39 Systematic desensitization, aversion therapy, flooding

G. Padma Priya

1. Introduction

Behaviour therapists have a repertoire of interventions which they tailor to assist clients to attain their goals. Systematic Desensitization, Aversion therapy and flooding are the techniques used in behavioural therapy. These three techniques can help people learn to manage and reduce aggressive impulses, compulsive behaviors, and anger outbursts. It can help them improve their current coping skills or learn new ones so that they’re more equipped to handle challenging or unfamiliar situations The techniques and strategies used in techniques these are also fairly straightforward and easy for most clients to understand and learn. This module discusses principles and strategies of Systematic Desensitization, Aversion therapy and flooding and the application of these principles and strategies in assisting clients to replace maladaptive behaviours with adaptive behaviour.

2.  The objectives formulated are to

• Define terms specific to Systematic Desensitization, Aversion therapy and flooding.
• Learn and apply principles, strategies of Systematic Desensitization, Aversion therapy and flooding.
• Discuss the goals of Systematic Desensitization, Aversion therapy and flooding approaches.

   3.  THERAPEUTIC INTERVENTIONS

Behaviour therapists have a repertoire of interventions which they tailor to assist clients to attain their goals. Where possible, behavior therapists rely heavily on research findings concerning the effectiveness of an intervention when applied to a particular problem. In those cases where the empirical evidence is insufficiently clear on non-existent, therapists use clinical acumen and judgment within the framework of behavioural principles. The most used behavioural techniques are Systematic Desensitization, Aversion therapy and flooding.

3.1 Systematic Desensitization

Systematic desensitization is a type of behavioral therapy based on the principle of classical conditioning. It was developed by Wolpe during the 1950s. This therapy aims to remove the fear response of a phobia, and substitute a relaxation response to the conditional stimulus gradually using counter conditioning.

Where behavioural assessments indicate that clients have certain specific anxiety or phobic areas, rather than just general tension, systematic desensitization may be the preferred intervention. However, adequate behavioural assessments are essential. There are numerous different theoretical explanations of the efficacy of systematic desensitization, some of which also have procedural implications.

Wolpe (1950) was the originator of systematic desensitization, a treatment he considered to be based on the reciprocal inhibition principle described. He acknowledges that systematic desensitization may be conducted concurrently with other behavioural interventions. Systematic desensitization involves three elements:

1.Training in deep muscular relaxation;

2.The construction of hierarchies of anxiety-evoking stimuli; and

3.Asking  the  client, when  relaxed,  to  imagine  items  from  the  anxiety-evoking hierarchies.

3.1.1 Training in relaxation

The acknowledged pioneer of relaxation training is Edmund Jacobson, the first and second editions of whose major work, Progressive Relaxation, appeared in 1929 and 1938 respectively. The physical setting of therapists’ offices should be conductive to relaxation. This involves absence of disruptive noise, interior decoration that is restful, and lighting which may be dimmed. Clients may be taught to relax in recliner chairs, or on mattresses, or, at the very least, in comfortable upright chairs with headrests.

From the start therapists can endeavour to see that clients view relaxation training as learning a coping skill which can be used in daily life rather than just treating them as passive persons. Furthermore, clients should be made to understand that success at learning relaxation requires practice and perseverance. Before starting relaxation, therapists can suggest that clients wear loose-fitting, comfortable clothing both during interviews items such as glasses and shoes.

Berstein and Borkovee observe that in teaching muscular relaxation there is a succession of events which must be observed with each muscle group. This tension-relax cycle has five elements:

1.Focus, focusing attention on a specific muscle group;

2.Tense, tensing the muscle group;

3.Hold, maintaining the tension for five to seven seconds;

4.Release, releasing the tension in the muscle group; and

5. Relax, focusing attention on the letting go of tension and further relaxation of the muscle group.

Having explained the basic tension-relax cycle, therapists may then demonstrate it by going through the cycle in relation to their own right hand and forearm and at each stage asking their clients to do the same. For example client is instructed to, ‘I’m focusing all my attention on my right hand and forearm and I’d like you to do the same’ progresses to I’m clenching my right fist and tensing the muscles in my lower arm tensed…’, the final relaxation phase tends to last from 30 to 60 seconds, frequently accompanied by therapist relaxation ‘patter’ about letting the tension go and acknowledging and experiencing feeling of deeper and deeper relaxation as they occur. Having been through the tension-relax cycle once, especially in the initial sessions the clients may be instructed to go through it again, thus tensing and relaxing each muscles grouping twice.

Therapists are then likely to take clients through the muscle groups, demonstrating them as necessary. There is sixteen muscle groups and suggested tensing instructions. The arms tend to come at the beginning, since they are easy to demonstrate. For most clients, relaxing parts of the face is particularly important because the most marked anxiety-inhibiting effects are usually obtained there.

Once clients have learned how to tense the various muscle groups, they are instructed to keep their eyes closed during relaxation training and practice. Towards the end of relaxation sessions, will discuss with the client issues that arise during the process of therapy. Terminating relaxation sessions may be achieved by therapists counting from five to one and when they get to one asking their clients to wake up pleasantly relaxed as though from a peaceful sleep. This termination session is also called as enjoyment period.

