Introduction and background
Specific phobia is the excessive and immediate fear and avoidance of a particular object or situation as described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V; American Psychological Association, 2013). Evidence suggests exposure-based interventions to be an effective choice of treatment for most specific phobias (Hood and Antony, Reference Hood, Antony, Davis, Ollendick and Öst2012), most commonly delivered in multi-session cognitive behavioural therapy (CBT). In Improving Access to Psychological Therapy (IAPT; as described by Clark, Reference Clark2011) primary care services, this could typically be delivered in 6–8 high-intensity CBT sessions.
Lars-Göran Öst (Reference Öst1989) proposes a one-session treatment (OST) module for specific phobias. The foundation of OST is specific exposure in vivo, termed behavioural experiments, which test the client’s specific catastrophic belief about the fear-evoking object or situation (Öst, Reference Öst1989). The therapist takes on an active role in participant modelling (Bandura et al., Reference Bandura, Jeffery and Wright1974), challenging the client’s catastrophic belief and negotiating behavioural experiments to gradually expose the client to the perceived threat (Öst, Reference Öst, Davis, Ollendick and Öst2012). While confronted with the fear-evoking object or situation, the client is able to habituate to the threat, and challenge catastrophic belief and avoidance until anxiety is reduced or extinguished (Zlomke and Davis, Reference Zlomke and Davis2008). While OST combines traditional principles of cognitive and behavioural therapy (Davey, Reference Davey2007), it distinctively differs as it is delivered in one single, prolonged therapy session of up to 3 hours (Öst et al., Reference Öst, Hellström and Kåver1992).
In pressured services, OST presents an opportunity to offer an effective and efficient face-to-face treatment with several potential benefits: decreasing resources and cost for the service, increasing convenience for the client (who is attending fewer sessions) and preventing therapist drift (which is common in exposure therapies; Waller, Reference Waller2009). OST has been successfully applied to various clinical settings (for a review, see Zlomke and Davis, Reference Zlomke and Davis2008) and recently found renewed interest in investigating its clinical and cost-effectiveness in children (Wright et al., Reference Wright, Cooper, Scott, Tindall, Ali, Bee and Wilson2018). Despite the potential advantages, there is limited published literature about the application of OST in an adult IAPT service (e.g. Flower, Reference Flower2018) and to our knowledge, there is no investigation on its benefits in such a setting.
This study aims to explore the feasibility of the application of OST in an IAPT primary care service in the North East of England and investigate if the potential benefits and time efficiencies are realised. Becker et al. (Reference Becker, Rinck, Türke, Kause, Goodwin, Neumer and Margraf2007), who studied prevalence rates of subtypes of specific phobias in Dresden, Germany, found animal phobias to be most prevalent at 5%, with blood injury and needle phobia having a 2.4% prevalence. In contrast, a search of our service waiting list revealed most people labelled their specific phobia to be of needles, and incidentally, all participants of this study presented with a phobia of needles. This case series report describes the delivery of OST to five clients. Data will be presented, comparing pre-intervention to post-intervention scores to assess the impact of the treatment. Subjective participant feedback was captured from post-treatment questionnaires. Using the principles of thematic analysis (Braun and Clarke, Reference Braun and Clarke2006), themes from the qualitative data are presented that highlight participants’ thoughts on completing an intensive rather than standard treatment.
Participants
Initially, seven clients who self-referred into the IAPT service had been identified at telephone screening as being suitable for high-intensity therapy for specific phobia. All described a phobia of needles. One person did not feel they were able to participate in treatment at that time and requested to stay on the regular waiting list; another person presented with significant co-morbidity at initial assessment and it was agreed that treatment should focus on other areas instead. Five people were taken on for treatment; they were four women and one man between the ages of 21 and 46 years. All participants gave their written consent for their data to be used in this study.
