Question 1

Does one-session treatment for children include cognitive restructuring as well as exposure?

Thomas Ollendick · Accepted Answer

One Session Treatment (OST), originally pioneered by my good colleague in Sweden, Lars-Goran Ost, is a cognitive-behavioral intervention that utilizes exposure activities to elicit distorted cognitions that are then "tested" during the exposure activity. Distorted cognitions are ascertained through a cognitive-behavior analysis that precedes the actual treatment. For example, if a child who is afraid of spiders indicates that she thinks the spider will run toward her and jump up her arm or face, this thought can be tested with simple graduated exposure activities. Most spiders will not run toward you, they will move away from you if you put out your hand and "walk" your index finger toward them. They actually scurry away! Was her thought confirmed - no - it was disconfirmed by this experiment. Similar behavioral exposure experiments  are undertaken in the 3-hour treatment. Typically we have at least 3 different phobic stimuli for treatment - in this example 3 different spiders. To date we have used OST with all of the major types of specific phobias in randomized controlled trials and controlled single case design studies.  It is now considered an evidence-based treatment and is used in many countries and in both clinical and research settings. Original articles can be obtained by googling our respective names.

One final note. We do not consider this to truly be cognitive "restructuring" in that a Socratic dialogue is not used to test the cognitions - they are tested during the exposure activity. We have published studies that show the changed cognitions partially mediate changes in the phobic response. In my work with young children - I refer to this as "thought-ectomy."  It is like a removal of a distorted thought that is replaced by a more adaptive though.

Question 2

Do you use virtual reality exposure for phobias that are difficult to treat in vivo?

Thomas Ollendick · Accepted Answer

Yes, we do.  In fact, in a study recently accepted for publication in Behavior Therapy, my long time colleagues in Australia and I tested the efficacy of virtual reality treatment with children who had a specific phobia of dogs using One Session Treatment (OST).  The work was conducted at Griffith University in Brisbane, under the leadership of Dr. Lara Farrell and her team. Eight children were treated. They were randomly assigned to a two-, three- or four-week baseline period and then treated virtually. The fear responses remained relatively stable over the baseline periods, and significant reductions were observed at post-treatment and one-month follow-up. Indeed, at one-month follow-up, 75% of the children were recovered and 88% completed a behavioral avoidance test they were not previously able to complete.  The study provides initial support for the effectiveness of VR OST.

At this time, other types of phobias have not been treated with virtual reality. We look forward to this being done in the future. This may be especially important given the effects of COVID-19 and use of telehealth procedures.

Question 3

Has this approach been used for emetophobia?

Thomas Ollendick · Accepted Answer

We have not used this approach (OST) with emetophobia in children. I belive however my colleague in Sweden, Professor Lars-Goran Ost has sed it with adults. We have used it with blood phobias in children so I believe it could be used with children and adolescents; however, as noted, we have not done so at this time. Please let me know if you attempt it and how well it works for you. Thanks.

Question 4

When would you choose intensive one session treatment over standard CBT for a child presenting with a phobia?

Thomas Ollendick · Accepted Answer

This is an excellent question. We have published a paper called "Have Phobias will Travel" to illustrate its use and efficacy for families who live far away from our treatment center in Virginia. They have traveled up to 1,000 miles away. This allows them to come to treatment over a 2-day period in which the cognitive-behavioral assessment is undertaken the afternoon of the first day and the 3-hour treatment is enacted the morning of the second day. We have done it in one day (morning - assessment; afternoon - treatment) but this is somewhat more difficult with young children and children who are comorbid with ADHD or Autism Spectrum Disorder.  Our preference is for the 2-day approach as it allows us time to arrange for the phobic stimuli we need for the behavioral exposures and to give the child a "break" between the assessment and treatment.

In addition, my colleagues from Sweden (Lars-Goran Ost) and Australia (Lara Farrell) and I recently published a paper on stepped care in which we recommend that bibliotherapy be tried first, followed by this brief treatment for those who do not respond to bibliotherapy, and then standard CBT or even psychopharmacology if OST is not effective.  Bibliotherapy appears to work for about 25% of individuals and OST works for about 60%. The remainder then might benefit from standard CBT. However we have shown that OST works comparably to standard CBT in a major review paper.  Still, we need to be flexible and to take into consideration family/patient preferences.

