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Clinical update Amy Wenzel, PhD S a b i n e P. S c h m i d , P h D A a r o n T. B e c k , M D Phobias Scope of the Problem A phobia is a persistent, excessive fear of a particular object or situation that causes avoidance, distress, and life interference. Specific phobias are among the most common psychiatric disorders, with 11% of the population meeting diagnostic criteria for specific phobia at any time in their life (Kessler et al., 1994) and 5.5% of the population meeting diagnostic criteria for specific phobia within a 30-day period (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996). There is little debate among clinicians regarding the most straightforward way to treat phobias, as most clinicians accept that treatment involves some sort of systematic exposure to the feared object or situation in order to achieve reasonable success (Antony & Barlow, 2002). In fact, very shortterm treatment (one to five sessions) is associated with clinically significant, long-lasting changes in up to 90% of cases (Öst, 1989; Öst, Brandberg, & Alm, 1997). Despite the fact that specific phobias are so common and that well-articulated treatment protocols are readily available, practitioners often experience uncertainty when they encounter a client with a specific phobia. For example, specific phobias are common in the general population, but rarely do individuals with specific phobias seek treatment for this problem (Kessler et al., 1999). Thus, clinicians are infrequently called upon to provide treatment. When individuals with specific phobias are indeed in treatment, it is usu- 36 Fa m i ly Th e r a p y m a g a z i n e ally for a psychiatric problem that is judged to be of greater severity (Sanderson, DiNardo, Rapee, & Barlow, 1990). It would follow that these particular clients are likely to present with a complex array of psychiatric symptoms that may or may not complicate the course of standard treatment for specific phobia. Clinicians often operate under the assumption that specific phobias are less severe than other psychiatric disorders. Indeed, this is often the case, as the fears are circumscribed enough that most individuals with specific phobias can arrange their lives so that they can easily avoid encounters with feared objects or situations (Antony & Barlow, 2002). Nevertheless, it is important for clinicians to be aware of the potential for pervasive life interference that can result if specific phobias are untreated. The consequences of specific phobias often manifest themselves more saliently when an individual experiences a major life transition where he or she can no longer avoid the phobic object or situation. For example, an individual with a driving phobia might suddenly spend hours to avoid certain highways or bridges when she takes on a new job at a different location. A dental phobic might develop major dental problems because he avoided routine maintenance for several years. There is very little research and discourse on the effects of specific phobias on relationships and family functioning. However, our clinical experience suggests that specific phobias can take on a profound role in a relationship culture or family system. Many of our adult clients with specific phobias describe conflicts with their partners over avoidance of phobic objects or situations. In extreme cases (e.g., a housebound agoraphobic woman whose husband assumes the role of care provider), a power imbalance can emerge which enables the partner of the phobic individual to assume substantial control in the relationship and the phobic individual to continue his or her passive avoidance under the guise of being “cared for” by the partner (Jackson & Wenzel, 2002). Many families of children with specific phobias have created elaborate, time-consuming rituals to structure the phobic child’s environment so that the child either successfully learns to deal with the phobia, or so that the family can avoid a “scene” involving the phobic stimulus. Thus, a specific phobia in any one family member has the potential to complicate family interactions, roles, and dynamics. Following is up-to-date information about the nature, assessment, and treatment of specific phobias, with consideration of the manner in which specific phobias affect close relationships and can be addressed from an interpersonal approach. Etiology It is important to understand the current thinking on the etiology of specific phobias, as many clients ask questions such as, “How did I [or my child] get this?” or “Why am I [or is my child] like this?” Historically, and from a behavioral perspective, it was thought that phobias developed through a two-stage process (Mowrer, 1939). That is, first the individual associates an aversive stimulus with a previously neutral stimulus, such that the neutral