Using Desensitization to Treat Anxiety
Anxiety around specific issues, often referred to as phobias, can have a debilitating effect on a person’s life. A paralyzing fear of public speaking, of flying, or of driving can severely limit one’s ability to function normally. Moreover, such anxieties tend not to be stable entities but rather active encroachments that constrict one’s existence within a closing circle. A fear of driving on major highways may expand to a fear of driving at all followed by a fear of getting into a car, then perhaps even a fear of leaving the house. Extreme cases may leave one afraid to get out of bed.
I have had success in treating such phobias using the desensitization technique outlined below. I describe the technique to clients as “boring the anxiety to death,” and give them advance notice that the exercise will be tedious, though effective.
One begins by using a breathing exercise to establish a baseline. I rely on so-called “belly breathing,” in which the abdomen moves out as one breathes in, and in as one breathes out. Clients accustomed to taking a breath by filling their chests may have to practice this new kind of breath-ing, but controlled belly breathing proves to be a rapid method for reducing anxiety. Ideally such breathing allows one to arrive at a baseline of zero (on a scale from zero to ten, where zero represents no anxiety and ten rep-resents the highly imaginable level of anxiety).
Next one asks the client to break the phobic activity into five to eight individual steps. A client who feared driving on Canada’s 400-level highways (the equivalent of American interstate highways), for example, came up with these steps: starting the engine; pulling out into traffic; signaling at an onramp; watching the speedometer mark the acceleration toward highway speed; merging into traffic on the highway.
The client then rank orders the individual steps from least to most distressing. One begins the desensitization technique by addressing the step that the client finds least upsetting. The client is asked to formulate a brief “mantra,” a positive assertion to be repeated throughout the process. The driving activity might have a mantra such as “I am a skilled driver and I will arrive at my destination safely.”
The client then describes the individual step as a narration in the present tense. “Pulling out into traffic,” for example, might comprise several sub-routines: “I turn on my left-signal indicator. I check my side mirrors and my rear-view mirror. I turn around to check my blind spot. I turn the steering wheel to the left. I slowly pull out into traffic.”
The desensitization technique requires interrupting the narrative at each sub-routine, measuring the anxiety level, breathing to reduce the anxiety back to the baseline level, then starting again.
Client: I turn on my left-signal indicator.
Therapist: What is your anxiety level?
C: Four.
T: Stop and breathe. Let me know when your level is back to zero.
(Client breathes)
C: Okay.
T: Repeat the mantra.
C: I am a skilled driver and I will arrive at my destination safely.
T: Tell the story again.
C: I turn on my left-signal indicator.
T: What is your anxiety level?
C: Three.
T: Stop and breathe. Let me know when your level is back to zero.
(Client breathes)
The process continues until the client is able to narrate the sub-routine while maintaining a zero level of anxiety. Then we proceed to the next sub-routine. Depending on the severity of the anxiety, it may require an entire session to get through just a few steps of the overall narrative.
Once the client is able to narrate each step of the procedure while maintaining a zero level of anxiety, we rearrange the steps into the actual order in which they would appear in the act of driving. (I usually take dictation from the client, then print out the narrative for the client to use in practicing the exercise at home.)
As the client narrates the action I interrupt at the end of each sentence to ask for an anxiety reading. If the level exceeds the baseline, the client must repeat the breathing exercise, repeat the mantra, and then tell the story again from the beginning. Eventually—and this may take a fair amount of time--the client can go from start to finish without experiencing anxiety. I then instruct the client to repeat the desensitization exercise at home at least once a day for a week before actually carrying out the phobic activity in practice.
A client who experienced paralyzing anxiety as a student in a large university class has given me permission to reproduce his words in carrying out the desensitization exercise. He reported that the professor would regular-ly make derogatory comments about students who, like him, sought refuge in the relative safety of the back row, and as a result the professor would specifically pose a question to be answered by members of that row. Knowing my client to be a third-year student, the professor would often look directly at him expecting a response, and if he actually managed to answer the professor might come back immediately with a follow-up question. The anxiety produced by this succession of challenges rendered my client incapable of raising his hand even when he knew the answer to the question. Moreover, he believed that if he ever actually overcame his fears and responded to a question, the professor would thereafter expect that he could do it all the time. This last step in the narrative called to mind the experience of crossing a river on a log--when one found this to be a terribly frightening challenge--and then, after finally succeeding in getting across the river, being called on to run back and forth several more times. No way!
The narrative for this particular phobia consisted of seven steps:
1. The professor poses a question in my direction.
2. She mocks the back row.
3. She looks at me directly.
4. I dare to raise my hand.
5. I give the answer and she smiles with slight approval.
6. I answer the question and she poses one right back at me.
7. If I answer once, I’m expected to do it all the time.
As a mantra, we devised the phrase, “I know the answer and I want to share it.”
The client rank ordered the individual steps as 1, 5, 6, 2, 7, 3, 4, so that the single most anxiety-producing step lay in daring to raise his hand in response to the professor’s question.
We began with the least threatening step in the narrative, with the professor directing a question to the students sitting in the back row. The dialogue began:
C: The professor asks a question.
T: What is your anxiety level?
C: Four.
T: Stop, begin breathing, and tell me when the level is back to zero.
C: Okay.
T: Repeat the mantra, then tell the story.
C: I know the answer and I want to share it. The professor asks a question.
T: What is your anxiety level?
C: Two.
T: Stop, and go back to breathing.
In this particular case we succeeded in processing the entire narrative within one session. More severe cases have required several sessions, in-cluding a case in which even locking the front door of the house before walking in the direction of the car aroused a marked level of anxiety on the part of the client.
Desensitization is a form of cognitive-behavioral therapy (CBT) favored by insurance companies because it produces measurable results in a relatively short time. Once a client has conquered a particular phobia to the extent of being able to practice the phobic activity in real life, I offer the possibility of addressing the underlying causes of the phobia.
Some phobias, such as a fear of snakes and spiders, appear to have been “hard-wired” into the human brain as an evolutionary protection against actual, physical threats. Most phobias, however, such as a fear of germs, or a fear for the safety of a son or daughter--when the offspring has now reached adulthood and is not engaged in any particularly perilous activity—result from unprocessed trauma. In my experience, unprocessed trauma carries with it negative self-beliefs, such as “I am powerless,” or “I did something wrong,” that extend a damaging influence on a person’s life. Overcoming the anxiety associated with a specific phobia generally does not suffice to process the traumatic memory, which typically will exert a negative effect in some other area. For this reason I urge clients to take the next step and process the underlying memories that produced the anxiety. Eye movement desensitization and reprocessing (EMDR) proves to be a rapid and effective technique for dealing with trauma, be it the so-called “capital T” traumas, such as surviving an automobile accident or sexual abuse, or so-called “small t” traumas such as severe bullying, humiliation or witnessing a violent dispute between one’s parents at an early age. In the long run, removing these traumatic obstacles to mental health prove to be an important adjunct to treating specific phobias.
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