Systematic desensitization

{{short description|Type of behavior therapy}} '''Systematic desensitization''' is a form of [[exposure therapy]] used to treat [[Phobia|phobias]] and [[Anxiety disorder|anxiety disorders]]. Developed by psychiatrist [[Joseph Wolpe]] in the 1950s, it is based on the principle of [[reciprocal inhibition]], which is the idea that anxiety and relaxation cannot coexist simultaneously.<ref name=":0">{{Cite journal |last=Wolpe |first=Joseph |date=1968-10-01 |title=Psychotherapy by reciprocal inhibition |journal=Conditional Reflex |language=en |volume=3 |issue=4 |pages=234–240 |doi=10.1007/BF03000093 |pmid=5712667 |issn=1936-3567}}</ref> By repeatedly exposing a patient to an anxiety evoking stimulus while they experience a physiological state antagonistic to anxiety (such as relaxation), their fear-response to the stimulus should progressively decrease.<ref name=":1">{{Cite book |last=Wolpe |first=Jospeh |title=The Practice of Behavior Therapy |publisher=Pergamon Press |year=1973 |edition=2nd |location=United States of America |pages=95–141}}</ref>

The goal of the therapy is for the individual to learn how to cope with and overcome their fear in each level of an [[exposure hierarchy]]. The process of systematic desensitization occurs in three steps. The first step is to identify the hierarchy of fears. The second step is to learn relaxation or coping techniques. Finally, the individual uses these techniques to manage their fear during a situation from the hierarchy. The third step is repeated for each level of the hierarchy, starting from the least fear-inducing situation.

== History == Emerging during the mid-20th century, Wolpe's work aligned with the rise of [[behaviorism]] in psychology and represented a shift from [[psychoanalysis]].<ref name=":2">{{Cite journal |last=Wolpe |first=Joseph |date=1981 |title=Behavior therapy versus psychoanalysis: Therapeutic and social implications. |url=https://doi.org/10.1037//0003-066x.36.2.159 |journal=American Psychologist |volume=36 |issue=2 |pages=159–164 |doi=10.1037/0003-066x.36.2.159 |pmid=7224325 |issn=0003-066X|url-access=subscription }}</ref> Rather than seeking to uncover the unconscious and root causes of anxiety disorders, systematic desensitization proposed that treatment should be more measurable, tangible and based on evidence.<ref name=":1" />

In 1947, Wolpe discovered that the cats of Wits University could overcome their fears through gradual and systematic exposure.<ref>Dubord, Greg. "Part 12. Systematic desensitization." Canadian Family Physician 57 (2011): 1299+. Print.</ref> Wolpe studied [[Ivan Pavlov]]'s work on artificial [[Neurosis|neuroses]] and the research done on elimination of children's fears by Watson and Jones. In 1958, Wolpe did a series of experiments on the artificial induction of neurotic disturbance in cats. He found that gradually deconditioning the neurotic animals was the best way to treat them of their neurotic disturbances. Wolpe deconditioned the neurotic cats through different feeding environments. Wolpe knew that this treatment of feeding would not generalize to humans and he instead substituted relaxation as a treatment to relieve the anxiety symptoms.<ref name="Rachman">{{cite journal | pmid = 6045340 | year = 1967 | last1 = Rachman | first1 = S. | title = Systematic desensitization | journal = Psychological Bulletin | volume = 67 | issue = 2 | pages = 93–103 | doi = 10.1037/h0024212 }}</ref>

Wolpe found that if he presented a client with the actual anxiety inducing stimulus, the relaxation techniques did not work. It was difficult to bring all of the objects into his office because not all anxiety inducing stimuli are physical objects, but instead are concepts. Wolpe instead began to have his clients imagine the anxiety inducing stimulus or look at pictures of the anxiety inducing stimulus, much like the process that is done today.<ref name="Rachman" />

