The Desensitization Paradigm

Joseph Strayhorn, M.D.

What is meant by desensitization?

            Desensitization means making a certain situation, or set of situations, less scary, upsetting, disturbing, or distressing than they were. For example, if someone has a fear of riding in an airplane and learns to ride in the airplane comfortably, the fear connected with the situation has been “desensitized.” People have used desensitization to lower the unpleasant emotion connected with bunches of situations. The word “aversion” refers to unpleasant emotion connected with a situation; the emotion can be fear, disgust, anger, shame, sadness, boredom – any bad feeling.   

What are some of the situations that people have desensitized themselves to?

            They’ve used desensitization with all sorts of aversions: fears or other negative emotions connected with driving, dogs, public speaking, dental work, heights, taking tests, social conversation, getting criticism, failing at something, being abandoned, being in a close relationship, trusting someone, being rejected, asserting oneself with someone, being alone, being in public, going to school, the dark, going to bed by oneself, sleeplessness, being observed by people socially, looking at one’s own body, appearing fat, appearing skinny, the possibility of getting an illness, bad memories of things that happened in the past, doing schoolwork, doing boring work of any sort, being in a boring situation, a demand or request from someone, exercising, insects, touching something that is felt to be contaminated, unwanted thoughts that pop into the head, unlucky numbers, snakes, getting shots or blood drawn, vomiting, seeing someone else vomit, certain smells, having a nightmare, and many others! 

What is meant by “exposure” during desensitization?

            If you are going to change your reaction to a situation, you have to in some way or another put yourself in that situation. That’s called exposure.

            But here’s a major discovery: you can do lots of good desensitization work by exposing yourself to the situation in your imagination, rather than in real life. That’s really good news: you don’t have to actually fail to practice handling failure. You don’t have to actually get yourself criticized to practice handling criticism. Practicing handling the situation in imagination is what I call fantasy rehearsal. In desensitization, you can rehearse in fantasy handling the situation without feeling bad, or at least without feeling as bad. Often, but not always, fantasy rehearsals are followed by real-life rehearsals.

What is a desensitization “hierarchy”?

            If you’re teaching someone to swim, you don’t want to start out by tossing them into deep water. If you’re learning piano, you are better off starting with “Twinkle Little Star” than with a very difficult classical piece. In the same way, if you’re learning to handle a certain type of situation without a bunch of negative emotion, you start with the easiest versions of that type of situation, and work your way up to the harder ones. That way you get to have a bunch of successes as you work your way along. The list of situations in order from easiest to hardest is called the hierarchy.

            When you’re making a hierarchy it helps to rate the “SUD level” of situations. SUD stands for “Subjective Units of Distress.” If you use a 0 to 10 scale, 0 means no distress at all, whereas 10 means extremely large distress. If you rank order different examples of the type of situation according to the SUD level, that gives you a hierarchy. You want to make sure that the hierarchy includes situations that are of low enough SUD level that you can start out with them, feeling fairly comfortable.

What’s an example of a desensitization hierarchy?

            Suppose someone has a fear of flying insects, particularly bees. With some help, the person generates the following hierarchy. The number after each situation is the SUD level for that situation.

Thinking about a picture of a potato bug in a book: 0

Seeing a potato bug on the dirt:  1

Seeing a butterfly landing on flowers: 2

Seeing a ladybug flying around: 4

Seeing a cartoon picture of a bee: 5

Seeing actual photographs of a bunch of bees in a hive: 7

Seeing a photograph of someone with bees on him: 7

Seeing a video of bees flying around: 7

Hearing a fly, flying around  8

Seeing a bee or wasp flying around near me 9


What are some ways of making up exposures with a LOWER SUD level?

1.      Do it in imagination rather than real life.

2.      Imagine that a miracle has occurred and that you can handle the situation with no distress at all; imagine yourself in the situation under this condition.

3.      See yourself in the situation as if you were looking at a video of yourself rather than seeing from your own eyes.

