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Systematic
Desensitization

 

 

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Page Contents: Introduction / Background and Critical Evaluation / Phobia or Obsession? / Self-Administered SD / Step One: Relaxation / Step Two: The Hierarchy / Step Three: Pairing / Potential Problems / In Vivo

 

Introduction

ONE METHOD that has been consistently proven to be effective in the treatment of anxiety and phobias is systematic desensitization. In this procedure, events which cause anxiety are recalled in imagination, and then a relaxation technique is used to dissipate the anxiety. With sufficient repetition through practice, the imagined event loses its anxiety-provoking power. At the end of training, when you actually face the real event, you will find that it too, just like the imagined event, has lost its power to make you anxious.

Originally developed to be administered by a psychotherapist, systematic desensitization has been shown to be effective when self-administered as well, and your greatest gains will come through your own regular practice. The examples utilized here will be for desensitizing yourself to Fear of Flying; you can, however, alter the examples to suit any type of anxiety.

 


 

Background

Have you ever heard anyone refer to Pavlov’s dogs? Well, these were the dogs used by the Russian physiologist I. P. Pavlov in studying the concept of classical conditioning. Pavlov knew for a fact that dogs—indeed all animals—salivate when eating. In his experimentation, Pavlov began to present a neutral stimulus, such as signal light or bell, before feeding the dogs. Obviously, the signal had no noticeable effect on the dogs’ salivation. But Pavlov kept the signal on when the dogs were being fed (and actively salivating), and, over the course of time, Pavlov found that the signal alone, even without his offering food, gradually caused the dogs to salivate.

So, in a nutshell, that’s the story behind classical conditioning. Given that an unconditioned stimulus (food) leads to an unconditioned response (salivation), a conditioned stimulus (light or bell), when paired consistently with the unconditioned stimulus (food) leads to a conditioned response (salivation) similar to the unconditioned response (salivation).

Interestingly enough, there’s a reverse side to classical conditioning, and it’s called counterconditioning. This amounts to reducing the intensity of a conditioned response (anxiety, for example) by establishing an incompatible response (relaxation) to the conditioned stimulus (a snake, for example). 

Through his experience in the late 1950s in extinguishing laboratory-induced neuroses in cats, a researcher named Wolpe developed a treatment program for anxiety [1] that was based on the principles of counterconditioning. Wolpe found that anxiety symptoms could be reduced (or inhibited) when the stimuli to the anxiety were presented in a graded order and systematically paired with a relaxation response. Hence this process of reciprocal inhibition came to be called systematic desensitization. 

Although his theoretical assumptions about the role of the sympathetic and parasympathetic nervous systems in extinguishing anxiety were actually erroneous,[2] his Systematic Desensitization program, as a practical application of his theories, proved to be highly successful. In fact, it revolutionized the treatment of neurotic anxiety.

Many researchers have since concluded that “exposure” to the feared object or situation is the critical factor in treatment. Systematic desensitization, some say, merely helps individuals expose themselves to feared situations.[3]

So, in plain language, regardless of why it works, systematic desensitization does work.

Critical Evaluation of Systematic Desensitization

Research has shown that systematic desensitization can be effective for any phobia, with the following considerations: 

Systematic desensitization is more effective for Specific Phobias than for disorders involving “free-floating” anxiety, such as Social Phobia or Agoraphobia.[4] 

Successful outcome of systematic desensitization is more likely when skill deficits are not causing the anxiety.[5] That is, if you develop anxiety about taking exams in school, and if you have a tendency not to study or do your homework, your anxiety is probably the result of not knowing the material; systematic desensitization may not be of much help in such a case. But if you know the material “backwards and forwards” and develop anxiety, then systematic desensitization might be used to desensitize yourself to performance fears. 

The effectiveness of systematic desensitization does not appear to depend on the intensity of your anxiety, the duration of your anxiety, or on whether the anxiety was acquired suddenly or gradually.[6] 

Some evidence suggests that systematic desensitization may not be as effective in treating anxieties that could have an underlying survival component—such as fear of the dark, fear of heights, or fear of dangerous animals—as in treating phobias that have been acquired from personal experience.[7]

 


 

Phobia
 
or
 
Obsession?