== Applications and uses ==

=== Three steps of desensitization === There are three main steps that Wolpe identified to successfully [[Desensitization (psychology)|desensitize]] an individual. #[[Exposure hierarchy|Establish anxiety stimulus hierarchy]]. The individual should first identify the items that are causing the anxiety problems. Each item that causes anxiety is given a subjective ranking on the severity of induced anxiety. If the individual is experiencing great anxiety to many different triggers, each item is dealt with separately. For each trigger or stimulus, a list is created to rank the events from least anxiety-provoking to most anxiety-provoking. #Learn the relaxation response. Relaxation training, such as meditation, is one type of best coping strategies. Wolpe taught his patients relaxation responses because it is not possible to be both relaxed and anxious at the same time. In this method, patients practice tensing and relaxing different parts of the body until the patient reaches a state of serenity.<ref>Wolpe, J. (1958). Psychotherapy by reciprocal inhibition. Stanford, CA: Stanford University Press.</ref> This is necessary because it provides the patient with a means of controlling their fear, rather than letting it increase to intolerable levels. Only a few sessions are needed for a patient to learn appropriate coping mechanisms. Additional coping strategies include anti-anxiety medicine and breathing exercises. Another example of relaxation is [[cognitive reappraisal]] of imagined outcomes. The therapist might encourage patients to examine what they imagine happening when exposed to the anxiety-inducing stimulus and then allowing for the client to replace the imagined catastrophic situation with any of the imagined positive outcomes. #Connect stimulus to the incompatible response or coping method by counter conditioning. In this step the client completely relaxes and is then presented with the lowest item that was placed on their hierarchy of severity of anxiety phobias. When the patient has reached a state of serenity again after being presented with the first stimuli, the second stimuli that should present a higher level of anxiety is presented. This will help the patient overcome their phobia. This activity is repeated until all the items of the hierarchy of severity anxiety is completed without inducing any anxiety in the client at all. If at any time during the exercise the coping mechanisms fail or became a failure, or the patient fails to complete the coping mechanism due to the severe anxiety, the exercise is then stopped. When the individual is calm, the last stimuli that is presented without inducing anxiety is presented again and the exercise is then continued depending on the patient outcomes.<ref>Mischel, W., Shoda, Y. & Ayduk, O. Introduction to Personality. John Wiley & Sons, Inc., 2008.</ref>

===Example=== A client may approach a therapist due to their great phobia of snakes. This is how the therapist would help the client using the three steps of systematic desensitization: #[[Exposure hierarchy|Establish anxiety stimulus hierarchy]]. A therapist may begin by asking the patient to identify a fear hierarchy. This fear hierarchy would list the relative unpleasantness of various levels of exposure to a snake. For example, seeing a picture of a snake might elicit a low fear rating, compared to live snakes crawling on the individual—the latter scenario becoming highest on the fear hierarchy. #Learn coping mechanisms or incompatible responses. The therapist would work with the client to learn appropriate coping and relaxation techniques such as meditation and deep muscle relaxation responses. #Connect the stimulus to the incompatible response or coping method. The client would be presented with increasingly unpleasant levels of the feared stimuli, from lowest to highest—while utilizing the deep relaxation techniques (i.e. progressive muscle relaxation) previously learned. The imagined stimuli to help with a phobia of snakes may include: a picture of a snake; a small snake in a nearby room; a snake in full view; touching of the snake, etc. At each step in the imagined progression, the patient is desensitized to the phobia through exposure to the stimulus while in a state of relaxation. As the fear hierarchy is unlearned, anxiety gradually becomes extinguished.

===Specific phobias=== [[Specific phobia]]s are one class of [[mental disorder]] often treated via systematic desensitization. When persons experience such phobias (for example fears of heights, dogs, snakes, closed spaces, etc.), they tend to avoid the feared stimuli; this avoidance, in turn, can temporarily reduce anxiety but is not necessarily an adaptive way of coping with it. In this regard, patients' avoidance behaviors can become reinforced – a concept defined by the tenets of [[operant conditioning]]. Thus, the goal of systematic desensitization is to overcome avoidance by gradually exposing patients to the phobic stimulus, until that stimulus can be tolerated.<ref>Kazdin, A. E., & Wilson, G.T. (1978). Evaluation of behavior therapy: Issues, evidence and research strategies. Cambridge, MA: Ballinger.</ref> Wolpe found that systematic desensitization was successful 90% of the time when treating phobias.<ref>Wolpe, J. ''The practice of behavior therapy.'' New York: Pergamon Press, 1969.</ref>