4.      Imagine someone else in the situation, handling it the way you’d like to.

5.      Imagine yourself seeing a video of the situation, looking at it on a screen that is a long way off.

6.      Create a version of the situation that is less threatening. For example: someone who is desensitizing to rejection imagines a little kid that the person doesn’t even know, saying, “I’m having a birthday party but I’m sorry, you’re not invited.” Someone who is desensitizing to going out in public goes out to a place not far from home, with a very trusted companion.

7.      Imagine that you have already handled the situation really well, and you are looking back and celebrating your “courage skills triumph.”

For most fears or aversions, it’s good to list a good number of situations connected with it – first encountering it, being in the middle of handling it, discovering it’s easier than expected, discovering it’s harder than expected, having handled it completely successfully, having handled it with incomplete success, looking back on it after a long time has passed, and so forth. All these may have different SUD levels associated with them. The goal is to get a wide range of situations to practice with, with enough low and medium SUD level situations that you can get into this without a lot of pain. Your progress in this should be as painless as possible!

How does relaxation fit in to the desensitization program?

            The original versions of desensitization put a big emphasis on muscle relaxation training. The idea is that it’s hard to have high negative emotion with your muscles very relaxed. So the strategy was to get the muscles very relaxed and practice imagining or having a real-life exposure to the situations on the hierarchy, while staying as relaxed as possible. Muscle relaxation is still a very useful skill to learn. I recommend the “breathe and relax the muscles” procedure. In this, you sit in a relaxed position, with your eyes open or closed as you prefer. On each breath in, you get a group of muscles in mind. Your face and head, your neck, your shoulders and upper back, your chest, your forearms, or your upper arms, etc., are where you focus your attention. On the breath out, you get those muscles as loose, limp, and relaxed as you can. Practicing this for as little as 1 or 2 minutes a day helps to build up the relaxation skill. There are lots of other methods of meditation and relaxation that can improve this important skill. Chapter 8 of my book, A Programmed Course in Anxiety Reduction and Courage skills, available on, describes about a dozen relaxation and meditation methods.

            All that is necessary for effective desensitization, however, is for the learner to practice some useful response other than the problematic emotional reaction. That good response doesn’t have to include relaxation. For example, suppose someone gets so anxious before athletic contests that they throw up and want to avoid the contest. Suppose they practice and learn, not getting very relaxed before the contest, but getting excited in a positive way – looking forward to the contest with a very high energy level that feels good. This is effective desensitization. And the high level of excitement may actually help the person’s athletic performance.

What’s the benefit of “prolonged exposure” in desensitization?

            Being in a scary situation for a long time without anything bad happening tends to teach us that the situation isn’t dangerous, and to reduce our fear levels. SUD levels tend to fall. Getting used to a situation is called “habituating” to it.

            On the other hand, suppose we expose ourselves to the situation for only a few seconds, feel great distress, and then escape from the situation. The resulting drop in our distress level rewards us for escaping, and probably increases our urge to escape next time. The urge to escape is pretty much the same as fear. So it’s a good idea when desensitizing, to stay in the scary situation long enough for the SUD level to drop while you’re still in the situation. Putting yourself in a scary situation and then escaping because it feels so bad can possibly increase the fear.

How do STEBC fantasy rehearsals fit in to the desensitization program?

            Rather than just imagining yourself in the situation, I have found it very useful for people to imagine themselves responding to the situation with just the Thoughts, Emotions, and Behaviors that they think are the best for that situation, and to imagine themselves Celebrating handling the situation so well. STEBC stands for Situation, Thoughts, Emotions, Behaviors, Celebration.

            There are two types of STEBC fantasy rehearsals: mastery and coping. In a mastery rehearsal, you imagine that a miracle has occurred, and you are immediately able to respond to this situation just as you’d like to, without any unwanted distress. In a coping rehearsal, you imagine that there is a SUD level still associated with the situation, but you cope with any distress and handle the situation well anyway. Both of these types of fantasy rehearsals are very useful to do.

