DESCRIPTION OF THE STRATEGY

Since the 1950s, systematic desensitization has been a primary behavioral intervention used
for a variety of fearand anxiety-based difficulties experienced by children and adolescents.
Developed by Joseph Wolpe, systematic desensitization is premised on the assumption that
fear responses cannot simultaneously exist in the presence of a competing response. This
basic principle is referred to as reciprocal inhibition. In essence, responses that are
incompatible or inhibitory to anxiety (e.g., relaxation, a state of calm) are created and
compete with the fear response. Because of their incompatibility, both responses cannot
coexist, and the anxiety decreases. Through repeated pairings of the inhibitory response with
the anxiety-provoking stimuli, the connection between the feared stimuli and the anxiety
response is diminished, a process known as counterconditioning. Fear and anxiety are the
most typical presenting problems for which systematic desensitization is utilized.
Systematic desensitization involves three separate components, including (1) relaxation
training, (2) the creation of an anxiety or fear hierarchy, and (3) the systematic presentation of
the fear hierarchy while the child is in a relaxed state. The implementation of systematic
desensitization follows these three components and consists of two phases. In the first phase,
the child is taught relaxation strategies. Most frequently, progressive muscle relaxation is
utilized. This component of training can take anywhere from 3 to 10 sessions; the primary
goal is for the child to attain a deep state of relaxation. Relaxation tapes are often created so
that the child can practice on a regular basis in the home context. To facilitate the acquisition
of skills, parents are often trained to coach their children in the relaxation procedures and to
reinforce their children's efforts. For children who have difficulty learning and utilizing
progressive muscular relaxation, alternative means of achieving a relaxed state can be
introduced, such as diaphragmatic breathing exercises, imagery exercises, or autogenic
training.
Simultaneous to the relaxation training, an anxiety or fear hierarchy is created. The
construction of a fear hierarchy essentially involves the creation of a number of different fearrelated scenarios that approximate the target fear or anxiety-provoking situation. Children are
asked to help create descriptions of different situations that produce different levels of anxiety,
fear, or tension. These scenes are then rank ordered from least anxiety provoking to most
anxiety provoking. For example, a child with a fear of receiving shots may begin by first
creating an imaginal scene that involves driving past the doctor's office. The next scene may
involve walking into the doctor's office with the child's parent, but not having an appointment.
A third scene might involve going to the doctor's office with the child's parent for an
appointment that would not involve a shot. A fourth scene might involve seeing a needle and
watching a friend or sibling receive a shot, and so on. A final scene in the hierarchy might
involve actually receiving multiple shots at the doctor's office. In addition to the feared
scenes, the child is also asked to identify one scene that is relaxing and nonanxiety provoking
(e.g., playing computer games, reading a book).
Once the fear hierarchy has been completed and it is apparent that the child can engage in the
requisite imaginal activities, the second phase of treatment is initiated. The child begins the
first treatment session of this phase by engaging in deep relaxation. Once that state is
obtained, the child is then asked to briefly imagine a scene from the hierarchy that is
considered to be the least tension or anxiety provoking. Once the child has successfully
engaged in imaginal exposure three to four times to this scene without significant anxiety, he
or she is then exposed to a subsequent hierarchy scene. Anywhere from one to four different

scenes can be presented per session, depending on the child's response. Scenes are typically
presented for about 10 to 15 seconds each time. Should the child begin to experience anxiety
or tension, he or she is requested to raise the right index finger. At that time, the therapist
instructs the child to imagine his or her relaxation scene and assists the child in utilizing
relaxation skills. Once the child has returned to a state of relaxation, the scene from the
hierarchy is presented again. Should the child not be able to successfully engage in imaginal
exposure without tension on two consecutive opportunities, the therapist directs the child to
move back down the hierarchy to a less anxietyprovoking scenario. The child is then asked to
reinitiate the imaginal process, and then moves again up to the hierarchy until he or she is able
to successfully remain relaxed during exposure to the most anxiety-provoking scene in the
hierarchy.