===Test anxiety=== Between 25 and 40 percent of students experience [[test anxiety]].<ref>Cassady, J.C. (2010). Test anxiety: Contemporary theories and implications for learning. In J.C. Cassady (Ed.), ''Anxiety in schools: The causes, consequences, and solutions for academic anxieties'' (pp. 7–26). New York, NY: Peter Lang,</ref> Children can suffer from low self-esteem and stress-induced symptoms as a result of test anxiety.<ref>{{cite journal | doi = 10.1007/BF01204848 | title = Cognitive, emotional, and physiological components of Test Anxiety | year = 1985 | last1 = Deffenbacher | first1 = Jerry L. | last2 = Hazaleus | first2 = Susan L. | journal = Cognitive Therapy and Research | volume = 9 | issue = 2 | pages = 169–180 | s2cid = 6032356 }}</ref> The principles of systematic desensitization can be used by children to help reduce their test anxiety. Children can practice the muscle relaxation techniques by tensing and relaxing different muscle groups. With older children and college students, an explanation of desensitization can help to increase the effectiveness of the process. After these students learn the relaxation techniques, they can create an anxiety inducing [[Exposure hierarchy|hierarchy]]. For test anxiety these items could include not understanding directions, finishing on time, marking the answers properly, spending too little time on tasks, or underperforming. Teachers, school counselors or school psychologists could instruct children on the methods of systematic desensitization.<ref>{{cite journal | doi = 10.1080/1045988X.1995.9944644 | title = Prevent School Failure: Treat Test Anxiety | year = 1995 | last1 = Austin | first1 = J. Sue | last2 = Partridge | first2 = Elizabeth | last3 = Bitner | first3 = Joe | last4 = Wadlington | first4 = Elizabeth | journal = Preventing School Failure: Alternative Education for Children and Youth | volume = 40 | pages = 10–13 }}</ref>

== Use of technology in systematic desensitization ==

=== Virtual Reality Therapy (VRT) === Since [[Ivan Sutherland]] created the first [[virtual reality]] (VR) technology head-mounted display in 1965,<ref>{{Citation |last=Sutherland |first=Ivan E. |title=A head-mounted three dimensional display |date=July 1998 |work=Seminal graphics |pages=295–302 |place=United States |publisher=ACM |doi=10.1145/280811.281016 |isbn=1-58113-052-X}}</ref> these technologies have improved significantly to create realistic and immersive replicas of the environment.<ref name=":3">{{Cite journal |last1=Bell |first1=Imogen H. |last2=Nicholas |first2=Jennifer |last3=Alvarez-Jimenez |first3=Mario |last4=Thompson |first4=Andrew |last5=Valmaggia |first5=Lucia |date=2020-06-30 |title=Virtual reality as a clinical tool in mental health research and practice |journal=Dialogues in Clinical Neuroscience |language=en |volume=22 |issue=2 |pages=169–177 |doi=10.31887/DCNS.2020.22.2/lvalmaggia |pmid=32699517 |pmc=7366939 |issn=1958-5969}}</ref> As a result, psychologists have begun to incorporate virtual reality in systematic desensitization.<ref name=":3" /><ref name=":4">{{Cite journal |last1=Maples-Keller |first1=Jessica L. |last2=Bunnell |first2=Brian E. |last3=Kim |first3=Sae-Jin |last4=Rothbaum |first4=Barbara O. |date=May 2017 |title=The Use of Virtual Reality Technology in the Treatment of Anxiety and Other Psychiatric Disorders |journal=Harvard Review of Psychiatry |language=en |volume=25 |issue=3 |pages=103–113 |doi=10.1097/HRP.0000000000000138 |pmid=28475502 |pmc=5421394 |issn=1465-7309}}</ref><ref name=":5">{{Citation |last1=North Max M. |chapter=Virtual Reality Therapy: An Effective Treatment for Psychological Disorders |date=1998 |chapter-url=https://doi.org/10.3233/978-1-60750-888-5-59 |access-date=2026-04-02 |publisher=IOS Press |last2=North Sarah M. |last3=Coble Joseph R. |title=Virtual Reality in Neuro-Psycho-Physiology |series=Studies in Health Technology and Informatics |doi=10.3233/978-1-60750-888-5-59 }}</ref> [[Virtual reality therapy|Virtual Reality Therapy]] (VRT) allows clinicians to expose patients to anxiety-provoking stimuli within a highly controlled and interactive digital environment.<ref name=":3" />