stimulus now is associated with a fear response (i.e., classical conditioning). Second, the individual avoids the phobic stimulus, which provides negative reinforcement because avoidance behavior is associated with relief and prevents him or her from experiencing fear and distress that would otherwise occur (i.e., operant conditioning). However, recent research suggests that this theory only characterizes a minority of individuals with specific phobias, as many phobic individuals do not recall a traumatic experience with the feared object or situation (Poulton, Davies, Menzies, Langley, & Silva, 1998). Instead, they often report that they have “always” been fearful or that the fear gradually developed into a phobia. Contemporary theory and research suggests that an interplay of factors contributes to the development of specific phobias. Kendler, Karkowski, and Prescott (1999) calculated heritability estimates ranging from 46% to 59% for particular classes of specific phobias. According to Antony and Barlow (2002), it is likely that a predisposition to specific fear-relevant reactions (e.g., a low threshold for an alarm response, a tendency to feel faint around blood or needles) is the particular characteristic that is inherited. But just as important to the development of specific phobias are unique or individual-specific environmental experiences (Kendler et al., 1999; Page & Martin, 1998). These unique experiences might involve a traumatic encounter with the feared stimulus, but they also could include observational learning (e.g., watching someone else react fearfully in the presence of a feared stimulus) or learning from information (e.g., reading about the danger of a feared stimulus) (Rachman, 1977). All of these experiences contribute to the development of beliefs that a particular stimulus is dangerous, that it is imperative to be on guard for a potential encounter with the stimulus, and that the individual does not have the resources to deal effectively with an encounter with the stimulus (Beck & Emery, 1985). The phobic individual places exaggerated importance on the aversiveness of the stimulus, which contributes to anxious apprehension about future encounters (Antony & Barlow, 2002; Beck & Emery, 1985). Thus, when clinicians are asked about the etiology of specific phobias by clients, they can explain that biological vulnerabilities prime individuals to have specific anxiety responses to actual or observed encounters with phobic stimuli or learned information about phobic stimuli, which in turn contribute to the development of maladaptive beliefs about the amount of danger posed by the stimulus, the frequency with which they will encounter the stimulus, and their ability to cope with the stimulus. Diagnostics Although the central feature of phobias is irrational fear, it has long been recognized that phobias are heterogeneous with regard to their clinical presentation and associated features (Marks, 1970). When the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association [APA], 1980) was introduced, the category of phobic neurosis was divided, such that agoraphobia and social phobia were separated from other phobias. Agoraphobia involves fear and avoidance of being in situations where escape might be difficult or help may not be available should a panic attack occur, and social phobia involves fear and avoidance of social and evaluative situations due to the possibility of embarrassment, humiliation, or negative evaluation. These disorders are viewed as comprising a broader range of symptoms and as being associated with more functional interference than specific phobias. Thus, theory and research about specific phobias applies to these conditions, but clinical scientists typically regard them as distinct diagnostic categories that have extensive literatures of their own. The DSM-IV (APA, 1994) specifies seven criteria, all of which must be satisfied, for an individual to be diagnosed with specific phobia. First, the individual must experience fear cued by the presence or anticipation of a specific object or situation that is marked, persistent, and excessive or unreasonable (Criterion A). In addition, exposure to the feared stimulus must almost invariably provoke an immediate anxiety response, which may take the form of a situation-specific panic attack (Criterion B). The person, if an adult, must recognize the fear as excessive or unreasonable (Criterion C). The feared situation or object must be avoided or endured with extreme distress (Criterion D). The avoidance, anxious anticipation, or distress in the feared situation(s) must interfere significantly with the person’s functioning, or the person must report marked distress about having the phobia (Criterion E). In individuals under age 18, the duration must be at least 6 months (Criterion F). Finally, the symptoms cannot