Course of therapy
The OST protocol (Öst, Reference Öst, Davis, Ollendick and Öst2012) was followed as closely as possible. Treatment was delivered by an experienced cognitive behavioural therapist and was supported by an assistant psychologist. Supervision was accessed through the therapist’s existing supervision arrangements with a senior clinician.
Pre-treatment interview (1 hour; face-to-face)
The pre-treatment interview presented an opportunity to confirm the diagnosis, formulate using the OST model, build rapport, and provide a rationale for the forthcoming treatment session. As proposed in the protocol (Öst, Reference Öst, Davis, Ollendick and Öst2012), a brief cognitive behaviour analysis was carried out in this session to establish the participants’ core catastrophic belief underpinning the phobia (i.e. what they predict could happen when confronted with a needle). There was variation across participants and the specifics of their formulations; however, in response to downward arrowing of cognitions (Beck, Reference Beck1979), the theme amongst all participants was ‘I will die’ or ‘I will come to serious harm’. This belief was rated in terms of the level of conviction from 0 (= being not convinced at all) to 100 (= being totally convinced of this belief).
As part of the formulation, safety behaviours were elicited, notably those that might arise in the treatment session. The forthcoming treatment was described to the participants in advance with key features outlined: that exposure to needles would be planned, graded and controlled (Öst, Reference Öst, Davis, Ollendick and Öst2012). The expectation was set by the therapist that this treatment represented the start of the client facing their fear, and that self-directed treatment is recommended once the sessions are complete.
Two participants reported a history of having fainted at the prospect of receiving an injection. In contrast to other types of phobia, this is a common response in blood injury and needle phobia seen in up to 56% of people with this diagnosis (Öst, Reference Öst1992). Blood injury/needle phobics can uniquely experience initial tachycardia followed by bradycardia, a drop in blood pressure and the potential for fainting (Mednick and Claar, Reference Mednick and Claar2012). For these two participants, applied muscle tension was included in the treatment protocol. This involved teaching the participant in the first assessment session a method of tensing their muscles for 10–15 s, followed by 20 s of returning to a normal level of tension (Mednick and Claar, Reference Mednick and Claar2012). Participants were provided with a written summary of the method to allow them to practise in between sessions and during the treatment session applied muscle tension was used alongside the planned experiments.
One session treatment (up to 3 hours; face-to-face)
Öst (Reference Öst, Davis, Ollendick and Öst2012) proposes that focusing experiments on the specific catastrophic belief that underpins the phobia allows the treatment to be completed in a single brief intensive session. The client is required to remain in contact with the feared object until their anxiety has reduced by at least 50%.
For needle phobia, Öst suggests the following: ‘intense prolonged exposure to three procedures that most injection phobic patients find anxiety-arousing: pricking of fingers, subcutaneous injections, and venepunctures’ (Öst, Reference Öst, Davis, Ollendick and Öst2012; p. 76). We did not manage to source anyone able to deliver actual injections within or outside of our IAPT service, hence we proceeded with treatment as far as possible using simulation, imagery, videos, pictures and handling of needles. This adaptation seems more feasible and easier to apply across IAPT services, and there are other examples of OST being adapted in this way (McMurtry et al., Reference McMurtry, Noel, Taddio, Antony, Asmundson, Riddell and Bleeker2015; Oar et al., Reference Oar, Farrell and Ollendick2015). The pictures (15 images of a variety of needles and injections) and videos (five different scenarios where an injection was given in a clinic setting) were found from an internet search, and the needle was kindly provided by a hospital trust site. While initially time-consuming to prepare (in our case about 5 h), once suitable material was collated for the first participant, it was re-used for all other participants.
In each treatment session participants were presented with pictures of needles, followed by videos of different procedures including venepuncture and cannulation. Subjective units of distress (SUDs) were collected throughout and learning was related to the catastrophic belief identified in the pre-treatment interview. As SUDs reduced and evidence to challenge the catastrophic belief was collected, the therapist encouraged participants to handle a needle and finally to simulate receiving an injection from the therapist. In each experiment, the therapist explained what would happen first and modelled how to interact with the object (Bandura et al., Reference Bandura, Jeffery and Wright1974). Throughout the process, the therapist drew attention to any safety behaviours, such as not looking directly at the picture, and encouraged the participant to drop these and fully commit to the experiment. At the end of the treatment session, the therapist and the participant jointly developed a brief plan on how experimenting would continue after the session.
