Systematic Desensitization Steps: 13 Techniques & Worksheets

Systematic desensitization is used to treat extreme aversions through a combination of graded exposure and relaxation.

It is an evidence-based behavioral intervention that is focused on helping clients overcome common fears or phobias.

Common fears include claustrophobia (fear of closed spaces), arachnophobia (fear of spiders), or, with OCD, a fear of contamination. While those suffering from phobias and OCD may know their fears are irrational, they feel powerless in controlling them.

This article will explain the approach and provide a step-by-step guide with some handy techniques, worksheets, and videos on how to use it in your practice.

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What is Systematic Desensitization Therapy?

Systematic desensitization therapy is a behavioral therapy intervention used to treat anxiety, phobias, OCD, and PTSD. It is predicated on the idea that the client has learned a conditioned aversive response (usually fear or disgust) to a specific stimulus (Pavlov, 1960 [1927], Skinner, 1963), and that this association can be broken by counter-conditioning (Wolpe, 1958; 1964).

The stimulus may be a specific situation, such as meeting new people, in the case of social anxiety, or a specific thing like spiders, in the case of arachnophobia. It could also be places, sounds, sights, and events associated with a traumatic experience with PTSD.

Systematic desensitization uses counter conditioning to teach a client a new response to the stimulus using relaxation techniques during graded exposure to the stimulus. In this way, the original fight-or-flight response of the sympathetic nervous system is replaced by the relaxation response of the parasympathetic nervous system (Fear, 2017).

The technique is called systematic desensitization, as the counter conditioning graded exposure proceeds systematically through three phases.

1. The client learns relaxation techniques that will counter condition their response to the aversive stimulus.
2. The therapist and client collaborate to produce a hierarchy of the client’s intensity of response to the stimulus at different levels of exposure to the stimulus.
3. The client is desensitized to the stimulus through systematically graded exposure to the stimulus and practices relaxation techniques to counter their aversive fight-flight response during the exposure.

These three phases are practiced over several sessions and homework may also be given to maintain the counter conditioning between sessions.

The easiest way to explain this approach is to use real-life examples, which are presented in the next section.

Who Developed Systematic Desensitization?

Joseph Wolpe (1958; 1964) developed this approach based on his theory of reciprocal inhibition, which found that two polarized emotional responses cannot coexist simultaneously.

In other words, nobody can experience anxiety yet be relaxed at the same time. Wolpe developed his approach when working with veterans suffering from PTSD after the second World War.

He used Pavlov’s research on classical conditioning (Pavlov, 1960 [1927]) to develop counter conditioning during graded exposure to aversive stimuli that were preventing the veterans from re-entering normal civilian life. With PTSD, specific stimuli, such as sounds, smells, words, and places, had become associated with traumatic experiences.

Wolpe paired a graded exposure to these stimuli with relaxation exercises. Because of the process of reciprocal inhibition, he found the veterans could not feel afraid and relaxed at the same time. He used graded exposure to the stimuli to avoid overwhelming his patients and reinforcing their aversive responses.

Exposure Therapy, Flooding and Systematic Desensitization

While systematic desensitization is based on counter conditioning using reciprocal inhibition, exposure therapy uses graded exposure to the stimulus while positively reinforcing tolerance of anxiety, until the anxiety is gradually extinguished (Abramowitz, 1996).

Meanwhile, flooding exposes the client to the feared stimulus directly in one session, so that anxiety floods the nervous system, and then reduces until it becomes extinguished (McLeod, 2015).

The problem with graded exposure is that rising anxiety may be experienced as intolerable, and the client may discontinue therapy. Also, flooding may be experienced as traumatic, lead to further psychological harm, and the termination of therapy (Abramowitz, 1996).

2 Real-Life Examples and Case Studies

The following 2 real-life examples are the easiest way to explain how systematic desensitization works.

1. Systematic Desensitization & Phobia Treatment

Arachnophobia is a relatively common phobia of spiders. When treating this, or any other phobia, the therapist and client would produce a list of scenarios about the feared object or situation and the client would then rate their anxiety levels in each situation on a scale of 1 to 10 (Lang & Lazovik, 1963).

These stimulus-response scenarios are ordered from the least intense at the lowest level (1) up to the most intense (10) at the top.

At the start, the therapist might simply discuss spiders and then lead the client through a relaxation practice. Next, the therapist introduces pictures of spiders, and again leads the client through a relaxation practice.

