Abdel‐Jalil, A., Baldwin, J. N., & Leaf, J. B. (2024). Exposure‐based treatments for fear and reactivity to medical procedures: A systematic review of the literature with implications for research and practice. Behavioral Interventions, 39(3).
https://doi.org/10.1002/bin.2010
Reviewed by Angela Fuhrmann-Knowles, MA, BCBA
Endicott College
Why research this topic?
Systematic desensitization is a behavioral intervention used to treat anxieties, fears, and phobias. Since its inception in the 1950s by Joseph Wolpe (Abramowitz et al., 2019), systematic desensitization has evolved into additional interventions, including counterconditioning, graduated exposure, and exposure therapy. One form of systematic desensitization involves teaching an individual to relax while imagining anxiety or fear-producing situations, starting from least feared to most feared (e.g., imaginal exposure; Cooper et al., 2020). Additionally, individuals may learn to relax in the presence of the actual feared things or events (e.g., in-vivo exposure). In this method, individuals create a fear hierarchy from the least to most anxiety-producing situations and are taught to engage in muscle relaxation in the presence of the feared items or events (Thomas et al., 2017).
In Cognitive Behavioral Therapy (CBT), exposure therapies are considered the gold standard when treating fears and phobias (Rauch et al., 2012). Particularly, systematic desensitization has been shown to be effective for treating what the DSM-5 labels as “specific phobias.” A common specific phobia that exposure therapies have been used for is fear and anxiety that occurs with medical procedures. These fears can prevent individuals from receiving needed medical care. A specific phobia of needles, for example, can lead to detrimental health consequences.
Previous reviews have identified the prevalence of medical phobias and interventions used to treat them. In a sample of 1,882 adults, Gatchel (1989) found that about 12% reported having dental care phobias. In a review of approaches for addressing dental fear, Appukuttan (2016) identified systematic desensitization as an effective intervention. Armfield and Heaton (2013) also identified systematic desensitization as an effective intervention for managing dental phobias. Although these authors detailed important information about the prevalence of and interventions for dental phobias, they did not conduct systematic literature reviews, nor did they evaluate the results of applications of exposure therapies, meaning the effectiveness of exposure therapies is unclear.
Due to the prevalence of anxieties and fears surrounding participation in medical procedures and the fact that exposure therapies are considered the gold standard of treatment for addressing this concern, Abdel-Jalil et al. (2024) conducted a review of the literature on exposure therapies. A literature review helps inform clinicians and recipients of services about the effectiveness of this type of intervention in addressing fear and phobias related to medical procedures and can help individuals make better-informed decisions about the interventions they participate in.
What did the researchers do?
The researchers conducted a systematic literature review of exposure therapies used to treat fears about medical procedures from 1955 to 2021. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). The PRISMA guidelines outline a multi-phase process, which includes identifying articles, screening and assessing each article’s eligibility for inclusion in the review, and determining the articles to be included.
To be included in the review, the articles had to involve the use of systematic desensitization to address fear or discomfort related to a medical procedure, be published in a peer-reviewed journal, be available in English, and be published between 1955 and 2021. In addition to not meeting these criteria, articles were excluded if the participants did not demonstrate an avoidance or phobia to a medical procedure and if the article was a review article or commentary. After searching the literature and ensuring the articles met the criteria for inclusion, the authors were left with 62 articles in total.
What did the researchers find?
The authors reviewed each article and collected data on various measures, which included publishing journal, participant characteristics, medical procedures, independent variables, experimental design, number of sessions, outcome measures and results, and social validity. This synopsis will not detail each measure from Abdel-Jalil et al. (2024), but some are detailed in the table below. The readers are encouraged to read the full article for further information. In reviewing the results, “n” represents the “number of articles.”
| Measure | What data were collected? | Results |
|---|---|---|
| Participant characteristics |
|
|
| Medical procedures |
|
|
| Independent variable(s) |
|
|
| Experimental design | Type of design |
|
| Intervention sessions | Number of sessions reported during intervention |
|
| Terminal behavior outcome (TBO) | Extent to which participants completed the medical procedure |
|
| Dependent variables | Behaviors addressed in each study |
|
| Assessment | Verification of phobia, hierarchy, progression criteria |
|
| Social validity | Presence or absence of social validity measures |
|
What are the strengths of the study?
This literature review by Abdel-Jalil et al. (2024) has multiple strengths. First, the researchers conducted this review according to the PRISMA guidelines. Adhering to these guidelines helps ensure that researchers report results that are transparent, complete, and detailed (Page et al., 2021). Second, the researchers reported high interobserver agreement (IOA) scores of 100% across all phases of the search. Because the IOA scores are high, consumers can be more confident that the articles included in this review met the inclusion criteria. Third, the researchers used inclusive search terms, meaning that the terms they used allowed for an expansive search of the literature. Because the terms were inclusive (e.g., searching “systematic desensitization” in isolation), this increases the likelihood that the researchers found most, if not all, of the relevant literature on this topic. Fourth, the results are displayed in tables within the article, making the information easy to access. Fifth, the researchers provided actionable steps for researchers interested in conducting experiments using systematic desensitization or exposure therapies. Some of these actionable steps include conducting a baseline assessment before implementing the intervention to assess whether this treatment is needed, outlining clear behavioral criteria for advancing through the steps of a participant’s fear hierarchy, and collecting social validity data.
What are the limitations of the study?
Abdel-Jalil et al. (2024) highlighted a limitation regarding data collection which was that if a study did not report the neurological status of the participants, they categorized them as “neurotypical.” It is possible that more of the participants had a diagnosis, but this information was missing from the articles.
