Phobias

Many people with specific and social phobias also suffer with other problems such as generalized anxiety disorder, post-traumatic stress disorder, depression, dysthymia, bipolar disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, intermittent explosive disorder, and problems with drugs or alcohol.

Sometimes people with social phobias use alcohol to cope with their anxieties and loosen up around other people. However, this often leads to the development of an alcohol problem on top of the social phobia. Also, people with both types of phobias sometimes suffer from a personality disorder, such as a paranoid personality, dependent personality, obsessive-compulsive personality, schizoid personality, or antisocial personality.

The 2005 U.S. National Comorbidity Survey Replication, and other studies like it, have found that specific and social phobias are two of the most common mental health problems in the United States. Every year, approximately 7 to 9 percent of the adult general population suffers with a specific phobia, and approximately 3 to 8 percent suffer with social phobia. However, over the course of a person’s lifetime, the odds increase for developing both disorders. Approximately 11 to 13 percent of adults will be affected by a specific phobia at some point in their lives, while approximately 12 to 13 percent will be affected by social phobia.

Women are almost twice as likely to struggle with a specific phobia, but the sexes are equally afflicted by social phobia. Typically, both disorders begin in childhood, although specific phobias can also start in a person’s midtwenties.

Without treatment, phobias rarely disappear by themselves. Most people who aren’t in treatment simply do their best to avoid their feared circumstance or object. Findings from the 2005 U.S. National Comorbidity Survey Replication found that people waited, on average, as long as twenty years before seeking treatment for a specific phobia and sixteen years before seeking treatment for social phobia.

This is unfortunate, considering that cognitive behavioral therapy is a very successful treatment for both types of phobia. In studies of cognitive behavioral therapy for specific phobia, the effectiveness has been as high as 80 percent. Cognitive behavioral therapy for specific phobia begins by teaching breathing and relaxation exercises to help people manage their anxiety level. Then it proceeds to progressively expose people to their feared situations in a safe and systematic way. Rarely does this treatment require the use of medication.

For social phobia, there are two effective cognitive behavioral treatment models. The first treatment helps the person build social skills, such as conversational abilities and body language, through rehearsal and role-playing. The second form of treatment takes place in a group therapy environment where participants help each other and provide feedback on their social interactions.

Acceptance and commitment therapy (ACT) is a form of behavioral therapy that has been shown to be effective for treating problems related to anxiety, and it might also be an effective treatment for both specific and social phobias.

Generally, people with both types of phobia initially seek treatment from their primary care physician. In many of these cases, it can be expected that they’ll be prescribed medication. Currently, there are no known medications that effectively treat specific phobias, but among the medications that have demonstrated effectiveness for treating social phobia are the antidepressant medications phenelzine (Nardil), fluvoxamine (Luvox), sertraline (Zoloft), and paroxetine (Paxil), as well as the antianxiety medication clonazepam (Klonopin). Some people find relief from their social phobia by taking these medications. However, the negative aspect is that the person’s relief then becomes dependent on continual usage of the medication.

Cognitive behavioral therapy (CBT) is a form of treatment that combines elements of both cognitive therapy and behavior therapy. Cognitive therapy examines the way people’s thoughts about themselves, others, and the world affect their mental health. Behavior therapy investigates the way people’s actions influence their own lives and their interactions with others. By combining the two, CBT examines the way people can change their thoughts and behaviors in order to improve their lives.

The CBT treatment for specific phobia is generally composed of seven steps:

1. Conduct an assessment and provide education
2. Develop controlled diaphragmatic breathing skills
3. Develop relaxation skills
4. Develop skills for coping with anxiety
5. Use imagery to confront feared situations
6. Engage in real-life exposure to the phobic situation
7. Prevent relapse

The CBT treatment for social phobia is very similar to the treatment for specific phobia, except this treatment focuses on fears related to social situations.

The CBT treatment for social phobia is usually composed of six steps:

1. Conduct an assessment and provide education
2. Challenge and correct anxious thoughts
3. Engage in real-life exposure to the phobic situation
4. Engage in safe and systematic exposure to panic-inducing symptoms
5. Practice effective communication skills
6. Prevent relapse

Step 1: Conduct an Assessment and Provide Education

The first step of the CBT treatment for specific phobia is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with specific phobia and not some other similar problem. This is often done with a fear questionnaire and a detailed history of the person’s behaviors.