Question 5

How does OST compare to standard CBT for phobias in children e.g., attrition rates and efficacy?

Thomas Ollendick · Accepted Answer

This is another excellent question. In our meta-analysis paper (2017), Professor Ost and I show that the two treatments are generally comparable; however, OST is preferred by a number of families due to the brevity of treatment and the ability to travel to receive the treatment in a circumscribed period of time. As for attrition, it may seem unbelievable, but we have had zero rates of attrition - it is only one session! No families have dropped out once they have agreed to treatment and begun treatment. We have had some families not agree to the treatment - across studies about 5%. It is rare for them to do so if we have done a good job explaining the treatment and the rationale for its use.

Question 6

What level of parental involvement do you have in your one-session treatment protocol with kids?

Thomas Ollendick · Accepted Answer

In our standard treatment, the parents are not involved directly in treatment; however, they are asked to facilitate maintenance of change following treatment by arranging for their child to be exposed to the phobic stimulus in their home community. There is no prescribed set of activities, however.

In a subsequent study, we did involve the parents more directly. We had them observe their child being treated for the first two hours and then brought into the treatment session to "transfer control" from the therapist to the parent. in this condition, we also worked out a prescribed 4-week maintenance program. Surprisingly, this "augmentation" did not produce better outcomes. In fact, both the standard and the augmented performed equally well. There could be many reasons for this outcome - not the least of which might be that the standard treatment is generally effective when used alone.

Question 7

Does OST work better for one phobia over other types of specific phobias?

Thomas Ollendick · Accepted Answer

The treatment has been used effectively with all of the DSM-5 major subtypes (Animal, Natural Environment, Situational,  BII, and Other - e.g., loud sounds costumed characters).  In general, it works best when the phobic stimuli can be readily obtained and brought into the session or the child taken  to the stimuli (e.g., airplanes). We use a lot of videos and youtube videos and trips to horticulture gardens, etc.  One of our studies did show it worked better for animal phobias but that has not been found in most of our studies.

Question 8

Is there any available online training?

Thomas Ollendick · Accepted Answer

We have provided training in various venues and at national and international conferences. Individuals have been trained in several places. Due to limited resources and time availability we are not currently providing online training - our manuals and chapters providing much detail are available from us.

Question 9

Can phobias ever be treated completely?

Thomas Ollendick · Accepted Answer

Well, this is a good and difficult question to answer because it is not clear exactly what "completely" means! We have verbal testimony, letters, photographs, and documentaries from several families that express their thanks and that their child is doing things he or she could never do before. Here I attach an email message from one family which I recently received:

"Hi Dr. Ollendick, I had to share one of the best days of my life!  Today I came home from work to be greeted by my daughter who was so excited to tell me that she was no longer afraid of dogs!  I cried! 
Today, she went to a friends house, that she knew had 2 dogs!  She said she went inside, they jumped on her but after a few minutes they became calm and she pet them!! OMG, my daughter pet a DOG, a live one at that!  I thought I would never see the day that she would be ok to be in house with dogs!"

"I truly believe that if we hadn't been part of your research program and received the treatment program, she wouldn't have ever been cured!  Amazing news! Thank you for accepting her into the program that proved your treatment of phobia works!"

This is but one example - I am not sure her phobia was "completely" cured, but she is doing so much better!

Question 10

What are the different types of phobias?

Thomas Ollendick · Accepted Answer

DSM-5 lists 5 major types:

Animal
Natural Environment
Blood-Injection-Injury
Situational
Other (e.g., costumed characters, loud sounds)

One Session Treatment has been used with each of these - both in adults and in children/adolescents.

Question 11

How long does cognitive behavioral therapy last?

Thomas Ollendick · Accepted Answer

Cognitive Behavior Therapy (CBT) in its standard format typically last 12 - 16 sessions. There are many, many studies that have been conducted in many, many countries that show it is effective with about 60% of the families who obtain it.  This has been shown to be the case in many reviews and meta-analyses. This has been shown to be true whether administered individually or in group and whetehr parents are actively involved in treatment or not.