The next step could be watching spiders on video, plus practicing relaxation. With each greater exposure, the therapist is careful not to overwhelm the client. The client’s usual fear response is gradually replaced by an increasing sense of relaxation, from in vitro (controlled conditions) to in vivo (real-life) exposures (Menzies & Clarke, 1993).

Graded exposures are always accompanied by relaxation. Steps could include exposure to a realistic plastic spider in the room, then in their hand. Next, a dead spider and asking the client to touch it with a stick, then with their hand. After that, the client could be exposed to a spider in a transparent container, then asked again to approach the container and touch the spider with a stick.

Finally, at the highest grade of exposure, they could be in a room alone with a dead spider, then with a spider in a container for a short period, and even a live spider they can learn to trap and remove. This will equip the client with the skills necessary to deal with spiders in real life rather than feeling disabled by their phobia.

With today’s technology, it’s possible to use what’s called VRET, which stands for virtual reality exposure therapy. This is an in-vitro form of systematic desensitization. VRET permits clients to work through each level of their anxiety hierarchy with the added safety and control of virtual reality (Rothbaum et al., 2000). VRET can also be conducted remotely or as homework between sessions.

2. Treatment of Anxiety Disorders (OCD)

OCD can often involve a fear of contamination with germs or pathogens. In such cases, systematic desensitization can be a very useful intervention. Clients with OCD may experience severe anxiety and panic should they have to use a washroom outside the home, for example. They may manage this by indulging in compulsive hand washing until their skin is raw or even avoid using the washroom altogether, leading to additional health problems.

The principles for dealing with a fear of contamination are broadly similar to those used to overcome phobias, as in our arachnophobia example above. Instead of using a spider, use pictures of objects your client perceives as contaminated or dirty.

Clients with OCD fear contamination from different things, so first, identify the objects and situations they fear most and factor that into a systematic desensitization intervention using the relaxation techniques and worksheets provided below.

2 Examples of Hierarchies

Different hierarchies are used to design a systematic desensitization intervention. One is for use with phobias and the other with OCD.

Ask your client for an example of an object or situation they avoid on a scale of 1 to 10, with 1 causing mild discomfort and 10 being panic. For example, if they have a phobia of spiders, then looking at a picture of a spider may make them uncomfortable, say a 2 or 3 while being in a room with a spider may induce panic, scoring 10.

When you initially expose your client to their fear, start at a level that causes some anxiety, but it does not overwhelm them. Then, you ask them to practice their preferred relaxation technique to ease the anxiety until they feel more comfortable and can tolerate the exposure.

1. Phobia

This Anxiety Hierarchy worksheet has been designed to help you organize a client’s anxiety or fear into a graded hierarchy of responses from the most intense to the least intense.

2. Obsessive Compulsive Disorder

This Trigger Hierarchy Worksheet has been designed to help you organize an OCD client’s triggering situations or objects into a graded hierarchy of responses from the most intense to the least intense.

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Step-by-Step Guide For Psychologists

This guide takes you through the systematic desensitization process using six steps. These steps should be applied during exposures of increasing intensity, which can be planned ahead using the hierarchy worksheets above, and relaxation techniques and worksheets below.

1. Psychoeducation

Educating your client about the aims of systematic desensitization, the methods, and the science behind them is essential. It will assure the client that although treatment will be uncomfortable at times, in the long-term, the approach has a strong evidence base supporting its effectiveness. Sharing the videos below with your client might be useful.

2. Establish hierarchy

After securing the client’s willingness to proceed and agree to treatment, help your client to identify anxiety-provoking or triggering situations. Establish a hierarchy of anxiety/ triggers with the assistance of our hierarchy worksheets for phobias and OCD.

3. Design intervention

Use the information obtained from the hierarchy worksheets in our graded exposure worksheet to design a systematic desensitization intervention tailored to your client’s specific needs.

4. Relaxation practice

Before proceeding with any graded exposure, invite your client to learn a relaxation practice. Different clients may find one easier or more effective than another. You can choose from progressive muscle relaxation, deep breathing, or guided visualization. We will describe each below.

5. Treatment plan

Establish the treatment plan with specific dates and times and assure your client they can stop the exposure whenever they need to. It is important that the client feels completely in control of the process and does not endure any trauma that will intensify their problems.

