This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of conducting exposure, and a supervision framework. It replaces neither your clinical judgement nor your professional responsibility. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself.
1. The programme at a glance
Indication. Established specific phobia in adolescents and adults, and in children from about seven years old with the adaptations of section 35: marked and disproportionate fear of an object or situation, avoidance or endurance at the cost of distress, and an impact on the person's life.
Reference model. In vivo exposure, conducted along inhibitory learning lines: the aim of each exposure is not to bring anxiety down but to disconfirm a precise prediction. To this are added the systematic removal of safety behaviours, the variation of contexts, and — for blood and injections only — applied tension.
Format. Eight sessions. Sessions 3 to 6 last 90 minutes: an exposure that stops after twenty minutes because the session is over teaches exactly the opposite of what you want to teach. Sessions 1, 2, 7 and 8 last 50 minutes. Two follow-ups, at one month and at three months. A three-hour single-session format exists and has been evaluated: section 13 says when to prefer it.
Target mechanism. To have the person discover, through experience and not through reasoning, that what they predict does not happen, or that if it does happen they can bear it. We are not trying to reassure them, nor to teach them to relax, nor to wait for the fear to fall away: we are trying to create the largest possible gap between what they expected and what they get.
| Session |
Subject |
Session output |
| 1 |
Assessing and sorting |
Sorting done, behavioural test, baseline measure |
| 2 |
The formulation and the hierarchy |
Written hierarchy, predictions formulated |
| 3 |
The first exposure |
One prediction disconfirmed, with figures |
| 4 |
Varying and surprising |
Three variants, one organised surprise |
| 5 |
Removing the crutches |
Exposure with no safety behaviour at all |
| 6 |
The worst case |
The feared situation faced in full |
| 7 |
Generalising |
Three new contexts, exposure done alone |
| 8 |
Review, relapse, maintenance |
Written plan, behavioural test repeated |
What the person takes away. Seven printable worksheets, listed in section 38 and downloadable from this page: my situations, my ladder, what I predict, my crutches, my exposure log, the corner for those close to me, my plan for what comes next.
What sets this programme apart from the other anxiety manuals on this site. Three things. The initial sorting, because four different disorders produce the same avoidance and three of them belong to another manual. The way exposure is conducted, which follows the inhibitory learning model rather than habituation — which changes the instructions, the stopping criteria and what you measure. And the place given to blood and injections, which are the one phobia where standard exposure can make things worse.
2. Before you begin
Who this programme is for
This text is addressed to psychologists, psychiatrists, psychotherapists and doctors trained in cognitive behavioural therapy. It assumes that you know how to conduct an exposure — that is, how to sit there while someone is very frightened, without reassuring them and without cutting it short.
It is not addressed to patients or to the people close to them. It contains procedures, thresholds and non-response criteria, and it describes exposures which, read by a phobic person with no support, would mostly produce anticipatory avoidance.
The question that comes first: is this really a specific phobia?
Four decisions are made before the first exposure. The first three are made in the first session.
What kind of avoidance is this? That is the sorting of section 3, and it is the question that governs everything else. Someone who avoids the lift because they fear a panic attack, someone who avoids it because they fear being shut in, and someone who avoids it because an assault took place in one are not treated in the same way.
Is it blood, injections or injuries? If so, what you do changes before the first exposure even begins. Section 5.
What is the real impact? A snake phobia in someone who lives in a city does not necessarily call for treatment; an injection phobia in someone due for surgery does, and quickly. Section 34 covers these situations.
What comes with it? Panic disorder, depression, another anxiety disorder, alcohol used as a crutch. Sections 8 and 9 give the differential diagnosis and the comorbidities.
What this programme does not treat
It does not treat agoraphobia. There the avoidance covers several situations linked by a common fear — not being able to escape or to be helped —, and the treatment differs in structure, even if it borrows the same tools.
It does not treat social anxiety. A young person who avoids the lift so as not to end up in it with a colleague does not have claustrophobia.
