Which of the following is the first level of exposure in systematic desensitization?

VI. Summary

Systematic desensitization is a venerable behavior therapy for fear and anxiety. Usually it entails remaining deeply relaxed while visualizing a series of increasingly fearsome scenes in which the patient confronts targeted events or situations. There are many theories about how systematic desensitization reduces fear; most “theories” are post hoc claims that systematic desensitization instantiates some other training regimen or process such as respondent extinction, habituation, counterconditioning, or self-efficacy augmentation. Joseph Wolpe's original theory of how systematic desensitization works appeals to learned inhibition of anxiety that is based on parasympathetic inhibition of sympathetic activation. Criteria have been developed to identify good candidates for systematic desensitization (e.g., there are four fears or fewer, there is evidence of a capacity for clear imagery, there is evidence of emotional discomfort while imaging frightening material). Scores of case studies and reports of clinical series attest to the efficacy of systematic desensitization. Several now classic experiments show the efficacy of systematic desensitization also. Much research on the outcomes of systematic desensitization was done in a way that renders it of little value. By and large research on the effects of systematic desensitization disappeared from the literature when exposure technology replaced systematic desensitization as the treatment of choice for phobic complaints. However, the earliest case studies and clinical series suffice to support the claim that systematic desensitization is effective and should be considered when in vivo exposure is not feasible or is initially refused. A case is described in which a 45-year-old female is treated for dental phobia that was based on claustrophobia and on social phobia.

I.D. Systematic Desensitization

Systematic desensitization consists of gradual, imaginal exposure to stimuli organized on a hierarchy constructed using SUDS ratings. The stimuli in Table 1, for example, could be used in systematic desensitization by having the patient imagine each stimulus. Typically, systematic desensitization is combined with some form of relaxation training. The patient is asked to sit back in a comfortable chair and practice a relaxation exercise. Once a state of deep relaxation is attained, the patient is asked to imagine the least upsetting stimulus on the hierarchy. Exposure duration might be only for a few minutes, alternating relaxation with imaginal exposure until the imagined stimulus no longer evokes fear or distress. The procedure is then repeated with the next stimulus on the hierarchy. The disadvantage of systematic desensitization is that it is slow, and that it is often necessary to eventually implement some form of real-life exposure in order to fully reduce the fears. The advantage is that it is easily tolerated and is therefore a good place to start when treating patients with extremely severe fears.

Systematic Desensitization

5.13.5.1 Systematic Desensitization

Systematic desensitization was developed from classical conditioning theory by Wolpe (1968) using reciprocal inhibition as a fundamental intervention. Reciprocal inhibition posits that two competing emotions cannot be experienced at the same time. Desensitization occurs when the anxiety associated with the phobia is reduced or eliminated after being paired with a competing emotion (i.e., at one time called counter conditioning, but more accurately described as new information now competing with old fearful learning; Davis and Ollendick, 2005). Desensitization mitigates the classically conditioned fear response (e.g., fear of heights) by supposedly weakening the capacity of the conditioned stimulus (e.g., heights) to elicit the conditioned response (e.g., anxiety/avoidance of heights), with the desired outcome being that heights no longer elicits a fear response (Davis and Ollendick, 2011; Ollendick et al., 2004). Systematic desensitization has three main steps: (1) training and induction of progressive muscle relaxation, (2) formation of a fear producing hierarchy, and (3) structured, graduated pairing of the items in the hierarchy without the individual experiencing fear (Davis and Ollendick, 2005; King et al., 2005; Ollendick et al., 2004; Van Hasett et al., 1979).

Wolpe (1968) designed systematic desensitization for use with adults, but adolescents with phobias are typically able to perform progressive muscle relaxation successfully. Younger children, however, may have difficulty attending to and learning the process in order to achieve the necessary level of relaxation to begin (Davis and Ollendick, 2011; King et al., 2005; Morris et al., 2007; Ollendick et al., 2004). Using relaxation protocols that are shorter, simpler, and use imagery (e.g., instruction to pretend to squeeze the last drop of juice from a lemon to relax the hand) may help facilitate muscle relaxation for younger children more so than traditional techniques (Ollendick et al., 2004).

The fear producing hierarchy consists of a rank-ordered list of fears from least to most anxiety-provoking. Adolescents are able to create the hierarchy with the therapist, but it is important that younger children receive parental help since they are not likely to be fully cognizant of the progression of stimuli that activate their phobic fears (Ollendick et al., 2004). The therapist assists by adding intermediate steps as necessary to create an appropriate successive graduation of anxiety-provoking steps. Hierarchies can vary considerably from individual to individual based on a variety of factors including one's perspective of the fearful event, the environment in which the phobic response might occur, person(s) present, the ease or difficulty of escape, and the level of embarrassment (Morris et al., 2007).

