Introduction The U

Introduction
The U.S National Institute of Mental Health had stated that there were about 10% of people who suffered from specific phobia, 7.1% from social phobia and 0.9% from agoraphobia. Phobia, an anxiety disorder, if being retarded from its treatment, would become uncontrollable which results to the incompetent in carrying normal routine and become socially isolated. This is because phobia accounts to the avoidance of particular places, situations, or objects due to its irrational fear. Generally, people have difficulties to distinguish between phobia and normal fear. Thus, psychologists had specified that fear is an unpleasant feelings and will be experienced by every human beings in response to danger (Marks, 1987) whilst phobia is beyond the ordinary fear in which it is more intense and long-lasting in nature (Turner and Romanczyk, 2012).

The majority of people are diagnosed with anxiety disorder prior to age 21, and it can be studied through the average age of phobias’ onset in which specific phobias are in the early childhood and adolescence for the complex phobia such as social phobia (social anxiety disorder) and agoraphobia. According to a report from Office National Statistics Psychiatric Morbidity, 2011, men are half times less likely to be diagnosed with anxiety disorders or only about 40% from phobias compared to women. Both men and women who suffer from phobias would experience several physical and psychological symptoms. The physical symptoms includes chest pain, faster heart beat, losing one’s balance, excessive shaking, etc while the feelings of fear, panic, ill and likely to die soon are the psychological symptoms.

A talk therapy that has showed to have high success rate in dealing with phobias is Cognitive Behavioral Therapy (CBT) which works by incorporating both cognitive and the behavioral therapies. This therapy is available to treat patients individually, in groups, via computer or internet in a short time by involving several techniques during the sessions such as Socratic questioning, behavioral experiments, thought records, situational exposure hierarchies, etc. Thus, this treatment tend to be carried in structure so that sessions time can be used efficiently and the collaboration between patient and therapist can be established in order to achieve its therapeutic goals which are cognitive restructuring and behavioural activation. Furthermore, the most important and the main CBT concept that patients and therapists should understand is that thoughts, feelings and behaviors are interconnected so if one modality is changed, others will be affected (Ellis, 2001).

In this paper, the discussion on how far does CBT effective in treating phobia will be explored to find out when it is effective or not to treat its phobia as well as to inform decision makers and clinicians that CBT may help patients to reduce its phobia but just to an extent as according to David A.Yusko, not all phobias can be cured with CBT. Hence, this essay will be examining: “How effective is cognitive behavioral therapy play a role in the treatment of phobias”?

Effectiveness of CBT on phobia
There are several researches that showed CBT is significantly effective in treating phobia and those researches were conducted by Tina Tan & Leslie Lim (2015), S.Shahnavaz ET AL (2016) and Mansson ET AL (2016).

For Tina Tan & Leslie Lim’s research, it aimed to identify the outcome after treating an urinary incontinence phobia with CBT therefore the researchers carried a case study on a 39 year-old woman who had urinary incontinence, involuntary loss of urine, phobia after holding her urine for thirty minutes and results her to have avoidance behaviors as she has urinary urges every 10-15 minutes in public places. Thus, her CBT therapists decided to treat her in seven sessions that includes the use of techniques and discussion on her progress. During those sessions, she was asked to record her negative thoughts in Daily Thought Record form and accomplish several homework assignments such as urine measurements, rating her subjective anxiety when driving to places and prepare situational exposure hierarchies for her exposure-habituation exercises. Besides, the therapists also used Socratic questioning to overcome her weaknesses in thinking rationally to her negative thoughts and told her to perform several behavioral experiments in which she needed to withstand from using toilet after 30 to 60 minutes arrival in unfamiliar public places. The results showed that Socratic questioning helps her a lot in thinking positive statements and able her to take deep breath in facing her fear. For the behavioral experiments, she showed improvement that she was able to expose to places and hold her urine for minutes after arrival. Moreover, she also reported that she felt more relaxed and have confident to drive alone for hours. So, these suggest that CBT had changed the way she thinks of her fear and make her to have courage to go against her avoidance behaviors that results from the specific phobia.