It does not treat post-traumatic stress disorder on its own. Avoidance of situations that recall a trauma is treated within trauma-focused care, and exposing without that can retraumatise.
It does not treat a proportionate fear. Someone who is afraid of driving after three accidents in two years, on a dangerous road, does not have a phobia: they have an accurate appraisal. Section 3 says so and section 37 returns to it.
What this programme is not
It is not a drug treatment, and section 14 says why the question arises so little here — and why, in this particular indication, a medication can actively harm the treatment.
It is not a relaxation method. Relaxation and controlled breathing are not part of the programme, and section 37 explains why that omission is deliberate.
It is not systematic desensitisation in the old sense, where you only move up a step once the previous one has become comfortable. Section 6 says what has replaced that rule, and why.
How to use it
Read the whole thing before the first session, particularly sections 3, 5, 6, 27 and 28: the sorting, the case of blood, the model, how to conduct an exposure, and safety behaviours. Those are the five places where an effective treatment becomes an ineffective one without anyone noticing.
Each session is described within the same frame: the aim, the sequence of steps, what you say, common mistakes, and the criterion for moving on.
Three warnings specific to this presenting problem.
It is the best-treated and the least-treated anxiety disorder. The effect sizes are among the largest in psychotherapy, and most of the people concerned never consult. Many come to you for something else, and the phobia is discovered in passing. Look for it.
Your own discomfort is the main limiting factor. The treatment consists in letting someone be very frightened in your presence without stepping in to soothe them. Most failed exposures fail because the therapist cut it short, reassured, or negotiated.
And you have to prepare the material. A spider phobia is not treated without a spider. Section 30 says what is used, what you ask the person to bring, and what virtual reality replaces.
3. Four situations not to be confused
This is the section that decides everything else, and it takes ten minutes. Four situations present with the same apparent symptom — someone avoids a precise situation — and three of them belong to a different treatment.
1. Specific phobia
What you observe. Fear triggered by an identifiable object or situation, almost immediate, disproportionate, with avoidance or very costly endurance. Away from the situation, the person is fine.
What goes with it. Anticipation that may be intense but stays focused: it is the flight that is dreaded, not the idea of leaving the house.
What that implies. This is the programme described here.
2. Panic disorder with situational avoidance
What you observe. The avoidance covers situations from which it would be hard to escape or to be rescued, and what is feared is not the situation itself but what might happen to the body: passing out, having a heart attack, going mad.
The question that settles it. "What exactly frightens you about the lift?" If the answer is "the lift, the idea of being shut in", it is a phobia. If the answer is "fainting, and nobody being able to get me out", it is panic disorder.
What that implies. Treatment first addresses the interpretation of bodily sensations, and interoceptive exposure has a place there that this manual does not describe.
3. Social anxiety
What you observe. Avoidance of a situation which, looked at closely, involves being watched. Eating in a restaurant, taking the lift with someone, driving while a passenger observes, going to the dentist and having to keep your mouth open in front of a stranger.
The question that settles it. "Would it be the same if you were completely alone?" If the fear disappears, it is not a specific phobia.
What that implies. A different protocol, and a hierarchy built out of social situations.
4. Trauma-related avoidance
What you observe. The avoidance is dated. It started after a precise event, and it comes with re-experiencing, nightmares, hypervigilance.
The question that settles it. "Since when? And what happened at that time?" A phobia that begins abruptly in an adult after an event should make you ask this.
What that implies. The trauma is treated in its own right, by a trained practitioner. Exposing directly to the avoided situation, outside that frame, can reproduce the traumatic experience instead of correcting it.
The three other things you have to have ruled out
Obsessive-compulsive disorder. Avoiding knives for fear of hurting someone, avoiding dirt for fear of contaminating, are not phobias. What points there: the fear is not about the object but about what the person might do or cause, and there are almost always rituals.
