Psych in Real Life: Behavior Therapy

Learning Objectives

  • Describe systematic desensitization

Behavior Therapy: How Does it Work?
Smiling picture of a college student with a pen in her mouth.

Meet Miriam. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. During the next few years, after she graduates, she wants to live in interesting places and get solid training and experience with a good corporation. Her dream is to start her own company, to be her own boss, and to do things that she can take pride in. For her, financial success and doing something worthwhile must go hand-in-hand.

But Miriam has a secret. She is terrified of speaking in front of people who are not her close friends. She has fought these fears for a long time, but she has never been able to conquer them. She is also aware of the fact that she will need to be able to speak to strangers comfortably and convincingly if she is going to meet her goals in business.

Now that you and your client have agreed upon your goals, it is time to choose a particular technique for the therapy. As a behavioral therapist, you are looking for a method to allow Miriam to learn a new response to the thought of public speaking. Now the idea terrifies her. After therapy is over, she should no longer be terrified and she may even look forward to the opportunity to speak in front of other people.

You know that everyone is not the same and different problems may call for different approaches to therapy. For these reasons, you have been trained in a variety of techniques that you can use to customize Miriam’s therapy to meet her particular needs. It is time to decide how you are going to help Miriam.

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Systematic desensitization works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. This is called “progressive exposure.” By learning to cope with anxiety with less-threatening situations first, the person is better prepared to handle the more-threatening situations. Even more important for treatment, the mind learns that nothing horrible happens. This retraining of the subconscious mind means that the situation actually becomes less threatening.

Same picture of the college student, Miriam, looking confused or frustrated while looking at her notebook.

The first steps in systematic desensitization is the development of a “hierarchy of fears.” This simply means that you must help your Miriam create a list of situations related to her fear of public speaking. Then you create a hierarchy. This means that you have her organize the situations from the least frightening to the most frightening.

For the next step in this exercise, you will need to take on Miriam’s role as the client. Imagine that you have developed a list of frightening situations, from ones that make you only slightly uncomfortable to ones that nearly make you sick with anxiety.

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Remember that systematic desensitization works by putting the person in a series of situations. The early ones are not threatening or are only mildly threatening. However, as soon as your client learns to cope with each situation, you start working on the next most frightening situation.

So we’re ready to start, right? Wrong!

Behavioral therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. This idea is that fear and anxiety cannot coexist with relaxation—if you are relaxed, you can’t be fully afraid.

However, most people are not very good at relaxing on command. So the behavioral therapist will teach the client how to relax effectively. The techniques are ones often used in meditation—slow breathing and focus on positive thoughts. Psychologist Kevin Arnold explains a deep breathing technique in this video.

Miriam’s Treatment

Miriam is an imaginary person, but behavioral therapy is used by thousands of therapist with their clients every day. Review the following table to discover how Miriam’s therapy progressed. Her story is based on a fairly typical series of therapy sessions, though please understand that each person’s course of therapy is unique.

Miriam’s Treatment
Therapy Sessions Session Description
Miriam’s therapy: Preparation Prior to starting progressive exposure, Miriam created her hierarchy of fears. She spent several two session working on relaxation. She practiced relaxation at home several times a day until she and you, her therapist, agreed that she was ready to start treatment.
Miriam’s therapy: Exposure Session 1 The bottom (lowest anxiety) of Miriam’s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a 1 to 10 scale, Miriam said 1: No fear at all.

Miriam brought two friends with her to the therapy session today. You had them sit in a comfortable part of your office, drinking tea and chatting for 15 minutes. Afterwards Miriam reported her fear level during the chat as a 1 on a ten-point scale: no fear.

You then had her sit in a comfortable chair and think about giving a talk about the challenges of her job to a small, friendly audience. At the beginning of this task, she rated her anxiety as 3 on a 10-point scale. As she thought about it—with helpful suggestions from you—she also relaxed, using her relaxation training. After about 10 minutes, she reported her anxiety had dropped to 1, the lowest level of anxiety on your scale.

You gave Miriam “homework”—to repeat this exercise twice a day until the next session.

Miriam’s therapy: Exposure Session 2 At the beginning of today’s session, you had Miriam repeat the task from the previous session of thinking about talking about her job to a small, friendly group. At the beginning she rated her fear at 2, but it dropped to 1 within a few minutes.

Now you took Miriam to the next level. You had her imagine telling a large audience of company executives about some technical problem she was working on at her job. At the beginning, just thinking about doing this led to a fear level of 5. After 10 minutes, her fear level dropped to 2. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.

You gave Miriam homework again—to practice a similar situation at home.

Miriam’s therapy: Exposure Session 3 You started this situation with a new scenario similar to the one Miriam did in the last session and practiced at home. She was quickly able to drop her anxiety level to 1.

You had a professional photography group create a video of someone very similar in appearance and manner to Miriam giving a talk in from of a small friendly audience on a topic similar to one Miriam might give. You asked her to watch this video and imagine herself in the place of the real speaker. She rated this a 6 on the anxiety scale. Over several repetitions, her rating dropped to 2.

For homework, Miriam watched the video several times a day. You instructed her in ways to make the video seem MORE REAL, so she could really feel the anxiety of being in front of people.

Miriam’s therapy: Exposure Session 4 You have had Miriam arrange to give a talk NEXT SESSION to a small group of Miriam’s co-workers. You also had Miriam prepare the talk. Today you practiced the talk with her. At the start of the practice session, with only you there, Miriam rated her anxiety level at 9 out of 10. Over the course of the hour, her anxiety level dropped to 5.

Her homework was to continue to practice the talk and to work on relaxation.

Miriam’s therapy: Exposure Session 5 Today, Miriam gave the talk to the small group. Her anxiety rating before she went in front of them was 10. Except for a little stumbling at the start, the 20-minute presentation went well. Miriam reported an anxiety level of 4 after the talk.
We’ll skip a few sessions. We hope you have the basic idea.
Miriam’s therapy: Exposure Session 5 In this last session, you have arranged for Miriam to be the introductory speaker at a literacy tutoring volunteer organization nearby. Miriam has done a small amount of volunteer work with the organization, but she knows very little about it. With the help of the staff, she prepares a talk during the week before this session.

The audience is composed of 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Miriam knows none of them and none of them has ever heard of her.

Miriam’s introductory comments take about 15 minutes. She rates her anxiety level before going out at 8. After the talk, she rates her anxiety at 2. In fact, she said it was almost fun.

After Therapy Miriam continues to see you for a few more sessions. You give her additional homework and you help her develop a plan that includes arranging to give professional presentations for her job and continuing to give talks at the literacy volunteer organization. Miriam reports that none of these ideas create an anxiety level above 3 when she thinks about doing them.

You just learned about Systematic Desensitization, a form of exposure therapy. Flooding is another type of exposure therapy. To understand how it works, let’s review a few points from Systematic Desensitization.

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In flooding therapy, you would skip the earliest situations described in systematic desensitization and you would move directly to highly threatening situations. Right after Miriam had mastered relaxation, your first session would require Miriam to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Miriam in situations that she would immediately rate as 9 or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Miriam (for your client), so it must be arranged carefully. But the same principles of learning work for flooding that work for systematic desensitization:

  • The person consciously works to replace anxiety and fear with relaxation.
  • The unconscious parts of the mind learn that the situation does not result in horrible outcomes. New expectations replace old fears.
  • Learning does not just happen immediately. Homework and repeated practice reinforce the new positive response to situations that once produced fear.

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