Looking at the research descriptions, it can be said that this research has high ecological validity as the situation involved is rather naturalistic therefore the results may be generalised to real-life settings. Besides, even if it only involved one patient but this case study provides a highly detailed information on the outcome of CBT sessions as the therapist only needed to focus on progressing her so the time was used effectively. For the behavioral experiments, it was carried with a slow increasement of urine prohibition duration so she would not experience any mental problems. However, its limitations are that it is a correlational study so there may be possibility of confounding variables to act as the third variable that correlates CBT with urinary incontinence phobia therefore the causal relationship cannot be established. Moreover, since the homeworks were recorded by herself so she may display social desirability effect in her self-reported data as well as having difficulties in recording the data accurately. Due to small sample size so it has low population validity in which the results may not be generalised to wider population as the CBT was tested only to one 39 year-old woman.

Whereas, S.Shahnavaz ET AL carried a trial that examine the effectiveness of CBT on dental phobia children in pediatric dentistry. The sample consists of 8 boys and 22 girls with age range of 7 to 18 year-old. Those children were then divided into groups of CBT and usual treatment. For CBT group, those children required to accomplish 10 sessions that already includes psychoeducation, behavioral discussion, education from parent in which parents needed to have dental tools to access children at home, relaxation techniques, cognitive restructuring and behavioral experiments by exposing children to dental procedures both in vivo and in films. Whereas, for usual treatment group, those children will receive treatment such as tell-show-do, distraction, premedication and general anesthesia. In the end, children from both groups were asked to complete Behavioral Avoidance Test (BAT), Structured Clinical Interview for Dental Anxiety (SCI-DA), Children’s Fear Survey Schedule–Dental Subscale (CFSS-DS), and Self-Efficacy Questionnaire for Specific Phobias (SEQ-SP). Then, the results showed that children who undergo CBT tend to score higher in the surveys in which 64% of them could accomplish all hierarchy’s stages of dental clinician situations in BAT and no longer met the diagnostic criteria of dental anxiety during the SCI-DA. Besides, 73% of them also showed improvement in the clinical procedures based on CFSS-DS and their fear tend to reduce as they have an increasement in self-efficacy as recorded in the SEQ-SP. Moreover, for usual treatment group children, they showed that their treatment is slightly effective as only 6% of them were able to complete BAT and show improvement in the CFSS-DS even if the SCI-DA reported that 18% of them were no longer met the phobia criteria. Hence, it suggests that CBT is more effective than usual treatment especially in term of fear’s improvement and reducing the phobia diagnosis.

The strengths of this study are that it established cause-and-effect relationship between the effectiveness of treatments, CBT and usual treatment, to the dental phobia children as it showed that in overall, CBT is more effective than usual treatment. Although the sample only involved children with different genders but it has high population validity as it fulfilled the aim so the findings may be generalised to another children in pediatric dentistry. Besides, it has high ecological validity as it was performed in a dentistry so the situation involved is rather naturalistic which leads to the results may be generalised to real-life settings. But, the experimental procedures would be difficult to replicate by other researchers so the reliability of the results may not be tested. Some surveys, CFSS-DS and SEQ-SP, were filled by themselves therefore response bias and social desirability effect may presence in their self-reported data. Furthermore, the results may not be reliable enough to draw a conclusion as the number of treatments visit varied and it is not a follow up study.

