. First, what patients usually do when they happen to
encounter the phobic stimuli; their anxiety level will increase rapidly and they escape from
the situation, since they believe that the catastrophe will occur if they remain. The escape
curve also illustrates the rather rapid dissipation of anxiety once the patient has escaped from
the phobic encounter. Second, it shows the two predictions that can be done in this situation;
the patient’s prediction that the anxiety will increase out of all proportions and result in the
catastrophe they believe is possible, and the therapist’s prediction that the anxiety curve will
reach a plateau and then gradually decrease while the exposure continues.
After describing this graph the therapist should point out the important differences
between natural encounters with phobic stimuli and the exposure during treatment. First, in
natural situations the exposure is unplanned, ungraded, and uncontrolled, while in the
treatment it is planned, graded, and controlled. Second, in natural situations the exposure is
very brief, while in the treatment it is prolonged (up to three hours). This time difference
means that there is ample time to test the two predictions, and find out if the patient or the
therapist is correct. Finally, in natural situations the patient is usually alone, while in the
treatment situation there is a team (patient and therapist) to deal with the phobic reactions.
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The therapist-patient relationship

In order to achieve as much as is usually accomplished in a 1-session format it is necessary to
have a very good and trustful relationship. The prime responsibility for creating this working
relationship lies with the therapist, and it starts during the interview. It is absolutely necessary
that the therapist takes the patient’s phobic problems seriously, and conveys the attitude that
even a specific and circumscribed phobia can be very impairing to the patient suffering from
it. It is also helpful to be able to describe how prevalent these types of phobias are, what the
common etiology is, average time of onset etc. This kind of information will show the patient
that the therapist has the kind of knowledge about specific phobias that they have asked about
but have not been able to obtain. Then it is easy for the patient to generalize and believe that
the therapist also knows how to do the treatment effectively.
When describing the treatment that the patient is going to receive it is important to
have a sensitive ear to any unexpressed questions or doubts that the patient may have. Giving
a CBT-rationale is often a straightforward task and most patients don’t have more than a few
questions. Still, it is important not to rush the patient, but give him/her the time necessary to
think about the treatment description. Usually, the treatment session takes place about a week
after the interview, and the patient is encouraged to think about the description and write
down any questions they may have during the interval so that these can be answered before
the start of the treatment. In doing this the therapist should emphasize that the treatment is
done as a team work.
The team-work principle. The 1-session treatment is conceptualized as a team-work
effort in which two experts are “joining forces to combat” the patient’s phobia. The patient is
an expert on his/her phobia, the cognitive, behavioral, and physiological reactions etc., and
the therapist is an expert on the treatment method to be used. Since the therapist has the
treatment expertise it is natural that he/she will be captain of the team. However, both
members have to work equally hard in order to achieve the goal. This means that the patient
cannot come to the treatment session with the expectation that the therapist will “take care of”
the patient’s phobia without his/her whole hearted participation. Going through a 1-session
treatment is the opposite of taking your dirty coat to the dry cleaners and pick it up next week
nice and clean. It is a lot of “dirty” work and the patient has to be committed.
The team-work principle also means that both the patient and the therapist must
answer questions during the session in an open and sincere way. It is especially important that
the patient give honest SUDS ratings and descriptions of cognitions when asked by the
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therapist. It is equally important that the therapist answers the patient’s questions in a sincere
way. There is one exception to this, however, and that is when the patient wants to know what
the last step of the treatment will be. In this case it is recommended not to answer directly, but
to say that “we don’t have to decide that right now, but to focus on the step we are working on
at this moment.” The clinical experience is that disclosing the goal that the therapist has for
the last step will only lead to a patient ruminating about how anxiety arousing, and
impossible, this will be, and thus prevent him/her from carrying out the current step in the
treatment.
Thus, the therapist starts building a good relationship to the patient already during the
interview, and it is then continued through the entire treatment session. This is done in
various ways, e.g. by suggesting exposure tasks that always are as close as possible to the
patient’s current limit. After the task has been described, modelled, and the patient has been
helped to carry it out there is a great boost in his/her confidence. All through this process the
therapist should be generous with praise as the patient tries, and gradually approximates the
behavior modelled by the therapist. Another way of improving the relationship is never to
betray the patient’s trust in the therapist. One example is during the modelling procedure, as
the patient is carrying out a task with a gradually reduced physical help of the therapist, many
want the therapist to hold their hand or at least be close and alert if the animal should do
something unforeseen. Such a request should naturally be met, and the patients will realize
that the therapist can be trusted if they feel too uncomfortable at a certain step. Still, the
therapist has to withdraw the physical help as soon as the patient feels comfortable with this.
The use of humor. In order to alleviate the tension during the session the therapist can
use humor, if he/she feels comfortable doing so. When using humor it is very important not to
say something that might embarrass or ridicule the patient. One should laugh with the patient
not at him or her. The use of humor can often have an anxiety reducing effect by putting the
patient’s phobic reactions into perspective.

The use of physical contact

During the second part of participant modelling the therapist uses physical contact to help the
patient to gradually interact more and more with the phobic object. When the patient gets
more experience and learns how to do it the therapist can gradually withdraw his/her help and
just instructing the patient how to carry out the interaction.
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However, physical contact is not restricted to the treatment of animal phobias. I have
found that patients can often experience a high anxiety level and weep during the initial part
of the session. In these instances it is important to be empathic and acknowledge that the
situation is very anxiety arousing. Furthermore, I tell the patient that it is quite natural to weep
and give him/her some paper handkerchiefs to dry the tears. In these instances it feels natural
to comfort the patient by putting ones hand on his/her shoulder, stroking the cheek etc. It is
also important to ask what went through the patient’s mind when he/she started to weep since
very useful cognitive material can be elicited this way. Naturally, one must be very sensitive
to the patient’s reactions and withdraw the physical contact if they seem to be uncomfortable
with it. If this is not the case this type of physical contact can greatly reduce the time that the
patient is weeping and rather quickly get him/her down to a manageable anxiety level. This
means that the exposure can continue after just a brief pause. When using physical contact in
this way to help the patient reduce his/her anxiety level it is important that the therapist
withdraws the contact as soon as the patient has obtained a reduction and can continue.
However, as is the case with humor, some therapists don’t consider it necessary using
physical contact and instead they use verbal means to help the patients reduce their anxiety.
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TREATMENT DESCRIPTIONS
Below follow descriptions of how a number of common specific phobias can be treated.
However, these descriptions should not be considered as the only way of doing the treatment,
but as examples of how it can be done. Individual therapists must be allowed a flexibility
regarding the specific content of the treatment and the descriptions that follow are my
personal way of carrying out the 1-session treatment, and the ways it has been done in the
randomized trials on spider phobia, blood phobia, injection phobia, flying phobia, and
claustrophobia. It should also be noted that so far there are no research comparing different
ways of doing this treatment.