Post-treatment follow-up and maintenance programme (30 minutes; telephone call)
Follow-up was completed approximately 1 week post-treatment by telephone. Further questionnaires were collected and the therapist reviewed what progress had been made with the continued experimentation. Plans were made for the future in terms of approaching needles and continuing to challenge the catastrophic belief and maintain exposure. Subjective feedback of the experience was collected by email.
Measures
IAPT measures were taken at every appointment, as follows.
Patient Health Questionnaire (PHQ-9; Kroenke et al., Reference Kroenke, Spitzer and Williams2001)
The PHQ-9 is a 9-item self-report screening tool. Symptoms of depression are scored on a 4-point Likert scale; higher scores reflect greater symptomatology. It has been found to be a reliable and valid measure of depression severity with a high internal consistency at baseline and end of treatment; Cronbach’s alpha is 0.83 and 0.92 (Cameron et al., Reference Cameron, Crawford, Lawton and Reid2008). The clinical cut-off score for caseness is 10 or above on the sum of all items (National Collaborating Centre for Mental Health, 2018).
General Anxiety Disorder Scale (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006)
The GAD-7 is a 7-item self-report screening tool. Symptoms of anxiety are scored on a 3-point Likert scale with higher scores reflecting greater symptomatology. It has been found to demonstrate adequate internal consistency; Cronbach’s alpha is 0.79–0.9 (Dear et al., Reference Dear, Titov, Sunderland, McMillan, Anderson, Lorian and Robinson2011). The clinical cut-off is 8 on the sum of all items (National Collaborating Centre for Mental Health, 2018).
Work and Social Adjustment Scale (WSAS; Mundt et al., Reference Mundt, Marks, Shear and Greist2002)
The WSAS is a 5-item self-report screening tool. It measures impairment in functionality in day-to-day life areas such as work, home management and social leisure activities. Each item is rated between 0 (‘not at all’ having a problem in this area) to 8 (‘very severely’ impaired in this area) with a maximum score of 40. Research suggests an excellent internal consistency (Mataix-Cols et al., Reference Mataix-Cols, Cowley, Hankins, Schneider, Bachofen, Kenwright and Marks2005). Cronbach’s alpha for the measure ranges between 0.70 and 0.94 (Mundt et al., Reference Mundt, Marks, Shear and Greist2002).
IAPT Phobia Scale (National Collaborating Centre for Mental Health, 2020)
This is a 3-item self-report screening tool on an 8-point Likert scale, designed to capture clients whose lives may be significantly impaired by the presence of social anxiety, agoraphobia and specific phobias but may score below the clinical cut-off on the PHQ-9 and GAD-7. Each item is rated between 0 (‘not at all’ having a problem in this area) to 8 (‘very severely’ impaired in this area). The cut-off for caseness is 4 or above on each item (National Collaborating Centre for Mental Health, 2020).
Additional measures were used to support the assessment of specific phobia, as follows.
Brunnsviken Brief Quality of life scale (BBQ; Lindner et al., Reference Lindner, Frykheden, Forsström, Andersson, Ljótsson, Hedman and Carlbring2016)
The BBQ is a 12-item subjective measure on quality of life assessing six areas (leisure time, learning, creativity, view on life, view of self, friends and friendship). Items are measured on a 5-point Likert scale with a maximum of 48 points, higher scores reflecting a higher subjective quality of life rating. The Cronbach’s alpha for the measure is 0.76 (n = 731).
