Desensitization Steps

        Those, then, are the basic principles involved in desensitization.  Here is a brief summary of the steps you will go through in desensitizing yourself:

Step 1.  Anxiety Hierarchy.  First, you will construct an anxiety hierarchy, which is a list of those situations involved in and leading up to your target situation ranked in order from the lease disturbing to the most disturbing.

Step 2.  Relaxation Training.  Then you will train yourself in deep muscle relaxation.

Step 3.  Desensitization Sessions.  You will then go through a series of desensitization sessions.  At the beginning of a session, using what you've learned from your deep muscle relaxation training (to be explained), you will relax.  You will then imagine a scene representing the weakest item on your hierarchy while maintaining your relaxed state.  A given step on your anxiety hierarchy must be repeatedly imagined until you no longer exhibit anxiety at the presentation of it.  You will then imagine the next higher anxiety-producing step, and so on.  Thus, the anxiety cues are gradually decreased until you can present the most frightening step without feeling any anxiety whatsoever.

 The desensitization procedure makes use of the fact that a person's anxiety response (tensing of muscles, feeling of discomfort, uptightness, etc.,) to the imagined  situation resembles his anxiety response to the real situation.  So, when you can feel entirely comfortable and relaxed when thinking of your target behavior, your real-life target situation will shortly begin to be progressively less anxiety-producing.  Experience with patients has proven this method of relaxing while imagining to be quite effective in reducing anxiety.  The purpose of the first half of this manual is to teach you precisely how to construct an anxiety hierarchy, learn deep muscle relaxation, and desensitize your self to the steps in your hierarchy, thereby helping you reduce the anxiety you experience in your target situation.  Thus, the first half of the manual is divided into three sections:

 _  1. Create The Anxiety Hierarchy    2. Deep Muscle Relaxation    3. Desensitization Sessions

Step 1. Create The Anxiety Hierarchy

        The anxiety hierarchy is a list of situations relating to your target behavior to which you react with varying degrees of anxiety.  The most disturbing item is placed at the bottom of the list and the least disturbing at the top.  In working on the hierarchy, you will begin with the top item on the list (that is, the least disturbing item) and work step by step through the hierarchy to the last item (the one which produces the greatest anxiety affecting your target behavior).  Thus, the hierarchy provides a framework for desensitization, through relaxation, of progressively more anxiety-producing situations. 

 Construction of an anxiety hierarchy can aid you in three ways: 

 1.    It helps you verbalize your problem and set it down in terms of concrete situations which you have, or perhaps will, come up against in real life.

2.    You will begin to analyze your problem further by breaking it down into situational components which will make it easier for you to see what specific things about the target behavior cause you anxiety; how they are related to anxiety-provoking situations other than your target behavior; and how the problem may be systematically approached.

3.    You will place the problem in a form that can be treated by this method.  Some people say that merely constructing the anxiety hierarchy has therapeutic value.  They have an increased understanding of the problem and a clearer idea of how and why they experience anxiety in certain social situations. 

Constructing The Hierarchy

        Constructing a good hierarchy is very important since it provides the framework for approaching the problem.  Time and care must be devoted to it.  As was stated above, the hierarchy is a list of the situations related to your target behavior which you react to with graded amounts of anxiety.  Such a hierarchy is constructed in three steps.  Now, please get a pencil and some paper and follow the instructions closely.

 1.    Write down as many situations as you can think of in which the problem occurs.  If you are nervous with strangers or members of the opposite sex, for instance, write down these specific situations in which you experience difficulty.  Write down all you can think of.  Your list will include some situations which are worse than others.  Some will be very frightening, some hardly frightening at all, and some in between.

 2.    Make a list of some of the VARIABLES that affect your anxiety level.  This can increase your insight into the causes of your anxiety and make it easier to create a good hierarchy.

  a )   Examples of variables affecting the amount of anxiety in presenting a speech to a class:  class size; length of speech; amount of preparation; importance of speech; how critical instructor is; length of time before the speech (week before, night before, walking to classroom, being called upon to give speech, etc.); how personal the speech is; degree to which others will disagree with it; etc.

  b )   Other common variables affecting anxiety levels; amount of rejection expected; sex of other person; attractiveness of other person; difficulty of test; etc.

  c )    Look at some of the sample hierarchies and identify variables affecting the amount of anxiety in them.  Of course each person is unique, but there are often similarities between hierarchies.

