In vivo Desensitization

Description of the Strategy

In vivo desensitization is a widely used, exposure-based strategy for the treatment of anxiety, fears, and phobias. This approach alone is a well-supported treatment of childhood fears and phobias; however, in vivo desensitization is often a component of cognitive-behavioral treatment packages. Other components used in conjunction with in vivo desensitization could include imaginal desensitization, contingency management, cognitive restructuring, and modeling.

In vivo means “in life,” which refers to the presentation of the feared stimuli or situation. Thus, the child or adolescent is directly exposed to the feared object. This is in contrast to imaginal exposure, during which the child is instructed to imagine the feared stimulus in rich detail. Desensitization, also called counterconditioning or deconditioning, is developed from classical conditioning theory. From this perspective, feared objects or situations are classically conditioned stimuli. Desensitization involves pairing a response incompatible with anxiety (e.g., relaxation) with the conditioned stimulus until the fear response is eliminated.

Treatment using in vivo desensitization involves three steps. First, children are taught a behavior that is incompatible with the fear response. They could be taught progressive muscle relaxation (PMR). During PMR, children are taught to systematically tense and release their muscles. Throughout instruction of PMR, children are taught to recognize the difference between tension and relaxation. This skill is then practiced regularly by the children. Other relaxation methods could be taught, including deep breathing and imagery. Often, relaxation instructions need to be altered for the child or adolescent, depending on his or her abilities. Other inhibitory or incompatible activities can include hypnosis, games, edibles, humor, conversation, and therapist contact. These may be more appropriate for a younger child or a child with attention problems who would have difficulty maintaining the attention required to learn relaxation techniques.

Second, feared situations are chosen for exposure. This is based on a fear hierarchy developed with the child's input. A fear hierarchy is a list of anxietyprovoking situations arranged from least to most anxiety-provoking. The child also can rate each of the situations using a fear thermometer. A fear thermometer is a drawing of a thermometer that allows children to indicate how anxious or fearful a situation is for them on a scale from 0 to 10. Lower ratings on the thermometer indicate less anxiety and higher ratings indicate greater anxiety. Younger children may need to rely more on the therapist and parent to assist in the development of the fear hierarchy. A fear hierarchy typically includes numerous levels, usually between 15 and 25.

Last, the child is gradually exposed to the feared situations identified on the fear hierarchy. Each item [Page 886]of the fear hierarchy is paired with the incompatible behavior. The incompatible response, most likely relaxation, is used to manage the fear encountered by the child along each step of the hierarchy. Subjective Units of Distress (SUDS), or ratings of subjective distress felt by the child, can be used by the therapist and child to monitor the level of anxiety during the exposure task. For a younger child, fear thermometer ratings can be used to track level of anxiety. The child or adolescent will be exposed to the feared stimulus long enough for habituation to occur; therefore, the child will maintain exposure to the feared situation until the anxiety attenuates.

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