Spider phobia treatment

Spider phobia is the most prevalent of the animal phobias, and the one having the most
outcome studies.
In order to fulfil the aims of graduation and control, four spiders in increasing sizes,
from 0.5 to 3 cm are used, and the spider is placed in a large plastic bowl (50x30x15 cm)
during the session. The first step is to teach the patient to catch the small spider with a glass
and a piece of paper (e.g. a postcard) and throw it out of the house, which is the goal for
natural situations. The glass is put upside down over the spider in the bowl and the postcard is
slid under it. The postcard functions as a "lid" and by putting one’s fingers under the postcard
the glass can be turned upright and the postcard removed with caution, in case the spider has
spun a thread on the card. After modelling the procedure the therapist helps the patient to
carry out this task. Usually it is repeated 3-4 times and the last time the patient is instructed to
hold the glass in the palm of his/her right hand and close to the body. At this point a brief
role-play can be carried out in order to "force" the patient to look closely at the spider. The
role-play consists of having the therapist play the part of a person born blind and the patient
has to describe what he/she is looking at in the glass by only using words that can convey any
meaning to a blind person. This procedure usually leads to a marked anxiety reduction.
The second step is touching the spider. Before starting this step the therapist should
ask the patient what he/she believes will happen if she puts her hand in the bowl. Almost
100% of our patients say that the spider will crawl up on their hands, up the arm and
underneath the clothes. This prediction can be tested out by the therapist putting his hand in
the bowl, then touching the spider from behind with the right index finger. What happens,
much to the surprise of the patient, is that the spider runs away. By repeating this 10 times the
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patient will realize that the spider gets tired quickly and runs gradually shorter distances.
Then the same procedure is repeated from the left side, the right side, and from the spider's
head. The conclusion is that the spider doesn't crawl up on the therapist's finger. This is then
followed by the patient touching the spider in the same way, which usually takes physical
guidance from the therapist. By letting the patient do this long enough, the assumption that
the spider will react differently towards a phobic person can easily be corrected.
The third step is letting the spider walk on the patient's hands. This can be done by the
therapist first taking the spider on his/her hands, letting it walk from one hand to the other.
Then the patient is encouraged, with the therapist's help, to put her index finger on the
therapist's hand so that the spider can walk across the finger and back on to the therapist's
hand. This is repeated a number of times, and then the spider is gradually allowed to walk on
all the patient's fingers, on the whole hand, and across to the other hand. Gradually the
therapist withdraws physical support, letting the patient manage on her own, just following
the therapist’s instructions. During this step the goal is to have the spider walk up to the
elbow (on both arms), letting the patient realise that she can move her hands faster than the
spider can run, to prevent it from crawling underneath her clothes.
The fourth step is having the spider walk on the patient’s body. One can start putting it
on the trousers (at knee level) and “guide” it as it crawls up towards the waist. When this has
been done a number of times, and the patient’s anxiety has been reduced, the spider can be
put on the shirt at waist level and have it crawl up to the neck. Naturally, this has to be
repeated until an anxiety reduction takes place.
The above four steps are then repeated with another 3 spiders of gradually larger size,
the largest being about 3 cm (with legs). When this is accomplished the patient is encouraged
to have two spiders (number 3 and 4 in size) walking on her hands simultaneously. This step
is of course more difficult, but by being relaxed in her arms and hands she can usually control
the spiders.
If there is time left in the session the therapist may offer the patient to go through the
“extra course”, which probably isn’t necessary in order to obtain a good result. This means
first having the largest spider put in the hair, while the therapist is standing behind the patient
to observe the spider and prevent it from crawling underneath the neckband. During this step
the patient is asked to tell exactly where the spider is by pointing with an index finger. It is
very common that the patients are incorrect because they can’t really feel the spider. The final
step is to have the spider put on ones cheek. The patient holds one hand over the neckband to
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prevent the spider from falling inside the shirt while the therapist cautiously puts the spider on
the patient’s cheek. Then he/she has to guard it so that it doesn’t crawl on the patient’s ear,
eye, nose or mouth. That the spider walks a bit on the cheek is acceptable though.
Throughout the session the patient is taught that she can have indirect control over the
spider by gradually being more correct in predicting what the spider is going to do. The
patient will learn that the spider isn't going to turn 180 degrees and suddenly run in the
opposite direction. Basically, it will crawl in the direction that its head is pointing.
The principle guiding how much time is spent on each step is the patient's SUDs rating
and belief in the catastrophic cognitions. The goal is that the patient should be able to handle
two spiders with low or no anxiety and no longer believe her catastrophic cognitions.