Health anxiety. Avoiding the hospital, medical documentaries, the words of illness, follows a different logic, and exposing without treating the hypochondriacal preoccupation yields nothing.
A proportionate fear. This is the easiest to miss because nobody thinks to look for it. Someone who is afraid of dogs because they have been bitten twice and who lives in an area where dogs roam free does not have a cognitive distortion. You help them, but not by proving that nothing will happen.
How you decide, in practice
Three questions, in the first session.
"What exactly would happen if you went?" This is the most productive question of the sorting. The answer almost always separates the four cases: the object itself, my body, what others think, what has already happened.
"Would it be the same if you were alone?" Separates phobia from social anxiety.
"Since when, and since what?" Separates phobia from post-traumatic avoidance, and picks out the abrupt onsets that deserve examination.
Mixed cases, which do exist
A long-standing phobia may become complicated by panic attacks, and someone with panic disorder may also have an unrelated dog phobia. You should neither file everything under one label nor multiply diagnoses.
The practical rule: treat first what costs the most, and check that the hierarchy you have built really matches the fear that was named. If the person is not progressing although the procedure is correct, the first thing to review is the sorting. Section 36.
4. The five types, and what they change
The classifications distinguish types of specific phobia. That division is not decorative: it changes the material, the duration, and — for one of them only — the technique.
The animal type
What you meet. Spiders, dogs, snakes, insects, mice, birds, cats.
What it changes. This is the type that responds fastest and best, and it is the one on which the single session has been most studied. It needs live material, and that takes preparation: see section 30.
What misleads. A dog fear that is in fact a fear of one particular dog, or an insect fear that covers disgust more than fear. Disgust is treated too, and it extinguishes more slowly than fear — saying so in advance avoids disappointment at the third session.
The natural environment type
What you meet. Heights, storms, water, darkness.
What it changes. Getting to the stimulus takes organising — a building, a swimming pool, waiting for a storm. This is where virtual reality has its best indication, and section 30 states its limits.
What misleads. Fear of heights often has a genuine vestibular component, and some of the people concerned do have objective unsteadiness at height. That contraindicates nothing; it is to be named.
The situational type
What you meet. Flying, enclosed spaces, lifts, tunnels, transport, driving.
What it changes. This is the type most often confused with panic disorder — see section 3 —, and the one whose treatment takes the most logistics. It is also the one with the latest onset.
The blood, injection, injury type
What you meet. Blood tests, needles, dental care, the sight of blood, surgery, wounds.
What it changes. Everything. It is the only type with a different physiological response and a technique of its own. Section 5, then section 29.
The "other" type
What you meet. Vomiting, choking, loud noises, costumed characters, illness transmitted by an object, falls in children.
What it changes. Two of these fears call for a particular approach because they bear on an internal sensation rather than on an external object: the fear of vomiting and the fear of choking. Section 31 covers them.
What the type does not change
The principle of exposure. It is the same everywhere: organise a gap between the prediction and what actually happens.
Removing the crutches. Universal.
Measuring. Universal.
5. The special case: blood, injections, injuries
This section is short, it is the most important one in the manual in terms of safety, and it is read before any exposure.
Why this type is different
Because the physiological response is biphasic. In every other phobia, confrontation produces a rise in heart rate and blood pressure. Here that first phase is followed by a sharp drop in heart rate and blood pressure, which can go as far as fainting.
Because that fainting is common. A substantial proportion of people with a blood or injection phobia report fainting episodes, and it is often the fear of fainting that organises the avoidance as much as the fear itself.
And because standard exposure is not enough. Exposing someone who faints produces an experience of failure, reinforces avoidance, and can injure them as they fall.
What you do instead
You teach applied tension before exposing. The technique consists in deliberately tensing large muscle groups to raise blood pressure and prevent fainting. It is described in full in section 29, and it is learned in one session.
You then expose, with applied tension in place. The exposure is conducted as it is elsewhere, with that single difference.
And you check that it works before moving on to the strongest situations.