Before moving on to a description of the systematic desensitization procedure, let’s pause here to distinguish a phobia from obsessive thoughts. Suppose, for example, that you encountered turbulence while you were flying in airplane. You might feel a surge of fear; in fact, you would have a good reason to be afraid in the moment, because turbulence momentarily upsets your environment. So concern about the turbulence would be healthy.

Now, if you developed concern about encountering turbulence again, that would be a anxiety, not fear, because, rather than being an actual fear of what is happening, it concerns what might happen.

A Phobia

If this anxiety causes you dread when you have reason to fly somewhere, this would be called phobic anxiety. Moreover, there are cognitive-behavioral treatments for this sort of anxiety. For example, you could use a form of cognitive-behavioral exposure therapy, such as systematic desensitization, to get back in a plane and start flying again. To do this, you would expose yourself to the dreaded situation in graded steps (as explained below), facing the anxiety of each step in turn until you actually were back on an airplane again.

Obsessive Thoughts

If this anxiety expresses itself purely as persistent thoughts of harm (for example, you keep thinking about turbulence even when you are not in an airplane and have no need to fly in an airplane), then the anxiety would be considered to be obsessive thoughts rather than a true phobia. Systematic desensitization would not be of any help here because there really is no single, clear-cut dreaded situation to which you can expose yourself for desensitization.

In this latter case, then, you might want to consider psychodynamic psychotherapy to resolve the unconscious motivation for the obsessive thoughts. For example, the thoughts about the turbulence could be a hint of your fear of your own (unconscious) anger at others, particularly your parents; if you can find out what is the source of your irritation with them, then you can express it all consciously. Thus you can be freed of your secret anger, and you can be freed of the guilt you feel for being angry with your parents—a guilt that can ultimately “kill” you (e.g., through self-sabotage), as suggested by your thoughts of turbulence causing the airplane to crash.

 


 

Self-
 
Administered
 
SD

There are three steps in the self-administered systematic desensitization procedure:

1.

Relaxation;

2.

Constructing an anxiety hierarchy;

3.

Pairing relaxation with the situations described in your anxiety hierarchy.

 


 

Step One:
 
Relaxation

The following systematic desensitization procedures will assume that you have become familiar and proficient with some form of relaxation technique. This could be Progressive Muscle Relaxation, Autogenics, or any other method of inducing a deeply relaxed state of mind. All that matters is that you choose a method of relaxation that is most comfortable for you.

 


 

Step Two:
 
Creating
 
the
 
Anxiety
 
Hierarchy

Overview

For this example, the hierarchy that you construct will be related to Fear of Flying, and it will contain situations or scenes involving some aspect of making a flight. These situations most likely will be situations you have actually experienced, but they can also be situations that you fear experiencing even though they have never actually happened to you. For example, you may want to include the item “The airplane has to turn around and return to the airport in an emergency” even though this has never actually happened to you. The important point is that items included in an anxiety hierarchy describe situations which produce varying levels of anxiety, some more worrisome than others—this is what hierarchy means, and the details of this will be presented below.

You should describe the items on your anxiety hierarchy in sufficient detail to enable you to vividly imagine each one. It might be sufficient to say, “Standing in line at the ticket counter,” but saying, “Standing in a long line at the crowded ticket counter, with nothing to do but wait to get my luggage checked,” might be more graphic. Remember that items are most effective if they can help you experience the event in your imagination, not just describe it.

 
Creating your Anxiety Hierarchy

You should attempt to create about 16 or 17 situations at the beginning. Most people tend to discard some items in the sorting process, so you can expect to end up with about 10 to 15 items in your final hierarchy. To aid in sorting the items, write each one on a separate index card.