1.    Now arrange these items in order from the least upsetting to the most upsetting by thinking about each one and imagining just how bad it would be to be in that situation.

2.    Now build your final hierarchy.  Most people include about 10-20 items (you may have more) beginning with items so mild that they are practically non-frightening.  You might have to invent some very mild items such as having someone say the word  "girl" (for guys who are afraid of girls), or looking at the picture of a professor (for people who are afraid of those with high status), etc.  The ten to twenty items should be chosen so as to contain very small jumps in severity from one item to the next, so that when you have finished an item you don't have a very much harder item just in front of you.  The final items, of course, should be the most severe items from the original list.

 This ranked list of anxiety evoking items constitutes the hierarchy that you will use in your treatment.  Modifications additions, combining of items, and further breaking-down of items on the hierarchy may be made at any time during the desensitization therapy.  Most people's hierarchies require some modification as desensitization.

 Sample Hierarchies

        To aid you in constructing your hierarchy, we have included five sample hierarchies below.  Studying these hierarchies will give you a good idea of how they are constructed and should help you construct yours.  These are, however, samples only to show you the form.  You must construct your own hierarchy which applies to your specific case.  

Step 2. Deep Muscle Relaxation

        As Discussed above in the introductory section of the manual, people are desensitized to the anxiety-evoking items on their hierarchy by stopping the anxiety with relaxation.  In order to do this, you must first learn to relax completely, and also learn how to achieve this relaxation at will.

        The technique which behavior therapists use to relax patients is known as deep muscle relaxation.  This technique will help you to achieve a very deep and thorough state of relaxation, enabling you to progress through the desensitization of your hierarchy.

        Before beginning your desensitization sessions, you should spend at least two half-hour sessions or two days, a half hour per day (beginning tomorrow) practicing the relaxation technique.  In order to receive the full benefit of deep muscle relaxation, you should observe the following guidelines in relaxation training:

 1.   Spend at least one twenty-minute session, every other day, relaxing and imaging the steps in your hierarchy.

 2.   Read and imagine acting out the steps in a setting in which you can carry through the full twenty-minute session uninterrupted.

 3.   It is of the utmost importance that the relaxation training sessions (as well as the desensitization sessions) be carried through without interruption.

 4.   It is also important that you concentrate completely on each of the relaxation procedures and carry out the exercises as instructed. 

 5.   Both the relaxation training sessions and the desensitization sessions should be carried out in a quiet, semi-darkened room.  Sit in a comfortable chair or lie down on a comfortable bed or couch.  It is important that you be comfortable and able to concentrate throughout a training session or a desensitization session.

 6.   In addition to practicing the relaxation exercises during an actual relaxation training session, it is helpful to practice the exercises at other times as well.  An excellent time to practice is during the minutes in bed before falling asleep.  Many people find that such practice not only increases the rapidity and effectiveness of achieving relaxation during a session but also helps them to fall asleep earlier and to snatch periods of relaxation during the day.

 When you are able to relax yourself completely in three or four minutes by briefly running through the relaxation exercises, then you are ready to begin your desensitization sessions.

        Many people need only 2 practice sessions.  If you find you need more, stay with them until you feel that you have achieved the ability to relax.  

And Now: >>>

Use the relaxation procedure on the "Self Desensitization" recording  (Side 2 and about 3 minutes into the recording ).  Practice them for twenty minutes for two days or until you can relax completely at will.

 Step 3.The Desensitization Sessions

        Having constructed an anxiety hierarchy of from ten to twenty items, and having practiced deep muscle relaxation so that you feel you have achieved the capacity to relax at will, you are ready to begin desensitizing yourself to the hierarchy.