Clients are likely to be given the homework assignment of practicing muscular relaxation for one or two fifteen-minute periods a day. Therapists should ask clients whether they anticipate any obstacles in practicing, such as finding a quite place, and help them to devise strategies for ensuring good homework. Clients who do their relaxation practice are much more likely to continue doing it.

3.1.2 Brief muscular relaxation procedures: When the full muscular relaxation procedures have been learned and clients are able to attain deep relaxation, briefer muscular relaxation procedures may be introduced. The idea here is to learn to attain deep relaxation with less time and effort. This skill may be useful both within and outside therapy sessions. Brief muscular relaxation procedures may involve sequential or simultaneous application of the tension-relax cycle to various muscle groups, albeit interrelated.

Sequence of brief muscular relaxation procedures are one variation is to tense muscle groups: the right arm muscles, the left arm muscles and the facial muscles are each tensed as single groups; the neck and throat muscles are tensed as previously; and the chest, shoulder and stomach muscles, the right leg and foot muscles and the left leg and foot muscles are each tensed as single groups. A four muscle group variation, which, even more than the seven muscle group variation, involves simultaneous as well as sequential relaxation, groups: arm muscles; face, neck and throat muscles; chest, shoulder and stomach muscles; and leg and foot muscles.

3.1.3 Simultaneous muscular relaxation: Simultaneous muscular relaxation involves tensing virtually all muscles at once. An introductory therapist statement might be ‘When I give the signal, I would like you to close your eyes tightly, take a deep breath and simultaneously clench your fists and flex your biceps, frown very deeply, pull your should blades together and tense your legs and feet. Now take a deep breath and tense everything… hold for five seconds… now release and relax as quickly and deeply as you can.’ When ready, brief muscular relaxation procedures should be incorporated into clients’ relaxation homework.

3.1.4 Mental relaxation: Mental relaxation is a part of systematic desensitization encouraged to engage in mental relaxation. Such relaxation usually involves imagining a peaceful scene. Such as ‘lying in a meadow on a nice warm summer’s day, feeling a gentle breeze, watching the clouds’. Therapists can discover which particular scenes clients find most conductive to relaxation. Frequently, mental relaxation is used after going through a muscular relaxation procedure.

3.1.5 Relaxation training considerations

Behavior therapists differ in the number of sessions they take for relaxation training. Furthermore, clients differ in the speed with which they attain a capacity to relax. ‘It is crucial to realize that the aim of relaxation is not muscle control perse, but emotional calmness’. A ten-session relaxation training timetable, with the first three sessions devoted to training in relaxing all muscles groups, the next four sessions to brief muscular relaxation, and the final three sessions to verbal relaxation procedures. Again, followed by daily homework practice is assigned. Therapists may vary their relaxation training timetable according to their clients’ needs and their own workload. Nevertheless, it is important that subjects have sufficient sessions to learn relaxation adequately.

3.1.6 Constructing hierarchies

‘An anxiety hierarchy is a thematically related list of anxiety evoking stimuli, ranked according to the amount of anxiety they evoke’. There are a number of considerations in constructing desensitization hierarchies. First, suitable themes have to be identified around which anxiety-evoking stimuli can be clustered. Needles to say, themes or areas which most debilitate clients’ functioning receive precedence. Such themes are likely to emerge from behavioural assessments and may concern any one of a number of stimulus situations, for example public speaking, examinations, eating in public, being with a member of the opposite sex, and sexual intercourse.

Second, clients can be introduced to the notion of a subjective scale of anxiety or fear. A common way of checking on the anxiety-evoking potential of hierarchy items is to say that zero is a feeling of no anxiety at all, and 100 is the maximum anxiety possible in relation to a particular theme. Thus individual items can be rated according to their positions on this subjective unit of disturbance scale (SUDS).

Third, appropriate hierarchy items need to be generated around each theme. Since clients are going to be asked to imagine the items, the situations require is specifically and graphically described. Therapists indicate the appropriate way for items to be formulated. Sources of hierarchy items may include data gathered in behavioural assessments, self-monitoring homework assignments, suggestions from therapists or clients, and questionnaire responses.

Fourth, the items generated around a particular theme need to be ordered into a hierarchy. This involves rating the items on a subjective units of disturbance scale and ordering them accordingly. Some of this work may be done as homework assignments, but therapists will need to check any hierarchy before starting treatment. Also, during treatment, hierarchy items may need to be re0ordered or reworded, or additional items introduced. Some therapists write, or ask their clients to write, items on index cards to facilitate ordering. In general, gaps of over ten units on the subjective anxiety scale are to be avoided. Where such gaps occur, therapists and clients can generate one or more intervening items.

3.1.7 Presenting hierarchy items

During desensitization sessions therapists ask clients to imagine various scenes when relaxed. A basic assumption is that clients are capable of imagining scene in such a way that they represent real-life situations. Goldfried and Davison (1976) observe: ‘it is therefore essential that one check whether a client can become anxious from an image even before considering this procedure’ (p.122). They suggest that clients’ imagine capacities should be tested by asking them, when not relaxed, to imagine a situation which, on the basis of their assessment data, causes them anxiety in real life. Sometimes clients can be helped to imagine scenes by being asked to verbalize what they can see in the situations. Also, therapists may provide fuller verbal descriptions of scenes.