Severity Measures for Specific Phobia – Adults (Craske et al., Reference Craske, Wittchen, Bogels, Stein, Andrews and Lebeu2013)
This scale is an ‘emerging measure’ to the DSM-V classification system published by the American Psychiatric Association (American Psychological Association, 2013; Schmit and Balkin, Reference Schmit and Balkin2014). The measure identifies the severity of symptoms of five different groups of specific phobias including ‘blood, needles or injection’. The patient is asked to rate their specific phobia on 10 items on a 5-point Likert scale from 0 (‘never’) to 4 (‘all of the time’). Higher scores represent greater symptomatology. Average total scores reflect the individual’s specific phobia in terms of none (0), mild (1), moderate (2), severe (3), or extreme (4). We did not find publications to reflect on the validity of this measure, but due to the credibility of the institution that published it and limited options to measure specific phobia, decided to include it as an outcome measure.
Medical Fear Survey (MFS; Kleinknecht et al., Reference Kleinknecht, Thorndike and Walls1996)
The MFS is a 25-item scale measuring fear of medical procedures. It categorises five different groups such as fear of injection and blood draws, fear of sharp objects and fear of blood. The client rates their symptoms of fear and tension from 0 (‘no fear or concern at all’) to 3 (‘intense fear’) with a maximum score of 75. There is some research suggesting promising psychometric validity (Hood and Antony, Reference Hood, Antony, Davis, Ollendick and Öst2012; Labus et al., Reference Labus, France and Taylor2000). However, it must be noted that there is a lack of norms for clinically diagnosed individuals with specific phobia.
Outcome
Table 1 shows pre- and post-outcomes on standard IAPT measures. Assessing symptoms of generalised anxiety (GAD-7; Spitzer et al., Reference Spitzer, Kroenke, Williams and Löwe2006), three out of five participants scored below the threshold of clinically significant disorder at the beginning of treatment with the OST protocol and remained below threshold at their follow-up appointment after the treatment with the OST protocol. Participants C and D recorded their symptoms of generalised anxiety to sit slightly above the cut-off score for caseness pre-treatment (at 9 and 10 points, respectively); both significantly improved post-treatment (down to 1 point each). Assessing symptoms of depression (PHQ-9; Kroenke et al., Reference Kroenke, Spitzer and Williams2001), all but one participant scored below cut-off and retained this; participant C improved significantly (down from 10 points to 1 point). Daily functionality (WSAS; Mundt et al., Reference Mundt, Marks, Shear and Greist2002) was not evidenced as clinically significant pre- or post-treatment with any participant. On the IAPT Phobia Scale (National Collaborating Centre for Mental Health, 2018), all participants scored above the clinical threshold for significant impairment by the presence of specific phobia at the beginning of their treatment. Post-treatment, one participant increased ratings (by 2 points) while all others reduced their scores with one participant doing so to below the cut-off.
Table 1. Outcome measures from General Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire (PHQ-9), Work and Social Adjustment Scale (WSAS) and IAPT Phobia Questionnaire pre- and post-treatment for each participant. Lower scores indicate less symptomology
Participants’ scores on the Medical Fear Survey (MFS; Kleinknecht et al., Reference Kleinknecht, Thorndike and Walls1996) pre- and post-treatment demonstrate that four out of five participants showed a decrease in symptomology of fear (see Fig. 1).
Figure 1. Scores pre-and post-treatment for each participant on the Medical Fear Survey. Lower scores indicate less fear.
Table 2 details participants’ self-rated level of conviction of their catastrophic belief (i.e. the participants’ catastrophic belief concerning the phobic object/situation derived from the cognitive analysis in the pre-treatment session; Öst, Reference Öst, Davis, Ollendick and Öst2012) pre- and post-treatment. Four participants stated this to have decreased by 45% or more, and one participant by 12.5%. Participants’ scores on the Severity Measure for Specific Phobia (Craske et al., Reference Craske, Wittchen, Bogels, Stein, Andrews and Lebeu2013) indicate a reduction of symptoms of specific phobia after OST intervention, with the exception of one participant (A) who increased by 1 point and one participant (B) by 4 points. On the Brunnsviken Brief Quality of life questionnaire (BBQ; Lindner et al., Reference Lindner, Frykheden, Forsström, Andersson, Ljótsson, Hedman and Carlbring2016), three participants retained the same scores and two increased in scores, indicating higher subjective quality of life ratings pre- and post-treatment.