Once people have been diagnosed with specific phobia, they should learn about the basic nature and causes of the disorder (as highlighted above). It’s also important to educate the person’s family and friends about the disorder, in order to help them understand how they might be playing a role in maintaining the disorder, as well as how they might be able to help during the treatment. In addition, it’s important for everyone involved to understand that CBT is an active form of treatment that requires the person and his or her loved ones to do work outside of the therapy session.

Step 2: Develop Controlled Diaphragmatic Breathing Skills

The second step is to develop controlled diaphragmatic breathing skills. This is important to learn because many people who struggle with specific phobia also suffer with panic attacks and have a habit of hyperventilating, a rapid, deep breathing pattern that often causes them to feel light-headed. (This by itself can sometimes trigger a panic attack.) Controlled diaphragmatic breathing—inhaling and exhaling to a slow, even count—can correct hyperventilation and distract people during an anxiety-producing situation. In general, it also helps many people feel calmer and more in control, especially when confronted with anxiety-provoking situations.

Step 3: Develop Relaxation Skills

The third step of the CBT treatment for specific phobia is to learn relaxation skills. This is a very important skill to master before engaging in the next steps of treatment, which involve exposing oneself to feared experiences. However, this skill is important for other reasons, too.

People with specific phobia often experience physical tension in addition to their mental stress. Learning relaxation skills can help relieve both problems, and there are a variety of different techniques that a person can learn. Included here are four of the most important. All of these techniques include focusing on slow, rhythmic, diaphragmatic breathing.

The first relaxation skill that’s taught is progressive muscle relaxation. It involves a seven-second tightening and releasing of specific muscle groups from head to toe, with emphasis on noticing the difference between the tense feeling and the relaxed feeling.

(Caution: People struggling with a phobia of blood, injections, or injury should not practice muscle relaxation. These are the only phobias in which there is a real possibility of fainting. These people should practice tightening their muscles when facing the phobia in order to avoid any possibility of fainting.)

The second relaxation skill is learning how to release muscle tension without first tensing the muscles. This is done by focusing attention on the muscles and visualizing the tension being released.

The third skill is cue-controlled relaxation, in which a person is taught to relax his or her body by saying a relaxing word, such as “peace” or “relax,” with each slow exhalation.

And, finally, the fourth relaxation skill is special-place visualization. This skill teaches the person to envision a place of safety and comfort in his or her imagination. The person can go to this “mental safe place” during the specific phobia treatment if he or she is overwhelmed by distressing feelings.

Step 4: Develop Skills for Coping with Anxiety

The fourth step of the CBT treatment for specific phobia is to develop skills for coping with anxiety. These skills can help the person handle anxiety-producing situations in everyday life, and they’re also essential for confronting the phobic situation and managing any panic attacks that might occur as a result.

The first skill for coping with anxiety is learning how to challenge phobic thoughts. People with specific phobias frequently overestimate the possibility of a negative outcome and simultaneously underestimate their own ability to cope in those situations. Thinking errors like these often perpetuate phobias. Therefore, it’s very important to learn how to challenge these kinds of thoughts by creating healthy coping statements and positive coping strategies. For example, when confronting a phobic situation, people might use coping statements such as “This will be uncomfortable, but I’ll do the best I can” or “I’ve done this before; I can handle this.” For a person with a phobia of driving on crowded streets, a helpful coping thought might be “If I have a panic attack while driving, I’ll pull over and wait for it to pass.”

The second skill for coping with anxiety is to begin using diaphragmatic breathing and coping statements in anxiety-producing situations, especially before those situations become too overwhelming or turn into panic attacks. Distraction techniques can also be used, such as talking to someone, engaging in repetitive activities like counting, and so on. Distraction techniques can be helpful in the early phases of the treatment for specific phobia, but eventually the person must learn to tolerate his or her anxiety without the use of distraction.

Developing acceptance is also very important for managing anxiety and specific phobias. When people fight their symptoms of anxiety and attempt to run away from or avoid those symptoms, their anxiety actually becomes worse. The opposite of avoiding anxiety is learning to accept that anxiety is uncomfortable, but that it will eventually pass. When people adopt this alternative approach, even a to a small degree, it prepares them to confront phobic situations in a healthier way.