Snake phobia treatment

Most patients with snake phobia experience more fear the bigger the snake is. Thus, it is good
to have three snakes in different sizes, e.g. a corn snake, a python, and a boa constrictor. The
smallest could be 2 feet and the largest about 5 feet. However, it is not necessary to have
different species of snakes as long as there are different sizes. A sizeable proportion of snake
phobics fear smaller snakes more than larger ones due to the quicker movements of the
smaller ones, so before starting the treatment you should always construct the hierarchy of the
individual patient. It goes without saying that you can only use non-poisonous snakes and
snakes that are used to being handled by people. It would be very difficult to continue a
treatment session if the snake bit the patient or displayed any other kind of aggressive
behavior.
When treating a snake phobic patient it is an advantage to have a fairly large room so
that you can seat the patient in one end and bring out the snake in the other. It is important
that the patient isn’t confined by the therapist with the snake; he/she should have free passage
to the door of the room. Knowing that one can leave the room without having to pass by the
snake will reduce the anticipatory anxiety and make an escape unnecessary.
The first step of the treatment is that the therapist brings out the smallest snake and
holds it in the hands/arms at a distance (as long as the room allows). The instruction to the
patient is that he/she should watch the snake at all times, observing its colors, pattern of the
skin, movements, tongue, etc. It is also important to get the patient’s SUDs ratings now and
then. When there has been a reduction in anxiety the therapist asks if it is OK to move about 3
feet closer. If the patient accepts the therapist moves closer, stops at the point agreed upon,
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and stays there until the patient’s anxiety level has decreased further. This approach continues
until the therapist has come all the way up to the patient and sits down on a chair 2-3 feet
away. After a while he/she can move the chair closer so that the patient could reach out and
touch the snake. This is attempted after the patient has adjusted to having the snake at such a
short distance. Since most snake phobics fear the mouth and the tongue of the snake you start
by having him/her touch the tail. Before the patient can do this you ask for a prediction of
what it will feel like touching the snake. Most snake phobics have the idea that the snake is
slimy and warm and they are surprised when they realize that it is dry and cool, i.e. the same
temperature as the room.
The first touch is usually done by the therapist holding the snake’s head away from the
patient while he/she can touch its tail. Since the patient usually touches the tail very briefly
you have to encourage him/her to repeat it a number of times, and for longer periods. When
this is going well the patient should touch the snake gradually closer and closer to its head. At
one phase you instruct the patient to hold one hand around the snake’s stomach and let it glide
in the palm of the hand. Then the patient can hold the snake with both hands getting
acquainted with its movements, and how the muscles feel. All the time it is absolutely
necessary that the therapist is in control of the snake. The patient must be certain that the
therapist will intervene if the snake should do anything unforeseen.
Since the patient avoids close contact with the snake’s head it is necessary to get to
this step. First you get the patient’s prediction of what will happen if he/she puts a finger in
front of the snake’s mouth. There is usually a strong belief that the snake will bite the finger.
This is first tested by the therapist putting his/her fingers in front of the snake’s mouth, giving
it ample opportunities to bite, while the patient is encouraged to watch closely. After this the
patient is asked for a preliminary conclusion in regards to the prediction. Then you do the
same thing with the patient’s hand, letting the snake be so close that the patient can feel its
tongue on the skin of his/her hand. When this has been done with reduced anxiety you ask for
a final conclusion concerning the probability of being bitten by this snake. In this situation it
may also be a good idea to discuss under what circumstances a snake of that particular species
would bite; to kill its prey or if it was threatened, e.g. being treaded on by accident.
The next step is to gradually let the patient take the snake over in his/her lap. The
therapist has to assist the patient and facilitate the transition in any way possible. When the
patient feels fairly comfortable handling the snake in the lap it is time to let it move around
more, e.g. crawling around the patient’s waist, up one arm, towards the neck etc. The final
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step could be having the snake around the neck; the patient feeling its skin against his/her
neck and cheek. If the patient is willing you could even suggest putting the snake under the
patient’s shirt or blouse trying to get it to crawl around the waist. The last two steps should, of
course, be viewed as an extra course.
Some snake phobic patients fear that a snake on the ground would crawl up their legs
and “attack” them that way. If this is the case you should first obtain the patient’s prediction
and belief rating, and then put the snake on the floor. The patient should stand quite close and
observe what the snake is doing and afterwards draw a conclusion in regards to his/her
prediction.
The above steps are then repeated with snakes #2 and #3. Usually this takes much
shorter time even if the snakes are bigger than the first one, since there is a fair amount of
generalization taking place. Before ending the session it is essential that the therapist makes
sure that all the catastrophic beliefs that the patient has have been tested. If one, ore more,
remains untested there is always a chance that it may be a risk situation for starting to avoid
snakes again.

Bird phobia treatment

Below follows a description for the treatment of a patient who is phobic of different types of
birds, not just one species. In some cases the patient only has a phobia for pigeons and then
the exposure is concentrated to situations containing a lot of pigeons, e.g. a square in the
center of town.
I have found it useful to start with a situation in which there is total control over the
birds, and thus a zoological shop having birds in cages is ideal. Usually, these shops have a
special bird room since the birds make quite a lot of noise. It is ideal, but not necessary, if the
door to the room has a glass window so that the patient can look into the room from the
outside. When the patient is ready you enter the room, stay in the middle, and close the door,
so that the patient will feel a bit more privacy. First the patient and therapist just stay in the
middle of the room in order for the patient to get familiar with the situation. Then the
therapist models how to touch the outside of the cages, after which the patient starts doing the
same thing with the physical help from the therapist. First you obtain the patient’s prediction
of what will happen when he/she touches the cage. Then you follow a hierarchy if the patient
believes he/she will experience different levels of anxiety depending on what birds are in the
different cages. After touching the cages (the sides, the top, and the front) for prolonged
 17

periods of time and without the therapist’s assistance you ask the patient to draw a conclusion
in regards to the prediction. Then it is time to proceed to the next step, which entails
opening the door to a cage and insert a finger, and then the whole hand. As above, you get the
patient to predict what will happen before you start this step. First the therapist models by
opening the door and putting the index finger inside, and then the hand touching the perch.
What almost always happens is that the birds recoil to the back of the cage, and don’t dare to
sit on the perch you are touching. Sometimes a bird fly to find a better place to sit and its
wings may touch your hand. Then the therapist helps the patients to do the same things, with a
lot of support and physical contact to begin with and then gradually less and less, until they
can do it on their own. When the anxiety level has decreased you ask the patient for a
conclusion concerning the prediction he/she made for this step. This usually is the end of the
work in the zoological shop.
The next phase can take place e.g. at a pond, where there are a lot of different birds
who are used to be fed by people. At this step it is necessary to have two loafs of sliced bread
so that you can get the birds to come close to you. However, you start by gradually
approaching the pond and walk around it at a “safe” distance. Then you start feeding them by
throwing pieces of bread around you. This will usually mean that you’ll have a fair number of
birds close to you. Immediately before this step you get the patient to predict what will
happen, especially what his/her catastrophic belief in this situation is. When you have
attracted the birds you help the patient, with verbal instructions and physical contact, to
remain in the situation and keep feeding the birds. Initially the patients throw the bread a long
distance in order to keep the birds out of the immediate vicinity. Then you have to expose
them to having the birds closer by dropping pieces of bread gradually closer, ending up with
bread on the top of your shoes. At this step you will have birds around your, and the patient’s
feet, and he/she may feel completely “surrounded” by birds. By remaining in the situation and
scrutinizing the patient’s catastrophic beliefs you will help the patient to achieve an anxiety
reduction. The next step is that the therapist gradually withdraws his/her help and increases
the distance to the patient, so that the patients will experience that they can accomplish this on
their own. Then it may be time to test out a very common belief held by bird phobics, i.e. that
the bird will fly so close to the patient that its wings will touch his/her body, which would be
very anxiety arousing. After observing that this doesn’t happen when you just throw bread on
the ground you may want to “scare” the birds to find out if they react in an uncontrolled way
then. This can be achieved if the therapist instructs the patient to continue feeding the birds
 18

