Systematic Desensitization is a highly structured stepwise exposure procedure that allows the person to face their fear a little at a time in small manageable steps. Additionally, the exposure is paired with relaxation exercises so the physical intensity of the fear response is lessened. Over time the feared situation is associated with a relaxed feeling rather than a tense one. Doing this involves combining some of the previous behavior training techniques that have been discussed in past posts.
1. Create a fear hierarchy - For those who are more familiar with Applied Behavior Analysis (ABA) this means creating a task analysis for the fear exposure. Break up the exposure in to a series of small steps starting with a nonthreatening exposure then VERY GRADUALLY increasing the threat until full exposure is achieved. These steps are written out on a list with only one step of the exposure performed each time. A person cannot proceed to the next step until they feel completely comfortable with their current step. If the person is able, have them identify the different aspects/steps of their fear and rate each step to make sure that the steps are being ordered in increasing intensity.
2. Develop a reliable relaxation response - The key is for the person to be physically calm as possible when facing their fear. Prior to any exposure, develop a relaxation response that lowers the person's arousal level and they feel comfortable using. Deep breathing is typically the easiest to learn. Just remember that the breaths need to be not just deep, but slow and soft as well. Timing is important, about 4 seconds in and out. Listening to a recording of ocean sounds can help a person time their breath to the rhythm of the waves. To help control the force of breath, think of the breathing in like sipping through a straw and breathing out like trying to blow large bubbles or slowly turning a pinwheel. If relaxation cannot be achieved through deep breathing, relaxation may be gained passively by listening to soft music or nature sounds and turning down the lights. Relaxation can be accompanied by positive thoughts such as I am safe, I am comfortable, or even a specific coping strategy ("If I have a problem I can call for help").
3. Perform each step of the hierarchy paired with the relaxation response - Once the person feels comfortable with the relaxation response it is time for the exposure. Start with the easiest/least intense step. After discussing what the exposure plan is and getting the person's consent begin with the relaxation exercise. Once the person appears calm expose them to step 1 of the hierarchy. Exposure can be live (actually seeing what is feared), in the person's imagination (creating a mental picture or thought). Likely the person will feel anxiety symptoms upon initial exposure but should gradually calm as they continue to perform the relaxation. They key is for the person to stay in that step of the exposure until they are completely relaxed. Early escape will only reinforce the fear. Once complete relaxation with that step has been achieved, then the exposure can end. Sometimes you can proceed to the next step if the person wants to, but often a break is needed. If the person gets stuck at a step, that step may need to be broken down further or an additional coping strategy may be needed. I'll give some examples next post.
Steven C Altabet, Ph.D.