Nancy was beginning graduate school. She had managed to earn her undergraduate degree without ever having to talk in class. Just the thought of her classmates watching her speak terrified her, causing her to tense all over, hyperventilate, and perspire. After the first day of attending graduate classes, Nancy soon realized that she could no longer avoid the inevitable. She learned that she would be required give a presentation in each of her four classes! Nancy was convinced that there was no way she would be able to pull this off. She was seriously considering quitting school altogether. As a last resort, she went to see a therapist at the university counseling center.
Here is what Nancy’s therapy entailed. First, over the course of several sessions Nancy’s therapist taught her how to achieve a deep state of calmness. While seated in a comfortable chair, Nancy tensed and un-tensed all the major muscle groups in her body in sequence according to her therapist’s instructions. She noticed experiencing a greater “at ease” feeling in a muscle following intentionally tensing it than before doing so. Her therapist also gave Nancy relaxation exercises to do at home between sessions. Over time, with practice both inside and outside of the therapy, Nancy learned to completely relax within just a few minutes.
During these same sessions, Nancy and her therapist talked about situations related in various ways to her fear of speaking in class. Eventually they narrowed it down to 11 items. Each item was assigned a value between zero and 100 based on how much anxiety she felt when thinking about it. The items were then ordered on a hierarchy from lowest to highest with respect their assigned scores.
| Item | Anxiety |
|---|---|
| 1. Present speech to all fellow students & professor in classroom | 100 |
| 2. Present speech to all fellow students in classroom | 90 |
| 3. Present speech to 10 fellow students in classroom | 80 |
| 4. Present speech to 10 strangers in classroom | 70 |
| 5. Present trial run of speech to ten strangers in classroom | 60 |
| 6. Present trial run of speech to five friends in classroom | 50 |
| 7. Present trial run of speech to ten friends in classroom. | 45 |
| 8. Present trial run of speech to professor in his office | 40 |
| 9. Present trial run of speech to entire family at home | 30 |
| 10. Present trial run of speech to mother at home | 25 |
| 11. Ask professor questions about presentation in his office | 20 |
Once the hierarchy was constructed and Nancy was well versed in deep muscle relaxation, a new twist was added to the therapy. First, Nancy was brought to a state of relaxation (which she could now do easily) through abbreviated instructions from her therapist. Then, her therapist had Nancy imagine a scene totally unrelated to her fear for several seconds, after which he asked her to report on how much anxiety she felt (using the same scale as above). She said she felt none at all. Next, while Nancy remained relaxed, the therapist had her imagine asking her professor questions about the presentation in his office (the bottom item on her hierarchy). He described the situation well enough so that Nancy could vividly and realistically visualize being in it. After several seconds, she was told to stop visualizing and continue relaxing for about the next 30 seconds; this was followed by instructions to imagine the same scene again. Immediately afterwards, Nancy was asked to state her anxiety level to this scene, and her response was 25 units. Nancy returned to a relaxed state; then, she was told to visualize the scene again. Her reported anxiety level to it this second time was 15 units. After a few more of these trials Nancy eventually said she felt no anxiety at all while she imagined questioning her professor. Given this result, the therapist then asked Nancy to visualize presenting a trial run of her speech to her mother (the next item up on her hierarchy). After repeated trials with this scene, Nancy also came to report no anxiety to it; consequently, she was required to imagine the next item up, and so forth. In this way, over several sessions, Nancy worked her way through increasingly fear-provoking situations, eventually arriving at the point where she could imagine her greatest fear, giving a full presentation to her entire class and her professor, without feeling any anxiety whatsoever (the top item on her hierarchy).
Nancy did not drop out of school, and when the time came to give a presentation in each of her classes she not only passed with flying colors, she actually enjoyed being the focus of the class's attention.