As was mentioned earlier, the situations or scenes in your hierarchy should represent a fairly well-spaced progression of anxiety. The best way to achieve this goal is to first grade the anxiety of each item by assigning it a number on a scale from 0 to 100, where 100 is the highest level of anxiety imaginable and 0 is no anxiety (complete relaxation). Write this number on the back of the index card for the item being graded. At this point, you need not worry about how well-spaced the items are; just give each item the first number grade that “pops into your head.”

When each item has an anxiety grade, your next step will be to sort the cards into 5 piles. Each pile will represent a different category of anxiety, as follows:

Pile

Anxiety Grade

Low Anxiety

1–19

Medium Low Anxiety

20–39

Medium Anxiety

40–59

Medium High Anxiety

60–79

High Anxiety

80–100

 

The goal here is to end up with at least two items in each pile. If this happens, congratulations. If not, you will have to go back and re-evaluate some items or create some new items. When you have finished, combine all the cards into one pile that is ordered from lowest to highest anxiety. This is your personal Fear of Flying anxiety hierarchy. Set the cards aside for one day.

It helps to check the accuracy of your ordering by shuffling the cards the next day or so. Without looking at the grades on the back of the cards, re-order them. Then check the grades to see if your second ordering is the same as the first. If not, make some adjustments. You don’t have to waste a lot of time with this; just try to get an order that feels right and that represents a fairly smooth progression from low to high anxiety.

 
Sample Fear of Flying Anxiety Hierarchy

The following is a sample hierarchy to help you develop your own hierarchy. Your items should, of course, be more fully detailed. Also note that any item’s relative anxiety level does not necessarily relate to its temporal sequence.

  

Packing luggage

Making reservations

Driving to the airport

Realizing you have to make a flight

Checking in

Boarding the plane

Waiting for boarding

Taxiing

In-flight service

Moving around the cabin

Climbing to cruising altitude

Descending

Waiting for departure

Taking off

Landing

Turbulence

 


 

Step Three:
 
Pairing
 
Relaxation
 
With the
 
Situations
 
From Your
 
Anxiety
 
Hierarchy

Overview of the Pairing Procedure

The overall goal of systematic desensitization is to reduce the ability of certain situations to cause anxiety. You will accomplish this by confronting each item of your anxiety hierarchy while you are in a deep state of relaxation.

 

As was stated earlier, before performing systematic desensitization it will be necessary to become familiar with some form of relaxation technique. Practice systematic desensitization in the same environment you use to practice relaxation.

 
Your systematic desensitization sessions should not exceed 30 minutes.

Also, you should not attempt to desensitize yourself to more than three of your anxiety hierarchy items per session.

Each session (except the very first one, of course) should begin with the last item from your previous session. That is, if the last item was successfully desensitized, then you should review it in the next session, and if it was not successfully desensitized, then you should begin with it in the next session.

Clearly, your progress will depend on how many times a week you practice. A schedule of two sessions per day, every day would be more ambitious than most people would attempt. Once a day five times a week would be admirable; two times a week would be average. Consider this plan for an anxiety hierarchy consisting of 15 items:

Session   Item Numbers

1

1–3

2

3–5

3

5–7

4

7–9

5

9–11

6

11–13

7

13–15

 

If you use a schedule of two sessions per week, you will complete the desensitization plan in about 3½ weeks. Using a schedule of five sessions per week, you will complete the desensitization plan in about 1½ weeks.

 

The Self-administered Systematic Desensitization Procedure

The self-administered systematic desensitization procedure is presented below. It consists of seven steps that are repeated for each item of your Fear of Flying anxiety hierarchy. Your task will be to work through each item of your anxiety hierarchy following these seven steps.

Step 1.

 

Induce relaxation using your preferred relaxation technique.

Step 2.

Read the appropriate item from your hierarchy. (In the first session, this will be the first item in the hierarchy. In all other sessions, this will be the last item from the previous session.)

Step 3.

Imagine yourself in the situation for a tolerable time.

Note. The length of “a tolerable time” will vary. Be careful of overloading yourself on the first encounter with an item, especially with high anxiety items. Although it might seem a short time, 10 seconds of imaginary exposure might be all you can tolerate. Slowly increase the amount of time you imagine the situation on subsequent presentations until you can tolerate at least 30 seconds of exposure.