In 1995, a case report conducted by Rothbaum et al. was the first to implement virtual reality when practicing systematic desensitization.<ref>{{Cite journal |last1=Rothbaum |first1=Barbara Olasov |last2=Hodges |first2=Larry F. |last3=Kooper |first3=Rob |last4=Opdyke |first4=Dan |last5=Williford |first5=James S. |last6=North |first6=Max |date=1995 |title=Virtual reality graded exposure in the treatment of acrophobia: A case report |url=https://linkinghub.elsevier.com/retrieve/pii/S0005789405801005 |journal=Behavior Therapy |language=en |volume=26 |issue=3 |pages=547–554 |doi=10.1016/S0005-7894(05)80100-5|url-access=subscription }}</ref> The study focused on a 19 year old student suffering from [[acrophobia]] and lasted 3 weeks. The results found virtual reality to be effective in treating the patient's fear of heights. Consequently, a larger study was conducted by the same researchers over an 8 week period, splitting a larger group of college students into [[Treatment and control groups|control and treatment groups]].<ref>{{Cite journal |last1=Olasov Rothbaum |first1=Barbara |last2=Hodges |first2=Larry F. |last3=Kooper |first3=Rob |last4=Opdyke |first4=Dan |last5=Williford |first5=James S. |last6=North |first6=Max |date=April 1995 |title=Effectiveness of Computer-Generated (Virtual Reality) Graded Exposure in the Treatment of Acrophobia |url=https://www.ovid.com/journals/ajps2/abstract/00000465-199504000-00022~effectiveness-of-computer-generated-virtual-reality-graded?redirectionsource=fulltextview |journal=American Journal of Psychiatry |volume=152 |issue=4 |pages=626–629 |doi=10.1176/ajp.152.4.626 |pmid=7694917 |via=Ovid}}</ref><ref name=":6">{{Cite journal |last1=Park |first1=Mi Jin |last2=Kim |first2=Dong Jun |last3=Lee |first3=Unjoo |last4=Na |first4=Eun Jin |last5=Jeon |first5=Hong Jin |date=2019-07-19 |title=A Literature Overview of Virtual Reality (VR) in Treatment of Psychiatric Disorders: Recent Advances and Limitations |journal=Frontiers in Psychiatry |volume=10 |article-number=505 |doi=10.3389/fpsyt.2019.00505 |doi-access=free |issn=1664-0640 |pmc=6659125 |pmid=31379623}}</ref> The results again concluded that systematic desensitization through virtual reality was statistically significant in reducing fear of heights, this time on a larger scale.