be better accounted for by another mental disorder (Criterion G). The requirement of insight into the unreasonableness or excessiveness of the fear was introduced in order to distinguish phobias from delusional fears, for which insight is lacking. In actuality, insight has been shown to j u ly a u g u s t 2 0 0 6 37 Clinical updat e 38 Fa m i ly Th e r a p y m a g a z i n e tain animal phobias, but not the other subtypes, experience disgust and repulsion in addition to fear (Tolin, Lohr, Sawchuk, & Lee, 1997). Moreover, BII phobias differ from all of the other types in the unique constellation of physiological symptoms. Whereas most phobias typically are associated with higher heart rates and primarily sympathetic activity upon exposure to the feared stimulus (Friedman, Thayer, Borkovec, & Tyrrell, 1993), BII phobias are associated with only a brief initial increase in arousal (typically lasting a few minutes or less), followed by a sudden fall in heart rate and blood pressure below baseline and frequently resulting in fainting (Thyer & Curtis, 1985). Assessment When screening for phobias, clinicians may start with a question such as, “Do you experience fear or discomfort when you are confronted with any of the following objects or situations: spiders, snakes, insects, other animals, closed places such as tunnels or elevators, water, heights, driving, flying, blood, injections, dental treatment, or other situations or objects?” (Antony, 2001a). Additional probing should determine the intensity and reasonableness of the fear, degree of avoidance, and degree of distress and functional impairment. Semistructured interviews such as the Structured Clinical Interview for DSM-IV (First, Spitzer, Gibbon, & Williams, 1994) and the Anxiety Disorders Interview Schedule for DSM-IV (Brown, DiNardo, & Barlow, 1994; DiNardo, Brown, & Barlow, 1994) systematically and comprehensively cover diagnostic criteria and may aid in the evaluation process. For treatment planning, a thorough inventory of fear-related thoughts, safety behaviors, and Specific Phobia in children It is important to distinguish phobias, which are excessive, persistent and maladaptive fears that cause marked distress or disruption in functioning, from developmentally appropriate childhood fears, which tend to dissipate within months (Bauer, 1976). Age-appropriate and relatively common fears in children include those related to the loss of nurturing, unfamiliar people, and loud noises (infancy); imaginary creatures, small animals, and the dark (early childhood); school and achievement (during school years); and those related to social life and bodily injury (later childhood and adolescence) (Silverman & Moreno, 2005). Although most childhood fears dissolve without intervention, some fears may develop into phobias, particularly if the child avoids the feared object or situation and fails to have corrective learning experiences. Epidemiological studies estimate that approximately 5% of children and adolescents in the United States suffer from specific phobia at any given point in time (Ollendick, Davis, & Muris, 2004). Animal phobias typically develop around age 6 or 7, and situational, blood, and dental phobias typically develop between ages 9 and 12 (Öst, 1987; Kendler, Neale, Kessler, & Heath, 1992). The onset of social phobia, claustrophobia, and agoraphobia is typically in adolescence or later (Öst, 1987). When left untreated, specific phobias tend to take a rather chronic course and may outlast many other psychiatric disorders (Barlow, 2002). As with adult treatment for specific phobias, “real life” exposure is considered an important ingredient of successful treatment. Given that children might be especially reluctant to engage in “real life” exposure, it is important that they have a sense of control over the frequency and duration of exposure exercises. In addition, the use of contingency management procedures (or reinforced practice) and modeling—directly by the therapist or indirectly using videos—may also be beneficial. Involvement of caregivers and the consideration of family influence and dynamics are advisable in the assessment and treatment for childhood phobias. A child’s phobia may disrupt family functioning, such as by preventing joint family activities that involve the feared stimulus. Therefore, psychoeducation of family members regarding the nature, maintenance, and treatment of the disorders, as well as their assistance in exposure exercises and contingency management plans, may be critical in breaking the vicious phobia cycle. Wide Group/Getty Images vary greatly among individuals with phobias. For example, as recognized in the DSM-IV, insight may be limited in children, which is why this requirement applies only to adults. Moreover, recent studies indicate that a large number of individuals who would otherwise qualify