Acceptance is also very important if a person’s anxiety increases beyond a moderate level and develops into a panic attack. At that point, very little can be done for the few minutes that the panic attack is running its course. During this time, the person’s body is flooded with adrenaline and other stress hormones just as it would be if the person were confronted with a life-threatening situation, such as being caught in a burning building. Known as the fight-or-flight nervous system reaction, this response will only last for about three minutes unless it is retriggered by ongoing anxiety-provoking thoughts. During the panic attack, accepting that there is nothing that can be done and riding it out for a few minutes is a more effective strategy than trying to fight the symptoms, which only tends to retrigger the panic attack. Other effective strategies include distracting oneself during the panic attack, focusing on other objects, and using controlled diaphragmatic breathing when possible.

Other skills for coping with anxiety include physical exercise, progressive muscle relaxation, engaging in healthy activities, challenging worrisome thoughts on paper, focusing on hobbies or crafts, and so on.

Step 5: Use Imagery to Confront Feared Situations

The fifth step in the CBT treatment of specific phobia is to use mental imagery to desensitize the person to phobic situations. In the context of phobias, desensitization means learning to relax while confronting the situation instead of allowing the situation to provoke anxiety and fear. However, in this intermediate stage of treatment, the person confronts the phobic situation in his or her imagination rather than in real life. This allows the person more control over the situation and offers opportunities to practice relaxation techniques and the use of coping statements. Plus, for some phobias, confronting them in the imagination is the only option; for example, in the case of phobias of disasters, such as earthquakes and plane crashes.

The desensitization process begins with making a hierarchy, a graded list of situations that cause anxiety. For example, a person with a phobia of dogs might experience mild distress when looking at dogs from a distance, moderate distress when within ten feet of a dog, and severe distress when thinking about petting a dog.

When creating a hierarchy of phobic situations, the person can alter a few different variables to create a graded list. These variables include proximity in space to the situation (a few feet versus a few inches); the proximity in time to the situation (a month away versus the day of the event); the length of time the situation lasts (a few minutes versus an hour); the intensity of the situation (driving in light traffic versus rush hour); and the presence of a support person during the exposure process (conducting the exposure with someone else versus being alone). The purpose of making the hierarchy is to allow the person to confront the least anxiety-provoking situations first, before taking on the task of confronting situations that provoke more anxiety.

Imagery desensitization begins with ten to fifteen minutes of relaxation, including diaphragmatic breathing, progressive muscle relaxation, and special-place visualization. Then the person imagines the details of the anxiety-provoking scene, as if he or she were in that scene at that moment. As the person’s anxiety level begins to rise, he or she continues using relaxation skills and periodically imagines being in the safe place he or she has created. With practice, the anxiety-provoking scene will eventually lose its strength and the person will no longer react to it with such intense feelings of distress.

Step 6: Engage in Real-Life Exposure to the Phobic Situation

After a person has successfully practiced imagery desensitization, the next step in the CBT treatment of specific phobia is to begin confronting feared situations in real life. This is the most important and powerful step in the entire treatment. Exposing oneself to feared situations takes courage and commitment, but without this step, the phobia cannot be treated effectively.

As in the previous step, the person creates a hierarchy of feared situations, or continues using the same hierarchy. For this step, the person might create in-between steps that make the exposure exercises more realistic. For example, a woman with a fear of dogs might need to approach dogs one foot at a time (five feet away, four feet away, and so on) rather than jump from five feet away to petting the dog. It might also be necessary to engage the help of a support person for certain steps of the hierarchy; this should be someone who understands the treatment’s goal and processes.

During the live exposure process, there are two ways a person can participate. The first is to engage the feared situation until the person’s anxiety rises to a moderate level, then temporarily retreat from the situation and use relaxation skills to reduce the anxiety before reengaging with the situation. Temporarily retreating from the phobic situation is different than avoiding the situation, which is what people with phobias typically do. The point of this stage of treatment is to continue strengthening the person’s relaxation skills and perceived control of the situation by temporarily disengaging from the situation and using the previously learned coping skills. Then the person returns to engaging with the phobic situation, rather than running away from it.

The second way to approach the skill of live exposure requires a stronger commitment to the process, but sometimes this second approach is even more effective than the first. The second approach is to stay in the feared situation beyond the point when it causes moderate anxiety and to tolerate the higher level of anxiety until it eventually diminishes, which might take as long as fifteen to forty-five minutes. Using either strategy, the person should continue to repeatedly engage with each situation until it no longer provokes significant levels of anxiety. Then the person is ready to move up to the next situation on the hierarchy. Both imagery desensitization and live exposure must be practiced regularly in order for the treatment to be effective.

Step 7: Prevent Relapse

Finally, the last step of the cognitive behavioral treatment for specific phobia is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of recurring phobia, such as avoiding feared situations, in order to take steps to prevent relapse.

