Hypnotherapy for Phobias: What Fear-Learning Research Tells Us About Why Phobias Persist

Phobias can look deceptively simple. Somebody is frightened of spiders, flying, needles, dogs or enclosed spaces. Remove the fear, and presumably the problem is solved.

But contemporary research into fear learning suggests a much more interesting picture. For practitioners using hypnotherapy for phobias, understanding how fears are acquired, maintained and updated can help us move beyond simplistic ideas about simply removing or reprogramming a fear.

Research into conditioning, avoidance and extinction has changed how we understand specific phobias and their treatment. It has also challenged some long-standing assumptions: that we always need to discover where a phobia originated, that successful treatment means eliminating fear, or that somebody needs to become progressively calmer whenever they encounter the thing they fear.

For hypnotherapists, this research provides a useful framework for thinking about what may actually need to change during phobia treatment.

What Does Fear Learning Tell Us About Hypnotherapy for Phobias?

One of the most obvious explanations for a phobia is conditioning.

Something frightening happens, the brain associates a particular object or situation with danger, and a fear response develops. Someone who has been bitten by a dog, for example, might subsequently experience fear around dogs.

Sometimes there is a clear experience like this in a client's history. Often there isn't.

People can acquire fears in other ways. We can observe somebody else's fear, receive frightening information about something, or gradually develop associations without being able to identify a single event that started the process.

And some fears appear considerably more commonly than others.

This has contributed to the influential idea of biological "preparedness": that humans may be particularly ready to acquire fears of things that represented dangers during our evolutionary history, such as snakes and spiders.

It is an appealing explanation, but the evidence is not as straightforward as we might assume. A systematic review by Åhs and colleagues examined 32 fear-conditioning experiments involving 1,887 participants. Only 10 of those experiments found the predicted greater resistance to extinction for fear-relevant stimuli such as snakes and spiders; 22 did not support the hypothesis. The authors concluded that the experimental evidence supporting preparedness theory as an explanation for specific phobias was weak.

For practitioners treating phobias, there is something important to take from this. We don't necessarily need to find a neat explanation for why a particular person developed a particular phobia before therapeutic change can take place.

Why Do Phobias Persist?

Imagine that you're terrified of lifts.

You arrive at a building and discover that your meeting is on the eighth floor. You immediately feel anxious. Your heart starts racing and you imagine becoming trapped inside the lift.

So you take the stairs.

Almost immediately, you feel better.

And that relief matters.

Avoidance has successfully removed you from something your brain has identified as dangerous. From a learning perspective, it can therefore become extremely compelling.

The problem is that avoiding the lift also prevents you from discovering what might have happened if you had entered it.

Perhaps you predicted:

I won't be able to cope.

I'll panic.

I'll be trapped.

Something terrible will happen.

Taking the stairs means those predictions remain largely untested.

The same principle can apply to more subtle "safety behaviours". Someone afraid of flying might fly but continually monitor the aircraft for signs of danger. Someone frightened of dogs might cross the road whenever one approaches. Someone with a needle phobia might postpone blood tests until they become unavoidable.

These responses make complete sense when viewed from the perspective of somebody who feels threatened. But they can also reduce opportunities for different learning to occur.

This is an important consideration in hypnotherapy for phobias because successful phobia treatment may involve much more than helping somebody feel calmer. We also need to consider what maintains the fear outside the therapy room.

Does Fear Need to Disappear?

Contemporary models of exposure have questioned whether fear reduction during the exercise itself should be the primary measure of therapeutic success.

One influential development has been the inhibitory learning model described by Craske and colleagues.

From this perspective, extinction doesn't necessarily mean erasing the original fear association.

Instead, new learning develops alongside it.

A person might previously have learned:

Dog = danger

New experiences might allow additional learning to develop:

Dogs can be present and I can remain safe.

I can experience anxiety and remain in control of what I do.

The outcome I predicted doesn't necessarily happen.

The original association hasn't necessarily vanished. Instead, another association has become available which can compete with it.

This distinction is important because it can help explain something therapists have long observed: fear can return.

Someone can make considerable progress and then experience their fear again in a different environment, after a stressful period, or following a long period without encountering the feared stimulus.

That doesn't necessarily mean treatment has failed. It may reflect the way fear and extinction learning are stored and retrieved.

Phobia Treatment and Expectancy Violation

One particularly useful concept within contemporary exposure research is expectancy violation.

Rather than simply asking how frightened somebody feels, we can become interested in what they believe is going to happen.

Suppose somebody has a spider phobia.

Their expectation might be:

If a spider comes close to me, I won't be able to cope.

Or:

It will jump on me.

Or:

My anxiety will become unbearable.

Therapeutic experiences can then provide opportunities to discover what actually happens.

This subtly changes our focus when treating phobias.

The aim isn't necessarily to ensure that the person feels completely calm in the presence of a spider. In fact, if they only ever encounter a spider when they have first achieved perfect relaxation, they may potentially learn something rather different:

I can cope with spiders as long as I'm completely calm.