In contrast to the 12 - 16 session format, One Session Treatment (OST) - a form of CBT - is delivered in one 3-hour session and it produces similar effects to those obtained in the standard format. Thus, clinicians and families have a choice between the two formats. To date, attempts to identify which types of families will benefit more from one format or another has not been established. In our OST, we have had families come from as far away as 1,000 miles making it possible for them to receive an effective treatment in a much briefer period of time. Both approaches require exposure tot the feared situation or stimulus. Some clinicians are reluctant to use exposure in their clinical practice - possibly suggesting they may not prefer the briefer approach. Overall, it has been shown that exposure is a critical element in effective CBT - whether it is the standard CBT or the OST variant.

Question 12

Why is cognitive behavioral therapy effective for phobias?

Thomas Ollendick · Accepted Answer

The most simple and direct answer is that CBT, whether the One Session Treatment (OST) variant or the standard CBT variant, is that the treatment addresses the major components of the fear response. That is, they address the distorted cognitions, the behavioral avoidance associated with the fear response, and the frequently accompanying physiological correlates.  This is achieved through psychoeducation, modeling, exposure, reinforcement, and the testing of faulty cognitions. A direct approach treatment is provided in the contest of a supportive and caring relationship with the clinician.

Question 13

How does a one-session treatment for needle phobia work?

Thomas Ollendick · Accepted Answer

Good question. It works the same way as it does for any phobia: that is, change occurs in distorted cognitions that are tested through behavioral experiments consisting of exposure to needles and blood injections, followed by reinforcement, and delivered in a supportive and caring manner. Oftentimes, this intervention needs to be delivered in a medical setting or at least by a clinician who is authorized to use needles and related stimuli. Here I provide reference to two papers which one of my colleagues from Australia, Ella Oar, and I and others have published. The details of the procedure are spelled out in these papers.

Oar, E.L., Farrell, L.J., & Ollendick, T.H. (2015). One session treatment for specific phobias: An adaptation for paediatric blood-injection-injury phobia in youth. Clinical Child and Family Psychology Review, 18, 370-394. doi:10.1007/s10567-015-0189-3

Oar, E.L., Farrell, L.J., Waters, A.M., Conlon, E.G., & Ollendick, T.H. (2015). One session treatment for pediatric blood-injection-injury phobia: A controlled multiple baseline trial. Behaviour Research and Therapy, 73, 131-142. doi:10.1016/j.brat.2015.08.002

In addition to these studies done with children it has also been treated in adults by Professor Lars-Goran Ost from Sweden.

Question 14

hello, Thank you for having the chance to ask a question , my question is about specific phobia ( adult) towards cats , does one session treatment work for adults ans how can I have protocol , or clinical scientific articles. Have a good day, Sophie ( Paris France)

Thomas Ollendick · Accepted Answer

Thank you for this good question. First off, I should note that animal phobias have been successfully treated in both adults and children. In our work with children, we have treated several children fearful of cats, dogs, bears, etc. I believe Professor Ost in Sweden has successfully treated cat phobias in adults.  I am providing reference to two of our studies below in which you can find more details on the  treatment procedure. You can also contact me if you wish to receive our treatment manual. Best wishes to you.

Ollendick, T. H., Ost, L-G., Reuterskiold, L., Costa, N., Cederlund, R., Sirbu, C., Thompson, T.E. III., & Jarrett, M. A. (2009). One-session treatment of specific phobias in youth: A radomized clinical trial in the United States and Sweden. Journal of Consulting and Clinical Psychology, 77, 504-516.

Ollendick, T. H., Ryan, S. M., Capriola-Hall, N. N., Fraire, M. G, & Austin, K. E. (2018). Have phobias, will travel: Addressing one barrier to the delivery of an evidence-based treatment. Behavior Therapy, 49, 594-603.

Question 15

One session.  How is that possible?

Thomas Ollendick · Accepted Answer

Very good question! Our One Session Treatment (OST) is delivered in one 3-hour session that follows a very careful cognitive behavioral analysis of the phobia so that we can be sure to incorporate the specific distorted cognitions and the behavioral avoidance responses in the treatment. Basically we set up a series of behavioral experiments in which the distorted cognitions can be tested and disconfirmed.  We have found the procedure to be effective with all of the major phobia types in DSM-5 in children. Professor Lars-Goran Ost in Sweden has shown similar effects with adults. Thus, it is possible but it does require a lot of work that is brief, intensive and concentrated. See the referenced article below for more detail on this approach. Good wishes.

Ost, L-G., & Ollendick, T. H. (2017). Brief, intensive, and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134-145

Question 16

Do you have any strategies or tips to assist getting exposure therapy perfectly matched to the client?