Some additional limitations exist within this literature review. First, the researchers did not include an assessment of the evidence in each article. Although the researchers did include indicators of effectiveness, such as statistical significance, percentage of non-overlapping data (PND) scores, and terminal behavior outcome (TBO), an evidence assessment adds strength to the certainty of the evidence. For example, the results of a single-subject design experiment can be effective and demonstrate experimental control, but the certainty of the evidence could be weak due to variables, such as not including an adequate number of data points before the intervention phase, not exposing a participant to baseline and interventions conditions, or not sufficiently analyzing data, among others (see Logan et al., 2008 for more details). Conducting an evidence assessment could provide further clarity about the evidence behind exposure therapies.
Second, while the researchers included information about whether articles included measures of social validity, they did not provide information about the social validity assessment results. In other words, the researchers found that 35 articles included some assessment of social validity, but how favorable the results of those assessments are is unclear. Nonetheless, they suggested that future research includes these assessments to ensure exposure therapies are effective and acceptable to participants.
What do the results mean?
An important finding from Abdel-Jalil et al. (2024) is that the participants completed the medical procedure (i.e., reached the TBO) in 42 out of 60 studies (i.e., 70%) that reported this measure. This finding indicates the effectiveness of exposure therapy in addressing fear and phobias related to medical procedures. Although effective, the researchers found that exposure components were often combined with other procedures, such as modeling and relaxation training, which makes it hard to determine which components are most successful when using exposure therapies and whether it is better used as a stand-alone procedure or in combination with other procedures.
Additionally, the participants were primarily neurotypical adults, which means results may differ when conducted across other populations, such as autistic children, and indicates a limitation regarding the generalizability of the findings. This finding underscores the necessity of further research that examines how this body of research translates across diverse profiles, such as participants with autism. Future studies could explore preliminary interventions that may enhance and improve outcomes using the interventions that may be more accessible to neurotypical participants (e.g., generating a hierarchy, imaginal exposure, learning from video models).
Further, because over half of the studies did not provide an explicit fear hierarchy nor specify the behavioral criteria for moving to an additional step, others may find it difficult to replicate the findings of these studies. Lastly, the results indicated high variability in the number of intervention sessions, ranging from one session to 161 sessions. Although the intervention proved effective in many studies, efficiency is important as well. More information is needed to identify the variables that increase the intervention’s efficiency and would help inform clinical practice and future research studies.
In closing, the researchers discussed Constructional Exposure Therapy (CET), as an alternative approach to typical exposure therapies, CET has emerging evidence as an effective and efficient procedure (Miller, 2022). The premise of CET is that although a phobia may be the result of classical conditioning (e.g., a dental procedure was not feared, but once it was paired with pain, it became a feared event), individuals learn behaviors that create distance between themself and feared things or events. These behaviors indicate that distance is a reinforcer, so CET uses distance to reinforce approach or alternative responses. These approach responses are shaped into repertoires that will help the individual succeed in the medical procedure (or another feared event). Removal of the feared thing or event is provided even if the individual does not engage in approach behaviors. In doing so, the phobic behavior patterns (e.g., hitting, crying, etc.) are no longer required because distance is provided for other responses. CET requires further research but may help shape the future of interventions used to address fear and phobic behaviors (see Layng & Abdel-Jalil, 2022 for more information, and Katz & Rosales-Ruiz, 2022 for an example with animals).
References
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. (2019). Exposure therapy for anxiety: Principles and practice. Guilford Publications.
Appukuttan, D. P. (2016). Strategies to manage patients with dental anxiety and dental phobia: Literature review. Clinical, Cosmetic and Investigational Dentistry, 35-50. https://doi.org/10.2147/ccide.s63626
Armfield, J. M., & Heaton, L. J. (2013). Management of fear and anxiety in the dental clinic: A review. Australian Dental Journal, 58(4), 390-407. https://doi.org/10.1111/adj.12118
Cooper, J. O., Heron, T. E., & Heward, W. L. (2020). Applied Behavior Analysis (3rd Edition). Pearson Education.
Gatchel, R. J. (1980). Effectiveness of two procedures for reducing dental fear: Group‐administered desensitization and group education and discussion. Journal of the American Dental Association, 101(4), 634-637. https://doi.org/10.14219/jada.archive.1980.0384
Katz, M., & Rosales‐Ruiz, J. (2022). Constructional fear treatment: Teaching fearful shelter dogs to approach and interact with a novel person. Journal of the Experimental Analysis of Behavior, 118(2), 278-291. https://doi.org/10.1002/jeab.784
Layng, T. V. J., & Abdel‐Jalil, A. (2022). Toward a constructional exposure therapy. Advances in Cognitive Therapy, Fall, 8-11.
Miller, A. (2022). A constructional approach to the treatment of food aversion. Poster: 48th annual convention. Association for Behavior Analysis: International.
Rauch, S. A., Eftekhari, A., & Ruzek, J. I. (2012). Review of exposure therapy: A gold standard for PTSD treatment. Journal of Rehabilitation Research and Development, 49(5), 679-687.
Thomas, K., Dowd, C., & Broman‐Fulks, J. J. (2017). Systematic desensitization (pp. 5355-5356). Encyclopedia of Personality and Individual Differences.
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). The Prisma 2020 statement: An updated guideline for reporting systematic reviews. BMJ. https://doi.org/10.1136/bmj.n71
Reference for this article:
Fuhrmann-Knowles, A. (2025). Research synopsis: Exposure‐based treatments for fear and reactivity to medical procedures: A systematic review of the literature with implications for research and Practice. Science in Autism Treatment, 23(6).
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