Systematic Desensitization: Relaxation Paired with a Fear Hierarchy, Step by Step

About this tool

Systematic desensitization is a behavior therapy technique for reducing a specific fear by pairing a deeply relaxed state with gradually more frightening versions of the feared situation, usually in imagination, until each step no longer produces anxiety. It was developed by the South African psychiatrist Joseph Wolpe in the 1950s and set out in his 1958 book Psychotherapy by Reciprocal Inhibition. The name describes the method: the fear is taken apart systematically, one rung at a time, and the person becomes desensitized to each rung before moving to the next. It is one of the earliest structured treatments for phobias and the direct ancestor of modern exposure therapy.

Wolpe's explanation for why it works was reciprocal inhibition. He argued that the body cannot be deeply relaxed and anxious at the same moment, so if a relaxed state can be made to occur in the presence of a feared cue, the relaxation inhibits the fear response and weakens the learned link between cue and fear. He borrowed the relaxation method from Edmund Jacobson's progressive muscle relaxation, shortened so it could be taught in a few sessions, and he introduced the Subjective Units of Distress Scale, or SUDS, a 0 to 100 rating the person uses to report how anxious a scene makes them. The SUDS rating is still used throughout anxiety treatment today.

The method has three steps. The first is relaxation training: learning to produce deep muscular relaxation on cue, practiced daily until it is reliable. The second is building the hierarchy: writing down ten to fifteen scenes involving the feared situation and ranking them by SUDS from the mildest, perhaps a 10, to the worst, a 100, with roughly even gaps between them. A hierarchy for a fear of flying might run from looking at a photograph of a plane, through booking a ticket and packing a bag, to the moment of takeoff in turbulence. The third step is graded pairing: in a relaxed state, the person imagines the lowest scene for a few seconds. In Wolpe's procedure, if anxiety rises they stop imagining, return to relaxation, and try again; the aim was to keep the relaxed state in place while the cue was present, not to stay with the anxiety. When the scene can be held in mind calmly on repeated trials, they move up one rung. Sessions continue until the top of the hierarchy can be imagined without distress.

This is where systematic desensitization and modern graded exposure part ways, and the difference matters if you are reading about the two together. Graded exposure keeps the hierarchy and the step-by-step climb but usually drops the relaxation pairing. Dismantling research from the 1970s onward found that confronting the feared cue was the active ingredient and that relaxation added little. Later work on emotional processing by Edna Foa and Michael Kozak, and more recently the inhibitory learning model described by Michelle Craske and colleagues, reframed the goal: the point is to learn that the feared outcome does not happen, or is tolerable when it does, and to let anxiety be present while that learning occurs. In that framing, working hard to stay relaxed can act as a safety behavior that gets in the way. Most therapists now use exposure, often in real situations rather than in imagination, and reserve systematic desensitization for specific cases or for people who find pure exposure too much to begin with.

What the evidence supports is fairly clear. Systematic desensitization reduces specific phobias, and it did so reliably in the studies that established it. Its theory of reciprocal inhibition has not held up as the explanation: people improve whether or not they are relaxed, and the relaxation is not what drives the change. Imaginal work is also weaker than real-life contact for most fears. So the method works, but not for the reason Wolpe proposed, and a plain exposure program will usually get there faster. The hierarchy you build here is the useful part: it transfers directly to the exposure plan a therapist agrees with you.

It suits people with one specific, concrete fear: a phobia of dogs, heights, driving, public speaking, or flying. Fear of needles, blood or injury is a special case: it often comes with faintness or fainting rather than panic, and for that pattern deep relaxation is not the usual first choice; clinicians teach a muscle-tensing method called applied tension instead. Have that fear assessed rather than running this worksheet on it. It is a poor fit for generalized worry, where there is no single hierarchy to climb, for obsessive-compulsive patterns, which need exposure with response prevention, and for post-traumatic stress, where imaginal work should be guided by a trained clinician. If the fear involves memories of an actual traumatic event, or if you feel detached or unreal when distressed, do not run this on your own.

Mistakes come in a few forms. Rushing the relaxation training, so there is no relaxed state to pair with. Building a hierarchy with huge gaps, so the next rung is a cliff. Imagining a scene vaguely rather than vividly, which lets you skip the fear instead of learning from it. Mixing the two methods: in Wolpe's procedure you step back to relaxation as soon as anxiety rises, while in modern exposure you stay with the scene so you can learn that the feared outcome does not arrive or can be tolerated. Switching between those two rules mid-session, so that you neither relax fully nor stay long enough to learn anything, gives you the worst of both. And treating a quiet imagination as the finish line: the real test is the feared situation itself, approached in the same graded order.

The worksheet on this page follows Wolpe's structure: a target fear, a relaxation plan, a ten-step hierarchy with SUDS ratings, and a session log so you can see which rung you are on and how the ratings fall over repeated trials. Fill it in and download the PDF. If your fear is severe, has lasted years, or is stopping you from working, traveling, or getting medical care, a therapist who practices exposure-based CBT can run the same process with better pacing and support. Psychology.com's directory lets you search for one by specialty at no cost. The Exposure Hierarchy Builder and the Fear Ladder on this site cover the modern exposure version of the same climb, and Progressive Muscle Relaxation teaches the relaxation skill Wolpe started with.

Reviewed by Michael Callans, MSW
Reviewed the description of Wolpe's three steps, the account of how modern exposure differs, and the worksheet structure for fidelity to behavior therapy practice.

References

1. Wolpe J. Psychotherapy by Reciprocal Inhibition. Stanford University Press; 1958.
2. Wolpe J. The Practice of Behavior Therapy. 4th ed. Pergamon Press; 1990.
3. Foa EB, Kozak MJ. Emotional processing of fear: exposure to corrective information. Psychological Bulletin. 1986;99(1):20-35.
4. Craske MG, Treanor M, Conway CC, Zbozinek T, Vervliet B. Maximizing exposure therapy: an inhibitory learning approach. Behaviour Research and Therapy. 2014;58:10-23.
5. Abramowitz JS, Deacon BJ, Whiteside SPH. Exposure Therapy for Anxiety: Principles and Practice. 2nd ed. Guilford Press; 2019.

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