Systematic desensitization, or graduated exposure therapy, is a behavior therapy developed by the psychiatrist Joseph Wolpe. It is used when a phobia or anxiety disorder is maintained by classical conditioning. It shares the same elements of both cognitive-behavioral therapy and applied behavior analysis. When used in applied behavior analysis, it is based on radical behaviorism as it incorporates counterconditioning principles. These include meditation (a private behavior or covert conditioning) and breathing (a public behavior or overt conditioning). From the cognitive psychology perspective, cognitions and feelings precede behavior, so it initially uses cognitive restructuring.

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.

Three steps of desensitization
There are three main steps that Wolpe identified to successfully desensitize an individual.
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 mechanism 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. 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.

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:
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.

Uses

Specific phobias
Specific phobias 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. Wolpe found that systematic desensitization was successful 90% of the time when treating phobias.

Test anxiety
Between 25 and 40 percent of students experience test anxiety. Children can suffer from low self-esteem and stress-induced symptoms as a result of test anxiety. 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 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.

Recent use
Desensitization is widely known as one of the most effective therapy techniques. 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, implosive therapy, and participant modeling.

History
In 1947, Wolpe discovered that the cats of Wits University could overcome their fears through gradual and systematic exposure. Wolpe studied Ivan Pavlov's work on artificial 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.

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.

See also
 Flooding (psychology)
 Immersion therapy
 Sensitization

References

External links
 Self-administered Systematic Desensitization

Anxiety disorder treatment
Behavior therapy
Behaviorism
점진적 노출 요법으로도 알려진 체계적 둔감화(Systematic desensitization)는 남아프리카 정신과 의사 조셉 볼프(Joseph Wolpe)가 개발한 행동 요법의 한 유형이다. 이것은 임상 심리학 분야에서 많은 사람들이 역 조건형성같은 고전적 조건형성의 조절을 기반으로하는 공포증 및 기타 불안 장애를 효과적으로 극복하고 인지 행동 접근과 그 응용 행동 분석의 동일한 요소를 공유하도록 도와준다. 행동주의적 접근에서 행동 분석가가 사용하는 경우, 내적 행동으로서의 불안 위계 목록을 기록해보고 이를 통해 내현적 조절(Covert conditioning)과  외적 행동으로서의 호흡조절이나 신체의 물리적 이완등을 통한 과도한 반응 조절을 시도하는 반작용 원칙을 통합하므로 이러한 맥락에서 근본적으로 행동주의를 기반하기도 한다. 그러나 인지 심리학 관점에서 인지와 감정은 운동 행동을 유발하는 메커니즘을 공유하는 부분을 전제한다.

예
클라이언트는 뱀의 공포증 때문에 도움을 받기 위해 접근할 수 있다. 상담자는 다음 세 단계의 체계적인 둔감화를 사용하여 클라이언트를 돕는 방법이다.

-불안 자극 계층 구조를 설정한다. 상담자는 환자에게 두려움 계층을 식별하도록 요청함으로써 시작할 수 있다. 이 두려움 계층은 뱀에 대한 다양한 수준의 노출에 대한 상대적 불쾌감을 나열한다. 예를 들어 뱀 그림을 보면 살아있는 뱀이 자신의 주위에서 우글대고 자신을 기어오르는 것과 비교하여 낮은 두려움 등급을 이끌어 낼 수 있다. 후자의 시나리오는 두려움 계층에서 보다 높아질 것이다.

-대처 메커니즘 또는 양립 응답을 습득할 수 있다. 상담자는 클라이언트와 협력하여 명상 또는 심근 이완 반응과 같은 적절한 대처 및 양립응답의 기법을 배우게된다.

-자극을 호환되지 않는 양립하는 응답 또는 대처 방법에 연결한다. 클라이언트는 이전 단계에서 제시된 깊은 이완 기술(즉, 점진적 근육 이완)을 활용하면서 불쾌한 수준의 두려움 자극을 최저에서 최고로 제시해 나간다.

