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Systematic
Desensitization |
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Introduction
|
 NE 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
|
Has this web page been helpful? Then please help support this
website in gratitude, as a “down-payment” on the success of your
hopes and dreams!
|
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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