=== Advantages === Since then, VR has been found to be an effective therapeutic tool for systematic desensitization, with studies implementing it to treat a range of conditions such as phobias, [[Post-traumatic stress disorder|PTSD]] and anxiety disorders.<ref name=":7">{{Cite journal |last1=Freeman |first1=Daniel |last2=Haselton |first2=Polly |last3=Freeman |first3=Jason |last4=Spanlang |first4=Bernhard |last5=Kishore |first5=Sameer |last6=Albery |first6=Emily |last7=Denne |first7=Megan |last8=Brown |first8=Poppy |last9=Slater |first9=Mel |last10=Nickless |first10=Alecia |date=August 2018 |title=Automated psychological therapy using immersive virtual reality for treatment of fear of heights: a single-blind, parallel-group, randomised controlled trial |journal=The Lancet Psychiatry |language=en |volume=5 |issue=8 |pages=625–632 |doi=10.1016/S2215-0366(18)30226-8 |pmid=30007519 |pmc=6063994 }}</ref><ref>{{Cite journal |last=Rajkumar |first=Ravi P |date=2024-09-15 |title=Augmented Reality as an Aid to Behavior Therapy for Anxiety Disorders: A Narrative Review |journal=National Institute of Health |volume=16 |issue=9 |pages= |language=en |doi=10.7759/cureus.69454 |doi-access=free |issn=2168-8184 |pmc=11402374 |pmid=39282478}}</ref><ref>{{Cite journal |last1=Martingano |first1=Alison Jane |last2=Persky |first2=Susan |date=July 2021 |title=Virtual reality expands the toolkit for conducting health psychology research |journal=Social and Personality Psychology Compass |language=en |volume=15 |issue=7 |article-number=e12606 |doi=10.1111/spc3.12606 |issn=1751-9004 |pmc=9624464 |pmid=36325429}}</ref><ref>{{Cite journal |last1=Cipresso |first1=Pietro |last2=Giglioli |first2=Irene Alice Chicchi |last3=Raya |first3=Mariano Alcañiz |last4=Riva |first4=Giuseppe |date=2018-11-06 |title=The Past, Present, and Future of Virtual and Augmented Reality Research: A Network and Cluster Analysis of the Literature |journal=Frontiers in Psychology |volume=9 |article-number=2086 |doi=10.3389/fpsyg.2018.02086 |doi-access=free |issn=1664-1078 |pmc=6232426 |pmid=30459681}}</ref><ref name=":5" /><ref name=":6" /> In general, research has demonstrated that individuals tend to respond to virtual environments as though they were real, which emphasizes the [[ecological validity]] VRT provides as a therapeutic tool.<ref name=":3" />

A key advantage of VRT is its ability to simulate a much wider range of environments.<ref name=":8">{{Cite journal |last=Spytska |first=Liana |date=December 2024 |title=The use of virtual reality in the treatment of mental disorders such as phobias and post-traumatic stress disorder |url=https://linkinghub.elsevier.com/retrieve/pii/S2666560324000562 |journal=SSM - Mental Health |language=en |volume=6 |article-number=100351 |doi=10.1016/j.ssmmh.2024.100351|doi-access=free }}</ref><ref name=":7" /> This allows scientists to work with scenarios that would otherwise be difficult, costly, or dangerous to recreate in the real-world.<ref name=":7" /> Furthermore, this provides clinicians with much greater control over potential [[confounding variables]] in the environment.<ref name=":3" /><ref name=":9">{{Cite journal |last1=Volovik |first1=M.G. |last2=Belova |first2=A.N. |last3=Kuznetsov |first3=A.N. |last4=Polevaia |first4=A.V. |last5=Vorobyova |first5=O.V. |last6=Khalak |first6=M.E. |date=2023-02-28 |title=Use of Virtual Reality Techniques to Rehabilitate Military Veterans with Post-Traumatic Stress Disorder (Review) |url=http://www.stm-journal.ru/en/numbers/2023/1/1816 |journal=Sovremennye Tehnologii V Medicine |volume=15 |issue=1 |pages=74–85 |doi=10.17691/stm2023.15.1.08 |pmc=10306958 |pmid=37388756}}</ref> For instance, although therapists are usually present during [[In vivo|in-vivo]] exposure and can influence a patient, this is not the case when using VRT, allowing for greater immersion.<ref name=":7" /> Similarly, VRT can ensure replicability of the fear-inducing stimuli across control and treatment groups, allowing scientists to tailor exposure hierarchies with greater flexibility than using traditional methods.<ref name=":3" />