while he/she takes a walk and then approaches the birds from behind, sneaking up on them.
When having come 5-6 feet from the patient the therapist may stamp the ground and clap the
hands in order to make the birds fly from the ground. If they behave uncontrollably in this
situation there is a chance that one could, by mistake, touch the patient. However, this has
never happened in the more than 20 bird phobia treatments that I have done. As always, you
get the patient to draw a conclusion in regards to the prediction. The final step, an extra
course if the patient feels like it, is to try to hand feed the birds. This can sometimes be
difficult, but if the birds are sufficiently used to people it may be accomplished. Naturally,
you obtain the patient’s prediction before starting to model the behavior. Then you help the
patient using physical assistance, and finally verbal instructions. It is OK if the patient uses
gloves at this step, at least to begin with, in order to find out if the bird bites or just nibbles in
order to get the piece of bread. As always, it is the SUDs rating that tells the therapist when to
finish the session, and when to carry on with further exposure. This phase ends with a
conclusion and rating of the belief.
The entire treatment session ends with a review of the patient’s original catastrophic
beliefs, obtaining current ratings of these, and a discussion of whether there are any beliefs
left that haven’t been tested in the session. If this is the case you continue with a suitable
exposure for that belief, otherwise the session is closed.

Wasp phobia treatment

Most people with wasp phobia don’t fear bees or bumble bees, but they react to the buzzing
sound. Once they realize that it isn’t a wasp they usually calm down. In some cases where the
phobia also includes bees and bumble bees it may not be necessary to use more than wasps in
the treatment, but in other cases you will have to use all three insects. The description below
is focused on how to conduct a treatment with just wasps.
The first step is to catch wasps, and this isn’t difficult providing it is a fairly warm and
sunny day; when it is cloudy and rainy it is much more difficult though. Assuming that you
have caught a number of wasps, you keep them in individual glass jars with screw lids and air
holes in the lid. To start the exposure with a live wasp it is an advantage if it is calm, and
doesn’t fly away. In order to achieve this you put the jar in the refrigerator for 20-30 min.
This will make the wasp docile and akin to a hibernating state. Then you take it out of the jar,
and put it on the soft side of a Scotch-Bright sponge. You have prepared a metal paper clip so
it fits over the waist of the wasp, and with this you keep the wasp on the sponge long enough
 19

to be able to trim its wings about 2 mm before if becomes fully alert in the room temperature.
This may be considered an act of cruelty to the wasp, but it is necessary in order to have a
certain amount of control over the wasp in the therapy room. When the wasp has got warm (in
a few minutes) it will try to fly away, making the buzzing sound which is frightening to the
phobic patient, but the wings aren’t long enough. Then you can let the wasp crawl around on
the table, and it is necessary to have a postcard or a piece of paper to prevent it from falling to
the floor. At this stage you could ask the patient for a prediction of what would happen if you
put your hand on the table, and then test this out. Then you let the patient do the same thing to
find out what the wasp is doing. Later you can let the wasp crawl up on a pencil, which you
hold between your thumb and index finger, to show the patient what the wasp does when he
reaches the tip of the pencil. It crawls on the bottom side of the pencil, and then you turn the
pencil so it is walking on the upper side again. Then you instruct the patient to do the same
thing, with the wasp crawling on the pencil. You want him/her to wait until the wasp has got
closer and closer before changing the grip from the right to the left hand, etc. Before ending
this phase you ask the patient for a belief rating concerning the initial prediction.
Some therapists don’t like to trim the wings of the wasp and then you start with letting
the wasp out of the jar near the window, and gradually approach it. By necessity, this means
that you have less control over the wasp in the initial part of the treatment and it may thus be
more difficult for the patients.
The next step is to bring out a jar containing a wasp which hasn’t had its wings
trimmed. Before unscrewing the lid you need to get the patient’s prediction of what the wasp
will do once the lid is off. Invariably, the wasp phobic says that the wasp will fly directly to
you and sting you. When this is tested the patients usually need a lot of physical help to
remain seated when the lid is removed. Sometimes it may take a while for the wasp to fly out
of the jar, but as soon as it is free the wasp flies towards the light, i.e. the window pane. After
banging its head against the window for a few minutes the wasp usually makes a trip into the
room. At this point the patient also needs the therapist’s help to remain in his/her seat since
the wasp may fly close to the patient’s head. After a brief trip the wasp returns to the window,
trying to “break the pane” to get out. It usually takes a few flights into the room before the
patient feels comfortable that the main interest of the wasp is to escape, and then a conclusion
regarding the prediction is drawn.
Some patients may have the belief that the only reason they weren’t stung by the wasp
is the presence of the therapist. Thus, the next step is gradually increasing the distance
 20

between patient and therapist, and eventually the patient opens the jar while being alone in the
room. When this has been done long enough for the patient to obtain corrective information
the next step is to repeat the same procedure in a small room, e.g. a bathroom or a toilet room
without windows. In this situation the patient is closer to the wasp and may feel trapped in
since the door has to be closed, otherwise the wasp might escape. In analogy with the
previous instances the initial catastrophic belief has to be elicited, rated by the patient, and
then tested during the exposure.
The entire session is ended when the patient can remain in the same room with the
wasp flying around, without experiencing undue anxiety, and without any remaining
catastrophic beliefs.

Blood-injury-injection phobia treatment

In previous research I have developed and evaluated a specific treatment method for blood
phobia called Applied tension (Öst & Sterner, 1987; Öst, Sterner & Fellenius, 1989; Öst,
Fellenius & Sterner, 1991). This is an intensive 5-session treatment having two aims: 1)
teaching the patient to recognise the first signs of a drop in blood pressure, and 2) teaching the
patient to apply a rapid and effective tension technique to reverse the blood pressure drop.
After practising the tension technique at home the patient is exposed to 30 slides of wounded
people, blood donation at the hospital's blood donor centre, and watching a real thoracic
operation, i.e. lung or open-heart surgery.
The above treatment has been reduced to a 1-session format with a maximum time of
2 hours. The session starts with the rationale for applied tension, i.e. by learning an effective
way to counteract the drop in blood pressure which occurs in the phobic situations fainting is
prevented. The first step is to make the patient aware of the very first sign of the blood
pressure dropping. These signs can be idiosyncratic, but include cold sweat, an unpleasant
sensation in the stomach, tunnel vision, singing in the ears, etc. To find out which is the most
common in the individual patient you interview him/her in detail about the last few times they
had this experience, i.e. fainted or were close to fainting.
Then a description and modelling of the tension technique follows. The patient is
taught to tense the gross body muscles (arms, chest, and legs) as much as possible and keep
tensing for 15-20 sec, and then releasing the tension and returning to normal, but without
relaxing. After a 30 sec pause the patient tenses again, and then releases the tension, etc. This
practice goes on for about 30 min with regular assessments of blood pressure in order to show
 21