6. Begin

You are now ready to begin. Look at the free worksheets below that detail a six-step systematic desensitization process, beginning with talking about their aversive stimuli, sharing related images, then guided visualization, videos, and finally distant real-life exposure.

The final step would be a real-life supervised exposure to the situation, generating the most intense anxiety.

7. Maintain

To maintain the counter conditioning achieved between sessions, offer your client our Systematic Desensitization Homework Worksheet for use between sessions.

4 Techniques For Your Therapy Session

The following techniques describe relaxation exercises you can use during your sessions and explain how to plan a graded exposure with your client.

Handy relaxation techniques

1. Progressive muscle relaxation

This exercise has been adapted from a free relaxation exercise offered by the British mental health charity, MIND.

First, the client needs to be comfortable, sitting with their back straight and feet touching the floor, then follow this script.

“Begin by clenching your toes as much as you can for a few seconds, then releasing them. Notice the difference between the two feelings. Then, tense your muscles and take a deep breath in, and relax as you breathe out.”

Use this script to move up the body to tense and relax calves, thighs, stomach, shoulders, and hands, asking them to clench and relax each muscle group in turn. You can also add the following:

“Take time to notice any parts of your body that feel tense, tight, or tired. Repeat this if you still feel tense until you relax.“

The NHS’s Every Mind Matters has an audio guide to relaxing your body on YouTube that you can share with your client to guide them through this exercise between sessions.

For other versions of this technique, please visit our article on progressive muscle relaxation.

2. Guided visualization: a calm place

Alternatively, you can guide your client through a visualization that engages all five senses and takes them to a calm place. The Beach is a free pdf which is a script by Dr. Prentiss Price of the Counseling and Career Development Center at Georgia Southern University that you can download for free and adapt as you wish.

3. Deep breathing

This practice will be especially useful for clients when they face real-life exposure, whether intentional or unintentional, as it can be practiced discreetly in any situation.

Ask the client to simply breathe in deeply through the nose to a count of three, and then out through their mouth to a count of three. Sometimes, holding the belly and counting as the breath rises and falls can be especially comforting and relaxing.

Designing your graded exposure plan

Using our Graded Exposure Worksheet, you can design your client’s gradual exposure to the aversive stimuli, meaning the object or situation they fear or avoid.

We share additional staged worksheets specifically designed for systematic desensitization sessions of increasing intensity below.

4 Useful Worksheets To Help Clients

These four worksheets describe specific methods for gradually exposing your client to aversive stimuli while countering anxiety by practicing relaxation.

Each worksheet describes a six-step process and how to use the anxiety rating scale.

1. Systematic Desensitization: From Discussion to Images
2. Systematic Desensitization: From Guided Visualization to Video
3. Systematic Desensitization: Exposure at a Distance
4. Systematic Desensitization Homework Sheet

The homework sheet is provided to maintain the counter conditioned response between sessions. After each session, where you have used any of the first three worksheets, give the client a printed copy of the homework sheet, and show which exercise they must practice.

Helpful Videos On The Topic

1. How to handle any fear

This entertaining video describes the origins of systematic desensitization therapy and how it works. Share this with a client who is considering trying the intervention.

2. Systematic Desensitization and Flooding

The video below describes how systematic desensitization works, and the differences between this gradual, controlled approach and the total immersion used during flooding.

The pros and cons of each technique are also discussed.

Tools From PositivePsychology.com

PositivePsychology.com has additional free worksheets for managing anxiety. Try our Anchor Breathing worksheet to help clients ground themselves when they experience anxiety, and our STOP the Panic worksheet to manage panic attacks.

Our Positive Psychology Toolkit© also contains useful tools to support your Systematic Desensitization treatment plan, including The Consequences of Experiential Avoidance psychoeducation tool. This explains how avoiding feared situations or objects intensifies distress in the long term.

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A Take-Home Message

Systematic desensitization is a highly effective, evidence-based behavioral therapy intervention for clients who avoid certain situations, whether this is because they experience phobias, social anxiety, OCD, or PTSD.

It differs from graded exposure and flooding because it is based on the principle of reciprocal inhibition, which replaces an aversive response, such as anxiety, with learned relaxation.

Importantly, the client is always in control of the intensity of exposure, which avoids further trauma and the compounding of avoidance behaviors.

Systematic desensitization is a valuable therapy that can free clients from their disabling fears and aversions, and enable them to live a more adventurous and fulfilling life.

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