뱀 공포증을 돕는 심상 자극의  상상(imagination) 및 심상 진행(imagined progression)은 다음과 같을 수 있다.
불안 위계 목록 -  1. 뱀 그림 ,  2. 근처 방에 있는 작은 살아있는 뱀 , 3. 입을 벌리고 혀를 내미는 살아있는 커다란 뱀 4. 뱀이 자신의 주위에서 우글대고 자신을 기어오를 수 있는 상황

상상되는 진행의 각 단계에서, 환자는 이완 상태에 있는 동안 자극에 노출되어 공포나 불안에 보다 더 민감하지 않은 경험을 하게 된다. 두려움의 계층 단계가 점차 진행되면서 클라이언트는 불안이 점차 강도가 높아지지 않도록 다룰 수 있게된다.

전문가들은 근육의 예에서처럼 근육의 긴장과 이완의 시간적 양적 양립의 대비는 이러한 심리학적 그리고 결과적으로 효과를 효율적이게 하며 따라서 이완을 통해 차분해지는 느낌만큼이나  실질적인 긴강감의 강도 역시 중요하다는 점을 언급한다.

이완훈련
이완훈련(弛緩訓鍊)은 근육이나 신경의 긴장을 이완시키기 위한 치료법으로 행동 수정 이론에서 도입한 것으로 특히 조셉 볼프(Joseph Wolpe)는 행동주의적 접근의 입장에서 신경증, 심신증의 증상을 잘못 학습된 부적응 상태로 보고 이러한 불안 상태를 해소시킬 목적으로 이 훈련을 채택하였다. 제이컵슨(Jacobson)은 체계적 근육 이완을 창안하였고, 이는 심리 치료에서 광범위하게 도입되었다.

점진이완훈련
점진이완훈련은 심리 치료에서 광범위하게 쓰는 것으로, 근육 이완 과정을 체계적으로 활용한 이완법이다. 근육의 긴장을 풀면 긴장감이 사라질 수 있다는 전제하에 시작한 것으로, 짧은 시간 안에 이완하는 것을 목표로 한다.  심상훈련이 관련되기도 한다.

호흡법
호흡법(呼吸法)은  복식 호흡 따위의 호흡 조정으로 호흡운동(呼吸運動)의 기능을 향상하는 방법으로 이완훈련의 하나이다. 이 경우 복식호흡(腹式呼吸)은 복근을 한 번 폈다 다시 오므렸다하는 이완과 긴장을 행할 때 가로막의 신축에 의존하는 호흡을 가리킨다.

같이 보기 
 로젠버그 자존감 척도
 레스콜라-와그너 모델
 노출-반응방지

참고

(박미자, 임걸. (2019). 스마트기기 활용 인지행동 미술치료가 정서불안 아동의 변화에 미치는 효과. , 17(5), 89-97.)http://www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE09251563
(김재선. (2015). 수학불안 감소를 위한 동기강화상담에 관한 소론. 교육연구, 23(), 83-103.)http://www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE06640830
(대학 골프선수의 등속성 근력 트레이닝과 심상훈련이 경기력에 미치는 효과
The Effect of Athlete Performance on Isokinetic Muscle Training and Image Training between Superior and Inferior Golfer,
안창식,한국체육측정평가학회지 제12권 제3호2010.1291 - 101 (11 pages)KCI등재)http://www.dbpia.co.kr/Journal/articleDetail?nodeId=NODE08766095
(Behav Res Ther. 1991;29(6):561-74. Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia.
Ost LG1, Fellenius J, Sterner U. Author information,Department of Psychiatry, University of Uppsala, Sweden.)https://www.ncbi.nlm.nih.gov/pubmed/1684704 (PMID: 1684704 )
(Applied tension, exposure in vivo, and tension-only in the treatment of blood phobia
Author links open overlay panelLars-GöranÖstJanFelleniusUlfSterner
Department of Psychiatry, University of Uppsala, Ulleråker, S-750 17 Uppsala, Sweden
Received 28 February 1991, Available online 3 June 2002.) https://doi.org/10.1016/0005-7967(91)90006-O

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