Table 2. Additional measures pre- and post-treatment per participant
Participant subjective feedback
Four out of the five participants returned feedback forms. Questions were around what had been helpful, whether they now felt able to face needles, and asked their opinion on doing a single 3-hour treatment session as opposed to multiple single sessions. All of their comments were overwhelmingly positive with no critical feedback received. From this, the following qualitative themes emerged (Braun and Clarke, Reference Braun and Clarke2006):
Facing the problem more intensely is better than a gradual approach
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C – ‘I thought the three-hour session was a good idea as it allowed me a longer time to get used to the thought of watching the videos and meant that it didn’t feel rushed ’
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D – ‘I think a three-hour session was better as it reduced any possible anxiety between sessions’
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A – ‘Decreases the amount of anxiety, felt in the run-up to the appointment, as there was only one appointment’
Participants commented that it was better to have one single appointment and to do the entire treatment in one long session, as this meant that they had enough time to experience a reduction in their anxiety and not have to stay in the hardest part of treatment for a more extended period of time. Weekly hour-long sessions only allow for brief experiments meaning that anxiety reduces at a far slower rate and over a more prolonged period of time which may be more difficult to engage in.
Improvement in session
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C – ‘As it was a long session it meant that I saw improvement when I left which wouldn’t have been noticeable after a one-hour session’
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B – ‘Highly effective – the extensive exposure to phobia stimuli rendered my panic and anxiety levels almost non-existent by the end of the session. It gave a real sense of change and progress in a short time’
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D – ‘the three hours go very quickly and it will be time well spent’
Participants commented that they noticed a significant change in the treatment session and this experience of feeling a difference seemed to be a strong motivating factor. The extended session meant that people were able to continue to take significant steps up their fear hierarchy in quick succession.
Future approach to needles
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B – ‘The outcome of my CBT with [therapist] was that I successfully completed a blood test with my GP’
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C – ‘I think that after watching some more videos I will be more likely to be able to face having blood taken or having to cannulate one of my own patients’
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A – ‘I was very sceptical but now feel very positive that I can deal with my anxiety’
All participants reported feeling pleased with what they had been able to achieve and felt more able to approach needles following treatment. Nobody requested further treatment.
Quality of life
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B – ‘A few months ago, I felt that I had an incurable almost shameful weakness. I now feel that I have the tools to deal with a small but rational fear … this treatment has changed my life. I feel a more complete, strong capable person as a direct result of the CBT I received ’
One participant, in particular, felt that treatment had been life changing and profound. B had previously had a course of standard CBT of nine sessions focusing on needle phobia with limited effect.
Discussion
Specific phobias are the extreme, immediate avoidance of specific objects/situations which can lead to severe, immediate consequences (Emmelkamp and Wittchen, Reference Emmelkamp, Wittchen, Gavin, Charney, Sirovatka and Regier2009). Studies have shown that they are not only common within the general population but also remain untreated for the majority of people suffering from them (Coelho et al., Reference Coelho, Gonçalves-Bradley and Zsido2020; Wardenaar et al., Reference Wardenaar, Lim, Al-Hamzawi, Alonso, Andrade, Benjet and de Jonge2017; Wright et al., Reference Wright, Cooper, Scott, Tindall, Ali, Bee and Wilson2018). Ongoing research is investigating whether early engagement with specific phobias could act as a preventative intervention for other anxiety disorders (Wright et al., Reference Wright, Cooper, Scott, Tindall, Ali, Bee and Wilson2018), which offers a promising rationale for promoting the treatment of phobias. The use of one-session treatment (OST; Öst, Reference Öst1989) was found to be a feasible and efficient way of offering intervention for specific phobias (Zlomke and Davis, Reference Zlomke and Davis2008), and there are indications of OST being more effective in a 1-year follow up in comparison with multiple single sessions (Öst et al., Reference Öst, Hellström and Kåver1992). This study aimed to investigate the feasibility of the application of OST in an IAPT primary care setting.