Systematic desensitization begins by having the youth fully relax (i.e., create an emotional state incompatible with the experience of fear), after which the events in the hierarchy are presented in ascending order. The child is exposed either in vivo or in vitro until anxiety starts to be experienced; since the goal is to weaken the association between the conditioned stimulus and the sensation of fear, any exposure involving the sensation of fear or anxiety is counterproductive (Davis and Ollendick, 2005). Wolpe (1968) recommended using any desirable behavior to elicit the competing emotion (e.g., food treat, playing with a toy), but relaxation has since become the go-to behavior used to elicit a competing emotion. The systematic desensitization procedure exposes the individual to a step in the hierarchy, has the individual achieve a sufficient level of relaxation, and then proceeds in this manner up the hierarchy until the highest step can be reached with minimal or no fear (Ollendick et al., 2004). Children under the age of nine may not have success with systematic desensitization due to maturational cognitive limitations (Ollendick et al., 1997). Therefore it is important for the therapist to assess the appropriateness of this technique based on the child's ability to master progressive muscle relaxation, use imagery sufficiently enough to imagine the events in the hierarchy, and be able to tolerate in vivo exposure.

Systematic desensitization has been one of the most common methods used to treat specific phobias and related anxieties. Morris et al. (2007) reported that early studies indicated treatment success for school, blood, and height phobias. Utee et al. (1982) found that in vivo exposure was better than in vitro exposure for 5–10-year-olds. For older children, in vivo and in vitro exposure were equally effective, pointing to a developmental limitation of younger children's ability to engage in an adequate imaginative process. Systematic desensitization was less effective in reducing the effects of physiological changes associated with specific phobias in comparison to motor and cognitive symptoms. However, these studies lacked present-day empirical standards, focusing primarily on single case studies that were largely descriptive in nature (Morris et al., 2007).

Davis and Ollendick (2005) reviewed systematic desensitization among other common treatments for specific phobias. Systematic desensitization was more effective than no treatment as well as relaxation when used as a single treatment, but was less effective than participant modeling, allowing it to achieve a probably efficacious status. However, they reported that while systematic desensitization has been shown to be efficacious for the behavioral component of fear alleviation, it only received experimental status for treating the cognitive and physiological components of fear at that time (Davis and Ollendick, 2005). An updated review by Davis et al. (2011) indicated that systematic desensitization continued to have experimental status in the treatment of childhood specific phobias. The componential analysis indicated that systematic desensitization was superior to wait-list control at improving behavioral symptoms and the subjective experience of anxiety. Physiological components were measured but not reported and cognitive components were not measured.

Systematic desensitization

Systematic desensitization falls at the other end of the dimensions of exposure methods, using brief, imaginal, and minimally arousing exercises. Pioneered by Wolpe (1961), systematic desensitization was among the earliest behavioral treatments studies for PTSD. It involves pairing imaginal exposure with relaxation, so that the anxiety elicited by the confrontation with the feared stimuli is inhibited by relaxation. First, the patient is instructed in muscle relaxation exercises. When a state of relaxation is achieved, the feared stimuli are introduced, via imagined scenarios, in a graded hierarchical manner, with the least anxiety-provoking scenarios presented first. When the patient begins to feel anxious, the instruction is given to erase the screen, focus on relaxation, and begin again. The scenario is repeated until it no longer elicits anxiety, at which point the next scenario is introduced. This process continues until the stimuli on the hierarchy no longer elicit anxiety. For example, a therapist may teach a patient to head off panic attacks by taking slow deep breaths. The therapist may gradually expose the patient to images or sensations that remind him or her of the trauma (battle photos, loud noises, smells) and then help him or her deal with the fears that come up.

a. Description of Treatment

Systematic desensitization is a form of exposure therapy developed by Joseph Wolpe in 1958. Based on reciprocal inhibition, it posits that an individual cannot be relaxed and anxious simultaneously. A hierarchy of the patient's fears is developed. In the first part of the therapy, the patient is taught relaxation training. Once proficiency in relaxation is attained, the patient is gradually exposed to the trauma-related items that frighten him or her, starting with the least feared situation object or memory. The patient is instructed to note the onset of anxiety symptoms, and the treatment is paused while the patient initiates relaxation techniques. When the patient has regained a sense of comfort, the exposure resumes. This cycle continues until the patient can tolerate all the stimuli on the fear hierarchy without anxiety.

II. Theoretical Bases

Systematic desensitization, as originally developed by Joseph Wolpe, was theoretically based on reducing anxiety by causing a response antagonistic to this anxiety to occur in the presence of the anxiety-producing stimulus. Thus, if the presence of a snake (the anxiety-producing stimulus), which normally produces anxiety, was paired with relaxation (a response antagonistic to anxiety), then a reduction in anxiety should occur. Wolpe thought that in this fashion the bond between the fear-producing stimulus (the snake) and the anxiety response would be weakened or reciprocally inhibited. Wolpe thought that it was important that a hierarchy of fear-producing stimuli (ranging from looking at the snake to approaching the snake to touching the snake) be constructed so the individual was not overwhelmed by anxiety early in the process. The procedure was based on the counterconditioning model in which the original bond between stimulus and anxiety response was automatically reduced or eliminated by the introduction of an antagonistic response.

