Part 12. Systematic desensitization

If we wish to conquer undesirable emotional tendencies in ourselves, we must assiduously, and in the first instance cold-bloodedly, go through the outward motions of those contrary dispositions we prefer to cultivate.¹

—William James, MD, Father of Psychology

Your skis are pointing out over the lip of Couloir Extreme, the most notorious on-piste run at Whistler. The drop might be 10 ft—hard to tell through this fog—but you’re more concerned about that first turn. A reasonable thought crosses your mind: “How did I get here?”

Systematic desensitization

Imagine there’s a highly evidence-based treatment that can help the agoraphobic, the posttraumatic stress sufferer, and the socially anxious, as well as those suffering “simple” fears of spiders and snakes. Although very effective, the treatment is time-consuming, messy, and poorly remunerated. Still interested? Please try to be—systematic desensitization could change the lives of many of your patients.

Systematic desensitization was developed by South African psychologist Joseph Wolpe. In the 1950s Wolpe discovered that the cats of Wits University could overcome their fears through gradual and systematic exposure. Although hardly a novel concept today, the idea of desensitization was very alien to the traditional psychoanalytic zeitgeist of that era.

Step by step

Whether the fear is of elevators or public speaking, the basic principles of systematic desensitization are the same.

1. Define the ultimate “level-10 scary” (eg, present grand rounds solo).

2. Define “level-1 scary” (eg, say hello to a stranger).

3. Brainstorm and rank all points in between.^*

4. Assign the “level-1 scaries” as homework.

5. In a week, review the homework and assign “level 2.”

Ten tips

1. Many patients (and their doctors) benefit from having a written rationale (eg, top 10 reasons I want to overcome my fear of hairy men). The going might get tough—and the patient will later weep for having bailed out.

2. Metaphors help patients understand the process. Working through exposure hierarchies is like earning grades at school or mastering video game levels.

3. It helps to “normalize” the anxiety. Remind patients that most fears are based in evolutionary mechanisms. Here again, metaphors can help: It’s like Big You gets it, but Little You doesn’t. Let’s be gentle (but assertive) with Little You as we work through the hierarchy.

4. Hierarchies with fewer than 15 to 20 items often don’t provide enough exposure—2 to 3 items for each of the 10 levels is ideal.

5. Schedule self-exposure times in advance, ideally daily. Avoid self-exposure while on holidays.

6. Prepare the patient for the inevitability of revisions. Some contingencies can’t be predicted (eg, the baby garter snake was jumpy). Get back on the horse quickly.

7. Advise the patient to continue each self-exposure until anxiety drops by at least 50%. If it doesn’t, it’s technically sensitization rather than desensitization. That’s not the end of the world, but it’s clearly not preferred.

8. Encourage patients to assess exposures based on behaviour rather than feelings: Yes, you still felt some anxiety—but you did it!

9. Ideally include exposures beyond “normal.” Although most height phobics have little day-to-day need to walk atop the CN Tower, a tower-top “graduation ceremony” might prove invaluable.

10. Encourage lifelong elective self-exposure. Former height phobics should take the high road whenever possible.

A psychoanalyst upon learning of Wolpe’s techniques

View from the top

You’re back on Couloir Extreme. How did you get here? It was systematic: you began with the bunny runs, gradually working up to the steeper pitches; eventually you skied most of the black diamonds of Whistler. The double-black Couloir Extreme took systematic work. With similarly systematic exposures, we can help our patients carve with grace through their psychological double-black diamonds.