Step 1: Conduct an Assessment and Provide Education

The first step of the CBT treatment for social phobia is to conduct an assessment of the person’s symptoms in order to verify that he or she is struggling with social phobia and not some other similar problem. This is often done with a social phobia rating scale and a detailed history of the person’s behaviors.

Once people have been diagnosed with social phobia, they should learn about the basic nature and causes of the disorder (as highlighted above). Learning more about the disorder will help the person make a plan for change, as well as make important decisions about whether to use medication or not.

It’s also important to educate the person’s family and friends about the disorder, in order to help them understand how they might be playing a role in maintaining the disorder, as well as how they might be able to help during the treatment. In addition, it’s important for everyone involved to understand that CBT is an active form of treatment that requires the person and his or her loved ones to do work outside of the therapy session.

Step 2: Challenge and Correct Anxious Thoughts

The second step of the CBT treatment for social phobia is to challenge and correct anxious thoughts. At the most observable level are anxious automatic thoughts. These are the fearful thoughts that people think and say to themselves that cause them to avoid social interactions and that often precede panic attacks. Two examples of automatic thoughts are “Other people will see how incompetent I am” and “If they see me sweating, I’ll die of embarrassment.” A person can be either aware or completely unaware of having a thought like this. However, in both cases the result is that the person feels anxious or afraid.

The initial stages of the CBT treatment for social phobia will be spent identifying and reevaluating these errors in thinking. This can be done with the use of a thought record. The thought record helps the person with social phobia identify his or her cognitive distortions, unhelpful thinking styles that perpetuate those automatic thoughts. For example, overgeneralizing involves making broad negative conclusions about life based on limited situations, and minimizing and magnifying involve discounting the positive and enlarging the negative aspects of life. Another cognitive distortion is mind reading, where people assume they know what others are thinking about them. And, finally, “should” and “must” statements involve creating unrealistic rules for oneself that are nearly impossible to live up to. For example, many people with social phobia believe that all of their actions must be done perfectly and mistakes are intolerable.

Next, the thought record helps the person identify the situations that trigger social phobia and the automatic thoughts that accompany those situations. For example, a man might recognize that every time he goes shopping he starts to worry that other people will notice that he’s nervous, which causes him to think, “I’m going to look foolish in front of all these people.” In this example, the thought record would help the man identify evidence that both supports and refutes his prediction, and help him create a more well-balanced thought that eases his anxiety. Using the previous example, in support of the automatic thought the man might say, “I’d look stupid if I got embarrassed and ran out of the store,” but refute this thought by noting, “I’ve never actually run out of a store before, no matter how bad I’ve felt.” Then, using these two thoughts, the man might come up with the alternative thought “Just because I sometimes feel embarrassed, it doesn’t mean that I’ll run out of a store and look foolish.”

The goal of this exercise is to lessen the strength of the initial automatic thought and the predictions made by the person’s cognitive distortion. Therefore, it also lessens the person’s level of anxiety. This exercise can also help the person make a more accurate prediction of what might happen in anxiety-producing situations and help the person identify what he or she would do if the worst did happen. Sometimes people need to be reminded of their strengths and positive attributes, and also be reminded to use rational coping statements or to try to see the situation from someone else’s point of view.

As the work on challenging automatic thoughts continues, a person using a thought record will usually begin to notice common themes among his or her anxious thoughts. These themes often point to deeper, more firmly entrenched core beliefs about one’s self that make a person more vulnerable to social phobia. These core beliefs, often called schemas, include thoughts like “I’m a failure,” “I’m incompetent,” and “I’m unlovable.” When these core beliefs are encountered, they too need to be challenged and modified using the thought record and other techniques.

Step 3: Engage in Real-Life Exposure to the Phobic Situation

The most important step of the CBT treatment for social phobia is for the person to engage in the feared activities in a safe and systematic way. As in the treatment for specific phobia, the person may choose to first engage in imagery desensitization, confronting feared situations in his or her imagination, but eventually the person will need to confront the feared situations in real life. The person might also need to practice stress-reduction techniques to help develop enough confidence in his or her ability to engage in the feared situations.

Exposing oneself to feared situations takes courage and commitment, but without this step the social phobia cannot be treated effectively. Before engaging in the live exposure, the person creates a hierarchy, a graded list of feared situations. The purpose of making the hierarchy is to help the person confront the least anxiety-provoking situations first. Then, after successfully confronting these situations, the person usually feels more confident to confront circumstances that produce greater levels of anxiety.

