Systematic Desensitization: How It Works & What to Expect (2023)

Systematic Desensitization Examples

Systematic desensitization will often follow a progression like the one outlined above with fear hierarchies and exposures, but the clients and therapists involved will also require creativity and a unique perspective to make the treatment tailored to one’s individual needs and experience. A more individualized process will result in better outcomes.

Specific Phobia: Fear of Heights

Sessions will begin with a combination of psychoeducation and relaxation training. Then, the therapist and client will work to create a fear hierarchy involving heights, starting with the most extreme trigger before moving to the lowest possible trigger and then filling in the gaps.

Using in vivo exposure, the therapist will lead the client through the progression of heights while offering reminders about relaxation skills and cognitive thinking patterns to help the experience. Someone riding on an escalator as an exposure will track their anxious response, usually on a ten or 100-point scale. If they begin at an 80 out of 100, they will continue riding the escalator until their anxiety falls below 40. At that point, the exposure is complete.

From there, the client can process and review the exposure with the therapist. Some people will complete multiple exposures in one day, while others will spread them out over time, depending on the physical and emotional toll exposures take.

Social Anxiety Disorder

Social anxiety disorders involve a severe and debilitating level of stress, fear, and worry when faced with other people or social interactions. This condition can significantly impair a person’s ability to work, go to school, and have meaningful relationships, but systematic desensitization can resolve these fears.6

With early sessions focusing on education, relaxation, cognitive skills, and a fear hierarchy, treatment may utilize a combination of in vivo and imaginal exposures. Perhaps, anxiety is so strong that imagined contact with others is enough to create a strong anxious response.

Good fear hierarchies aim to have the client complete exposures beyond what they would typically have to do. For example, someone with social phobia could plan to speak in front of a group of 100 people, even though there would be no reason to do this ordinarily, because it will create higher levels of habituation and self-efficacy that will generalize to future challenges.4

OCD With Fear of Contamination

OCD presents in many forms, but a person who is obsessed with cleanliness, fears germs or contamination and compulses by washing their hands could respond quite well to systematic desensitization. In this case, the fear hierarchy will include a list of things the person finds “dirty, diseased, or gross.”

The exposures may begin by touching something like a doorknob or button on an elevator before progressing towards toilet seats and raw chicken. Again, overshooting the normal expectation could result with the client taking a trip to a sewage treatment plant or touching animal droppings, even though they would not normally encounter either.

Touching these items will trigger the desired level of stress and anxiety, but the response always diminishes in a predictable way when they stick to the plan. Since the hand washing compulsion is such an important part of this form of OCD, the client and therapist will have to make arrangements for limited and controlled handwashing.

How to Find a Therapist Who Practices Systematic Desensitization

Because systematic desensitization is a widely used treatment option, finding a therapist who is experienced with the practice should be relatively easy. While there may not be many practitioners who would claim they “specialize” in systematic desensitization, many are competent in the practice. To search for an expert clinician in a specific area, consider using an online directory.

Who Is Able to Provide Systematic Desensitization?

Systematic desensitization is a complex variation of CBT, but since it pulls from so many fundamentals of therapy, a provider does not need additional training or certifications to offer the treatment. Of course, the therapist should have the appropriate education and experience, as well as access to supervision to help guide the process.

Cost of Systematic Desensitization & Does Insurance Typically Cover it?

For a person with a diagnosed mental health condition, insurance companies will cover the treatment as they would any other evidence-based intervention. People interested in systematic desensitization should be sure to check with their insurance company to identify any deductibles, copays, and other out-of-pocket expenses they can expect.

Without insurance, systematic desensitization usually costs between $50 and $150 per session, which may be a cheaper option than medications to treat the same conditions. One study found exposure therapy to cost about $1,600 less than medication therapy when used for PTSD treatment.7

10 Key Questions to Ask a Therapist When Considering Systematic Desensitization

Gaining as much information as possible from the treatment provider before initiating any therapy can serve as a guide to the coming sessions. This information can also establish expectations that are fair and realistic. Let answers to your questions either build trust and confidence in the therapist or provide a sign that another provider may be a better option.

Here are ten key questions to ask a therapist using systematic desensitization:

  1. Is systematic desensitization an appropriate treatment for me?
  2. When will exposures take place? During session, or will I be expected to engage in exposures in between sessions?
  3. How long will my treatment last?
  4. Can we speed up or slow down the process?
  5. How long have you been performing systematic desensitization?
  6. Do you receive consultation or supervision from an expert?
  7. Should I use in vivo, imagined, virtual reality, or a combination of exposure techniques to feel better?
  8. Will the anxiety return after treatment ends?
  9. What if an exposure is too scary and I need to stop?
  10. Will you use other types of treatment with the systematic desensitization?

What to Expect at Your First Appointment

Depending on the provider and your needs, the first session of systematic desensitization therapy could represent the entire course of treatment as you and your therapist quickly work to learn relaxation, build a hierarchy, and move through exposures at a rapid pace. Some exposure treatments are conducted during one long session, instead of several one-hour-long sessions.1

In most situations, though, the first session will focus on assessment and education. The therapist will gather information to ensure your symptoms can be well-treated with systematic desensitization, and then, you will devise a treatment plan with goals and timeframes.