        Briefly, an item is desensitized by imagining it in vivid and realistic detail while trying to maintain a state of complete relaxation.  The item is repeatedly imagined until you are able to imagine it with feelings of complete relaxation and comfort, i.e., without experiencing any anxiety or tension.  When you are able to imagine a given item with complete relaxation, you then move on to the next item and repeat the process:  Imagine each item in vivid and realistic detail while remaining relaxed.  In this way, you proceed through the hierarchy from less to increasingly more anxiety-provoking items and desensitizing the hierarchy item by item.

Imagining an Item

        Each item on your hierarchy describes a situation.  For the desensitization to be effective it is extremely important that when you imagine the situation described by an item, the image in your mind be as realistic as possible, and as if you were actually experiencing the situation.  An excellent way to make your image realistic is to imagine the situation very vividly and in complete and minute detail.  You should imagine all the accessory details of the situation and all the sights, sounds, and smells that you would be aware of were you actually experiencing the situation.  For example, if an item involved your making a date with a member of the opposite sex, you should have an image of the other person and his or her facial expressions and your gestures, etc.  You should notice all the aspects of the other person and his or her face, smiles, eye contact, etc.  Make the other person seem real and alive.  Hear your voices and the words you say and notice your emotions and thoughts, etc.  You should imagine all these sensations vividly and make them an integral part of your image of the situation.  Or, if an item involves your speaking with a high status professor, you should have a very specific and complete picture of yourself and that person and the clothes he is wearing and the way he is standing and his facial expressions and the words that are said between you, and your own reactions and feelings about the conversation.  With only a little practice in imagining all the details of a situation, you will soon be able to make your images very realistic.

The Completion of an Item

        It is important for you to know when you have completed an item and are ready to move on to the next item on the hierarchy.  During your training sessions and practice of deep muscle relaxation, you will learn what it feels like to be completely relaxed and at ease.  An item is completed when you can experience the feeling of complete relaxation while vividly imagining the item as you do when you practice deep muscle relaxation without the item in mind.  One pitfall in this progress is leaving an item before it is really finished.  In order for an item to be completed, the degree of relaxation you can attain while imagining it must be total.  That means that even if you feel the slightest bit of tension or nervousness, you are not completely desensitized to that item.  Stay with the item until you feel absolutely no nervousness, until you feel just as calm as the relaxing exercises.

        In desensitizing yourself to an item, you first relax completely using what you have learned in the training session.  When you are completely relaxed, you then imagine the item vividly.  You will soon learn to perceive when tensions and anxiety enter into the imagined scene and interfere with your relaxation.  If you feel anxiety while imagining the scene, immediately stop imagining the item and imagine a relaxing scene or just focus on relaxing again.  You may then try the scene again or add new items to your hierarchy to fill in any gaps.

Step By Step Conduct of a Desensitization Session

        The number of sessions necessary varies in accordance with many factors.  For relatively simple problems, experience has shown that ten to twenty sessions is often sufficient.  Occasionally fewer are necessary and sometimes many more.  However, it is not wise to set a limit or expectations on the number of sessions you will need to desensitize your hierarchy; just proceed step-by-step through the hierarchy and moving on to a new item when you have completed the previous one.

        In the beginning, when you are working on the low-anxiety provoking items, you may be able to complete several items in a single session.  Later, as you reach items which provoke more anxiety it may take more time to desensitize yourself to an item and perhaps several sessions to complete a single item.

        It is an excellent idea to set yourself a regular schedule for the sessions.  You will be desensitizing every other day.  Since the sessions are only twenty minutes apiece, this should not be a great burden.

        The setting is basically the same for the sessions as that of the relaxation training sessions:  work in a quiet, semi-darkened, private room where you will not be interrupted; sit comfortably on a chair or lie on a bed or couch; work without interruption for the duration of the twenty minutes.

Desensitization Session Steps

        Each session is conducted in the same basic way, according tot he following outline:

 1.   Sit upright or recline on the chair or couch, making yourself as comfortable as possible.

 2.   Have two piles of cards placed conveniently so that you do not have to reach for them.  It is best to have the cards immediately before you, on your lap.  Memorize the first 3-4 items of each stack of cards.