When creating a hierarchy of phobic situations, the person can alter a few variables to create a graded list; for example, the duration of the exposure, the place where the exposure occurs, and whether or not a support person is present. For example, a woman with a phobia of public speaking might begin her exposure hierarchy by making an announcement at work (short duration), then proceed to speaking in front of a group of strangers with her husband present (presence of a support person), and finally make a speech at a conference without her husband present (duration, place, and support person). After each situation on the hierarchy is accomplished with minimal anxiety, the person is ready to move up to the next situation on the hierarchy.

The key to making a successful hierarchy is to make each step realistic, predictable, and controllable. People shouldn’t take on situations that are beyond their present skill level. They should also be able to predict, with some certainty, what the range of possible outcomes are for the situation, and be aware of what they will do in each of those scenarios.

Most live exposure exercises require the person to stay in the feared situation beyond the point when it causes moderate anxiety. During these long-term exposures, the person learns to tolerate the high level of anxiety until it eventually diminishes, which might take as long as fifteen to forty-five minutes. If this length of exposure is extremely difficult for the person, shorter exposures might also be helpful. But no matter what strategy is chosen, the person should continue to repeatedly engage with each phobic situation until it no longer provokes significant levels of anxiety. Then the person is ready to move up to the next situation on the hierarchy.

Undoubtedly, these exposure exercises will make the person feel anxious. However, this feeling will gradually disappear over the course of the exercise unless the person resists or fights the anxiety, which will only make it stronger. In order to not fight the anxious feelings, the person needs to tolerate and accept those feelings and acknowledge that they will disappear over time. Some people find it helpful to imagine their anxious thoughts floating away on a cloud, while others use a coping statement like “I’m strong enough to get through this” to help them tolerate the distressing feelings.

And regardless of whether the person uses imagery desensitization, live exposure, short-term exposure, or long-term exposure, he or she must practice regularly in order for the treatment to be effective.

Step 4: Engage in Safe and Systematic Exposure to Panic-Inducing Symptoms

As was stated above, many people who struggle with social phobia also struggle with panic attacks. As a result, many of them have developed a fear of their own bodily sensations, such as a change in heartbeat or sweaty palms. As a result, they frequently monitor their bodies for these “symptoms,” and when they detect one, it’s often enough to trigger a panic attack. However, the truth is that everyone feels sensations like these; they are part of the normal experience of being alive. Thus, part of the CBT treatment for social phobia is to renormalize these physical sensations and help people master their fear by exposing them to those sensations in a safe and systematic way. This is often called interoceptive exposure. It’s very important to the success of the treatment that the person refrain from using safety behaviors while engaging in these exposures; examples include carrying medication in a pocket “just in case,” or having a safety person present during the exposure. These safety behaviors limit the effectiveness of the exposure.

Step 5: Practice Effective Communication Skills

For many people with social phobia, one of the core problems is lack of effective communication skills. This is actually good news, because effective communication skills are easy to learn; they just take practice. Among the skills that are often needed are assertive communication skills, effective listening skills, nonverbal communication skills (body language), conversational skills, job-interviewing skills, social and dating skills, and public speaking skills.

Step 6: Prevent Relapse

Finally, the last step of the cognitive behavioral treatment for social phobia is preventing relapse after treatment is complete. The key to relapse prevention is for the person to continue using the cognitive and behavioral skills learned in treatment and to recognize the early signs of recurring phobia, such as avoiding feared situations, in order to take steps to prevent relapse.

Acceptance and commitment therapy (ACT) incorporates elements of behavior therapy, meditation and mindfulness practices, and scientific research on how humans think and learn.

ACT (pronounced “act”) is based on the principle that many psychological problems are caused by efforts to control, avoid, or get rid of emotions and thoughts that are undesirable. Often, people try to get rid of feelings and thoughts that make them sad or anxious, just as they get rid of other things they don’t want, such as old clothes. However, as ACT points out, feelings and thoughts can’t be controlled. A person can’t throw them out like an unwanted pair of shoes. In fact, the harder a person tries to control his or her thoughts and feelings, the more powerful they often become and the longer they stick around.