RESEARCH BASIS
Research evidence exists that supports the use of systematic desensitization in the successful
treatment of phobias, fears, and anxiety. Notably, the majority of this research involves case
studies and single-subject designs, and unfortunately most of these studies have evaluated
systematic desensitization in combination with other treatments. Only on rare occasions has
the efficacy of this procedure been evaluated with controlled treatment studies using random
assignment. Because of the lack of controlled studies, systematic desensitization has been
deemed probably efficacious rather than well established according to standards created
for empirically supported treatments. Indeed, additional research is needed to examine the
efficacy and effectiveness of systematic desensitization, especially given the widespread
clinical acceptance of this approach.
Notwithstanding the relative lack of a strong research base, some authors have tentatively
identified those factors that may influence the clinical effectiveness of systematic
desensitization. Such factors include the child's willingness to or ability to successfully
engage in relaxation, age of child (9 years and above), compliance with homework
assignments, motivational level of parent and child, and skill at imagery. Clinicians should be
mindful of such factors as treatment is undertaken.

RELEVANT TARGET POPULATIONS AND

EXCEPTIONS
Systematic desensitization has been used to treat a wide variety of anxiety disorders,
including generalized anxiety disorder, specific phobia, social phobia, school refusal or
phobia, posttraumatic stress disorder, panic disorder, and selective mutism. In addition, this
procedure has been utilized to target a wide variety of specific fears (i.e., test anxiety,
darkness, blood, heights, food swallowing, motion sickness) and painful medical procedures.
Notably, systematic desensitization has been used as well with individuals with mild to
moderate levels of developmental disabilities and cognitive impairments. Thus, systematic
desensitization has witnessed wide acceptance among clinicians for treating childhood anxiety
disorders, fears, and phobias. Notably, this procedure is often used in combination with other
behavioral and cognitivebehavioral interventions (e.g., covert conditioning, modeling, in vivo
desensitization) and is integrated readily into treatment packages.
Systematic desensitization procedures may not be recommended for extremely young children
(i.e., under the age of 4 or 5), and some researchers have expressed concerns about the use of

this procedure with children under the age of 9. For younger children, it may be difficult to
have them engage in the imagery process itself. Some research does exist to support the use of
shaping procedures as a means of teaching individuals how to successfully engage in imagery.
Picture cards, video models, and audiotapes have also been used to facilitate the acquisition of
vivid images.
To the extent that parents are equivocal in their support of this treatment procedure, success is
also less likely and clinicians may choose an alternative therapeutic approach. Developing
relaxation skills typically requires home-based practice that is most successful when parents
are positively involved and committed to the intervention. In addition, if parents express
reluctance to have their child experience the anxiety associated with imagining the fear
hierarchy, the child may be less likely to engage in the process and may experience
anticipatory anxiety that could interfere with the intervention.

COMPLICATIONS
In some cases, the level of fear or anxiety is sufficiently high that the child is unable to
actively engage in either the relaxation component of training or the creation of the fear
hierarchy. In those cases, supportive therapy, reassurance, or even medication management as
a final resort may be in order. Teaching the parents strategies for ameliorating the child's fear
can also be helpful before beginning systematic desensitization proper.
It is also notable that some children appear to be unable to achieve a state of deep relaxation,
or they report subjective distress (fears of losing control) in their attempt to relax. Slow
shaping procedures may be in order for these individuals, or use of alternative means of
relaxation, that is, listening to their favorite music on tape, hypnosis.

CASE ILLUSTRATION
Tonya was a 10-year-old girl who presented to the clinic with a fear of dogs. Tonya was an
only child and came from a family with no pets. Her mother reported that Tonya had limited
exposure to dogs growing up, as neither close friends nor extended family members had dogs.
Tonya and her family had recently moved to a new home where neighborhood dogs were
common. While meeting a neighbor and his dog, the exuberant dog jumped up on Tonya and
knocked her down. This startled Tonya, and she wanted no further contact with the dog. Later
in the week, Tonya was outside in her yard when this dog got into an altercation in front of
Tonya's house with another neighborhood dog. Tonya reported being frightened by the sounds
of the dogs fighting as well as the response of the adults (i.e., yelling at the dogs, yelling at
Tonya to get in the house).
Tonya began avoiding being outside and refused to walk near the neighbor's house. To get to
school, she was required to walk past this house as well as several other homes with large
dogs. Tonya subsequently began asking her parents to drive her to school. When being driven
to school was not possible, she began reporting stomach pains and headaches and requested to
stay home. At times her parents allowed her to stay home, while at other times they required
her to go to school. On the days Tonya did go to school, she was observed to run down the
middle of the street when passing those homes with dogs. Other fears reported during the
intake included fear of the dark and fear of fire. These fears had not interfered with Tonya's
daily routine and were reported as being only mildly disturbing.

