Setting Up a Systematic Desensitization

Joseph Wolpe claimed a 90% cure rate with systematic desensitization.

• Premise: A fear response is learned so we can unlearn it
• Using the process of counter conditioning, Wolpe identified responses that were opposed to fear
• Client is taught to engage in those responses in situations that normally produce fear
• Most common fear antagonist is relaxation

Procedure

Step 1: Set up a Fear Hierarchy

• Construct a list of fear-producing situations associated with the target fear, aiming for about 15-20, and ordering them in the list with the most intense at the top and the least intense at the bottom of the list
• Fear-producing associations include those things that result in avoidance of the behavior associated with the fear

Step 2: Establish a means of achieving deep muscle relaxation

• Assist the client to achieve a state of deep relaxation through imagery, deep breathing and tense-relax of large muscles, so that the client is comfortable and familiar with this sensation and can recognize it
• Assist the client with the relaxation for a few sessions in the absence of the fear stimulus until satisfactory competence with the relaxation state is mastered
• Assist the client in controlling the scene with a non-threatening image

Step 3: Implementation

• Assist the client to relax (preferably using context cues, in the same setting as the original relaxation training took place)
• Begin to introduce cues from the fear hierarchy, starting with cues from the bottom of the hierarchy list
• Encourage the client to bring up an image of the cue for 10 seconds, to the point of anxiety, then pass it, returning to a focus on the relaxation
• Arrange for a way for the client to communicate the level of anxiety experienced
• Have the client focus on relaxing for 30 seconds, with deep breathing
• Repeat this process for the next two or three items on the hierarchy list
• If the client is unable to complete an item, return to it or reconstruct that item to smaller items until they become manageable
• When the client is able to pass an item without anxiety, move on to the next

Sample Fear: Riding in an elevator

Assume several sessions have been taken to set up the fear hierarchy and to assist the client to achieve mastery in achieving a state of deep relaxation.

Therapy

• Fear hierarchy list (in descending order):
  • The elevator is stopped and the doors have not yet opened
  • The elevator is in motion, gaining speed, and the doors are closed
  • The elevator begins to move and the doors are closed
  • The doors close
  • Entering the elevator
  • Pushing the button to call the elevator
  • Seeing the elevator.
  • Realizing the need to take the elevator
• Assist the client to achieve a state of deep relaxation.
• Encourage the client to visualize or imagine realizing the need to take the elevator for 10 seconds or until anxiety appears.
• Watch for the sign of anxiety and instruct the client to pass it, returning to the relaxed state.
• Allow the client to remain relaxed for about 30-60 seconds and repeat.
• If the client is able to visualize that scenario without anxiety, then move to the next cue and repeat the process.
• If the client is not able to visualize that scenario without anxiety, repeat that scenario until mastery, or go back and break the scenario into smaller elements and attempt to desensitize those.

After the client has progressed through the steps of visualization-relaxation using the hierarchical cues, it may be advisable to progress to the following techniques:

1. Graded in-vivo desensitization: Taking the client through the hierarchy in real life
2. Contact desensitization: hierarchy plus modeling with the therapist (?) and practice
3. Flooding: Putting the client in the real-life situation all at once with no gradual introduction
4. Virtual reality: computer-generated scenarios controlled by the client to simulate fearful situation