Additionally, a biological experiment that performed by Mansson ET AL aimed to determine whether the structural plasticity and functional response of social anxiety disorder (SAD) patients will change after undergo psychological treatments. The sample consists of 26 healthy participants and 26 SAD patients. Those healthy participants were used only to take their Magnetic resonance imaging (MRI) scan of the brain as the control group. Whereas, for the experimental group, those 26 patients would be divided to groups of Internet-delivered CBT (iCBT) and Attention Bias Modification (ABM). The iCBT group would run for 9 weeks while twice a week over 4 weeks for ABM group. Besides, the patients were asked to fill the social anxiety self-report questionnaire through the internet, took MRI scan before and after their treatments were completed, and performed a public speaking task to rate their discomfort, fear and distress. The results showed that CBT patients were having a decrease volume of grey matter in the left amygdala, dorsomedial prefrontal cortex and bilateral precuneus compare to ABM patients. Furthermore, after CBT treatment, patients tend to have similar amygdala response, which is positive, with the healthy participants and had a reduction in the right amygdala grey matter volume and blood oxygen level dependent which leads them to have improvement on giving public speaking speech. Therefore, these indicates that iCBT is more effective in changing the amygdala response and blood oxygen level of patients to be as similar as how a healthy brain works compared to ABM.

This study is limited by the small sample size used so it has low population validity as the results may not be generalised to wider population because the number of participants were limited. To perform MRI scan, they were placed into a laboratory so the situation involved is rather artificial therefore it has low ecological validity in which the results may not be generalised to real-life settings. Besides, response bias and social desirability effect may presence in their self-report questionnaire in which these may affect results’ reliability. Nonetheless, its strengths are cause-and-effect relationship may be determined as the effect of treatments, ABM and CBT, to the biological factor of SAD patients can be seen. The experiment has a highly control over variable so the procedures may be replicated and results’ reliability may be tested. Last, since control and experimental group involved equal number of participants so an accurate comparison can be obtained.

Ineffectiveness of CBT on phobia
Research conducted by Ravikant ET AL (2015), Castro ET AL (2014) and Brandon ET AL (2011) had found results that contradicts the previous CBT researches therefore they argued that CBT is not significantly effective in treating phobia.

Ravikant ET AL studied the outcome of brief CBT in SAD patients. The sample consists of 7 married and unmarried Indian patients that have mild, moderate and severe SAD. Those patients were being evaluate at pre-post treatment and 1 month follow up by completing self-reported questionnaire on Brief fear of negative scale (BFNE) and several independent rater measures such as Clinical global impressions (CGI) scale for the illness severity, Liebowitz social anxiety scale (LSAS) for the fear and avoidance, Social Interaction Anxiety Scale (SIAS) for interaction in groups and partners, and Social phobia rating scale for measuring the distress, self-consciousness, negative beliefs and behaviors. For the CBT, it was delivered individually for six sessions which included homework assignment, discussion on progress, behavioral experiment, socialization to cognitive behavioral model, verbal reattribution and changing negative behaviors. The results showed that during post treatment, 3 patients had reduction in BFNE, 4 patients had slightly improvement on all social anxiety measures and 2 patients shown overall improvement on the social anxiety measures but not on SIAS. Also, one patient reported to have the LSAS-avoidance measure become worsened after CBT and at follow up study. Hence, it suggests that brief CBT is less effective for treating SAD as there are patients worsened and showed only a temporary improvement on the measures.

This study has its strengths which are high ecological validity as CBT is performed in clinical settings which means the situation involved is rather naturalistics so the results may be generalised to real-life settings. Besides, the participants used have similar primary diagnosis of SAD therefore the results obtained may be reliable. For the surveys, since most of it was filled by an independent rater so it has limited bias and better quality on measures. Nevertheless, it also have several limitations such as low population validity as only 7 Indian patients were being treated with CBT so the results obtained may not be generalised to wider population with culture differences. For follow up study, the results might be unreliable because after post treatment, they might be in stages where they were trying to adapt to the reality therefore 1 month is considered to be quite fast for taking next measures. Furthermore, it is a correlational study as only CBT treatment was used to treat SAD so an insufficient information of differential treatment effect couldn’t establish cause-and-effect relationship.