for a diagnosis of specific phobia may be excluded because they do not view their fear as excessive (Jones & Menzies, 2000). Thus, it is important for clinicians to understand the rationale for the insight criterion and use their clinical judgment in assigning a diagnosis of specific phobia in cases of excessive fear and avoidance of a non-delusional quality. The DSM-IV defines five categories of phobias: (1) animal type, which includes fears of spiders, snakes, cats, dogs, mice, birds, and other animals; (2) natural environment type, which includes fears of being near water, storms, and high places; (3) blood-injection-injury (BII) type, which includes fears of seeing blood, medical procedures, and injuries, receiving injections, and having blood drawn; (4) situational type, which includes fears of driving, flying, and being in enclosed spaces; and (5) other type, which includes fears of vomiting, choking, loud sounds and other residual fears not belonging to any of the other categories. The distinction among subtypes is partially supported by statistical covariation, such that fears within subtypes generally co-occur more frequently than fears across subtypes (Öst, 1992). In addition, subtypes differ along other clinically relevant dimensions such as age of onset, severity, focus of apprehension (i.e., interoceptive versus external triggers), and physiological response (Hugdahl & Öst, 1985; Craske et al., 1996; Marks, 1988). For instance, individuals with BII phobias and cer- Phobias avoidance strategies (both overt and more subtle ones) is essential. Not only are phobic thoughts and behaviors targets of treatment, but subtle avoidance behavior, such as averting one’s gaze at the sight of the phobic stimulus, if unrecognized, may undermine exposurebased interventions. A number of self-report inventories assess fear and avoidance of particular objects and situations. The 72-item Fear Survey Schedule–III (FSS–III) (Wolpe & Lang, 1964, 1969) and the extended 108-item version of the FSS-III (Wolpe & Lang, 1977) are among the most popular screening tools for phobias in both clinical and research settings. The scales list a large range of specific objects and situations and clients rate the intensity of fear they associate with each item on a five-point Likert scale. In addition, many clinical scientists have developed self-report inventories to capture fearfulness and avoidance of stimuli related to particular specific phobias. There are a number of inventories that target various animal phobias (e.g., spider phobia, snake phobia, dog phobia) and BII and medical phobias. In contrast, there is only one published self-report inventory that targets natural environment phobias (i.e., heights) and only a handful that target situational phobias, most of which focus on claustrophobia and one focuses on the fear of flying. A comprehensive description of self-report inventories assessing aspects of specific phobias can be found in Antony (2001a, b) and in McCabe and Antony (2002). Perhaps the most accurate way to obtain a clear understanding of the severity of a client’s specific phobia is to observe him or her first-hand in the presence of the phobic object or situation using a Behavioral Approach Test (BAT) (Antony & Swinson, 2000). A Progressive BAT requires the client to gradually approach a feared stimulus while the clinician records variables such as the number of steps taken toward the stimulus, self-reported level of anxiety on a 0-100 scale, self-reported fearrelevant cognitions, subtle avoidance behaviors (gaze aversion), and physiological reactivity (heart rate). A Selective BAT requires the client to generate a list of feared situations (i.e., exposure hierarchy; see description below), and the same variables as in the Progressive BAT are measured. In addition to providing clinicians with a thorough understanding of the extent of their client’s specific phobias, BATs are used to individually tailor treatment (such as by establishing an exposure hierarchy), track progress, and evaluate the success of treatment (Antony, 2001a; Barlow, 2002). Treatment Options Most clinicians agree that some type of exposure to the feared stimulus is necessary for the treatment of specific phobias (Antony & Barlow, 2002). Imaginal exposure involves exposure to vivid images of feared stimuli, whereas in vivo exposure involves actual encounters with feared stimuli. An early exposure treatment for specific phobias, systematic desensitization, required clients to imagine a graded hierarchy of feared stimuli while simultaneously engaging in muscle relaxation. This treatment was grounded in behavioral theory, as it was reasoned that the pairing of relaxation with images of the feared stimulus would extinguish the fear response. However, few clinicians currently use systematic desensitization in the treatment of