What may be more valuable is discovering:

I can experience some fear and still cope.

I don't have to escape immediately.

My prediction doesn't always come true.

I have more capacity to deal with this than I expected.

Craske and colleagues suggest several ways in which exposure learning may be strengthened, including expectancy violation, reducing reliance on safety signals, varying the nature of exposure and practising across different contexts.

That has significant implications for the way hypnotherapists approach phobia treatment.

What Does the Evidence Tell Us About Exposure Therapy for Phobias?

Exposure remains one of the most strongly supported psychological approaches to specific phobias.

A major meta-analysis by Wolitzky-Taylor and colleagues examined 33 randomised treatment studies and found that exposure-based approaches produced large effects compared with no treatment and also outperformed placebo and alternative psychological treatments.

More recent research has examined whether effective phobia treatment necessarily needs to take place over many sessions.

A 2022 meta-analysis examined single-session and multi-session in-vivo exposure across 67 studies involving 1,758 participants. Both produced large treatment effects, and the researchers found no significant differences between their pooled effects at post-treatment or follow-up. Single-session approaches required substantially less total treatment time.

There is an important message here for hypnotherapists.

Length of treatment isn't necessarily the same thing as depth or effectiveness of treatment.

A relatively brief intervention can potentially create powerful learning experiences when it is carefully assessed, appropriately planned and therapeutically meaningful, although it's always important to remember that some clients might need more than one session.

Where Does Hypnosis Fit into Phobia Treatment?

Hypnotherapists have a long history of working with phobias, but we need to be careful about the claims we make.

It is easy to describe hypnosis as though it simply provides access to the subconscious mind, where the therapist can locate the original fear and remove it. This isn't my priority and contemporary fear research suggests a considerably more interesting picture.

Rather than thinking only about removing something, we can think about creating opportunities for new learning.

Hypnosis can provide a flexible context in which clients explore expectations, rehearse different responses, experience themselves responding differently to previously feared situations, build confidence in their ability to cope and prepare for behavioural experiences outside the therapy room.

Imaginal work can be particularly useful when direct exposure isn't immediately practical. We can explore feared situations, notice predictions and responses, introduce different possibilities and help the client begin experiencing greater flexibility in how they respond.

This is one of the ways in which hypnotherapy for phobias can be informed by contemporary fear-learning research rather than relying solely on traditional ideas about uncovering and removing the original cause of a fear.

But we also need to recognise the evidence supporting real-world behavioural experience.

An imagined encounter with a dog is not identical to standing near a real dog. Imagining boarding an aeroplane isn't the same as flying. Talking confidently about needles isn't the same as attending a medical appointment.

A meta-analysis by Wolitzky-Taylor and colleagues found an advantage for in-vivo exposure over alternative exposure formats immediately after treatment, although that difference was no longer evident at follow-up.

Effective phobia treatment may therefore involve thinking beyond what happens during hypnosis itself.

Hypnosis can form part of a broader therapeutic process in which internal change is connected with meaningful experiences in the client's everyday life.

Moving Beyond "Getting Rid of Fear"

Fear has a purpose. It helps us respond to potential danger.

The problem with a phobia isn't simply that somebody is capable of experiencing fear. It is that their threat response has become disproportionately attached to a particular stimulus or situation and begins restricting their choices, behaviour or quality of life.

Our therapeutic goal doesn't therefore have to be a person who never experiences fear.

It might be somebody who can see a spider and remain in the room.

Someone who can board a flight despite noticing some anxiety.

Someone who can attend a medical appointment without weeks of avoidance beforehand.

Someone who discovers that anxiety can rise and fall without dictating what they do next.

For practitioners interested in hypnotherapy for phobias, contemporary fear-learning research gives us an opportunity to think more deeply about what we are actually trying to achieve.

Instead of asking only:

How can I make this fear disappear?

We can ask:

What does this person currently expect, what keeps reinforcing that expectation, and what experiences might allow something different to be learned?

That is a much richer starting point for phobia treatment — and one that allows hypnosis to sit within a broader understanding of how fear is learned, maintained and changed.

You can find out more about The Phobia Fix approach hypnotherapy training here.

References

Åhs, F., Rosén, J., Kastrati, G., Fredrikson, M., Agren, T., & Lundström, J. N. (2018). Biological preparedness and resistance to extinction of skin conductance responses conditioned to fear relevant animal pictures: A systematic review. Neuroscience & Biobehavioral Reviews, 95, 430–437.

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58, 10–23.

Odgers, K., Kershaw, K. A., Li, S. H., & Graham, B. M. (2022). The relative efficacy and efficiency of single- and multi-session exposure therapies for specific phobia: A meta-analysis. Behaviour Research and Therapy, 159, 104203.

Wolitzky-Taylor, K. B., Horowitz, J. D., Powers, M. B., & Telch, M. J. (2008). Psychological approaches in the treatment of specific phobias: A meta-analysis. Clinical Psychology Review, 28(6), 1021–1037.