Thomas Ollendick · Accepted Answer

Well, this a most important question. I am not sure we ever get it "perfectly" matched but we do try our best. With our treatment, a careful cognitive behavior analysis occurs prior to treatment. This is typically a one-hour session in which we get to "know" the client and to more fully understand the parameters of the phobia - including its antecedents and consequents along with the distorted cognitions, avoidance responses, and accompanying physiology. This is critical to get the "right" stimuli to bring into the session and how to arrange the exposure activities for the client. Generally, the 3 hours of treatment are broken down into 3 segments. Using something like a phobia of dogs, we will have 3 different types of dogs - small/big, active/docile, different breeds, etc. Bottom line: an attempt is made to do the match, you mention above. For some cases we undoubtedly do better than others. However, it is clear to us that the better the match the better the outcome. Thanks.

Question 17

Is One-Session Treatment effective for children if a parent shares the same phobia?

Thomas Ollendick · Accepted Answer

Wow, I am getting some good questions! We have now treated hundreds of phobias in children and in some cases either the parent "had" the same phobia as a child or currently "has" the same phobia as a parent. I do not have exact numbers here, but I believe this is true in about 5% - 10% of the cases we have treated. When it is present in the past, the treatment seems to go extremely well because the parent better understands what their child is experiencing (although I must say in a few cases it does not - they might say something like "you just need to get over it like I did" - that is not helpful). We work with the parent to ease such comments. For those parents who currently have the same phobia, we do one of two things: 1) if it is severe and impairs their ability to help with the treatment we encourage them to receive treatment first - not always desirable though! 2) We try to work with the non-phobic parent (or perhaps a grandparent) to help the child. In limited cases, we have enlisted the good help of an older sibling - actually in one case, it was a younger sibling! We are still learning how to handle such cases - any thoughts from you?

Question 18

How would you approach a treatment plan for social phobia or Anthropophobia, particularly when the client doesn't wish to try due to the inherent fear, though recognizes the problem and feels sorry for herself. Thank you.

Thomas Ollendick · Accepted Answer

Social phobia is somewhat more difficult to treat than specific phobia. We do not use our One Session Treatment (OST) because this condition also frequently requires social skill building in addition to fear reduction procedures.  There are standard 12 - 16 session CBT programs for social phobia developed my Phil Kendall in the US and Ron Rapee in Australia. That said, when your client is reluctant to enter treatment you will likely need to use Motivational Training to help the client prepare herself for the exposure and related activities required in CBT interventions. I know this is not a full response or an adequate response to your good question but I do hoe it is somewhat useful.

Question 19

What is the one session treatment for phobia for bugs/insects? I know about gradual exposure technique starting with pictures, plastic models to the real thing. Are we talking about "flooding" in an intense one session therapy? Thank you for your response.

Thomas Ollendick · Accepted Answer

You are right on track with what you state about gradual exposure. One Session Treatment (OST) also uses a graduated approach but it does so in one extended 3-hour session. It is NOT flooding. We work with the client via a cognitive behavior analysis to more fully understand the antecedents, consequents, distorted cognitions, avoidance responses, etc. and then package it into what we call this brief, intensive and concentrated treatment. There is a considerable literature about the desirability of this kind of "packaging" and of course many studies demonstrating the efficacy of OST - now viewed as an evidence-based treatment for specific phobias in children and adults.

I am including the reference here for one study that Professor Ost from Sweden and I published on these approaches. I hope you will find it useful. Good wishes.

Ost, L-G., & Ollendick, T. H. (2017). Brief, intensive, and concentrated cognitive behavioral treatments for anxiety disorders in children: A systematic review and meta-analysis. Behaviour Research and Therapy, 97, 134-145.

Question 20

What is OST?

Thomas Ollendick · Accepted Answer

Literally, OST is an acronym for "One Session Treatment." It is a brief one 3-hour session based in CBT principles. It was initially developed by Professor Lars-Goran Ost from Sweden in the 1990s. In more recent years, he and I and others have extended the approach with children and adolescents. It is now viewed as an evidence-based treatment for specific phobias in children, adolescents, and adults. I am attaching a recent meta-analysis that he and I wrote on this and related approaches.

Thanks for the question and I wish you the very best!

Treating Phobias in Children