specific phobias, as in vivo exposure is both more effective and more time efficient (Marks, 1987), and some empirical research suggests that adding relaxation to exposure protocols does not result in increased effectiveness (Öst, Lindahl, Sterner, & Jerramalm, 1984). Although the central feature of in vivo exposure is that it involves an actual encounter with the stimulus, there is tremendous variation in its particular implementation. For example, we know that massed exposure (e.g., 10 daily sessions) is more effective in reducing phobic symptoms than spaced exposure (e.g., 10 weekly sessions) (Foa, Jameson, Turner, & Payne, 1980). Data from recent studies suggest that an expanding-spaced exposure protocols (where sessions begin close together and are gradually spaced out throughout the course of treatment) are beneficial because they provide optimal circumstances for the initial reduction in fear, but also reduce the probability of a return of fear following treatment (Rowe & Craske, 1998a). In addition, exposure appears to be most effective when sessions occur in a variety of different contexts and using a variety of different feared stimuli in order to ensure that reduction in fear generalizes to multiple settings and stimuli (Bouton, Mineka, & Barlow, 2001; Rowe & Craske, 1998b). Moreover, cliniciandirected exposure is significantly more effective than self-directed exposure (Öst, Salkovskis, & Hellström, 1991). What, then, is the optimal approach to conducting in vivo exposure with a specific phobic client? If the clinician has an ample chunk of time with the client, there is evidence that a single 3-hour session is sufficient for clinically significant reductions in fear in 95% of clients (Öst, 1996). If the clinician has the more typical 50-minute time slot with the client, then as few as five sessions will achieve clinically significant results, particularly when sessions are spaced relatively close to one another. It is also recommended that clinicians facilitate exposure to a number of different feared stimuli in order to promote generalization. Specific phobias can be treated either in individual or group format (Öst, 1996); if a group format is chosen, then it is pertinent that the clinician ensures that each client has ample direct exposure with the phobic stimulus (Öst, Ferebee, & Furmark, 1997). Regardless of the particular schedule of exposure sessions, it is crucial that clients continue the exposure exercise until their fear decreases rather than escape the situation (Antony & Barlow, 1998). In addition to in vivo exposure, there are other empirically supported treatments for specific phobias that are relevant for use in particular circumstances. As discussed, BII phobia is associated with a unique constellation of physiological symptoms, such that the majority of these clients experience fainting due to parasympathetic activation rather than a fight/flight response due to sympathetic activation. Applied tension is a treatment approach that involves training clients to tense their muscles in order to increase their blood pressure and thereby prevent fainting. Once clients learn applied tension skills, they are presented with BII stimuli and instructed to use the skills to prevent phobic responses. Fear and fainting associated with BII phobia are typically reduced after one session of applied tension (Hellström, Fellenius, & Öst, 1996), and there is evidence that it is associated with a greater reduction in BII phobic symptoms than in vivo exposure alone (Öst, Fellenius, & Sterner, 1991). Regardless of the particular in j u ly a u g u s t 2 0 0 6 39 Clinical updat e 40 Fa m i ly Th e r a p y m a g a z i n e quent sessions, the client undergoes systematic exposure to the items included on the exposure hierarchy, beginning with the easiest items and progressing through the more difficult items. Clients are encouraged to engage in structured exposures to feared stimuli in between sessions. Antony and Barlow (1998) suggest that this approach to in vivo exposure is successful in treating many of their clients in 1–5 ses- sions. However, they acknowledge that other clients benefit from adjunctive cognitive restructuring. Cognitive restructuring for specific phobias involves three components. First, clients are encouraged to learn everything they can about the phobic stimulus in order to develop a sense of controllability and predictability. Second, clients develop strategies to address probability overestimation, which occurs when they assign an unre- Nico Kai/Getty Images vivo exposure therapy protocol, evidence is accumulating that change in anxious cognitions is associated with fear reduction during treatment (Shafran, Booth, & Rachman, 1993). Thus, it is logical that cognitive therapy would be an effective approach in modifying distorted beliefs about phobic stimuli, as it would