The recurrent themes in the patient’s difficulties
and anxieties are isolated and then ordered in
terms of their power to induce anxiety (from situa-
tions that provoke very low levels of anxiety
through situations that precipitate extreme anxiety
reactions). A typical anxiety hierarchy consists of 20
to 25 items in approximately equal intervals from
low through moderate to extreme. The following
anxiety hierarchy was that of a 24-year-old female
student who experienced severe examination anxi-
ety (Wolpe, 1973):
- Four days before an examination.
- Three days before an examination.
- Two days before an examination.
- One day before an examination.
- The night before an examination.
- The examination paper lies face down before
her.
7. Awaiting the distribution of examination
papers.
8. Before the unopened doors of the examination
room.
9. In the process of answering an examination
paper. - On the way to the university on the day of the
examination. (p. 116)
This hierarchy illustrates two points. First, it is
organized largely along spatial-temporal lines. Sec-
ond, the items are not exactly organized in a logical
fashion. One might expect item 10 (the most
anxiety-provoking item) to be placed near the mid-
dle of the hierarchy. This suggests how idiosyncratic
hierarchies can be—after all, it is the patient’s anxi-
ety, not the clinician’s!
In the desensitization procedure, the patient is
asked to imagine the weakest item in the hierarchy
(the item that provokes the least anxiety) while
being completely relaxed. The therapist describes
the scene, and the patient imagines (for about 10
seconds) being in the scene. The therapist moves
the patient up the hierarchy gradually (between
two and five items per session). However, if at
any time the level of anxiety begins to increase,
the patient is instructed to signal, whereupon the
therapist requests that the patient stop visualizing
that scene. The therapist then helps the patient to
relax once more. After a few minutes, the proce-
dure can be started again. Ideally, over a period of
several sessions, the patient will be able to imagine
the highest item in the hierarchy without discom-
fort. A typical example of the instructions given to a
male patient during desensitization is provided by
Goldfried and Davison (1994):
(The client has been relaxing on his own in the
reclining chair.) OK, now just keep relaxing
like that, nice and calm and comfortable.
You may find it helpful to imagine a scene
that is personally calm and relaxing,
something we’ll refer to as your pleasant
scene.... Fine. Now, you recall that 0 to
100 scale we’ve been using in your relax-
ation practice, where 0 indicates complete
F I G U R E 14-1 Joseph Wolpe has been primarily
identified with the development of systematic desensiti-
zation as a method of reducing anxiety.
Courtesy of Joseph Wolpe404 CHAPTER 14