Our study found OST to be an efficient method of delivering effective CBT intervention for specific phobia in an IAPT primary care service in the North East of England. The time and cost of travelling to appointments for both clinician and client is reduced. Administration time associated with the preparation and write-up of the session is reduced, as well as fewer resources such as appointment letters required from the service. These efficiencies represent cost and time savings for services with limited resources, despite the need for initial preparation. Prior to our case series, an assistant psychologist spent about 5 hours putting together suitable resources for the behavioural experiments. This involved finding appropriate pictures, videos and props. Once this was completed for the first participant, the same resources were used for each subsequent participant with no further time investment. Now that the resources are collated it will be easy and quick to replicate the treatment in the future.
One concern at the outset of the project was how we would manage non-attendance at the 3-hour treatment session as this clearly represents a significant amount of therapist time. Therefore in the pre-treatment interview, the therapist explained there would be only one opportunity to do treatment (unless there were significant extenuating circumstances) and advised that it would be hard to re-allocate this time at the last minute. During the course of treatment, all five participants attended all appointments and not one was cancelled or rearranged. It was suggested by the participants that due to commitments in their lives, it was far easier for them to schedule one long treatment session than having to attend multiple sessions. They described this intervention as being far more convenient. It is a possibility that for people who are generally functioning quite well, this option of intensive treatment is more suitable than having to take time out of work or arrange childcare for multiple weekly commitments.
Some adaptations were made to the original protocol due to the practicalities of offering actual injections. OST protocol for needle phobia suggests in vivo exposure in the form of finger pricking, subcutaneous injections and venepunctures (Öst, Reference Öst, Davis, Ollendick and Öst2012). This proved to be extremely difficult to arrange. There were multiple attempts to collaborate with local trust phlebotomy departments, GP surgeries and colleagues in health departments, but all cited service pressures and constraints as the reason for them not having the time and resources to assist. Clinicians within our service with a nursing background were concerned about ethical and governance issues and declined to take part. This issue may not be representative of the national picture and it seems other services have been more successful. Flower (Reference Flower2018) reports successful delivery of OST by a psychological wellbeing practitioner in cooperation with a phlebotomist in an IAPT service. However, for many IAPT services using simulation, imagery, videos, pictures and handling of needles seems more feasible and easier to apply. A meta-analysis of seven studies found that while in vivo exposure was more efficacious in the short term, this advantage no longer presented at follow-up (Wolitzky-Taylor et al., Reference Wolitzky-Taylor, Horowitz, Powers and Telch2008). All in all, these innovations allow for the protocol to be followed in an accessible, and also effective way in routine clinical practice.
Overlearning is described as ‘the participant successfully interacting with the stimulus at levels not expected in the natural environment’ (Zlomke and Davis, Reference Zlomke and Davis2008; p. 211) and Öst describes this as a fundamental part of the protocol (Öst, Reference Öst1989). There was significant opportunity for this in the adapted experiments carried out; however, without actually completing multiple injections, it could be argued that this was inhibited. The results of this study suggest that the adapted intervention was sufficient to yield good results, and it is expected that if it is possible to include injections that this might further enhance outcomes. Öst commented in the original protocol of the importance of therapist presence and of the client seeing the therapist touch and interact with the phobic object, then having the opportunity to interact with the phobic object together (Öst, Reference Öst1989). This was deemed to be an important feature of the work and contributed to overlearning that was achieved.
