Systematic desensitization is a type of exposure therapy based on the principle of classical conditioning. It was developed by Wolpe during the 1950s.
This therapy aims to remove the fear response of a phobia and substitute a relaxation response to the conditional stimulus gradually using counter-conditioning.
The patient is counterconditioned, taught a new association that is to counter the original behavior learnt. The new response they learn is relaxation instead of fear (being mindful) because fear and relaxation cannot coexist (reciprocal inhibition).
A desensitization hierarchy is constructed, and the patient works their way through, visualizing each anxiety-provoking event while engaging in the relaxation response.
The number of sessions required depends on the severity of the phobia. Usually, 4-6 sessions, up to 12 for a severe phobia. The therapy is complete once the agreed therapeutic goals are met (not necessarily when the person’s fears have been completely removed).
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How exposure works
- In vitro – the client imagines exposure to the phobic stimulus.
- In vivo – the client is actually exposed to the phobic stimulus.
Research has found that in vivo techniques are more successful than in vitro (Menzies & Clarke, 1993). However, there may be practical reasons why in vitro may be used.
There are three phases to the treatment:
First, the patient is taught a deep muscle relaxation technique and breathing exercises. E.g. control over breathing, muscle detensioning, or meditation.
This step is very important because of reciprocal inhibition, where, once the response is inhibited because it is incompatible with another. In the case of phobias, fears involve tension, and tension is incompatible with relaxation.
Second, the patient creates a fear hierarchy starting with stimuli that create the least anxiety (fear) and building up in stages to the most fear-provoking images. The list is crucial as it provides a structure for the therapy.
Third, the patient works their way up the fear hierarchy, starting at the least unpleasant stimuli and practicing their relaxation technique as they go.
When they feel comfortable with this (they are no longer afraid), they move on to the next stage in the hierarchy. If the client becomes upset, they can return to an earlier stage and regain their relaxed state.
The client repeatedly imagines (or is confronted by) this situation until it fails to evoke any anxiety at all, indicating that the therapy has been successful.
This process is repeated while working through all of the situations in the anxiety hierarchy until the most anxiety-provoking.
Thus, for example, a spider phobic might regard one small, stationary spider 5 meters away as only modestly threatening, but a large, rapidly moving spider 1 meter away as highly threatening.
The client reaches a state of deep relaxation and is then asked to imagine (or is confronted by) the least threatening situation in the anxiety hierarchy.
Wolpe (1964) successfully used the method to treat an 18-year-old male with a severe handwashing compulsion. The disorder involved a fear of contaminating others with urine.
After urinating, the patient felt compelled to spend 45 minutes cleaning his genitalia, two hours washing his hands, and four hours showering.
Treatment involved placing the young man in a state of relaxation and then asking him to imagine low-anxiety scenes (such as an unknown man touching a trough of water containing one drop of urine).
As the patient’s anxiety gradually dissipated, Wolpe gradually increased the imaginary concentration of urine.
In addition, a real bottle of urine was presented at a distance and moved closer to the patient in gradual steps.
Finally, Wolpe could apply drops of diluted urine to the back of the patient’s hand without evoking anxiety. A follow-up four years later revealed complete remission of the compulsive behaviors.
The fact that the systematic desensitization technique can be applied to images means that many of the practical disadvantages involved in vivo exposition with this type of phobia can be eliminated.
One weakness of in vitro exposition is that it relies on the client’s ability to be able to imagine the fearful situation. Some people cannot create a vivid image, and thus systematic desensitization is not always effective (there are individual differences).
Systematic desensitization is a slow process, taking 6-8 sessions on average. Although, research suggests that the longer the technique takes, the more effective it is.
The progressive structure of systematic desensitization allows the patient to control the steps he/she must make until fear is overcome. This absence of disturbing elements makes this technique less likely to provoke abandonment of the therapy.
Systematic desensitization is highly effective where the problem is learned anxiety of specific objects/situations, e.g., phobias (McGrath et al., 1990). However, systematic desensitization is not effective in treating serious mental disorders like depression and schizophrenia.
Studies have shown that neither relaxation nor hierarchies are necessary and that the important factor is just exposure to the feared object or situation.
Systematic desensitization is based on the idea that abnormal behavior is learned. The biological approach would disagree and say we are born with a behavior, and therefore it must be treated medically.
Treats the symptoms, not the cause(s) of the phobia. Systematic desensitization only treats the observable and measurable symptoms of a phobia. This is a significant weakness because cognitions and emotions are often the motivators of behavior, and so the treatment is only dealing with symptoms, not the underlying causes.
Social phobias and agoraphobia do not seem to show as much improvement. Could it be that there are other causes for phobias than classical conditioning?
For example, if a fear of public speaking originates with poor social skills, then phobic reduction is more likely to occur in a treatment that includes learning effective social skills than systematic desensitization alone.
Lang et al. (1963) used systematic desensitization with a group of college students who were all suffering from a snake phobia. They underwent 11 sessions to work through a hierarchy. Hypnosis was used to assist in the maintenance of relaxation. The P’s fear rating fell, and improvements were still evident six months later.
Rothbaum et al. (2000) used systematic desensitization with participants who were afraid of flying. Following treatment, 93% agreed to take a trial flight. It was found that anxiety levels were lower than those of a control group who had not received systematic desensitization and this improvement was maintained when they were followed up six months later.
Capafons et al. (1998) recruited 41 aerophobia sufferers for a media campaign in Spain and treated 20 of them with systematic desensitization, and had 21 members of a control group. The treatment group was given 2×1 hour sessions of in vivo and in vitro techniques a week over a 12-15 week period.
During a flight simulation, self-reports and physiological measures of anxiety were used. The results showed all but two of those who had systematic desensitization treatment reported lower levels of fear and were seen to have less anxiety, and one member of the control group showed signs of improvement. While systematic desensitization is effective, it was not 100% effective
Systematic desensitization is a treatment method that increases the feeling of self-control; that is, the therapist suggests, guides, or helps but does not represent the nucleus of the treatment.
The risk of dependence upon the therapist or of perceiving improvements as being external to the patient are thus minimized in this technique.
Lang, P. J., & Lazovik, A. D. (1963). Experimental desensitization of phobia. The Journal of Abnormal and Social Psychology, 66(6), 519.
McGrath, T., Tsui, E., Humphries, S., & Yule, W. (1990). Successful Treatment of a Noise Phobia in a Nine‐year‐old Girl with Systematic Desensitisation in vivo. Educational Psychology, 10(1), 79-83.
Menzies, R. G., & Clarke, J. C. (1993). A comparison of in vivo and vicarious exposure in the treatment of childhood water phobia. Behavior Research and Therapy, 31(1), 9-15.
Rothbaum, B. O., Hodges, L., Smith, S., Lee, J. H., & Price, L. (2000). A controlled study of virtual reality exposure therapy for the fear of flying. Journal of consulting and Clinical Psychology, 68(6), 1020.
Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.
Wolpe, J. (1964). behavior therapy in complex neurotic states. The British Journal of Psychiatry, 110(464), 28-34.