ART for phobias: what to know first

Accelerated Resolution Therapy (ART) has not been studied in people with phobias, so there is no direct evidence that it works for them. Exposure-based therapy, especially facing the feared thing in real life, is the best-supported treatment for specific phobias, based on more than 30 randomized studies. ART may be worth considering when a phobia clearly began with a particular frightening event, but exposure is usually the better place to start.

What a specific phobia looks like

A specific phobia is a strong, persistent fear of a particular thing or situation, out of proportion to the actual danger and hard to reason away. Common examples include flying, heights, enclosed spaces, animals, needles, blood, vomiting, driving and storms.

Many people with a phobia know the fear is bigger than the risk. The problem is what they do to avoid it: turning down the job that needs travel, skipping medical care, planning routes around bridges, or missing a family wedding. If the fear is starting to shrink your life, it is worth treating.

Some fears are better understood as part of something else. Fear of driving after a crash, or of crowds after an attack, may be post-traumatic stress rather than a phobia. Car accidents and ART and the anxiety therapy page cover those situations.

Why exposure therapy comes first

Exposure therapy means approaching the feared thing gradually and deliberately, with a therapist, until the fear response settles. For a fear of dogs, that might start with photos, then a dog across the street, then a calm dog on a lead. You stay in control of each step.

A 2008 meta-analysis of 33 randomized studies found exposure-based treatment produced large effects compared with no treatment, and outperformed both placebo conditions and other active psychotherapies. Treatments involving real-life contact with the feared thing did better than imaginal exposure or virtual reality.

Exposure therapy can sound like being thrown in at the deep end. It isn't meant to be. You and the therapist build a ladder of steps together, from the least frightening to the most, and you do not move up until the current step feels manageable. You can say no to any step, and the pace is agreed, not imposed. The discomfort is real, but it is planned for.

That last finding is relevant to ART. ART's exposure step is imaginal: you picture a scene for a short time rather than meet the feared thing in real life. On current evidence, real-life exposure is the stronger approach for most phobias.

When ART might be considered

Some phobias trace back to a specific event: someone who was bitten by a dog as a child, or who had a frightening flight with severe turbulence, and whose fear has been tied to that memory ever since. In that situation the memory itself may be part of what keeps the fear going, and ART works on one memory at a time. That reasoning is plausible, but it has not been tested.

ART might also come up for someone who has tried exposure therapy without enough change, or who has a phobia alongside trauma that is already being worked on. Even then, I would usually expect some real-world practice with the feared situation to be part of the plan, because that is where the evidence is.

How ART would work for a fear

You would bring a specific scene to mind for a short time, such as the moment of the bite or the plane dropping, while I guide sets of about 40 side-to-side eye movements, and we would pay close attention to what your body does. When the physical fear has settled, a step called Voluntary Image Replacement lets you change the distressing images to something you choose. An ART session step by step has the detail.

ART sessions often run longer than a standard 50-minute appointment, and we agree the length in advance. I would not promise a number of sessions for a phobia or anything else.

A few safety notes

• Medication. Some anti-anxiety medications, including benzodiazepines taken for flying or procedures, may blunt the response to ART. Tell me what you take and when.
• Eye conditions, migraines or vertigo can make the eye movements difficult. They are worth raising before a first session.
• Afterward. In the ART trials a few people felt more anxious or slept badly after a session. It was uncommon and not serious, but it helps to plan a quiet evening.

If a fear is costing you trips, treatment or time with people, it is worth treating. If you want to talk about whether exposure, ART or both makes sense, get started here.