the patient that the tension technique actually leads to an increase in blood pressure, and
usually heart rate. After a brief pause, the application training is started. In this phase we use
10 color slides of wounded people; mainly traffic or work related accidents. As in the other
phobias you initially get the patient’s prediction of what will happen when he/she is exposed
to blood-injury stimuli, and a rating of the strength of this belief.
Then the first slide is projected on the screen giving a picture size of about 3x4 feet.
The patient is instructed to watch the slide without screwing up one’s eyes, closing the eyes,
or looking away. At the same time he/she has to scan the body for the very first signs of a
drop in blood pressure, and as soon as this is noticed, apply the tension for 20-30 seconds.
After releasing the tension the patient has to scan again to find out if the reaction remains, and
if this is the case he/she starts to tense again and apply the tension for as long as necessary.
The goal is to be able to watch the slide without feeling faint. When this is achieved there is a
brief pause before continuing with the next slide, using the same procedure. If there is any
time left in the session after the 10 slides have been worked through the patient can be
exposed to other stimuli, e.g. pricking of a finger, watching blood in a test tube, and blood
stained bandages, while applying the tension technique. The reason why 2 hours is used
instead of 3, as in other specific phobias, is that the patients would get very sore muscles after
practising tension for such a long period.
In some cases of blood phobia in children there is a generalization so that they react
with fear and/or fainting during biology classes when reading about internal organs,
circulation of the blood, etc. In these cases the exposure entails listening to someone reading,
and reading looking at pictures yourself.

Injection phobia treatment

The 1-session treatment consists of intense prolonged exposure to three procedures that most
injection phobic patients find anxiety-arousing; pricking of fingers, subcutaneous injections,
and venipunctures. The goal is to prick 10 fingers, to do 10-12 subcutaneous injections, and
2-4 venipunctures.
During the behavioral analysis interview(s) it is important to get a detailed description
of the patient’s behavior in the phobic situations, as well as his/her catastrophic cognitions
when exposed to the phobic stimuli. Research (Öst, 1992) shows that about 50% of the
injection phobic patients have a history of fainting in these situations, and this is what they
fear will happen. It is necessary to teach this subgroup the tension technique described for
 22

blood phobia so that they are prepared to act should the blood pressure drop occur. In other
injection phobics it is primarily the pain they fear, and their cognitions center on how
unbearable the pain of the injections will be. Still other patients describe a strong feeling of
disgust when a needle, or any sharp object, penetrates the skin. Then there are various
idiosyncratic beliefs, e.g. that a blood vessel that has been penetrated with a needle will not
stop bleeding and the person will die due to the blood loss, or that the needle that has been
inserted will break, wonder in the body, and when it reaches the heart the patient will die. All
of these beliefs have to be taken seriously, and it is the therapist’s responsibility to be creative
enough to set up behavioral experiments to test these cognitions in reality.
As in all 1-session treatments the team-work between therapist and patient is of crucial
importance and the therapist should arrange a therapy situation that is as different as possible
from the ordinary hospital or outpatient settings in which the patients have had their negative
experiences. If you work in a medical setting there is a certain smell that the injection phobics
associate with anxiety, failure, and perhaps fainting. Thus, I recommend that you bring the
necessary utensils to an ordinary therapy room in which the patient can feel comfortable.
The general principle to follow when treating an injection phobic is first to describe
and demonstrate each small step in the procedures, and then getting the patient's permission to
perform the particular step. It is extremely important that the patient can trust the therapist not
to do anything without his/her explicit permission. This means that you have to work with the
patient to motivate him/her and reduce the resistance in order to get the permission. When the
therapist has got the impression that the patient is “ready” he/she asks “Can I prick now?” If
the patient says Yes, the therapist performs the procedure. If there is a No the therapist has to
continue the work of motivating the patient. At a certain stage you may find that the patient
doesn’t say No, but at the same time can’t say Yes, since this is opposed to their own self
image as an injection phobic. However, the patient may tell you Yes in a non-verbal way, and
this gives you the permission to go ahead. Usually, the difficulty of giving a verbal answer
dissipates rather quickly, and for the major part of the session you can rely on the patient
saying Yes when he/she is ready.
Generally, the patients rank venipunctures as the most difficult, followed by
subcutaneous injections, and pricking of fingers. Thus, the first phase means that the patient
will have his fingers pricked. You start with obtaining the patient’s prediction (and belief
rating) of what will happen if you prick his/her finger. Then you demonstrate the lancet and
how it works, the grip you want to take of the patient’s fingertip etc. In some cases this phase
 23

is fairly simple, and you soon get the permission to prick. In others you may have to devise a
number of intermediate steps in order to get the patient to agree to the procedure. One step
may be to remove the needle part and just put the tube on the patient’s fingertip. In cases who
are very fearful of the pain you might put a plaster on the fingertip before pricking it, which
the patient may perceive as less painful. When you have pricked the first fingertip you get the
patient to rate the degree of anxiety and pain perceived, and to compare this to the expected
values. After a brief pause you continue with the next finger, and so on. This phase is
completed when you have pricked all 10 fingers, or after two consecutive trials in which the
experienced fear was 30 or less. Before proceeding to the next phase you get the patient’s
current rating of the catastrophic belief.
The second phase consists of subcutaneous injections on the back of the upper arms,
and as always you ask for the patient’s prediction and belief rating, after you have explained
what you want to do but before starting the procedure. In this phase you usually have to teach
the patient about what a subcutaneous injection is, how far the needle is inserted in the fat
tissue, etc. You also bring up the possibility that the needle prick may not be perceived at all,
i.e. if the needle doesn’t hit a pain cell or a pressure cell there is no signal going to the central
nervous system. By doing this you want the patient to at least entertain the possibility that it is
only a matter of chance if the prick will lead to pain or not.
This phase is divided into two parts; the first entailing just insertion of the needle and
immediately taking it out, and the second in which 0.5 ml of saline is injected. You usually do
4-6 trials of each. As with the previous phase you have to prepare the patient mentally before
you can insert the needle. If the patient experiences too much anxiety at the prospect getting
pricked by the needle you have to make smaller steps. One step would be to let the patient
handle the syringe with the needle and “play” with it for a while. Another step is to tape a
needle of the inner side of the lower arms so that the tip of the needle is close to the skin. In
some cases a piece of overhead film can be put between the needle and the skin to make it
easier initially. This is the withdrawn gradually. When the patient has agreed to your
suggestion you insert the needle, take it out and ask for the anxiety and pain ratings. If the
patient didn’t feel any pain or pressure you say that he/she was lucky the first time, and if
there was a pain sensation you can predict that in 25-30% of the pricks the patient will not
experience anything at all. Usually, it is the first trial that is the most difficult for the patient,
and it gets easier the further you proceed in this phase. You end the phase after 4-6 needle
insertions and the same number of actual injections (half in each arm), or if the patient’s
 24