            It can take a good bit of thought to decide on the thoughts, emotions, and behaviors you’d like to include in a STEBC fantasy rehearsal. It’s often useful to collaborate with some person with experience in this, and to get the rehearsals written down. Then, you can read them, aloud or silently, over and over, every day. If after several days you begin to get somewhat bored with reading them, that’s often a good sign – for example, it’s hard to be extremely scared and bored at the same time.

            There are two ways to ask the SUD level question with fantasied situations. One is: “How bad does it make me feel, right now, to imagine this situation?” and the second is, “What’s my guess about how bad I would feel if I were in this situation in real life?” Both of these SUD ratings are informative and useful. Lots of people have found that doing mastery fantasy rehearsals does not bring on a high SUD level; this may be a good way to start out with learning to handle a certain situation. In fact, lots of people have found that mastery fantasy rehearsals are painless. If so, they are a great way of making progress in desensitization without inflicting discomfort on yourself. “No pain, no gain” is NOT the motto of desensitization, at least in my practice of it. (There are some gurus who appear very much to believe in the “No pain, no gain” idea.)

            There are some examples of STEBC fantasy rehearsals in Chapter 10 of my book, A Programmed Course in Anxiety Reduction and Courage Skills, the full text of which is available at More examples are in Chapter 17 of A Programmed Course in Psychological Skills Exercises, also on that website.

Here's an example of a mastery fantasy rehearsal for use by someone who is working on an “academic work aversion.” The person has experienced criticism and self-criticism for academic work, so that the idea of sitting down to do homework brings up a high SUD level.

Mastery Fantasy Rehearsal

Situation: I sit down to do some homework.

Thoughts: It’s really nice that the thought automatically going through my mind is, “Doing anything on this is better than doing nothing.” That means I can’t lose! I already celebrate that I sat down to get started on this, and I anticipate that I’ll celebrate each bit of work that I do. The ability to do this sort of thing is going to help me for the rest of my life.

Emotions: Miraculously, there’s no SUD level. In fact, I’m sort of curious about the stuff I’m working on. I’m proud of myself for what I’ve done so far. I have a nice liberated feeling, that I’m freed up to do this work.

Behaviors: I do the work, and for each little bit that I do, I say to myself something like, “Congrats, you’re making progress!” If there’s something I don’t know how to do, I try various options for figuring it out, and if I still can’t, I don’t worry about it and move on! I use my brain to figure out ways that what I’m learning and practicing could be helpful to me or someone else.

Celebration: I got some good work done! And it is super wonderful that I was able to do this without any work-aversion-distress at all!

Coping Fantasy Rehearsal

Situation: I sit down to do some homework.

Thoughts: I can feel the tendency to tense up and worry that I’ll do badly on this. But this is a chance to push through the aversion that I have, and to create a “courage skill triumph” that I can feel good about. If I can do that, I’ll deserve to really feel good about myself. I remind myself that succeeding does not mean doing everything perfectly. It just means putting out a good effort on every part of this assignment.

Emotions: I feel a pretty high SUD level. I feel scared of being inadequate to this task. But I also feel compassionate to myself, and I’m determined to avoid getting down on myself and beating myself up if I find this hard. And I feel proud of myself for taking on this challenge.

Behaviors: I give each part of this assignment my best shot. When there’s any part that I feel I’ve done correctly, I say to myself, “Good for you!” And even if I don’t feel good about that at the moment, I know I’ve achieved something good. If there’s any part that I don’t know how to do, I use various options to figure it out (look it up in my text materials, look it up on the Internet, work some on the foundation skills, ask somebody for help, just take my best guess…). If I can’t figure it out, I move on to the next and try to focus on that, and try to avoid getting down on myself for not knowing something. I keep in mind that just by giving this my best effort, I’m chalking up a great success, even if my work is very far from perfect.