Moreover, for Castro ET AL’s study, it aimed to examine which treatment between virtual reality, traditional CBT and antidepressants are more effective for treating long term agoraphobia patients therefore 11 patients without panic disorder and 39 with panic disorder of age 24 to 60 year-old were used and allocated to groups of virtual reality exposure + CBT + drug + in vivo exposure (VRET), traditional CBT + drug (CBT) or the drug group itself that act as control group.
For the experimental, VRET and CBT, group, patients would undergo 11 individual treatment sessions that involve psychoeducation and cognitive restructuring techniques with additional to in vivo exposure in CBT and both in vivo exposure and to virtual anxiety environments such as airport building and plane, square and street, underground car park and elevator, etc. Besides, all patients would be evaluated at pre-post and follow up study by completing measures such as Cognitive and overt behaviors when alone and accompanied (Al), Agoraphobic cognitions questionnaire (ACQ), Body sensations questionnaire (BSQ), Beck anxiety inventory (BAI), Liebowitz social anxiety scale (LSAS), Subjective units of anxiety (SUA), and Behavioral avoidance test (BAT). Results showed that CBT group scored higher on ACQ, BSQ, BAI and Al at follow up but overall, the measures were decreasing from the pretreatment to follow up while VRET group had 50% decreasement in all measures at follow up and able to spend longer time alone in BAT provided environments compared to CBT group. For drug group, they showed less improvement and become worsened on some measures at post treatment. Also, there were 4 CBT and 1 VRET patients denied to join BAT exposure. So, these indicate that the CBT is more effective than drug but not VRET because VRET virtual environments had made agoraphobia patients to have better improvement.

This study has limitations such as low population validity as it has small sample size used which is only 50 patients therefore the results may not be generalised to wider population. For both VRET and CBT group, they received different doses of antidepressant that were considered as confounding variables that lead them not explaining the role of treatments separately. Also, it has been reported that there were 7 patients suffered then left when in vivo exposure sessions began so this means it has harmed patients and caused them to withdraw from it therefore ethical issues was established here. However, its strengths are it was a long-term study with 6 months follow up so the information on the effectiveness of treatments after post treatment can be seen. Since there were different treatments’ groups with different effects on SAD so the cause-and-effect relationship can be determined in which VRET is more effective than CBT and CBT is more effective than drugs. Additionally, the treatments were carried in clinics which means the situation involved is rather naturalistic therefore it has high ecological validity in which the results may be generalised to real-life settings.

Lastly, Brandon ET AL performed a study to a 32 year-old Chinese female to examine the outcome of treating SAD immigrant with CBT in U.S. Her therapist, an European American man, decided to treat her in 16 sessions that includes psychoeducation, cognitive restructuring with english language for nine sessions then in chinese language, behavioral experiment by maintaining conversation with coworkers and professor at new job, discussion on progress and giving homework assignment such as making fear and avoidance hierarchy. Besides, she was also asked to fill a Fear of Negative Evaluation-Brief Version (BFNE) questionnaire at pre-post treatment to be evaluated. Results showed that she has slightly improved on BFNE with 5 scores lowered. Also, for hierarchy, she reported that she become better when facing her anxiety situations but her avoidance worsened in job interview and conversation with authority. Thus, socio-cultural difference may cause CBT become ineffective to treat SAD.

This single case report has strengths in which it has high ecological validity as clinics situation was rather naturalistic therefore the results may be generalised to real-life settings. Since there was only one patient so the therapist could focus in founding her problems shortly such as by changing the language used to continue the cognitive restructuring. In term of cultural norms, even if she was considered to be collectivist and individualist for the therapist but this has provide information that cultural differences can be an issue in treatment interaction and therefore affect the improvement. Whereas, its limitations are that even the sample was a Chinese female who immigrated to U.S but it still has low population validity in which the results may not be generalised to males because the treatment outcome may be different. For the procedures, it might be difficult to replicate by other researchers as it has low control over variables therefore the results’ reliability may not be tested. Moreover, the cause-and-effect relationship cannot be determined as no differential treatments effects were recorded so only correlation between CBT and SAD chinese patient can be established.