Step 4.

Stop imagining the situation and determine the level of anxiety that you are experiencing (on a 0–100 scale). Re-establish your relaxation again and relax for about 30 seconds.

Step 5.

Re-read the description of the situation. Imagine yourself in the scene for a tolerable time.

Step 6.

Stop and again determine your level of anxiety. If you are experiencing any anxiety, return to Step 2. If you feel no anxiety, go on to Step 7.

Step 7.

Move on to the next item of your hierarchy. Repeat the above procedure for this next item, beginning with Step 1.

 
End each session with several minutes of relaxation.

If you find it convenient, you may make a set of index cards with an abbreviated set of instructions for each step of the desensitization procedure. Use one step per card. The following are suggestions:

CARD

Abbreviated Instructions

1

Relax.

2

Read the anxiety situation.

3

Imagine the situation for a tolerable time.

4

Stop.
Determine your anxiety level.
Re-establish relaxation.

5

Re-read the anxiety situation.
Imagine the situation for a tolerable time.

6

Stop.
Determine your anxiety level.
If anxiety is present, return to Card 2.
If no anxiety, go to Card 7.

7

Next item.
Return to Card 1.

 

As a final reminder, when you are desensitizing high anxiety items, repeat one cycle of the desensitization process after you have reached a level without anxiety, just to reinforce your ability to relax in that situation.

 


 

Potential
 
Problems

You might encounter either of two major problems during systematic desensitization:

You might experience no anxiety at the presentation of an item.

You might be unable to decrease a high level of anxiety even after numerous cycles.

Some causes and solutions are presented below.

 
Problem 1:
Little or no anxiety is produced on the first or second cycle of an anxiety hierarchy item.

CAUSE

SOLUTION

The situation is not being imagined vividly enough.

Describe the situation in greater detail.
  or
Imagine the scene for a longer period of time.

 

The situation induces a lower level of anxiety than a previous item.

Describe the situation in greater detail.
  or
Eliminate this item.

 

Problem 2:
A high level of anxiety persists after numerous cycles.

CAUSE

SOLUTION

The situation has not been placed in the appropriate order in your hierarchy.

Develop a new item to be placed before this item.
  or
Place this item later in your hierarchy.

 

The situation is so embellished that it contains elements of scenes later in your hierarchy.
 

Rewrite the description of this item.

You are focusing on a scene too long for the intensity of anxiety it has the power to produce.

Decrease the amount of time imagining the scene.
  or
Rewrite the item to break it into two new items.

 


 

In Vivo
 
Contacts

Research has shown that long-term success in overcoming a fear of flying depends on taking an actual flight (in vivo) after treatment is complete. Some people call it a graduation flight. You might feel comfortable doing this on your own, or you might want a psychologist to accompany you, either on a commercial airline or on a small charter aircraft. Either way, remember that once you make one flight, the next flights become easier. Before each flight, you should work through your anxiety hierarchy to reinforce your ability to remain relaxed.

Above all, remember to practice your relaxation technique on a daily basis, so you can both cope with daily stress and also improvise short desensitization sessions as needed.

 


 

Gratitude
 

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Notes:

1. Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford: Stanford University Press.
 
2, 3. Taylor, C. B., & Arnow, B. (1988). The Nature and Treatment of Anxiety Disorders. New York: The Free Press.
 
4, 5, 6. Rimm, D. C., & Masters, J. C. (1987). Behavior therapy: Techniques and empirical findings. New York: Academic Press.
 
7. Ohman, A., Erixon, G., & Lofberg, I. (1975). Phobias and preparedness: Phobic versus neutral pictures as conditioned stimuli for human autonomic responses. Journal of Abnormal Psychology, 84, 41–45.

 
Additional Resources
 
Related pages within A Guide to Psychology and its Practice:
Autogenics Training
Posttraumatic Stress Disorder
Progressive Muscle Relaxation
Stress
 
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INDEX of all subjects on this website
 
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