Systematic Desensitization and Exposure Therapy

The Intervention

Systematic desensitization involves two activities. The first is helping students learn how to relax their mind and body when in an anxiety provoking situation. The second involves practicing being in the anxiety provoking situation and using the relaxation techniques to help them reduce their anxiety. Technically, this approach is grounded in a concept called reciprocal inhibition, which means that our body cannot have two conflicting physiological responses (i.e., fear and calm) at the same time. The feared or anxiety provoking situations can be external (e.g., feared activities or objects) or internal (e.g., physical sensations). The goal of this intervention is to reduce your student’s fearful reaction to the situation by teaching relaxation exercises (deep breathing, visualization), creating a hierarchy of feared stimuli (e.g., situations, objects.), and taking small steps towards overcoming the anxiety by pairing the feared stimulus with exercises that produce relaxation, until the feared stimulus produces the relaxation response. Overtime, the stimuli will become associated with calmness rather than fear. The goal of this intervention is to reduce your student’s anticipatory worry and fearful reaction to situations by creating a hierarchy of feared stimuli (e.g., situations, objects) and taking small steps towards overcoming anxiety.

Why Systematic Desensitization?

People who experience anxiety can learn to overcome their worry and anxiety by repeated exposure to the feared situations or items. Repeated and extended exposure to feared stimuli can reduce anxiety through a process called habituation. In order for habituation to occur and be helpful, students must stay exposed to their feared situation or object repeatedly for an extended period of time. This can be very uncomfortable, and some people quit before exposure has a chance to work. Systematic desensitization was developed to help people be successful with exposure. Students learn coping techniques, statements to say to themselves, and physical techniques that help them take small steps towards success and increases their likelihood of improving. In Beacon, we focus on systematic desensitization as the primary approach to helping students with worry and anxiety.

Who Can Provide This Intervention?

Systematic Desensitization should only be provided by mental health professionals with training in cognitive behavioral therapy and systematic desensitization. There are many training programs and courses at professional conferences, online, and through professional organizations to learn these techniques.  

Basic Principles

Exposure Hierarchy

In order to implement systematic desensitization, you develop an exposure hierarchy with your student. This hierarchy or “fear ladder” is a list of anxiety provoking stimuli related to the feared scenario. You will want to ensure that these steps on the hierarchy are specific. Rather than creating overgeneralized goals (e.g., learn to pet a dog, stop being worried about going to birthday parties), you will create steps that are specific and well defined (e.g., watch someone else pet a dog, say hello to someone new at recess). These steps should be varying degrees of difficulty and you and your student should rate each step on its degree of difficulty. This could be on a 1-10 or 1-100 scale, or for younger students you may want to use a simpler rating scale with images.

Example Fear Ladder

1. Say hi to someone in the hallway – fear rating 3
2. Start a conversation with someone in class – fear rating 5
3. Join in on some else’s conversation – fear rating 6
4. Ask a question in public – fear rating 7
5. Make a mistake while asking a question – fear rating 9
6. Make plans to do something social – fear rating 9
7. Give a presentation in front of the class – fear rating 10

Getting Buy-In

Getting buy-in from your students can take some effort. Exposing yourself to fears or anxieties is not a pleasant experience and most children with anxiety related disorders tend to avoid activities that cause them distress. It is important to work collaboratively with the student to develop the fear hierarchy to ensure they feel ownership and control over the exposure process. Techniques such as motivational interviewing or values work may also be needed to help students maintain motivation to engage in the intervention.

Subjective Units of Distress

While you are engaging in a systematic desensitization or exposure task, have your student rate their subjective units of distress (SUD) every 3 to 5 min until they are back to 0. SUDs are a measure of how much distress, anxiety, or fear your student is feeling in the moment during your task. Usually these are rated on a scale of 0=not at all distressing to 10=the most distressing. It may be helpful to show your student an image of a thermometer as a way to illustrate these SUDs ratings. Often a student’s SUDs ratings will start very high and as the student remains in the situation, their SUDs should decrease and eventually, come back to a 1 or 0. Ending the exposure before these SUDs come back down to a normative level can make the fear and worry worse so it is important to stay in an exposure situation for as long as it takes for the student to become calm.  

For young students, use developmentally appropriate language that they understand rather than using the term SUDs. Reflect the language that they use to describe their anxiety and get your student’s input to help come up with this term.

Learning Relaxation and Coping Strategies

The student will learn relaxation and coping strategies to use during their exposures to help bring their SUDs back into a normative range. Before engaging in the exposure, the student should spend time learning and practicing these skills without being exposed to what worries them. There are a variety of cognitive and relaxation techniques that you can practice with your student (see list below). It may take some trial and error to decide what works best for them.

Mindfulness Strategies

• Guided imagery
• Progressive muscle relaxation
• Breathing exercises

Tips for Engaging Your Student in Exposures

1. Validate their concerns, exposures can be uncomfortable and scary!
2. Help them identify where their anxiety is causing them impairment. You can draw on this to help them feel motivated to take steps to help change their thoughts.
3. Remind your student that these exposures will take place in a safe environment and that you will not put them in harm’s way.
4. Empower your student to communicate with you about their feelings on the exposures. Do they feel like it is getting too difficult too quickly? Maybe you need to add some intermediate steps or move more slowly.  

Steps to Implement

1. Identify the overarching goal of the exposures. For the example above, the goal is to help the student overcome their social anxiety.
2. Collaboratively create a list of feared stimuli.
3. Rate the fear stimuli on a scale denoting how distressing that situation would be.
4. Put the list of feared stimuli in order from lowest level of distress (easiest) to highest level of distress (hardest).
5. Introduce and discuss potential coping strategies that may be useful in feared situations (e.g. progressive muscle relaxation, visualization, deep breathing, self-statements). Practice the coping techniques with the student in comfortable situations without any exposure.
6. Begin to engage in the exposures. This will not be done in one or two sessions. Generally, exposure systematic desensitization takes around 8-12 sessions.
7. Have your student rate their SUDs every 3-5 min. They should remain in the exposure until their SUDs return to a normal level.
8. After engaging in an exposure, discuss what the exposure was like with their student. Have them share how they felt and what they learned.
9. Reward your student for facing their fears.
10. Repeat steps 5-9 with the next exposure step on your hierarchy.

Tips for Success

1. Make sure that when creating your student’s fear hierarchy or ladder, it is a collaborative process.
2. When creating a fear hierarchy, consider a variety of exposures. You may want to use imaginative exposures (e.g., imagining you see a snake on the ground), in vivo exposures (e.g., ordering a drink at a coffee shop), interoceptive exposures (e.g., breathing through a straw to induce feelings of shortness of breath), or a combination depending on the presenting fear or anxiety.
3. For young children, you may want to create some sort of reward system for their efforts in their exposures.
4. You may need to update your fear hierarchy as you are working and that is okay!