=== Example === A modern application of VRT within systematic desensitization is in the treatment of [[Post-traumatic stress disorder|Post-Traumatic Stress Disorder]] (PTSD).<ref name=":8" /> VRT is valuable for treating PTSD as some traumatic events cannot be recreated in a clinical setting.<ref name=":7" /> A [[randomized controlled trial]] by Beidel et al. involving 92 Iraq and Afghanistan veterans found significant reductions in PTSD symptoms across both treatment groups, with 65.9% of participants no longer meeting [[Medical diagnosis|diagnostic criteria]] for PTSD after treatment.<ref>{{Cite journal |last1=Beidel |first1=Deborah C. |last2=Frueh |first2=B. Christopher |last3=Neer |first3=Sandra M. |last4=Bowers |first4=Clint A. |last5=Trachik |first5=Benjamin |last6=Uhde |first6=Thomas W. |last7=Grubaugh |first7=Anouk |date=January 2019 |title=Trauma management therapy with virtual-reality augmented exposure therapy for combat-related PTSD: A randomized controlled trial |url=https://linkinghub.elsevier.com/retrieve/pii/S0887618517301263 |journal=Journal of Anxiety Disorders |language=en |volume=61 |pages=64–74 |doi=10.1016/j.janxdis.2017.08.005 |pmid=28865911 |url-access=subscription }}</ref> More recently, research has explored using VRT on a wider scale by tailoring treatment to specific populations and conflicts. For example, BraveMind is a VRT system which works on creating highly detailed customizable scenarios for war veterans.<ref>{{Cite book |last1=Mozgai |first1=Sharon |last2=Leeds |first2=Andrew |last3=Kwok |first3=David |last4=Fast |first4=Ed |last5=Rizzo |first5=Albert Skip |last6=Hartholt |first6=Arno |chapter=Building BRAVEMIND Vietnam: User-Centered Design for Virtual Reality Exposure Therapy |date=November 2021 |title=2021 IEEE International Conference on Artificial Intelligence and Virtual Reality (AIVR) |chapter-url=https://doi.org/10.1109/aivr52153.2021.00056 |publisher=IEEE |pages=247–250 |doi=10.1109/aivr52153.2021.00056 |isbn=978-1-6654-3225-2 }}</ref> These tailored virtual environments are now being created internationally, such as with the Virtual Ukraine project, which addresses the specific experiences of soldiers and civilians affected by the ongoing [[List of wars involving Ukraine|conflict in Ukraine]].<ref>{{Cite journal |last=Spytska |first=Liana |date=2024-12-01 |title=The use of virtual reality in the treatment of mental disorders such as phobias and post-traumatic stress disorder |url=https://www.sciencedirect.com/science/article/pii/S2666560324000562 |journal=SSM - Mental Health |volume=6 |article-number=100351 |doi=10.1016/j.ssmmh.2024.100351 |issn=2666-5603|doi-access=free }}</ref>

=== Limitations === Although VRT has led to promising findings, this form of therapy also comes with several limitations. First, early studies outlining its benefits such as Rothbaum et al. used small sample sizes of 20 participants, which limits the [[Generalizability theory|generalizability]] of their findings.<ref name=":4" /> More broadly, some studies have argued most existing research has low methodological quality which interferes with the reliability of results.<ref name=":3" /><ref name=":9" /> Finally, practical barriers such as the cost of and access to VR equipment also present a challenge to implementing VRT on a wider scale.<ref>{{Cite journal |last1=Felnhofer |first1=Anna |last2=Pfannerstill |first2=Franziska |last3=Gänsler |first3=Lisa |last4=Kothgassner |first4=Oswald D. |last5=Humer |first5=Elke |last6=Büttner |first6=Johanna |last7=Probst |first7=Thomas |date=2025-03-18 |title=Barriers to adopting therapeutic virtual reality: the perspective of clinical psychologists and psychotherapists |journal=Frontiers in Psychiatry |volume=16 |article-number=1549090 |doi=10.3389/fpsyt.2025.1549090 |doi-access=free |issn=1664-0640 |pmc=11958971 |pmid=40171310}}</ref><ref>{{Cite journal |last1=Sarkar |first1=Urmimala |last2=Lee |first2=Jane E |last3=Nguyen |first3=Kim H |last4=Lisker |first4=Sarah |last5=Lyles |first5=Courtney R |date=2021-09-22 |title=Barriers and Facilitators to the Implementation of Virtual Reality as a Pain Management Modality in Academic, Community, and Safety-Net Settings: Qualitative Analysis |journal=Journal of Medical Internet Research |language=en |volume=23 |issue=9 |article-number=e26623 |doi=10.2196/26623 |doi-access=free |issn=1438-8871 |pmc=8495579 |pmid=34550074}}</ref>