 3.   Make sure your cassette recorder is within easy reach and locate the beginning of the relaxation instructions on side 2 of the Self-Desensitization Instructions.  Relax yourself completely using what you have learned from the relaxation training.

  4 .   When you feel relaxed, start your desensitization session.  Use the following procedure to guide you:

 a)     Each time you imagine an item on your hierarchy, we will call this a "trial."  Each trial lasts 25 seconds, during which you keep the image as vividly before you as possible while trying to remain completely relaxed.  At the end of each trial, take a 15 second rest, during which you should think about your body getting more and more relaxed.  (Imagine a positive scene from between each hierarchy scene).

 b)     The session is divided into blocks of three trials.  You should stay with a given item until you can imagine it three consecutive times (a block of three trials) with absolutely no tension or anxiety of any kind.  If you successfully complete an item at the beginning of your desensitization session, go on and work on another, but don't desensitize yourself to more than two items per session.  Remember to stay with each particular item until you have gotten through a complete block of three trials without any anxiety.

 c)     If you have tried a given item for nine trials (or three blocks) and are still feeling anxiety when you visualize it, then go back to the previous item and complete an anxiety-free block of three trials on that one.  Then try the difficult item again.  If, after going through this three times, the difficult item still doesn't yield, this means that the jump is too great between it and the previous item.  You should then modify your hierarchy by inserting one or two items between these two.  These new items should be less anxiety-provoking than the one which gave you trouble but slightly more anxiety-provoking than the last one you completed.  One good way to invent such intermediate items is to consider the situation of the difficult item and then think up ways to make that situation slightly less fearful.  If the difficult item appeared very early in the hierarchy, this means that you are starting off with items that are too difficult, and that you should begin the hierarchy with a couple of very easy items and then work up very slowly.

 d)     You should begin each session with the last item you completed in the previous session.  Thus, if you were working on item #6, for instance, and had not completed it when the session ended, you should start the next session with item #5 and stay with it until you have again imagined it three consecutive times without anxiety.  Then go on to #6.

 e)     When you have completed the hierarchy, that is, when you are desensitized to the most difficult item, go back through the entire hierarchy once more just to make sure that you are in fact thoroughly desensitized t each item.  On this run-through you should be able to imagine each item on the list three consecutive times without the slightest tension or nervousness.  If any item still evokes the slightest bit of anxiety, stay with it until it is completely anxiety-free.  You may reach the end of your hierarchy before the end of the four weeks or you may not and just work at your own pace.

The Transfer of Therapeutic Effects to Real-Life Situations

        The completion of an item on your hierarchy in desensitization sessions indicated that you are making progress toward the alleviation of your problem.  The real test that you are solving the problem, however, is that your ability to imagine a situation without anxiety is followed by an ability to experience the real-life situation without anxiety.  For some people, such transfer is almost immediate:  some people take longer to achieve the ability to experience the analogous real-life situation without anxiety.  The lag may range from a few days to several days or weeks, depending on the person and the particular item.

        Should you have progressed a good way into your hierarchy without noticing any significant transfer to analogous real-life situations, that is, situations related to your target behavior, it is likely that you are not desensitizing the items completely.  This can often be remedied by spending a full session on relaxation between each group of 5 to 8 desensitizing sessions.  Then be sure you are completely anxiety-free before leaving one item and proceeding to the next.

        After you have completed a few items successfully in your hierarchy, begin to follow this important rule.

  1 .   ACTIVELY SEEK OUT those situations which you are about ready for in your hierarchy.

  2 .   AVOID  situations very high on your hierarchy which you are not ready for.

 3.   If you end up in a situation that has a negative outcome, you may experience a "set-back."  In that case, just back up a ways in your hierarchy and repeat steps and/or add new steps.  PERSISTANCE is THE MOST IMPORTANT DETERMINANT OF ULTIMATE SUCCESS ! ! !

 4.  SEEK encouragement and assistance from those who can adequately provide it to you.  Having family or friends, or a counselor routing for you can be very helpful.