directly influence the course of fear reduction. The small number of studies that have examined cognitive therapy in the treatment of specific phobias suggests that it is more effective than psychoeducation (de Jongh et al., 1995), and that it is equally effective as relaxation (Craske, Mohlman, Yi, Glover, & Valeri, 1995). One study, however, found cognitive strategies in the absence of behavioral experiments less effective in reducing phobic symptoms than in vivo exposure (Booth & Rachman, 1992). In all, cognitive therapy appears to be an efficacious treatment for specific phobia, but that in vivo exposure appears to be the key ingredient for evaluating fearrelevant cognitions. Recently, Antony and colleagues developed a combined cognitive behavioral protocol for the treatment of specific phobias that integrates a number of behavioral and cognitive strategies to address the full range of behavioral, cognitive, emotional, and physiological phobic symptoms (see Antony & Barlow, 1998, for a description). In the early sessions of this protocol, clients are oriented to the treatment and are guided in defining the parameters of their specific phobia (e.g., thoughts, feelings, and physiological symptoms associated with the phobia; avoidance, safety seeking, and protective behaviors). In addition, the client and clinician develop a list of 10–15 feared situations in order of difficulty, called an exposure hierarchy. In subse- alistically high likelihood that some predicted event will occur (e.g., that they will have an automobile accident). For example, the clinician assists clients in examining the evidence that supports and refutes that prediction or in identifying realistically the probability that the negative event will occur. Third, clients develop strategies to address catastrophic thinking, which occurs when they anticipate an excessively negative impact of a predicted event. In these instances, clinicians encourage clients to evaluate how bad the predicted event really would be; what, realistically, is the worst thing that could happen; and how they could cope with this event if it were to occur. All of the treatment strategies discussed up to this point occur in the context of individual psychotherapy. There is a small amount of literature that describes the manner in which partners and family members may assist in the treatment of an anxious client. Baucom, Shoham, Mueser, Daluto, & Stickle (1998) classified couple and family treatments for anxiety disorders into three broad types. Partner-assisted or family-assisted interventions (PFAIs) involve the partner or family member as a surrogate therapist or coach in treating the identified client. Disorder-specific couple or family interventions focus on the manner in which couple and family interactions serve to maintain and exacerbate symptoms in an identified client. Unlike PFAIs, these therapeutic interventions target relational issues, but only those issues that directly relate to the expression of the individual’s disorder. General couple or family therapy targets relationship and family system issues that may or may not directly relate to individual symptoms. Rarely has the efficacy and Phobias effectiveness of couple and family approaches to the treatment of anxiety disorders been examined in the empirical literature. Research conducted 10 to 20 years ago indicates that partnerassisted exposure therapy was equally as effective as other forms of exposure therapy in treating agoraphobic avoidance (Cobb, Mathews, Childs-Clarke, & Blowers, 1984; Emmelkamp, Van Dyck, Bitter, Heins, Onstein, & Eisen, 1992). Moreover, partner-assisted exposure provides the additional benefit of reducing marital distress as well as phobic avoidance (Cobb et al., 1984). One study found that adding a communication skills training component to partner-assisted exposure for agoraphobia resulted in greater reductions in subjective anxiety and increased unaccompanied excursions compared to partnerassisted exposure with relaxation (Arnow, Taylor, Agras, & Telch, 1985). These results raise the possibility that teaching couples to discuss and solve problems in coping with their phobic symptoms can improve the effective- ness of an exposure intervention. To our knowledge, no systematic empirical investigation of partner- or family-assisted exposure in the treatment of specific phobias has been conducted. However, therapists can use the literature on PFAIs for other anxiety disorders as a guide in developing an evidence-based, partneror family-assisted intervention. Antony and Barlow (1998) noted that partners and family members can provide encouragement and model adaptive behavior during between-session exposure homework assignments. They suggested that partners and family members attend therapy sessions in order to understand the rationale for exposure, the components