What to ask in the first session
Have you ever passed out? Under what circumstances? How many times? Were you injured falling? Is there a family history of fainting?
And the question that matters most: what are you avoiding because of this? Blood tests, a vaccination, blood donation, antenatal care, an operation, accompanying someone to hospital. Section 34 covers what happens when the avoidance carries medical consequences.
What you say
"What happens to you is not the same as an ordinary anxiety attack. Your blood pressure goes up, then it drops, and it is the drop that makes you faint. We are going to start by teaching you to prevent that drop — it takes half an hour to learn — and then we can deal with the fear."
What you do not do
You do not expose before teaching applied tension, unless the person has never fainted and you have checked that.
You do not have them lie down as a matter of course. It prevents the drop but it also prevents the learning, and it is one more crutch to remove later. You use it long enough to install the technique, no longer.
And you do not take the fainting for play-acting. It is real, measurable, and it has a physiological explanation that should be given.
Frequently asked questions
Do you really have to do a behavioural test at the first session?
Yes. It is your only objective measure, it is what will let the person see their own change at session 8, and it is often what persuades them to come back. See section 11.
The person refuses to approach, even the first step.
The first step is too high, or this is not a specific phobia. Come down a notch by changing dimension — a photo, another exemplar, a greater distance — and ask the three questions in section 3 again.
What do I do if anxiety does not come down during the exposure?
Nothing in particular: that is not the criterion. What matters is that the prediction has been tested. See sections 6 and 27.
How long should an exposure last?
As long as it takes to find out whether what was predicted happens. In practice between twenty and sixty minutes, and that is why sessions 3 to 6 last 90 minutes.
Can two phobias be treated at once?
Better one at a time, starting with the one that costs the most. The second usually goes much faster, because the mechanism is already understood.
My patient takes an anxiolytic before every session.
See section 14. It is a chemical crutch and it weakens the learning. You arrange the withdrawal with the prescriber, you do not decide it alone, and you do not run the decisive exposures while it is in place.
My patient fainted during the exposure.
If the type is blood-injection, that is expected and it can be prevented: section 29. Otherwise it is rare — lie them down, raise the legs, and afterwards resume the same exposure, even briefly, so as not to end on an avoidance.
Disgust is not coming down although fear has fallen a great deal.
That is usual, and it does not call the treatment into question. Disgust needs more repetition and extinguishes more slowly. Say so in advance, otherwise the person concludes it has failed.
Can you do without real-life exposure?
No. Virtual reality, videos and imagination serve to build low steps and to make workable situations you cannot summon. They never close a hierarchy. See section 30.
In how many sessions?
Eight in this manual, one in the format described in section 13 for phobias with a circumscribed object. A complex situational phobia, a comorbidity, or a phobia with a medical stake often takes more.
The fear came back six months later.
That is expected and it has a name: section 32. Two sessions of resumption almost always suffice, provided you do not wait. That is why the course of action is written down at session 8.
What do you do when you have no spider, no dog and no lift in the consulting room?
You go out. A large part of the exposures in this protocol happen outside: pet shop, car park, fire escape, park, a colleague's dental surgery. The consulting room is for preparing and analysing.
A six-year-old is afraid of dogs, should we treat?
Not necessarily. The question is impact: if they can no longer go to the park or to a friend's house, yes. Otherwise a few pieces of advice to the parents and a review later will do. See sections 10 and 35.
The person says they are afraid but that they do not avoid.
They endure, and that is a form of phobia that often gets missed. Look for the crutches: they are almost always what makes the endurance possible, and they are removed like the others.
Should you look for the origin of the fear?
No. It fills the session, it satisfies a legitimate curiosity, and it changes neither the hierarchy nor the predictions. Many phobias have no identifiable founding event anyway.
The partner always comes along and finds it normal to do so.
They are part of the maintaining arrangement without knowing it. See section 33: you explain, you agree on a precise change, and you give them worksheet 6 — otherwise they will hear it as a reproach.