anxiety level has been very much reduced beforehand. As in the previous phase, the last step
is to obtain the patient’s current belief ratings.
The last phase is drawing blood from a vein in the bend of the arm (venipuncture). As
in the previous procedures you ask for the patient’s prediction and belief rating, after you
have explained what you want to do but before starting the procedure. Initially, you explain
how the vacutainer works, e.g. showing the two sharp ends of the needle and letting the
patient listen to the sound when the vacuum is broken, and the reason a tourniquet is used.
Then you start to prepare the patient mentally in order to draw the blood. Sometimes it is
difficult to obtain blood, especially if the vein is small and deeply embedded, but this isn’t
really necessary. The important fact is that you get the permission to insert the needle.
Usually, you want to do one venipuncture in each arm, but depending on the patient’s anxiety
reactions it may be two. The phase ends with the patient’s giving a current rating of the
catastrophic belief and a discussion of any remaining beliefs that hasn’t been dealt with. If
there is any the session should continue to include this, or it can be discussed during the post-
treatment session.
In children and adolescents with injection phobia it is common that the patients have
major problems trusting the therapist due to their negative experiences with medical staff in
the past. Invariably, they describe having been very fearful but still being injected by force. It
is understandable that a child will have problems to distinguish between the therapist and
medical staff, since the therapist has the same utensils for the exposure. In these cases it is
necessary for the therapist to work much more with the rationale and to develop the patient’s
unconditional trust in the therapist. It should also be noted that the child’s goal for the
treatment session can be quite different from that of the therapist, and any attempt of the
therapist’s to “force” his/her goal on the patient will fail. The child may only want to be able
to handle and play with the utensils, and not actually getting shots. During the treatment the
exposure is done in a much more playful way than with adults, e.g. by squirting water with
the syringes etc.

Claustrophobia treatment
The 1-session treatment of claustrophobia consists of intensive exposure to the 2-3 most
anxiety arousing situations of the individual patient. Examples of situations covered are
staying in small windowless rooms with the door locked, riding lifts, and going by bus or
underground train, etc. As in all 1-session treatments it is important to carry out a proper
 25

behavioral analysis, specifically focused on the patient’s catastrophic beliefs. If these aren’t
directly tested in the treatment there is risk that only a partial improvement will be obtained.
Examples of beliefs that claustrophobic patients may hold are that if they get stuck in an
elevator they would die due to suffocation, or if the lock to a toilet door has jammed the panic
reaction would cause them to loose control or to go crazy. In this respect there is quite a large
similarity to the catastrophic beliefs reported by panic disorder patients.
It is important to emphasize the team-work relationship and involving the patient in
decisions concerning the kind of exposure to be used. The patient should have a feeling that
he/she can influence the exposure session by submitting suggestions concerning the content
of the session. The communication between patient and therapist must be completely honest
and an attitude of "let us test and see what happens to me when I am exposed to the worst
phobic situations" should be conveyed to the patient. Since the patient usually has a high
anticipatory anxiety when coming to the treatment session, it is very important to help the
patient focus on the task at hand instead of ruminating about the last step.
The example of being in a small windowless closet or lavatory can be used. Before the
start of the exposure it is important to ask the patient to make a prediction and belief rating so
that it is clear what the exposure focuses on. Initially, the patient is instructed to open the door
just to take a look, but not to enter. Usually, he/she wants to check the lock to be sure about
how it is opened from the inside. Then the patient is encouraged to enter the room and close
the door. If they want to, the patient can exit without locking the door. The next step is to lock
the door and stay there for a while. While the patient is inside the therapist prompts him/her to
constantly talk aloud and verbalise what they do, how they feel, and give SUDs ratings. In
this way tendencies to cognitive avoidance are greatly reduced. After a while the patient may
want to exit and talk face-to-face with the therapist about the experience. As soon as possible,
however, he/she is instructed to enter the closet again and lock the door with the goal to stay
longer than the first attempt. The final goal being that the patient should be able to stay inside
the locked room for 5 min with a maximum SUDs-rating of 20. If the patient finds that the
therapist's presence outside the room has a calming effect he/she should walk away some
distance from the room. When the exposure is ended the patient makes a new rating of the
catastrophic belief. Even if the worst didn’t happen, i.e. the lock didn’t jam, there usually is a
substantial shift in the belief rating, e.g. from 90% to 40%.
 26

If there is enough time left after the first situation another may be worked with or
some generalisation training, e.g. in a storage room and a public convenience with a coin-
lock, can be done.
Flying phobia treatment
The 1-session treatment of flying phobia is based on the same exposure in-vivo principle as in
the other specific phobias. However, it is of course not possible to arrange "behavioural
experiments" during a flight, at least not with a regular airline. Instead, the testing of the
patient's catastrophic cognitions must be done indirectly.
The description below is based on the procedure used in an outcome study on flying
phobia (Öst, Brandberg & Alm, 1997), which was sponsored by the Scandinavian Airlines
System in such a way that the project received free tickets for domestic flights with empty
seats, leaving from Stockholm airport. The session starts at the bus terminal in the city where
the therapist and patient meet to take the bus to the airport. This bus trip, which takes 30-40
min, is used to elicit the patient's catastrophic cognitions concerning travelling by air, and
tying these to the different phases of a flight. These can cover a number of steps from going to
the airport to sitting in the plane during turbulence. The important factor is helping the
patients to speak openly about what they fear and when during the flight these fears are
elicited. When they reach the airport the therapist and patient go to the ticket office to collect
their tickets and then they walk to the gate to check in. After a brief waiting period they board
the plane and fly for 45-60 min. After disembarking they immediately check in again and take
the same plane back to Stockholm. Then they take the bus back to the city.
From arriving at the airport to the second landing (coming back to Stockholm) there
are a number of idiosyncratic situations that the individual patient will have pin-pointed as
being connected to certain catastrophic thoughts. The therapist's role is to predict these
circumstances before they occur and remind the patient about his/her thoughts concerning that
situation. When the situation has passed the therapist asks the patient to draw conclusions
about what really happened and contrast that to his/her belief. The session continues in this
way and during the bus trip back to the city the patient is encouraged to summarize what
he/she has learnt during the session and how these experiences can be built on to continue
flying without the therapist's presence.
However, the treatment can also be carried out in a small sports plane with four seats.
The patient is sitting in the front seat next to the pilot, and the therapist is sitting in the back
seat. The pilot is informed about flying phobia and instructed how to answer the patient’s
 27