that make it successful (such as clients retaining control in behavioral exercises), and therapist behaviors that are helpful (guidance, coaching, and support). Eventually, however, the goal is for phobic clients to conduct exposure exercises on their own so that they do not rely on their partner or family members as a “safety signal.” Terminology Behavioral Approach Test (BAT). A tool used to assess a client’s behavior and level of anxiety as he or she approaches a feared object or situation. In Vivo Exposure. “Real life” exposure to a feared object or situation. Imaginal Exposure. Exposure to a feared object or situation that occurs through vivid images. Systematic Densensitization. A type of imaginal exposure in which the client imagines feared objects or situations while relaxing. Exposure Hierarchy. A list of feared situations ranging from the easiest to most difficult that is used to guide exposures in session. Applied Tension. A treatment for blood-injury-injection phobia in which the client is taught to tense his or her muscles in the presence of feared stimuli in order to prevent fainting. Partner or Family Assisted Exposure (PFAI). Inclusion of a partner or family member in exposure therapy so that he or she can serve as a “coach” as the phobic individual attempts exposurebased homework assignments between sessions. Antony, M. M. (Ed.). (2001b). Summary Phobias are a heterogeneous group of disorders that are best understood and conceptualized by an interplay of biological, cognitive, and behavioral components. Specific phobia is a common psychiatric disorder that is very responsive to systematic behavioral or cognitive behavioral interventions involving in vivo exposure components. A person might consider seeking treatment for a phobia if he or she notices disruption in his or her normal routine or functioning associated with lowered life satisfaction. The idea of in vivo exposure might be threatening to a phobic individual, as it involves prolonged encounters with feared objects and situations. However, in vivo exposure is extremely effective because phobic clients (a) have clear expectations for treatment and have control over the speed with which they approach the feared stimuli; and (b) learn first-hand that there is little danger associated with feared stimuli. Although in vivo exposure has proven effective in individual psychotherapy, marriage and family therapists might involve partners and/or other family members to “coach” clients in exposure exercises assigned as homework between sessions. Professional Resources Books and Workbooks Antony, M. M. (Ed.). (2001a). Specific phobia: A brief overview and guide to assessment. In M. M. Antony, S. M. Orsillo, & L. Roemer (Eds.), Practitioner’s guide to empirically based measures of anxiety. AABT clinical assessment series. (pp. 127-132). Dordrecht, Netherlands: Kluwer Academic Publishers. Measures for specific phobia. In M. M. Antony, S. M. Orsillo, & L. Roemer (Eds.), Practitioner’s guide to empirically based measures of anxiety. AABT clinical assessment series. (pp. 133-158). Dordrecht, Netherlands: Kluwer Academic Publishers. Provides practitioners with a guide for an empiricallybased assessment of specific phobia, including screening questions. Antony, M. M., & Barlow, D. H. (2002). Specific phobias. In D. H. Barlow (Ed.), Anxiety and its disorders, second edition: The nature and treatment of anxiety and panic, (pp. 380-417). New York: The Guilford Press. A comprehensive chapter on diagnostics, etiology, assessment, and treatment of specific phobias written by two leading experts. It reviews the most recent empirical research and resources. Antony, M. M., & Swinson, R. P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association. This book describes empirical literature on the diagnostics, etiology, epidemiology, and empirically-validated treatments of phobic disorders and panic. It contains a chapter on specific phobia. Beck, A. T., Emery, G., & Greenberg, R. L. (1985). Anxiety disorders and phobias: A cognitive perspective. Cambridge, MA: Basic Books. This classic and highly influential book (newly edited in 2005) focuses on basic concepts, etiology and treatment of anxiety disorders from a cognitive perspective. Bourne, E. J. (1998) Overcoming specific phobia—Therapist manual: A hierarchy and exposure-based protocol for the treatment of all specific phobias (best practices series). Oakland, CA: New j u ly a u g u s t 2 0 0 6 41 Clinical updat e Harbinger. Therapist guide involving specific instructions for an empirically-validated, 10-session, cognitive-behavioral treatment for specific phobias. It can be used in combination with the Overcoming Specific Phobia Client Manual by the same authors. Craske, M. G., Antony, M. M., & Barlow, D. H. (1997). Mastery of your specific phobia: Therapist guide. San Antonio, TX: Psychological Corporation Incorporated. This book contains general and session-by-session instructions on conducting cognitive-behavioral therapy for specific phobia. It is used with the Mastery of Your Specific Phobia Client Workbook. School of Medicine. Part of her research involves the investigation of cognitive biases in anxiety disorders and the understanding of mechanisms that underlie change in cognitive therapy for anxiety disorders. She has published over 60 articles and book chapters and is co-editor of Cognitive Methods and Their Application to Clinical Research (APA Books, 2005). Her research is currently funded by the National Institutes of Health, the National Alliance for Research in Schizophrenia and Depression, and the American Foundation for Suicide Prevention. Sabine P. Schmid, PhD is a post- Online Resources Anxiety Disorder Association of America (ADAA) www.adaa.org The ADAA is a professional organization that meets annually for scientific exchange of the latest research on all anxiety disorders. National Institute of Mental Health www.nimh.nih.gov Offers descriptions of symptoms and treatments of all major anxiety disorders including phobias (http://www.nimh.nih. gov/healthinformation/ anxietymenu.cfm?textSize=L) and includes information on new developments, statistics, and organizations related to phobias http://www.nlm.nih.gov/ medlineplus/phobias.html and other anxiety disorders (http:// www.nlm.nih.gov/medlineplus/ anxiety.html), as well as links to local resources including clinical trials involving free treatment. Amy Wenzel, PhD is research assistant professor of clinical psychology in psychiatry at the University of Pennsylvania 42 Fa m i ly Th e r a p y m a g a z i n e doctoral fellow at the University of Pennsylvania School of Medicine. She recently completed her graduate degree at Vanderbilt University, where she conducted research on perception biases in social anxiety, cognitive behavioral approaches to the understanding of depression and anxiety, and applications of the tripartite model of anxiety and depression to treatment outcome research. Aaron T. Beck, MD, university professor of psychiatry emeritus at the University of Pennsylvania School of Medicine, is the founder of cognitive therapy. He has received numerous awards for his work, including research awards from the American Psychiatric Association, the American Psychological Association, and the Institute of Medicine. He has also been listed as one of the 10 Americans with the greatest influence in the history of American psychiatry. Dr. Beck is the author or co-author of over 500 publications, including 17 books. His cognitive therapy, the most heavily researched form of psychotherapy, represents a major advance in the understanding and treatment of a variety of psychiatric disorders including affective disorders, anxiety disorders, substance abuse, personality disorders, and schizophrenia. References American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders, third edition: DSM-III. Washington, DC. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition: DSM-IV. Washington, DC. Antony, M. M., & Barlow, D. H. (1998). Specific phobia. In V. E. Cabalto (Ed.), International handbook of cognitive and behavioural treatment for psychological disorders (pp. 1-22). Oxford: Pergamon/Elsevier Science Ltd. Antony, M. 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September 1–30 National Alcohol and Drug Addiction Recovery Month Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment (800) 729-6686 [email protected] www.recoverymonth.gov 10 World Suicide Prevention Day International Association for Suicide Prevention Screening for Mental Health, Inc. (781) 239-0071 [email protected] www.stopasuicide.org October 1–7 Mental Illness Awareness Week National Alliance on Mental Illness (800) 950-NAMI www.nami.org 1–7 Mental Illness Awareness Week (Canada) Canadian Alliance on Mental Illness and Mental Health [email protected] www.miaw-ssmm.ca 5 National Depression Screening Day Screening for Mental Health, Inc. (781) 239-0071 [email protected] www.mentalhealthscreening.org 10 World Mental Health Day World Federation for Mental Health [email protected] www.wmhday.net The AAMFT offers a variety of consumer brochures that can be used in your office (with space on the back for your stamp or business card), or used in direct mail marketing for your practice. Please contact [email protected] to order brochures on Alcohol Problems, AD/HD, Bipolar Disorder, Bipolar Disorder in Children and Adolescents, Borderline Personality Disorder, Children of Alcoholics, Depression, Mental Illness in Children, Obsessive Compulsive Disorder, Panic Disorder, Postpartum Depression, Schizophrenia, Substance Abuse and Intimate Relationships, Suicide Ideation and Behavior, and Suicide in the Elderly. Over 40 titles are available.