Discussion
The psychological studies above support the discussion on the effectiveness of CBT in the treatment of phobias and have suggested that CBT is effective as it helps to alter the patients negative thoughts or beliefs by motivating them to think about the positive statements that may assist them to handle themselves when they are exposed to phobic places or other behavioral experiments requested, thereof, this makes them tend to have strong good feelings that leads to better self-efficacy or possibilities of no longer possess its phobia. From the biological perspective, the patients may also acquire several changes such as the decreasement in volume of amygdala’s grey matter unto how a healthy amygdala supposed to be and since their amygdala which responsible for emotions or the fear are being controlled, therefore they tend to respond positively to the stimuli. When comparing both CBT and treatment as usual, CBT is considered to be better especially on the treatment planning because the involvement of parental education outside the treatment sessions may help to catalyse the patients’ rate of improvement as they could be trained not only in the settings by the therapists but instead anytime with their parents. Moreover, few studies also showed that CBT has succeeded in achieving its goals of modifying the patient’s distorted thinking after going through homework assignments, behavioral experiments, and the evaluating or identifying the dysfunctional thinking or belief techniques, which lead them to become less likely experiencing unreasonable fears to their phobic situations as they could behave accordingly to what they think.

However, it becomes insignificant if it was being delivered individually, briefly and traditionally to SAD or agoraphobia patients as in brief CBT, there is no psychoeducation offered and the treatment was only carried for 6 sessions therefore their phobia tend to relapse because they were treated in short period of time as well as their families did not receive information on how to interact with the patients and knowledge on what the patients can do or should avoid. In comparison with VRET, VRET is far more effective because the patients get to undergo same behavioral experiment as the traditional CBT with the addition of exposure to various reality environments therefore they tend not to have big concerns if the treatment was over as they had learnt how to overcome their discomfort in various real-life environments. Furthermore, if the CBT therapist and patient has cross-cultural issue, the outcome obtained after treatment may not be maximal, although the treatment was delivered individually, because their language barrier as well as the difference in cultural dimensions do play a major contribution during the treatment. Thus, they might have an odd collaboration because an individualists tend to be independent and have an open communication during discussions while a collectivists would feel uncomfortable to open oneself freely as individual especially to the outgroup member because they have the sense of interdependence and prefer to have indirect communication to maintain harmonious interpersonal relations (Adair ; Brett 2005).

Nevertheless, the above results cannot be fully relied upon as the studies were limited with similar limitations. From its methodology, there are two correlational study that showed CBT and phobia are only related as there are no manipulation in independent variable affects the dependent variables so cause-and-effect relationship cannot be demonstrated in which it would be difficult to determine whether CBT treatment really effective to treat phobia or not because there might be third variables exists between them and cause CBT to be effective. Also, most studies had used more than one questionnaires in gathering facts to make conclusion because the researchers could collect many data in short time and obtained objective response from the patients as it is a standardised survey. However, questionnaire may lead to social desirability effect as the patients may answer it not based on facts because they think those answers are what the researchers expected therefore it would decrease the results’ accuracy. To reduce this bias, the questions or instructions should be modified in more positive ways that could make them to answer honestly. Another noticeable, since the patients have known the aim of the study so they may display demand characteristics throughout the experiment or when answering the self-reported questionnaires which leads to less accurate results being obtained.
Moreover, there was a research that was conducted in laboratory where the situation involved is somewhat artificial and well-controlled therefore it has low ecological validity which means the results may not be generalised to natural settings as different outcome may be obtained. Since, in those studies, the patients were needed to undergo interview to ensure that their phobia met its phobia’ criteria therefore the studies only contained small sample size. Having small sample size tend to establish lack of population validity, which means the findings may not represent the wider population as few studies showed to only involved the eastern culture so it may not be relevant if it was used to represent the western culture as well as since the age range used were restricted therefore different outcome might be obtained if different ages of patients were being examined. To make the findings become more representative, large groups of patients with different ages and cultures would be required depending on who the research objectives are.