Some trepidation around the Fear Clinic

I am feeling trepidatious about my weekly visit to the 'Fear Clinic', a docuseries where patients enter a 'confrontation room' for total exposure to their object of fear. The first episode presents the usual suspects; mice and rats, followed in episode two by a man who was terrified of balloons. 

As a psychologist who has worked closely with patients in acute distress, I have learned that the patient's motivation for recovery and the therapist's level of expertise are decisive factors in the success of any treatment. 

Professor Merel Kindt (University of Amsterdam), who has worked in psychology for over four decades, explains that full exposure offers a 'cure' for phobias that have obstructed quality of life for a lively range of terrified patients. Post exposure, on the following day, patients are prescribed a 'beta-blocker' and invited to attend the 'confrontation room' once more.

Informed by 'cutting-edge neuroscience', the treatment 'changes the way emotional memory is resaved in the brain, as the patient sleeps overnight'. Professor Kindt provides evidence for the treatment in a series of academic papers where patients are exposed to a fear stimulus and re-exposed after receiving medication, with some success.

Aside from the mesmerising experiences documented in this show, the life-changing results are a little misleading. 'Flooding', a psychological treatment established in the 1960's, is based upon the tenet that after repeated exposure to the feared object/situation, fear will be reduced, or become extinct. However, exposure is not the only factor at play here. The environment at the Kindt clinic offers several unseen therapeutic processes. Patients are embraced into a milieu of up-beat psychologists working on their laptops, which immediately provides a reassuring clinical atmosphere, likely to generate a clinical 'crowd-effect', potentially lowering patient distress. 

The team are constituted by highly qualified, charismatic clinicians who lightly guide the patient into the 'confrontation room' with absolute conviction in the therapeutic process. Medication (Propranolol) is offered with a subtle communication that it has powerful transformational properties, and these factors combined are likely to induce a placebo effect. 

The success of the treatment is measured on day two, where the psychologist is present beside the patient as they are re-exposed to the stimuli. Outside of the clinic, in the real world, a highly experienced psychologist will not be holding the patient's hand when they next encounter their fear. This means that we cannot know if their fear has been extinguished, and demonstrates poor 'external validity'.

It is possible that the patient may encounter their feared object/situation in six months or one year and experience Return of Fear (ROF), in the program, long-term outcomes are not addressed. These confounding variables make the treatment challenging to replicate – a key determinant of scientific efficacy. 

In 1909 Freud famously presented the story of 'Little Hans', the boy who was afraid of horses. Freud theorised that Hans's phobia had meaning that extended beyond the feared object. The patients at the 'Fear Clinic' recount stories locating the origin of their phobias and several dynamics are clearly at play. In episode three Miriam recounts her terror of encountering sheep on a school trip and shares the pain and 'betrayal' experienced when her peers engineered another sheep encounter just for laughs. In this case, her experience transcends beyond pure phobia and has wider meaning about identity and belonging. It is unlikely that exposure to sheep will provide long term amelioration of the issues that underpin her distress. 

Exposure therapy has a valuable role in the clinical treatment of phobias and the 'Fear Clinic' invites us to observe how patients with high levels of motivation can achieve successful outcomes. In clinical practice therapists encounter a wide range of patients with varying levels of motivation for change, and this can include patients who are ambivalent about recovery. 

While the program highlights the successes of psychological interventions, everyday practice presents modest gains influenced by the clinician's level of expertise and patient variables including resistance to change, and high rates of attrition and relapse. 

The Kindt Clinic is an inspiring snapshot of psychology in action, but in everyday practice, psychological gains are modest and long-term outcomes should always be clarified.