Needle phobia was the most commonly identified specific phobia on the service waiting list, in contrast to literature stating that animal phobia is the most common subtype (Becker et al., Reference Becker, Rinck, Türke, Kause, Goodwin, Neumer and Margraf2007). A possible explanation for this is that needle phobics are more likely to be unable to avoid having an injection. Three of the participants worked in healthcare settings and were required to handle needles as part of their job, and two wanted to access medical treatment that required them to have an injection. For all participants there were significant gains to be had through overcoming their phobia, including career progression and improved physical health, suggesting that motivation to seek out treatment was high. Potentially this type of context could increase self-referral rates in contrast to other specific phobias. In terms of generalisability of this model to other phobia subtypes, this does seem feasible; however, extra time would be required to prepare resources for different targets. It would be interesting to know the most prevalent subtypes of phobias presenting to IAPT services as this could inform which resources would be most useful to develop.
One limitation of our work is the unreliability of measures used. Literature on needle phobia suggests that physical and mental distress of the phobic person can prevent healthcare-seeking behaviour (e.g. vaccination, interventions for chronic health conditions, dentistry, etc.) and arguably lead to impediment to the health care system (Emmelkamp and Wittchen, Reference Emmelkamp, Wittchen, Gavin, Charney, Sirovatka and Regier2009; McMurtry et al., Reference McMurtry, Noel, Taddio, Antony, Asmundson, Riddell and Bleeker2015; Taddio et al., Reference Taddio, Ipp, Thivakaran, Jamal, Parikh, Smart and Katz2012). Treatment at primary care level seems appropriate; however, standard IAPT measures of recovery did not capture the problem effectively. Most participants were not within caseness, but all presented with a phobia of needles significantly affecting their lives. It was difficult to find valid and accessible measures to track outcome and positive impact on participants’ lives post-treatment. One potential strategy for recording treatment success might be video recording the session. Originally Öst (Reference Öst1989) suggested that this should routinely be part of treatment, particularly for the participants who doubt their achievements due to the speed of change and progress. For example, participant A only reported 10% belief change (see Table 2) but provided very positive qualitative feedback and also some changes in behavioural avoidance. It is possible that this participant felt apprehensive about embracing the change, and that this is represented by the modest change in belief rating. In hindsight, more goal-based measures or monitoring of behavioural avoidance might have been informative to assess outcome in our participants.
Future research is needed to investigate the use of primary care appropriate psychometric tools for specific phobia interventions. It could also focus on more intensive evaluation and analysis of outcome measures to comment on clinically significant change comprehensively. The effectiveness of OST versus multiple session CBT for specific phobia in an adult population would be a good potential comparison study. Another area for development could be the feasibility of this intervention being offered by low-intensity workers with appropriate training and supervision (as seen in Flowers, Reference Flower2018) rather than high-intensity workers.
Conclusion
Overall, the outcome of this service improvement project seems promising and in line with existing studies that show the effectiveness of OST in specific phobia (e.g. Öst et al., Reference Öst, Hellström and Kåver1992). The application to IAPT primary care services seems feasible.
Acknowledgements
The authors would like to acknowledge the participants who kindly consented to us using their data and were happy to contribute to this service evaluation.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors
Conflicts of interest
Layla Mofrad and Ursula Hiermeier have no conflicts of interest with respect to this publication.
Ethical statements
Layla Mofrad and Ursula Hiermeier have abided by the Ethical Principles of Psychologists and Code of Conduct set out by the BPS. In line with Newcastle upon Tyne Hospitals NHS Foundation Trust policies, no ethical approval was needed for this service improvement project.
Key practice points
(1) OST is a feasible, efficient and effective way to treat needle phobia in IAPT. Using this protocol is an opportunity to streamline treatment and make time and cost savings, and is also agreeable and more convenient for clients.
(2) In this study, adaptations were made to allow treatment to take place when it was not possible to access actual injections as proposed in the protocol – for example, the use of pictures, video and simulation.
(3) The OST model and the process of using applied muscle tension is described.
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