Systematic Desensitization in 10 Steps

Clinical Psychiatry News - Volume 36, Issue 9, Page 23 (September 2008)

In previous discussions about behavioral strategies that can be used to treat patients in anxiety-provoking situations, I have referred to the procedures of reciprocal inhibition and systematic desensitization.

Several psychiatrists and psychologists have asked to me to further describe the steps taken when developing a program of systematic desensitization.

It appears that many therapists who want to provide optimal care for their patients have come to realize that behavioral techniques really work.

Why the surprise?

Traditional open-ended talk therapy centering on hoped-for understanding of problems—with unsubstantiated constructs—often fails to resolve the problems that the patient needs resolved. Therapists are now looking for more practical solutions to emotional problems that clearly offer specific, timely, and measurable results.

A few months ago, I wrote a column focusing on patients with phobic responses while going over bridges and through tunnels (“Finding a Way to Cross the Bridge,” February 2008, p. 17). In that piece, I described the relaxation technique (reciprocal inhibition) coupled with systematic desensitization. The idea of systematic desensitization is to use a hierarchy of in vivo stressors and anxieties coupled with pleasant experiences in treatment.

Most clinicians will develop a hierarchy with the patient, going from the least stressful situations to those that are more stressful or phobic. Others feel that moving directly into the most stressful is the method of choice. I disagree. I do not believe that jumping into a severely stressful set of images—flooding a person with stress—is an optimal strategy. For some patients, this approach is unsafe.

The hierarchy developed with the person who feared bridges and tunnels used 10 visualizations, going from non-anxiety provoking to severe anxiety as reported by the patient.

Here is a listing of the 10-step hierarchy:

1. I Eat an enjoyable breakfast and contemplate a successful day's work.

2. Check the weather and traffic before preparing to leave.

3. Leave the house and start to feel anxious. This is where a pleasant scene is coupled with the beginnings of the stress/anxiety.

4. Get into the car (which would lead to some apprehension). Again, a pleasant experience of the patient's design is used.

5. Start driving to the highway that leads to a bridge or tunnel. Irrational thoughts about a bridge collapsing or getting stuck on the bridge start to occur. Link those thoughts to a positive memory, such as graduating from college or going to a party with a spouse. The anxiety lessens.

6. Drive along the highway. Shift into a pleasant scene.

7. Catch glimpse of the bridge that will be crossed about a half-mile away while rounding a bend in the highway. As anxiety grows, profuse sweating begins. The patient begins to move into a pleasant or rewarding scene. (Remember, the patient picks the scene.)

8. Go into the flow of traffic and move onto the approach of the bridge. Notice the traffic is slowing. Shift into a very pleasant memory. (Just as in number 7.)

9. Get onto the bridge.

10. Cross the bridge with a feeling of success.

Whether you work this program in 2 sessions or 20 sessions becomes a matter of patient severity and the specific approach of hierarchies and imagery you work with. The important point may be that the treatment is not open-ended for either the patient or for you. The use of behavioral therapies, based on learning theory, is well studied and documented in the literature.

And along with the visits, of course, the patient must practice regularly at home to maintaining the skills she has learned as a new coping mechanism.

This particular approach is centered around a basic theme in the patient's life—going to work and eating a pleasant breakfast first—as the desensitization process begins.

Some other forms of desensitization could be specifically goal oriented, with only the specific situation of the bridge or tunnel incorporated into the program. These are individual approaches the therapist can use. I like the thematic mode. For me, this mode brings in a total picture of the person's life, starting with the stress-free act of pleasantly eating breakfast.

A few years ago, I treated a medical student who froze and went into a panic at exam time—fearing that he would forget everything he knew. In this case, I did a countdown of days to the examination, starting at day 10 and jumping forward day by day. At no time did I approach any speculation of why this was occurring. Nor did I try to thematically develop a theory based on what the patient had for breakfast. I went to the specific problem.

A previous therapist in the school's mental health system had suggested to this student: “Maybe you don't really want to be a doctor.” Such wild speculation would not be an uncommon jump in traditional talk therapy. The student didn't like the idea, and, of course, as we all know, he was labeled “resistant.”

As we moved forward visualizing the upcoming exam, day by day, I offered some coupling of relaxation techniques and pleasant imagery aimed at calming the anxiety as we approached the exam day. The student began to feel calmer and calmer, but he reminded me that going to the exam was not the problem, per se. The problem was forgetting the material.

I did not think that he was resisting; I thought he was educating me about his problem.

I began to offer a visualized strategy of coupling the 10-day countdown to the exam, with him visualizing the test material on the same screen on which he was visualizing his 10-day countdown to the exam. The student switched from anxiety to mastery as he saw the material in front of him, knowing he could ace the exam and not fail.

This is no different from sitting in an exam and being able to suddenly see a page that you've been studying in your mind's eye.

After the student knew and mastered this technique, the test anxiety lifted. We did this in three visits.

This man was motivated to be a doctor and today is a fine surgeon. Imagine how following the notion of not wanting to be a doctor would have ill served him.

Imagine what might have happened had the patient remained in this treatment and ended up being “therapized” in the wrong direction.

We've still got some old notions that the patient is not cured unless the therapist gets to the root or real cause of the problem. It's about time we left this idea as a generalization and began to think that it might apply to only a small proportion of the people we treat.

Furthermore, as a profession, we often imply that a treatment might not be successful if it does not fit with our chosen set of theories.

I remember a therapist suggesting to a patient who had chronic back pain with no physical findings and wanted to try biofeedback to go and try it—even though it might not work.

What an unsupportive piece of advice for a good alternative therapy.

I hope I've outlined several techniques upon which you can build. Let me know your thoughts on using behavioral therapies, and I will try to pass them on to my readers.

PII: S0270-6644(08)70626-X

doi:10.1016/S0270-6644(08)70626-X