Behavioral Treatments for Anxiety

Learning Objectives

  • Explain how behavior therapy can be used to treat anxiety

Behavior Therapy and Anxiety

CBT and exposure therapy, a type of behavior therapy, are the two most commonly used interventions in the treatment of anxiety disorders. Exposure therapy has its roots in classical conditioning. In exposure therapy, patients make contact with the feared stimuli and this contact is maintained until the anxiety associated with the contact subsides. This process is termed habituation and it can only occur if the patients are prevented from using their usual escape or avoidance behavior (extinction). Several versions of exposure exist. Systematic desensitization (SD) is on the gentler part of the spectrum. Systematic desensitization (SD) is based on the idea of reciprocal inhibition proposing that two opposite emotions can not co-exist (e.g., fear and relaxation are mutually exclusive). In systematic desensitization (SD), relaxation training is followed by gradual (usually imaginary) exposure to the feared stimuli starting with the least feared stimulus. In contrast, flooding involves immediate exposure to the stimulus. Exposure therapy has been described as the most effective way to treat fear. Research indicates that the efficacy of exposure is optimal when it is graduated, repeated, and prolonged with practice tasks clearly specified.

Let’s look at this case study with Jessica to see this type of therapy in practice.

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

Meet Jessica. She is smart, ambitious, creative, and full of energy. She is studying at a university, majoring in business. 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 Jessica 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 Jessica 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 Jessica’s therapy to meet her particular needs. It is time to decide how you are going to help Jessica.

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Systematic Desensitization

SD works by gradually—step-by-step—exposing the person to situations that are increasingly more anxiety-producing. The anxiety-producing event is called “progressive exposure.” By learning to cope with anxiety during 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 step in systematic desensitization is the development of a “hierarchy of fears.” The hierarchy of fears simply means that you must help Jessica create a list of situations related to her fear of public speaking. Then you create a hierarchy. The creation of the hierarchy 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 Jessica’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!

Behavior therapy teaches the client to cope with an anxiety-producing situation by replacing fear with an alternative response. A common alternative response is relaxation. The 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.

Jessica’s Treatment

Jessica is an imaginary person, but behavior therapy is used by thousands of therapists with their clients every day. Review the following table to discover how Jessica’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.

Jessica’s Treatment

Therapy Sessions Session Description
Jessica’s therapy: Preparation Prior to starting progressive exposure, Jessica created her hierarchy of fears. She spent two sessions 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.
Jessica’s therapy: Exposure Session 1 The bottom (lowest anxiety) of Jessica’s fear hierarchy was chatting with friends about everyday topics. When asked to rate the fear level associated with doing this on a one to 10 scale, Jessica said one: no fear at all.

Jessica 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 Jessica reported her fear level during the chat as a one on a 10-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 three 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 one, the lowest level of anxiety on your scale.

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

Jessica’s therapy: Exposure Session 2 At the beginning of today’s session, you had Jessica 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 two, but it dropped to one within a few minutes.

Now you take Jessica 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 five. After 10 minutes, her fear level dropped to two. You repeated the exercise with a different topic and a different group, with similar results. Relaxation was practiced throughout the session.

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

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

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

For homework, Jessica 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.

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

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

Jessica’s therapy: Exposure Session 5 Today, Jessica 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. Jessica reported an anxiety level of four after the talk.
We’ll skip a few sessions. Hopefully, you have the basic idea.
Jessica’s therapy: Exposure Session 5 In this last session, you have arranged for Jessica to be the introductory speaker at a literacy tutoring volunteer organization nearby. Jessica 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 comprises 45 people, all interested in doing literacy tutoring, who have come to the literacy center for an information session. Jessica knows none of them and none of them has ever heard of her.

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

After Therapy Jessica 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. Jessica reports that none of these ideas create an anxiety level above three 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 Jessica had mastered relaxation, your first session would require Jessica to give an actual talk. You would probably not start with the most extreme situation, but your goal would be to start Jessica in situations that she would immediately rate as nine or 10 on the anxiety scale.

Flooding has the potential to be more traumatic for Jessica (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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behavior therapy: a therapy focused on changing behavior; helping patients cope with an anxiety-producing situation by replacing fear with an alternative response

exposure therapy: being exposed with a feared stimulus until the anxiety associated with the contact subsides

flooding: a type of exposure therapy when a patient is exposed to high-anxiety inducing situations instead of gradual exposure

systematic desensitization: a type of exposure therapy consisting of gradual exposure to a feared stimulus that is paired with relaxation training