 1.   Make sure your problem is not lack of SKILLS to be successful.  If it is, get help with improving skills.

 2.   If you need a little more incentive to get you going, make CONTRACTS  (written preferred).  Example:  AI will have a (celebration, trip on Saturday, etc.) if I give the speech.  I will eat dinner only after I ask Sara for a date, etc.

  3 .   Role Playing.  The other technique you will be using in this project is role playing, and the remainder of this manual deals with that technique and that of record keeping.  Since you have read a substantial amount, you might want to take a break and continue reading in about ten minutes.  Don't get too tired.  But be sure to read and understand this entire manual!  NOTE:  Most of the role playing techniques can be done in your imagination.  This is also an effective way to do it if you cannot find a group partner.

 You will be working on desensitizing yourself to the steps on your hierarchy every other day.  In order to maximize your success, you may combine the desensitization procedure explained above with another procedure, role playing.  Therefore, you will be alternating desensitization and role playing, doing desensitization every other day and role playing every other day.

 After you have spent two days learning how to relax yourself (start on Friday so these days would be Friday and Saturday).  Spend one day working on the first one or two items of your hierarchy.  Then, on the fourth day, role play the item with another person for 1.-15 minutes.  The next day, of course, you would be back to desensitization and work on completing the items on your hierarchy which are the first and second step with positively no anxiety in desensitization.  To repeat, then, on Friday and Saturday you'll be practicing relaxation, role play, on Tuesday you'll desensitize, etc.  You will be alternating these two procedures throughout the experiment and role playing the item(s) you worked on in desensitization the day before.  

Role-Playing

        Role playing is one successful technique that can aid you in unlearning the anxiety you've learned to experience with your target behavior and can help you feel more calm and comfortable in your target situation.  Briefly, role playing is simply acting out a behavior that makes you feel anxious with someone you feel calm and comfortable with.  Using role playing, then, you will act out each step on your hierarchy.  Role playing each step will help you to become less anxious about those situations related to your target behavior.  You will be using the hierarchy you have constructed and will slowly work your way from step to step by acting each one out until you feel calm and comfortable in the role playing situation.  You will go through this acting out process with someone who you feel very comfortable with, someone who can pretend is a person involved in your target situation but who does not  make you anxious.  

Role Playing Partner

        It is very important that your role playing partner be someone your are completely comfortable with.  This way you can continue to associate a comfortable, relaxed feeling with each step in your hierarchy.  His or her characteristics, such as sex and age, can be largely determined by your own preferences.  Be sure the person is interested in helping you and willing to work with you about 15 minutes every other day for four weeks.  Stress the importance of completing the project to your partner and that the project is important to you and to your psychology grade.  Be sure that your partner will stay with you through the experiment.  It would be very disappointing to you and the experimenters if you were proceeding well with your modification plans and then had to forfeit valuable time in looking for another partner.

        Often family members or close friends are ideal role playing partners.  They are already concerned with your welfare, easily available, and usually the most relaxing people for you to be with.

        You can present the experiment as a project for your psychology course and tell the partner how he too can benefit from the experience.  He will learn a technique for modifying some of his own anxieties, help you get a good course grade, and be pleased at your progress with your target behavior.

        Most of all, make sure the person you pick is someone who takes your project seriously and really wants you to improve.  To repeat, then, when picking your role playing partner, make sure that he or she has these characteristics:

 1.   (S)He must be a person with whom you are completely comfortable.

 2.   (S)He must be seriously interested in helping you succeed with your modification plan.

 3.   (S)She must be available every other day for 15 minutes over a four week period.

 Briefly explain these points to the person when you ask him to be your partner:

 a)     (S)He can learn a successful technique for modifying all kinds of anxiety.

 b)    (S)He can help you improve an important aspect of your social interaction.

 c)     S)He can help you get a good grade in psychology.

 d)    It will only require about 15 minutes of his time every other day.