Celebration: Hooray! I gave it a really good effort! That was a really good “exposure to the aversive situation,” and a triumph in my goal of desensitizing myself to this! If I keep this up, eventually I’m going to be comfortable doing this!

The fantasy rehearsals would be different for different people. They should be tailored for the individual.

Here's an example of a mastery fantasy rehearsal, for use by someone who is working on a fear of rejection and abandonment.

Mastery Fantasy Rehearsal

Situation: Someone whom I was part of a “couple” with, and whom I wanted to stick together with, just told me in no uncertain terms that they want to break up.

Thoughts: This is bad news for me, but it isn’t the end of the world. I can do OK in life without being in a relationship with this person. If I can handle this situation well, I have reason to really feel good about myself. I have some decisions to make. I need to decide how to handle this once it’s done, but for now I need to decide what to do and say back to the person. I could express anger at being rejected. I could ask questions about why. I could suggest we stay friends. I could say maybe someday we can be friends, but for now it would be better to stay away from each other altogether. I could actually say something positive about the relationship we had. I’m choosing to plan to stay away from each other a while, say a quick positive word, and go away from the person.

Emotions: It’s kind of miraculous that I feel sad, but not devastated. I feel determined to handle this well. I feel proud of myself for the thinking I’ve done so far.

Behaviors: I say, “Maybe at some point we’ll be friends, but for now I want us to stay away from each other for at least several weeks, and not talk or text or anything. We had some good times, that I hope may become pleasant memories at some time. I guess it’s time to say goodbye, and good luck.” And then I walk away.

Celebration: I handled this in a mature way. I like my decision not to drag this out. If I can make the future decisions about handling this in a really mature way also, I am going to deserve to feel even better.

Here’s an example of a coping fantasy rehearsal of the same situation:

Coping Fantasy Rehearsal

Situation: Someone whom I was part of a “couple” with, and whom I wanted to stick together with, just told me in no uncertain terms that they want to break up.

Thoughts: OK, this is creating pretty overwhelming emotion in me right now. I think I need not to communicate about this until I’ve given that emotion some time to go down some.

Emotions: I feel a SUD level now that is pretty close to the top of the scale. But I also feel some determination to act like a mature person in response to this.

Behaviors: I say, “OK, time for me to be by myself,” as I’m walking quickly away. I get by myself and have a good cry. I relax my muscles some. I keep reminding myself that I want to take care of myself, I want to handle this well, I want to make myself proud of myself. I make a plan to get some support from someone else, and I see if they are available. In the meantime, I feel agitated, so I go for a really fast walk with some running, just to use some physical energy and help myself relax. I can decide later, whether or how to be in touch with the person I’d been in the relationship with.

Celebration: Hooray, this was a super difficult situation to handle, and I’ve done a great job of it so far!

Again, these are just examples. Different people would make different choices about how they would want to think, feel, and behave, depending on what situations they are dealing with, their own value systems, and the mental images and back stories for the situations they are creating that are not expressed in the short “situation” description.

Once rehearsals like these are written down, the person can read them, silently or aloud, every day, and notice what the SUD level is while reading them. It helps to try to imagine vividly what is going on.

How do you know when desensitization has succeeded?

            When you’re able to imagine the situations you’ve identified, and imagine yourself responding well to them, without much of a SUD level, that’s a really celebration-worthy outcome. If you find that when you imagine the situation, the desired responses of thoughts, emotions, and behaviors tend to come to mind automatically, that’s a great success. Lots of the time, but not always, the real proof of success is when you can encounter the situations in real life and handle them well, without a lot of distress. (I say not always, because sometimes the situation exists only in your memory or imagination: for example, you’re desensitizing yourself to memories of bad things that happened in the past, or fears of nuclear war breaking out.) You will know when desensitization has succeeded when you find that the work you have done on it has made your life better – has made you happier, less often distressed, able to do things you avoided before, able to be better to your fellow human beings.