Self-control desensitization was originally developed by Marvin Goldfried in 1971 and was based on a somewhat different theoretical rationale. Rather than considering relaxation as “reciprocally inhibiting” the anxiety response, Goldfried proposed a mediational model that was a forerunner of cognitive-behavior therapy. This mediational model consists of two aspects: the active construction of the muscular relaxation response and a cognitive relabeling of the entire sequence between the fear-producing stimulus and the fear response. Theoretically, the client learns a method of actively coping with the anxiety rather than an automatic weakening of a psychological bond taking place. The client also learns to identify proprioceptive cues that are associated with muscular tension and to relax them away, essentially coping with these proprioceptive anxiety responses rather than the actual situations that elicit the anxiety With considerable repetition, the client also learns to react to anticipatory anxiety with anticipatory relaxation, and eventually this process can become automatic in nature. However, both self-control desensitization and systematic desensitization are based on an important assumption of the counterconditioning model that the relaxation response must be stronger than the anxiety response for counterconditioning to occur.

Both systematic desensitization and self-control desensitization originally postulated that the construction and use of a hierarchy of anxiety-producing stimuli was important because a too-rapid introduction of an anxiety-producing stimulus might overwhelm the new relaxation response. If that occurred, it was thought that anxiety would reduce the relaxation rather than the reverse. However, research by Goldfried and Goldfried indicated that the use of a hierarchy of target-relevant behavior was not necessary for effective self-control desensitization. More recent research conducted on systematic desensitization itself has shown that a hierarchy may not be as necessary as originally thought. Implosive therapy (or “flooding”), in fact, is based on the opposite rationale—that it is more effective to begin at the top of the hierarchy rather than the bottom so that rapid extinction might take place. Thus, the construction of a hierarchy has been deemed less important as the theoretical explanatory model shifted from a counter-conditioning to a coping skills model. Likewise, in line with the mediational model, it was not considered as important to terminate the anxiety-producing scene if anxiety increased; rather the client should implement the model by coping with the anxiety itself and relaxing it away. Only if the client is unable to tolerate the anxiety should the scene be terminated. The coping skills model assumes that skills are enhanced by practice and success under somewhat adverse conditions.

Systematic Desensitization

Systematic desensitization is an effective therapy strategy designed to reduce anxiety. The individual is first equipped with relaxation skills and then is asked to come up with a hierarchy of increasingly anxiety-provoking stimuli or situations. When using this technique, an individual is placed in a deeply relaxed state and is presented with a series of gradually increasingly anxiety-provoking situations using imaginal exposure. The therapist starts with the least anxiety-provoking stimulus on the hierarchy and then slowly works up to more anxiety-inducing stimuli. The therapist asks the individual to imagine the stimulus, and when the individual experiences anxiety during the exposure exercise, the therapist asks the individual to allow him- or herself to get rid of the image and then induces the original relaxed state. This procedure is used for longer and longer periods of time until the individual is able to retain the image without experiencing any anxiety; this is continued until the hierarchy is completed successfully.

Systematic Desensitization

Multiple studies demonstrated that systematic desensitization is an effective treatment for phobias and other anxiety disorders. Wolpe (1958, 1969, 1995) explained these therapeutic results on the basis that deep muscle relaxation reciprocally inhibited anxiety. A detailed discussion of research that undercuts this clinical hypothesis is presented in Chapter 11. Some investigators claimed that systematic desensitization worked because of counterconditioning. Other investigators claimed habituation was the real cause. Still other investigators claimed that extinction was the real cause. Tryon (2005) falsified these and other explanations before providing a connectionist explanation that also fits the facts. In short, Wolpe’s explanation of an effective treatment was wrong.

Interventions/Therapies

Wolpe's method of systematic desensitization by reciprocal inhibition involved three phases. The first phase typically involved deep muscle relaxation exercises. Wolpe assumed that one could not be both relaxed and anxious at the same time. The second phase was hierarchy construction where the client rank ordered stimulus features. The third phase was pairing the stimuli on the hierarchy with relaxation, beginning with the least feared stimulus, until that stimulus no longer produced fear. Then the patient was asked to relax in the presence of the next most feared stimulus. These sessions were frequently conducted via imagination in that clients were asked to imagine the feared stimulus after completing deep muscle relaxation exercises. Desensitization could also occur in vivo. In this case assessment began with a behavioral approach test. For example, if the person was afraid of snakes they would be asked to come as close to a confined snake as possible. They would undergo relaxation training and repeat the behavioral approach test while relaxed. Social reinforcement was provided for increased approach.