== Limitations and criticisms == The main criticism studies have raised towards systematic desensitization emphasize flaws in Wolpe's original theory and overarching practical limitations; some research has suggested relaxation and fear hierarchy are not as important as Wolpe originally suggested.<ref name=":10">{{Cite journal |last=McGlynn |first=F |date=1981 |title=The current status of systematic desensitization |url=https://linkinghub.elsevier.com/retrieve/pii/0272735881900015 |journal=Clinical Psychology Review |volume=1 |issue=2 |pages=149–179 |doi=10.1016/0272-7358(81)90001-5|url-access=subscription }}</ref><ref name=":11">{{Cite journal |last1=Arch |first1=Joanna J. |last2=Abramowitz |first2=Jonathan S. |date=July 2015 |title=Exposure therapy for obsessive–compulsive disorder: An optimizing inhibitory learning approach |url=https://linkinghub.elsevier.com/retrieve/pii/S2211364914000992 |journal=Journal of Obsessive-Compulsive and Related Disorders |language=en |volume=6 |pages=174–182 |doi=10.1016/j.jocrd.2014.12.002|url-access=subscription }}</ref><ref name=":12">{{Citation |last1=Thomas |first1=Kelsey |title=Systematic Desensitization |date=2017 |encyclopedia=Encyclopedia of Personality and Individual Differences |pages=1–3 |editor-last=Zeigler-Hill |editor-first=Virgil |url=http://link.springer.com/10.1007/978-3-319-28099-8_952-1 |access-date=2026-04-22 |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-319-28099-8_952-1 |isbn=978-3-319-28099-8 |last2=Dowd |first2=Correy |last3=Broman-Fulks |first3=Joshua |editor2-last=Shackelford |editor2-first=Todd K.|url-access=subscription }}</ref> More generally, these weaknesses, mean systematic desensitization is being used less frequently and new models are progressively being implemented.

=== Theoretical criticisms === A major criticism is regarding relaxation and its importance in minimising fear response. Although Wolpe highlighted it as critical for reciprocal-inhibition and thus systematic desensitization,<ref name=":0" /> studies have found conflicting results regarding its importance.<ref>{{Cite journal |last1=O'Brien |first1=Gerald T. |last2=Borkovec |first2=T.D. |date=December 1977 |title=The role of relaxation in systematic desensitization: Revisiting an unresolved issue |journal=Journal of Behavior Therapy and Experimental Psychiatry |volume=8 |issue=4 |pages=359–364 |doi=10.1016/0005-7916(77)90003-9 |issn=0005-7916}}</ref><ref name=":10" /><ref name=":12" /> Research has indicated that desensitization conducted alongside relaxation exercises is often equally effective to desensitization without relaxation.<ref name=":10" /> Moreover, in further contradiction to Wolpe, some studies have demonstrated beginning exposure with items at the top of the fear hierarchy produces comparable and sometimes better outcomes than starting with the least anxiety-provoking stimuli.<ref name=":11" /><ref name=":12" />

As a result, alternative theoretical models have been proposed to better account for the mechanisms of exposure therapy. For instance, these include Foa and Kozak's emotional processing theory and Craske et al.'s inhibitory learning model.<ref>{{Cite journal |last1=Rauch |first1=Sheila |last2=Foa |first2=Edna |date=June 2006 |title=Emotional Processing Theory (EPT) and Exposure Therapy for PTSD |url=http://link.springer.com/10.1007/s10879-006-9008-y |journal=Journal of Contemporary Psychotherapy |language=en |volume=36 |issue=2 |pages=61–65 |doi=10.1007/s10879-006-9008-y |issn=0022-0116|url-access=subscription }}</ref><ref>{{Cite journal |last1=Craske |first1=Michelle G. |last2=Treanor |first2=Michael |last3=Conway |first3=Christopher C. |last4=Zbozinek |first4=Tomislav |last5=Vervliet |first5=Bram |date=July 2014 |title=Maximizing exposure therapy: An inhibitory learning approach |journal=Behaviour Research and Therapy |language=en |volume=58 |pages=10–23 |doi=10.1016/j.brat.2014.04.006 |pmc=4114726 |pmid=24864005}}</ref> The development of these alternative frameworks underlines how Wolpe's original reciprocal inhibition model may be insufficient in fully explaining why and how systematic desensitization works.