questions. He should only give technical information and must not say, e.g. “This is not
dangerous”, since that kind of reassurance only prevents the patient from getting information
that can correct their misconceptions. The therapist is leading the team and works with the
patient’s cognitions and behavior during the session. Examples of exposure situations are
going through the check-list, taxing, taking-off and landing immediately (just 1 m up), flying
one circle around the airport, flying a longer distance, etc.

Other specific phobias

The 1-session treatment has also been used clinically for phobia of mice and rats, dogs, cats,
horses, cows, frogs, worms, hedgehogs, ants, and various insects. Besides these animal
phobias there are examples of its use for phobia of heights, choking, vomiting, thunder and
lightning, and deep water. The principles for using the 1-session treatment are the same
irrespective of the content of the specific phobia and the above descriptions should be enough
for an experienced cognitive-behavior therapist to “translate” and adjust them to any specific
phobia not detailed above.

POST-TREATMENT
The maintenance program
General overview. The maintenance program is introduced when the patient returns
for the post-treatment assessment, usually one week after the therapy session. First one should
review what has happened during the treatment, starting by describing what the patient's
problems looked like when he/she came for treatment. Then the patient should repeat the
rationale for the treatment, and how that tied in with his/her phobic problems. Next follows a
brief repetition of the different steps included in the treatment and a thorough description of
how the patient's phobic problems changed during the treatment.
Maintaining the skill. If the treatment has been conceptualized as a method for
acquiring skills with which the patient can handle phobic reactions, then the importance of
maintaining that skill follows naturally. I often use the analogy of a person learning to drive a
car. After obtaining the driver's licence one is still not a very skilled driver. It is necessary to
continue driving a car to experience different traffic conditions, and to learn to handle these
effectively, progressively refining one’s skill. This reasoning is usually very easy for the
 28

patient to understand, and it then follows naturally that the same principles apply to the skills
acquired through treatment.
Anxiety is a normal reaction. Before starting to describe the actual maintenance
program it is worth re-emphasising to the patient that anxiety, in its many forms, is a natural
part of human life. Reference can be made to studies of the prevalence of anxiety problems in
the general population (e.g. Myers et al. 1984; Norton, Dorward and Cox 1986). Patients
often find these figures quite astonishing.
Thus, there is a high probability that the patient will experience some anxiety in the
future and because of this he/she needs to practice the skills acquired during treatment, in
order to be better able to use the skills should it be necessary to do so. It is, however, not
necessary to practice as much as during treatment session per se, just to follow the program
agreed with the therapist.
Setback versus relapse. Many anxiety patients have a marked tendency of thinking in
all-or-nothing terms. This is manifested in them not being able to differentiate between a
setback and a relapse, or in believing that having got rid of the panic attacks they will never
experience anxiety again. If this is the case one should emphasize that there is no treatment
available today, and there probably will not be one in the future, that can vaccinate a person
against anxiety.
It is of utmost importance to describe to the patient, and make sure that he/she
understands, the difference between a setback and a relapse. A setback is a temporary failure
to manage a situation in which one has experienced anxiety before the treatment but which
one has managed after treatment for quite a while. A relapse, on the other hand, means that
the patient is back to square 1, i.e. experiences as much anxiety and in as many situations as
before the start of treatment. Thus, there is a huge difference between a setback and a relapse,
and it is up to the patient to prevent the setback from developing into a relapse, or to deal with
it in an efficient way. I have often found it useful to set it up as a choice that the patient now
has, which he/she didn't have before treatment, between continuing on the "right road", i.e.
coping with anxiety when it occurs, or giving in and going back to the former state when the
anxiety reactions where directing the patient's life. In this way it is fairly easy to get the
patient committed to the necessity of maintaining the anxiety management skill.
What to do in case of a setback. Before describing what to do in case of a setback it is
often helpful to review with the individual patient what the high-risk situations for a setback
in are. Examples of such situations might be holidays, illnesses, conflicts at work or with
 29

spouse, etc. Alerting the patient to the possibility of setbacks in such situations may make
him/her better prepared to deal with them effectively.
It is useful to give the patient a list of instructions (see Table 1) to follow in case of a
setback. Take, for example, a claustrophobic patient who after treatment has been able to ride
elevators without problems for a number of months. One day she/he suddenly gets a strong
anxiety reaction in the elevator, gets off prematurely, and after a long rest takes the stairs to
the ground floor. For this patient the instructions should be first to repeat practising the skill
learned during therapy in the safety of her home, and then to try the same situation again as
soon as possible, while being prepared to apply the skills if necessary.

Table 1: Instructions on what to do when a setback occurs

1. Tell yourself that this is what the therapist said would occur sooner or later, and it's not a catastrophe. It is not
a relapse, but a temporary failure to manage a situation that you have managed before.
2. Restrict the setback, i.e. don't let it spread to similar situations.
3. Rehearse the coping-skill you acquired during therapy in a non stressful situation.
4. Enter the setback situation as soon as possible, and focus your attention on the very first signs of anxiety
coming on.
5. Apply your coping-skill as soon as you feel the first anxiety signals. Keep applying it and stay in the situation
until the anxiety reactions dissipate.
6. Leave the situation when the anxiety is reduced, and when you have finished your business there.
7. If this doesn't work plan to try a somewhat easier situation by thinking back on what happened during
the treatment.
8. If it works go back to the setback situation and repeat steps 4-6.
9. If this still doesn't work, call the therapist as soon as possible to discuss the problem or to arrange for an extra
therapy session.

