What is systematic desensitization?

Introduction

Systematic desensitization, also called graduated exposure therapy, is a behavior therapy used in the treatment of fears, phobias, and anxiety disorders. The therapist asks the client to imagine successively more fear- or anxiety-arousing situations while engaging in a behavior, generally relaxation, which competes with being afraid or anxious. With treatment, the client’s fear or anxiety reactions gradually subside. Therapeutic intervention is warranted when the intensity of the fear or anxiety is disproportionate to the actual situation, interferes with normal functioning, and affects the quality of life.

Systematic desensitization involves three steps. First, the therapist teaches the client the technique of deep muscle relaxation or some other response that is incompatible with fear or anxiety. Deep muscle relaxation training involves first learning to distinguish between relaxed and tense states of different skeletal muscle groups and then learning to achieve deep muscle relaxation on command without tightening the muscles. Second, the therapist helps the client construct an anxiety hierarchy in which situations are ordered from least to most anxiety-evoking. Multiple hierarchies may be needed if a client has several problems, and the hierarchies may be modified if new concerns arise during treatment. Third, the therapist instructs the client to maintain a state of relaxation while imagining a scene from the anxiety hierarchy as it is described by the therapist (imaginal exposure). Therapy begins with the item on the hierarchy that elicits the least discomfort and advances to the next item only after the client can reliably relax to the presentation of the preceding item. Each scene is imagined for a few seconds at a time. If the client experiences an increase in fear while imagining a scene, the therapist instructs the client to discontinue imagining the fear-eliciting item and to concentrate on relaxing. The third step may be done under hypnosis.

The goal of systematic desensitization is to replace the anxiety associated with an item on the anxiety hierarchy with a new and competing response such as relaxation. The premise underlying this treatment is that a person cannot be simultaneously afraid and relaxed. For example, physiological correlates of fear such as rapid heart beat and increased respiration rate are the opposite of those associated with deep muscle relaxation in which the heart beat and breathing rate are slowed. During therapy, a client will also be encouraged to confront in real life (in vivo exposure) the imagined situations that no longer elicit fear in the treatment sessions.

Clinical psychologists Peter Lang and David Lazovik, along with others, conducted a number of laboratory studies of systematic desensitization in the 1960s using snake-phobic college students. One study of twenty-four snake-phobic students reported that students benefited significantly from their treatment both in the short term and at a six-month follow-up, as measured by avoidance of an actual snake and self-ratings. Moreover, there was no evidence of symptom substitution, a concern Freudian psychoanalysts had expressed about treatment of the overt manifestation of anxiety (fear and avoidance of snakes) rather than the underlying unconscious and unresolved conflict (anxiety about sex).

Subsequent research has shown that the essential component in systematic desensitization is repeated exposure to situations or stimuli that elicit fear or anxiety but with no actual negative consequences for the client. Exposure is generally considered one of the most powerful and dependable methods for reducing or eliminating human fears and anxiety, and is the key element in the behavioral component of cognitive behavior therapy.

History

Systematic desensitization was developed by the South African psychiatrist Joseph Wolpe during the 1950s on the basis of counterconditioning experiments he did with cats from June 1947 to July 1948 at the University of Witwatersrand. After using classical conditioning to make cats afraid of their cages, Wolpe demonstrated that their conditioned fear response could be eliminated by feeding the cats at locations progressively closer to their cages. This finding confirmed a 1924 report of counterconditioning by Mary Cover Jones, a student of the behaviorist John B. Watson, who successfully extinguished a young boy’s fear of rabbits by very gradually moving a rabbit toward the boy as he ate.

In developing a method for extinguishing human fears, Wolpe modified and shortened the progressive muscle relaxation (PMR) method perfected by the physician Edmund Jacobsen in the 1930s, which could take more than two hundred hours to master. Wolpe also pioneered the idea that treatment of anxiety elicited by an imagined situation would transfer to its real-life counterpart. In Psychotherapy by Reciprocal Inhibition (1958), Wolpe reported that 90 percent of his clients showed significant improvement with systematic desensitization.

Underlying Theory

Wolpe’s observations of his fearful cats learning to eat in the presence of gradually incremented anxiety-evoking cues convinced him that eating inhibited their fear reactions. He formulated the principle of reciprocal inhibition: When an animal eats in the presence of a fear stimulus, an inhibitory connection is strengthened between the fear stimulus and the fear reaction. Thus, if a response (fear) is inhibited by an incompatible response (eating) and followed by reinforcement (for example, a reduction in drive), a significant amount of conditioned inhibition of the fear response will develop to the fear-eliciting stimulus. The theoretical influences of the Russian physiologist Ivan Petrovich Pavlov and of the psychologist Clark L. Hull are evident in Wolpe’s concept of reciprocal inhibition.

Reciprocal inhibition is a defining feature of the widely accepted dual process theory of motivation. According to this theory, there are two motivational systems underlying behavior, one that is appetitive, or positive, and the other that is aversive, or negative. Activation of the positive motivational system inhibits the negative motivational system, and activation of the negative motivational system inhibits the positive motivational system. Such reciprocal inhibitory links explain why an anxious person or fearful animal generally has no appetite.