The ACT treatment for phobias generally includes eight steps:

1. Educate about phobias, anxiety, and ACT
2. Develop creative hopelessness
3. Clarify values
4. Commit to taking action
5. Develop acceptance
6. Focus on contact with the present moment
7. Utilize cognitive defusion
8. Stay committed to values and actions

Step 1: Educate About Phobias, Anxiety, and ACT

The initial step of the ACT treatment for phobias is to educate the person about phobias and the nature of anxiety. It’s especially important for the person to understand the nature of anxiety from an ACT point of view. According to this treatment, anxiety and fear themselves are not the causes of phobias. Rather, it’s the person’s avoidance of anxious and fearful emotions and thoughts that make each type of phobia an overwhelming problem. Starting with the early stages of treatment, it’s also important for people to understand that ACT is an active, participatory treatment designed to help them live a more fulfilling life, not necessarily a “happier” one.

Step 2: Develop Creative Hopelessness

In order to develop what ACT calls “creative hopelessness,” a person must conduct a thorough evaluation of the strategies that he or she has already used to cope with fear and anxiety. After doing this, the person often recognizes that all of these strategies have been unsuccessful or actually made the problem worse. This is because these strategies are actually attempts to avoid and control feelings of fear and anxiety, which can never be successful. For example, a man who attempts to control his anxiety by drinking alcohol actually develops a worse problem, as does a woman who tries to avoid her anxious feelings by choosing not to talk to her loved ones about them. But rather than just being hopeless, this stage of treatment is also creative because it allows the person to begin exploring new, more successful ways of coping with fear and anxiety.

Step 3: Clarify Values

ACT acknowledges that life is often lived on autopilot, without much sense of what a person really cares about. Clarifying and establishing what a person values can often help that person live a more fulfilling life, despite having occasional feelings of anxiety or fear. Values are the elements of life that give it meaning and importance, like “maintaining a loving relationship with my spouse or partner” or “being an active member of my community.” These values are like compass headings that guide a person through life. They are not destinations at which a person can ever arrive. A person can never stop maintaining a loving relationship and still have a loving relationship. Values are concepts that point a person in the direction of a fulfilling life, and ACT uses many types of values clarification tools to help people identify their values.

Step 4: Commit to Taking Action

After a person has determined his or her values, it’s important to establish goals that support those values and then commit to taking actions that fulfill those goals. For example, if a person’s value is to be an active member of her community, she might list a number of different goals to fulfill that value, such as “attend community meetings twice a month.” This is something that can be completed and thereby create a sense of valued living. The ACT treatment for phobias includes development of skills and goals that lead to taking committed action.

Step 5: Develop Acceptance

In ACT, learning to accept feared situations and anxious emotions is the alternative to trying to control or avoid them. Acceptance can be hard, but it’s often the only way people can reclaim control of their lives. Many situations cannot be altered, no matter how much a person wishes them to be changed. Accepting this fact is often the first step in reengaging with life. Accepting what cannot be changed frees a person from struggling against it and allows that person to start taking actions based on what he or she values in life.

In order to cultivate acceptance, people are encouraged to experience the anxious emotions that they have been avoiding, to cease fighting things that cannot be altered, and to engage in situations that have been evaded.

Step 6: Focus on Contact with the Present Moment

Focusing on what’s happening in the present moment can help people develop more flexible coping strategies for handling fear and anxiety. When people dwell on the past, they often become sad, and when they anticipate the future, they often become anxious. In both cases, they miss what’s happening at the present time. Paying attention to what’s happening in the moment gives people more control over the decisions they’re making and allows them to see more possibilities in life. This skill is often developed with present-focused mindfulness skills, such as focusing on the rising and falling of the breath or on physical sensations in the body.

Step 7: Utilize Cognitive Defusion

Cognitive defusion is a mindfulness technique that helps people observe their anxious and fearful thoughts without becoming attached to them. “Defuse” is an invented word that means to unstick or to unfuse one’s self from the words that arise in thoughts. The goal of this stage of treatment is to allow people with phobias to function more freely without judging themselves, their feelings, or their thoughts. Thoughts and emotions often arise haphazardly, so it’s easy to see that each type of phobia could worsen over time if a person were to follow or believe every thought and emotion that arose.

Cognitive defusion is often accomplished using meditation or mindfulness techniques, such as imagining thoughts floating by on a cloud, repeating the words of a thought over and over until they lose meaning, or imagining a thought as something outside of oneself. By observing the process of thinking and feeling, the goal is to create space between the person and his or her experience. This gives the person more control over decisions made based on those thoughts and feelings.

Step 8: Stay Committed to Values and Actions

In order to create a fulfilling life, it’s crucial for people to continue making decisions based on what they value in life, rather than based on the thoughts and feelings they have tried to avoid in the past.