Is Systematic Desensitization Effective?

Systematic desensitization is consistent, effective, and backed by years of evidence. It is the primary treatment for phobias, social anxiety, and other anxiety disorders, and is also highly effective for PTSD and OCD.

Statistics & Facts

Research and studies on systematic desensitization and other exposure therapies find:3

  • 90% of people who experience one session of in vivo exposure report less fear, less avoidance, and less overall impairment with results lasting for years
  • 65% of people who used exposure therapy for a specific phobia noted their disorder being eliminated after one session
  • For people with OCD, 86% reported lower symptoms with exposure compared to only 48% of those who received medication
  • Exposure therapy produces results that last longer after treatment ends compared to medication-only treatment and treatment using exposure and medication

Risks of Systematic Desensitization

The primary risk of systematic desensitization comes from inexperienced therapists or frightened clients who do not allow the full desensitization to occur. After exposure, if the anxious response is not allowed to reduce to less than 50%, the fear becomes sensitized, not desensitized, which means the person will have stronger reactions in the future.4

In people with PTSD, systematic desensitization risks creating a retraumatizing effect. This increase in symptoms could be short-term or long-term, so the therapist and client must plan and prepare for the chance of this occurring.8

Criticisms of Systematic Desensitization

Criticism of systematic desensitization comes from proponents of other exposure therapies. For example, some may believe that the addition of relaxation actually slows the progress by lowering the full extent of the fear response.1
These critics believe that by diminishing the stress, the person is not allowed to build the habituation that they would from other exposures without relaxation.

Though this criticism is valid, a client may prefer the idea of lower anxious responses and may be more inclined to begin and follow through with treatment. Plus, relaxation techniques are helpful tools for many situations and can be used in and out of systematic desensitization.

How Is Systematic Desensitization Different Than Other Therapy Techniques?

Systematic desensitization shares many similarities to exposure therapy, general CBT, and other forms of therapy that involve some level of real or imagined exposure. By having so many alike features, it becomes challenging to distinguish systematic desensitizations from other therapy techniques.

Systematic Desensitization vs. Exposure Therapy

Systematic desensitization is not a treatment separate from exposure therapy. Instead, systematic desensitization is a form of exposure therapy. There are many ways to complete a course of exposure therapy, and anytime the focus is on gradual and methodical exposure with the incorporation of relaxation, the therapy is systematic desensitization.

Systematic Desensitization vs. EMDR

Systematic desensitization and eye movement desensitization and reprocessing (EMDR)are both available treatments for PTSD and other anxious disorders. Both encourage the person to re-experience the trauma through exposure to lessen its impact.

The major difference with EMDR is the importance of directed eye movements, sounds, touches, and other types of bilateral stimulation. These help to reprocess the trauma, so the client is no longer as affected by the unwanted experiences.9
These aspects are absent from systematic desensitization.

Systematic Desensitization vs. Exposure & Response Prevention

Exposure and response prevention (ERP) is the first-line psychotherapy option for OCD, and though it incorporates many elements of exposure therapy, it uses a customized direction to produce better outcomes for people with obsessions and compulsions. ERP uses the same exposure aspects as systematic desensitization, but with the focus on response prevention, it ensures that people do not engage in the compulsive behavior as a way to reduce their mental discomfort.10 Breaking this association is challenging but essential.

History of Systematic Desensitization

Psychology in the first half of the 20th century was ruled by psychoanalysts who believed unconscious thoughts and desires fueled a person’s feelings and actions and building insight to these issues could create change. When Joseph Wolpe proposed a person could change their feelings by changing their behaviors in the 1950s, it seemed like a foreign concept to the psychological establishment.4

Certainly, the concept of facing your fears is nothing new, but Wolpe was the first mental health professional to discover and document how exposing oneself to the source of their fears in a gradual and progressive way can result in symptom relief. Today, it fits in perfectly with many concepts of CBT and psychology as a whole.

Over the years since Wolpe’s work in South Africa, many practitioners and researchers have explored ways to make exposure more effective. With advances linked to virtual reality, systematic desensitization is being used in ways Wolpe could have never imagined.

Top Articles
Latest Posts
Article information

Author: Prof. Nancy Dach

Last Updated: 02/05/2023

Views: 6215

Rating: 4.7 / 5 (77 voted)

Reviews: 92% of readers found this page helpful

Author information

Name: Prof. Nancy Dach

Birthday: 1993-08-23

Address: 569 Waelchi Ports, South Blainebury, LA 11589

Phone: +9958996486049

Job: Sales Manager

Hobby: Web surfing, Scuba diving, Mountaineering, Writing, Sailing, Dance, Blacksmithing

Introduction: My name is Prof. Nancy Dach, I am a lively, joyous, courageous, lovely, tender, charming, open person who loves writing and wants to share my knowledge and understanding with you.