 Try to pick up your role playing partner by Monday, March 15, so you can begin to role play the first one or two steps on your hierarchy that day and after successfully desensitizing the item(s) the day before.  To repeat, you will be pretending that your role playing partner is someone connected with your target behavior.  Therefore, since you are role playing, the sex or age of your partner does not matter.  For example, if you are a male who is modifying his anxiety around women, you wouldn't have to pick one to be your role playing partner.  You could pick your mother or your father, your next door neighbor and any one person who cares about your progress and who you feel very much at ease with.  If you are modifying anxiety around groups or more than one stranger, your role playing partner would play the role of the group of strangers.  Role playing is a technique which simulated a real life situation, therefore, your role playing partner can be of great help to you in this project.  

ROLE PLAYING SESSIONS

 As stated above, you should pick your role playing partner and begin to role play the first step on your hierarchy on Monday.  On Monday, get together with your partner and find a quiet, private place where you can role play for about 15 minutes without being interrupted.  Begin with the first item on your hierarchy.  Before the session begins, carefully explain to your partner the characteristics of the person (or people) he'll be acting out.  Make sure you both understand the parts you'll be playing.  If, for example, you are role playing step one in a hierarchy that deals with anxiety about interacting with members of the opposite sex, and your first step simply is to look at a member of the opposite sex, you will just pretend that your role playing partner is a member of the opposite sex.  If your target behavior is talking to your boss and your first step is saying hello to the boss when he looked like he's in a grumpy mood, your role playing partner would play the boss by looking gruff and acting like he's in a bad mood.  You will have told him how to act before you start the session, of course, so you won't have to stop in the middle of role playing and explain something to your partner, thereby breaking the effect.

 Of course, you are to feel very comfortable, confident, and at ease when you are role playing.  If you role play an item and feel at ease, role play it two more times so you'll be roll playing the item three consecutive times without feeling any anxiety at all.  If, however, you feel anxiety when you role play a particular item, role play it three more times.  If you still feel anxiety on the fourth role playing trial, return to the previous item on your hierarchy and role play it three times without feeling uncomfortable or anxious.  Go on to the difficult item and try role playing it again.  If you still don't feel at ease role playing the difficult item, you probably need to insert one or more steps in your hierarchy between the two items.  If this happens, insert the new step(s) and begin role playing it (them).  Be sure to always role play an item three times without feeling any anxiety before you go on to the next item.  Try to achieve the relaxed state you use in your desensitization sessions.

 The length of time it takes for you to role play different items will be different for various items.  Some items (like, for example, the first ones on your hierarchy) will take only a few seconds or minutes to role play.  An example of this would be a man who is modifying his anxiety around women and who was role playing a step on his hierarchy that said "smiling at a woman".  That step would only take a few seconds to role play.  If he role played the step three times without feeling anxiety during a session, he could go on in his hierarchy and role play  one more item.

 If you complete an item and have 5 or 10 more minutes left in your role playing session, go on to the next item, but do not role play more than two items per day (same as for desensitization).  But try to complete at least one item per session.  As you come to the last items on your hierarchy, you may find that your items take longer to role play than the beginning ones on your hierarchy.  For example, you might be role playing an item that says Ahave a 10 minute conversation with my boss.  In that case, you may have to spend a few half hour role playing sessions on each step near the end of the study.  If this happens and you cannot complete the item in one day, continue role playing it the next session.  (As we said before, You'll be role playing every other day.)

 Between each trial, or each time you role play the item, take a 15 second break during which you and your partner relax.   During this time, you can return to your normal relationship, but be prepared to resume your roles.  When you complete the role playing of an item (three times without feeling any anxiety in the role playing situation) and you're ready to go on to the next item, take a break and tell your partner the role he will be playing next.

 Be sure that you and your role playing partner take the role playing sessions seriously.  Concentrate on the roles you are playing.  Imagine the situation vividly, as you do in desensitization.

 The role playing technique should help you relax when you are in the real life situation; it will help make you aware of the various components of the situation you will encounter in real life.  It will help you improve your smoothness and your skills.  It will also help you replace old habits with new ones by repetition.

ONCE YOU LEARN THE PROCESS OF SELF-DESENSITIZATION YU CAN USE IT TO OVERCOME ALMOST ANY UNREALISTIC ANXIETY!  SAVE THESE INSTRUCTIONS FOR USE IN THE FUTURE.  REPEAT THEM AS NEEDED.