According to her teacher, Tonya had several close friends and was continuing to perform
above grade level despite recently missing school. However, Tonya's teacher did report
concerns that if Tonya continued to miss school, her grades would drop. She also reported
frequent comments by Tonya about not wanting to walk home and concerns about dogs
getting loose in her neighborhood.
Treatment began by teaching Tonya relaxation skills. A brief rationale was given to Tonya and
her mother regarding the need to learn relaxation skills, and a description of what to expect
was provided. A large overstuffed reclining chair was utilized, as Tonya preferred to sit and
recline during this procedure rather than lie on a couch. A script was used to guide Tonya in
progressive muscle relaxation (e.g., Imagine a dinosaur is about to step on your stomach;
make it hard). She was able to demonstrate adequate engagement in the task, and no
difficulties with relaxation were noted. An audiotape of the procedure was made during the
session and given to Tonya and her mother to take home. It was agreed to have Tonya practice
the skills for about 10 to 15 minutes twice a day by listening to the tape once each night
before she went to sleep and once each afternoon prior to doing her school homework. Three
subsequent sessions were spent on practice, with the script being phased out and Tonya
internalizing the relaxation process. Tonya was successfully able to do this and became
proficient at inducing a relaxed state on command. It was indicated that Tonya was practicing
on average about once daily with her relaxation tape. While this was less than the twice daily
recommendation, her development of the skills indicated that this was sufficient.
In addition to the relaxation skill training, time was also spent developing a fear hierarchy
specific to dogs. Thirteen different situations were generated, ranging from seeing a picture of
a dog (very little anxiety) to walking past a house with a dog locked inside (moderate anxiety)
to petting multiple dogs in a small space, including the dog who knocked Tonya over and got
into the fight (high anxiety). In addition, an anxiety-free scene also was selected. Tonya
identified reading a book on her bed as her relaxing situation. Time was spent practicing
imagining this scene as part of the relaxation training. Tonya was able to verbally describe the
scene and reported feelings of relaxation when she imagined herself in the scene.
Given Tonya's quick mastery of relaxation skills, desensitization began during Session 5.
Tonya was asked to spend about 5 minutes relaxing in the recliner and indicate when she was
in a relaxed state by raising her right index finger. The therapist then presented the scene from
the fear hierarchy with the lowest anxiety level and asked Tonya to imagine the scene as
vividly as possible. Tonya was able to successfully imagine this scene (viewing a picture of a
large dog) on three consecutive tries without any distress and was able to move up the
hierarchy to the next scene (imagining being inside her house and seeing a dog in the fenced
yard several houses down the street). Tonya experienced anxiety at this point and was
instructed to imagine her relaxation scene. After several minutes of relaxation, she was again
asked to imagine the scene from her fear hierarchy. This time she was successful and was able
to imagine the scene three consecutive times without distress. Six subsequent sessions
involved Tonya imagining additional scenes. Each scene was presented until she was able to
visualize it for 10 to 15 seconds without anxiety on three consecutive occasions. As Tonya
approached the higher end of the hierarchy, she had more difficulty imagining the scenes
without anxiety and had two occasions where she had to return to previously mastered scenes.
However, with minimal prompting to imagine her relaxation scene, she was able to
successfully advance through the hierarchy. Upon completion of all the identified scenes,
Tonya described a willingness to play with and pet dogs and reported no concerns about being
around dogs she was acquainted with or who were with their owners. She had resumed

walking to school on a daily basis, and her somatic complaints decreased. Tonya did report
some minor fears of dogs fighting and of walking past houses where unknown, unrestrained
dogs lived. As this fear was considered appropriate due to safety considerations, Tonya's
overall progress in therapy was considered a success.
Larry L. Mullins and Sharon M. Simpson
Further Reading

Entry Citation:
Mullins, Larry L., and Sharon M. Simpson. "Systematic Desensitization with Children and
Adolescents." Encyclopedia of Behavior Modification and Cognitive Behavior Therapy. 2007.
SAGE Publications. 15 Apr. 2008. <http://sage-ereference.com/cbt/Article_n2127.html>.