Clinical psychologists Michael D. Spiegler and David C. Guevremont summarize additional explanations for why systematic desensitization works, including simple extinction; changes in the client’s thinking, such as being more realistic, having altered expectations, or increased self-confidence; and attention from the therapist.

Variations

Relaxation is the most frequently used competing response in systematic desensitization but it is not always optimal for some clients. Children, for example, may find it easier to use pleasant thoughts or humor and laughter as responses incompatible with anxiety. Other competing responses that may, under some conditions, be more appropriate than relaxation are sexual arousal, assertive behavior, and eating.

Fear or anxiety is the most common response to be treated with systematic desensitization, but treatment of other negative reactions including anger, jealousy, motion sickness, speech disorders, and racial prejudice has been successful. In Psychotherapy by Reciprocal Inhibition, Wolpe describes the case of a twenty-seven-year-old male client, Mr. E., whose unreasonable jealousy was threatening his engagement to Celia, his girlfriend. Whenever Celia said something nice about another man, Mr. E. experienced intense feelings of jealousy that would persist for days, making him irritable and excessively critical of anything Celia did. Following several interviews and training in relaxation, an anxiety hierarchy was constructed. Treatment was conducted under hypnosis and began with the lowest disturbing item: Celia commenting that his friend John (who was not viewed as much of a competitor by Mr. E.) has a nice way about him. After several months of imaginal exposure and various modifications to the anxiety hierarchy, Mr. E., who by then was married to Celia, could tolerate her speaking excitedly to another young man at a party.

Advances in technology have allowed therapists to use virtual reality or computer simulated exposure to replace in vivo exposure, which is not always practical, affordable, or safe. In a review of the research on virtual reality applications to mental health, clinical psychologists Lynsey Gregg and Nicholas Tarrier conclude that the relative effectiveness of exposure technology, in vivo and imaginal exposure, has yet to be fully determined.

Comparisons

A study by clinical psychologist Gordon L. Paul compared systematic desensitization and insight-oriented psychotherapy (which focuses on the source of a phobia) for the treatment of students with severe anxieties about public speaking. In a two-year follow-up, 85 percent of those in the systematic desensitization group showed significant improvement relative to pretreatment compared with 50 percent in the psychotherapy group and 22 percent in an untreated control group. Once again, there was no evidence of symptom substitution: no one in the systematic desensitization group reported new fears.

In their 2004 paper, clinical psychologist F. Dudley McGlynn and colleagues discuss reasons for the abrupt decline in academic-research interest in systematic desensitization based on relaxation in the 1970s and its reduced use in clinical practice since the 1980s. The decrease in peer-reviewed papers on systematic desensitization is attributed to a change in editorial policy toward studies using a pretreatment and posttreatment comparison to assess the effectiveness of systematic desensitization. The methodology used in such analogue desensitization studies was sharply criticized by clinical psychologists Douglas A. Bernstein and Gordon L. Paul. Their influential critique raised concerns about uncontrolled experimental demand effects and whether subjects were sufficiently phobic for meaningful conclusions to be drawn about treatment efficacy. Clinicians lost interest in systematic desensitization first because of the emergence of competing therapies, most notably flooding, implosive therapy, and participant modeling, and later because of the emergence of exposure technology and the shift toward cognitive behavior therapy.

Application to Animals

Applied animal behavior science is a field that covers research on and the treatment of behavior problems in companion animals or other domestic animals. Counterconditioning has been used to treat a variety of fear-related behavioral problems in dogs, including fear of other dogs, humans, and loud noises (such as thunderstorm, fireworks, and gunshots). A common protocol for treating a noise phobia usually involves exposing the fearful dog to increasingly louder prerecorded presentations of the sound that elicits fear while simultaneously playing with the dog and rewarding with treats for maintaining a calm and relaxed demeanor. As in systematic desensitization, the dog starts exposure training with a low intensity sound that elicits negligible anxiety and is exposed to an increment in the intensity of the fear-eliciting stimulus only when the dog remains completely relaxed at the preceding volume.

Bibliography

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Butler, Rynae, Rebecca J. Sargisson, and Douglas Elliffe. “The Efficacy of Systematic Desensitization for the Treating of Separation-Related Problem Behaviour of Domestic Dogs.” Applied Animal Behaviour Science 129.2–4 (2011): 136–145. Print.

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Gregg, Lynsey, and Nicholas Tarrier. “Virtual Reality in Mental Health.” Social Psychiatry & Psychiatric Epidemiology 42.5 (2007): 343–354. Print.

Hoffman, Seymour, and Frumi Gottlieb. “Flooding and Desensitization in Treating OCD: A Case Study.” International Journal of Psychotherapy 18.1 (2014): 27–34. Print.

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McGlynn, F. D., Todd A. Smitherman, and Kelly G. Gothard. “Comment on the Status of Systematic Desensitization.” Behavior Modification 28.2 (2004): 194–205. Print.

Paul, Gordon L. “Insight Versus Desensitization in Psychotherapy Two Years After Termination.” Journal of Consulting Psychology 31.4 (1967): 333–348. Print.

Spiegler, Michael D., and David C. Guevremont. Contemporary Behavior Therapy. 5th ed. Pacific Grove: Brooks, 2009. Print.

Wolpe, Joseph. Psychotherapy by Reciprocal Inhibition. Stanford: Stanford UP, 1980. Print.