If this doesn't work, either because the patient has another anxiety reaction or can't
bring themselves to try it, a different strategy is in order. The patient should try to remember,
or otherwise figure out, what could be a somewhat easier situation to enter, in order to prevent
generalization and demonstrate to oneself that the anxiety is restricted to the first situation. If
even this presents problems the patient is instructed to call the therapist as soon as possible,
not running the risk of allowing difficulties to generalize to a wider range of situations. Often
the problems can be sorted out on the phone and the patient can be provided with additional
hints for coping with the problematic situations. The therapist can question the patient in such
a way as to help them generate their own solutions from their existing repertoire. If this is not
effective a booster session should be given as soon as possible, followed by telephone
contacts for a few weeks.
Forms for maintenance practice. At the last session the patient is provided with a set
of forms (see Figure 2) for recording the continued maintenance practice for a 6-month
 30

period. These forms are filled out and mailed to the therapist every 4 weeks for 24 weeks.
Upon receiving a form from the patient the therapist calls him/her up and talks about what has
happened in terms of anxiety reactions and applying the learned skill. This usually takes 10-
15 min. Sometimes the therapist writes a letter with his/her comments.
In the top of the form the therapist fills out (for the first 4-week period) what
maintenance practice the patient is supposed to engage in and how often (left part), and what
consequences this will have for the patient's daily life. The subsequent forms are filled out by
the patient in connection with the telephone calls so that further improvement after the end of
treatment can be incorporated in the maintenance program. Otherwise some patients might
not consider the possibility of gradually confronting more difficult situations.
In the bottom part of the form the patient records each day which of the tasks have
been performed. This allows the therapist to see if the patient avoids any of tasks, if one task
is done on certain days only, etc., and to calculate the percentage of agreed upon tasks that
actually has been performed. Previous research has found a significant correlation between
percent tasks performed and outcome at follow-up (Öst, 1996).

Outcome of randomized clinical studies

The 1-session treatment has been used in nine outcome studies on the following types of
specific phobias; spider phobia, individual treatment (Öst, Salkovskis & Hellström, 1991;
Hellström & Öst, 1995), spider phobia, group treatment (Öst, 1996; Öst, Ferebee & Furmark,
1997; Öst, Stridh & Wolf, 1997), injection phobia (Öst, Hellström & Kåver, 1992), blood
phobia (Hellström, Fellenius & Öst, 1996), flying phobia (Öst, Brandberg & Alm, 1997), and
claustrophobia (Öst, Alm, Brandberg & Breitholtz, 2001).
Before describing at the outcome of these studies it is important to take a look at how
the 1-session treatment is accepted by the patients in these studies. Table 2 shows that very
few patients (1.2% in total) decline to participate after being randomized to this condition and
none has dropped out of the treatment. These figures are as good, or better than those for the
5-session treatment which has been the comparison condition in most studies.
 31

Table 2: Acceptability of the 1-session treatment

Declining Dropping
Type of phobia n participation out
Injection 20 1 0
Blood 20 0 0
Flying 15 1 0
Claustro 15 0 0
Spider: Individual 27 0 0
Spider: Group 58 1 0
Snake 50 1 0
Dental 20 0 0
Various (in children) 110 0 0
Total 335 4 (1.2%) 0

To get a summary view of the efficacy of the 1-session treatments the proportion of
clinically significant improved patients are described using the behavioral criteria outlined in
Table 3.

Table 3: Criteria used to assess clinically significant improvement (CSI)

Phobia Criterion
Injection Having a blood sample withdrawn
Blood Watching a videotape of thoracic surgery for 30 min
Flying Taking an unaccompanied flight from Stockholm and back. Flying time 90-120 min
Claustro Riding a small lift 18 storeys, or staying inside a small windowless toilet room 5 min
Spider Touching a spider (1 inch) with bare hands

Applying the criteria of Table 3 results in the proportions in Table 4. At post-

treatment the 1-session treatment gave nominally higher proportions than the 1-session
treatment for injection phobia, flying phobia, and claustrophobia, while it was lower for blood
phobia. At the 1 year follow-up assessment the 1-session treatment was nominally higher than
the 5-session conditions for injection phobia, blood phobia, and claustrophobia, while there
was no difference for flying phobia. However, in none of these studies did the differences
reach a statistically significant level. When it comes to spider phobia the 1-session treatment
was significantly better than a self-exposure manualized treatment, both at post- and follow-
up assessment.
 32

Table 4: Proportion of patients displaying clinically significant improvement

Type of phobia Post-treatment Follow-up 1 yr

1-S 5-S 1-S 5-S
Injection 95% 84% 95% 84%
Blood 90% 93% 100% 90%
Flying 93% 79% 64% 64%
Claustro 80% 63% 80% 63%
Spider: Individual 89% 31% (SE) 93% 37% (SE)
Spider: Group 74% — 86% —
Snake 75% — 75% —
Dental 80% 85% 80% 85%
Various 78% — 82% —

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phobia. Behaviour Research and Therapy, 1996, 34, 101-112.

Hellström, K. & Öst, L-G. One-session therapist directed exposure vs. two forms of manual directed self-
exposure in the treatment of spider phobia. Behaviour Research and Therapy, 1995, 33, 959-965.

Öst, L-G. One-session treatment for specific phobias. Behaviour Research and Therapy, 1989, 27, 1-7.

Öst, L-G. A maintenance program for behavioral treatment of anxiety disorders. Behaviour Research and
Therapy, 1989, 27, 123-130.

Öst, L-G. One-session group treatment of spider phobia. Behaviour Research and Therapy, 1996, 34, 707-715.

Öst, L-G., Alm, T., Brandberg, M. & Breitholtz, E. One vs. five sessions of exposure and five sessions of
cognitive therapy in the treatment of claustrophobia. Behaviour Research and Therapy, 2001, 39, 167-183.

Öst, L-G., Brandberg, M. & Alm, T. One vs. five sessions of exposure in the treatment of flying phobia.
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Öst, L-G., Ferebee, I. & Furmark, T. One-session group therapy of spider phobia: Direct vs. indirect treatments.
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Öst, L-G., Hellström, K. & Kåver, A. One vs. five sessions of exposure in the treatment of injection phobia.
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Öst, L-G., Salkovskis, P. & Hellström, K. One-session therapist-directred exposure vs. self-exposure in the
treatment of spider phobia. Behavior Therapy, 1991, 21, 407-422.

Öst, L-G., Stridh, B-M., & Wolf, M. A clinical study of spider phobia: prediction of outcome after self-help and
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Öst, L-G., Svensson, L., Hellström, K., & Lindwall, R. One-session treatment of specific phobias in youth: A
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