=== Practical limitations === Systematic desensitization has also been criticized for being time consuming and reliant on the patient's capacity for imagination.<ref name=":5" /> For example, in patients with severe phobias, completing the process usually requires multiple sessions, sometimes requiring over 10.<ref>{{Cite journal |last1=Chen |first1=Jie |last2=Zhou |first2=Duoqi |last3=Gong |first3=Dan |last4=Wu |first4=Shunli |last5=Chen |first5=Weikai |date=2024-04-09 |title=A study on the impact of systematic desensitization training on competitive anxiety among Latin dance athletes |journal=Frontiers in Psychology |volume=15 |article-number=1371501 |doi=10.3389/fpsyg.2024.1371501 |doi-access=free |issn=1664-1078 |pmc=11037396 |pmid=38655213}}</ref> Additionally, as the technique relies on the patient's ability to imagine anxiety-provoking situations, it may be less effective for individuals who struggle with mental visualization such as those struggling with [[aphantasia]].<ref name=":5" /> However, the development of VRT has been proposed as one means of addressing this limitation.

More generally, Wolpe's theory has been criticized from a [[Psychoanalysis|psychoanalytical]] standpoint for addressing the symptoms of anxiety rather than its underlying causes, which has been argued to limit long-term effectiveness of treatment.<ref name=":2" /> Finally, while systematic desensitization has appeared effective for phobias and anxiety, it has been reported as unsuccessful when treating individuals suffering from more serious conditions such as [[schizophrenia]].<ref>{{Cite journal |last1=Serber |first1=Michael |last2=Nelson |first2=Philip |date=July 1971 |title=The ineffectiveness of systematic desensitization and assertive training in hospitalized schizophrenics |url=https://linkinghub.elsevier.com/retrieve/pii/000579167190022X |journal=Journal of Behavior Therapy and Experimental Psychiatry |language=en |volume=2 |issue=2 |pages=107–109 |doi=10.1016/0005-7916(71)90022-X|url-access=subscription }}</ref> This suggests the therapy's efficacy varies depending on the nature of the condition being treated.

===Decline in clinical use=== In recent decades, systematic desensitization has become less commonly used as a treatment of choice for anxiety disorders. Since 1970 academic research on systematic desensitization has declined, and the current focus has been on other therapies. In addition, the number of clinicians using systematic desensitization has also declined since 1980. Those clinicians that continue to regularly use systematic desensitization were trained before 1986. It is believed that the decrease of systematic desensitization by practicing psychologist is due to the increase in other techniques such as [[Flooding (psychology)|flooding]], implosive therapy, and [[Observational learning|participant modeling]].<ref>{{cite journal | pmid = 14997948 | year = 2004 | last1 = McGlynn | first1 = F. D. | last2 = Smitherman | first2 = T. A. | last3 = Gothard | first3 = K. D. | title = Comment on the status of systematic desensitization | journal = Behavior Modification | volume = 28 | issue = 2 | pages = 194–205 | doi = 10.1177/0145445503259414 | s2cid = 36104291 }}</ref>

==See also== * [[Flooding (psychology)]] * [[Immersion therapy]] * [[Sensitization]]

==References== {{reflist}}

==External links== * [http://www.guidetopsychology.com/sysden.htm Self-administered Systematic Desensitization]

{{Cognitive behavioral therapy}} {{Psychotherapy}}

[[Category:Anxiety disorder treatment]] [[Category:Behavior therapy]] [[Category:Behaviorism]]