A desensitization session may start with therapists verbally relaxing clients. After therapists are assured that clients have attained states of deep relaxation, they may start presenting scenes along clients have attained states of deep relaxation, they may start presenting scenes along the lines of ‘Now I want you to imagine that you are thinking about exams while revising at your desk three months before exams…’ Therapists start with the least anxiety-evoking scene on hierarchies. Wolpe (1990) used to ask clients to raise their index finger when the scene was clear. Then he would let the scene remain for five to seven seconds and terminate by saying ‘Stop the scene.’ Next clients would report their subjective units of disturbance (SUDS) level. After 20 to 30 seconds, clients could be asked to imagine the same scene again. If this caused no anxiety, the therapist could withdraw the scene, possibly spend time further relaxing the client, and move on to the next hierarchy item.

In instances where the anxiety created by the presentation is no more than moderate, the therapists can repeat the presentation of the scene, possibly encouraging clients to relax more deeply before further presentations.

3.2 Flooding

Flooding might be described as a cold- turkey extinction therapy. Unlike the gradual exposure paired with relaxation that constitutes systematic desensitization, here the procedure involves prolonged exposure to vivid representations of the stimuli that elicit fear, or to the actual fear-producing stimuli, in circumstances in which these stimuli cannot be avoided. Flooding is based on an extinction theory and preferably involves in vivo exposure to the feared stimuli where possible. As in systematic desensitization, the technique depends on the therapist’s first finding out exactly what it is that the client most fears.

Flooding has proved to be particularly useful in the elimination of obsessive-compulsive rituals. Obsessive-compulsive rituals usually have to be with one or two themes: contamination and checking. When the fear is contamination, flooding involves having clients actually “contaminate” themselves by touching and handling dirt or whatever substance they are trying to avoid and preventing them from carrying out their anxiety-alleviation rituals (in this case, usually hand washing), so that they will realize that what they fear actually posses no real threat.

A variant of flooding is implosive therapy (also called imaginal flooding), in which the feared stimuli, instead of being confronted, are merely imagined. First, as usual, the therapist obtains from the client a careful description of the fears in question. Then the client is asked to sit back and imagine highly vivid anxiety-provoking scenes based on that description, though the scenes are usually embellished, in addition, with painful details taken from the client’s past history, with stimulus cues based on psychodynamic theory, and with whatever gruesome additions the therapist’s imagination can provide. The following example of a scene used in implosive-therapy research with snake phobic:

[imagine that the snakes are] touching you, biting you, try to get that helpless feeling like you can’t win, and just give up and let them crawl all over you. Don’t even fight them anymore…. And now there is a big giant snake, it is as big as a man and it is staring at you and it is looking at you; it’s ugly and it’s black and it has got horrible eyes and long fangs, and it is coming towards you…. Horrible, evil, ugly, slimy, and it’s looking down on you, ready o strike at you.

Repugnant as these sounds, it is often effective. Implosive therapy has not been evaluated as thoroughly as systematic desensitization, but in a few comparative studies it proved approximately as successful as systematic desensitization in relieving snake phobias.

3.3 Aversion theory

Aversion therapy involves modifying undesirable behavior by the old-fashioned method of punishment. Punishment may involve either the removal of desired reinforces or the use of aversive stimuli, but the basic idea is to reduce the “temptation value” of stimuli that elicit undesirable behavior. The most commonly used aversive stimulus is electric shock, although drugs may also be used. As we will see, however, punishment is rarely employed as the sole method of treatment.

Apparently the first formal use of aversion therapy was made by Kantorovich (1930), who administered electric shocks to alcoholics in association with the sight, smell, and taste of alcohol, an early version of the Antabuse drug treatment in use today (Antabuse produces nausea when a person drinks alcohol). Since that time, aversion therapy has been used in the treatment of a wide range of maladaptive behaviors, including smoking, drinking, overeating, drug dependence, gambling, sexual deviance, and bizarre psychotic behavior. As normally employed, it is a Type R therapeutic procedure, targeted at suppression of problematic responses. Because we have described the use of aversion therapy earlier in the course of our discussion of certain abnormal behavior patterns, we will restrict ourselves here to a review of a few brief examples and principles.

The Punishment by electric shock to be effective in extreme cases of severely disturbed autistic children. In one case, a seven-year-old autistic boy, diagnosed as severely retarded, had to be kept in restraints 24 hours a day because he would continually beat his head with his fists or bang it against the walls of his crib, inflicting serious injuries. Though it may seem paradoxical to employ punishment to reduce the frequency of self-destructive behavior, electric shock following this behavior was nevertheless effective, bringing about complete inhibition of the maladaptive behavior pattern in a relatively short time.

Aversion therapy is primarily a way-often quite an effective one-of stopping maladaptive responses for a brief periods of time. With this interruption, an opportunity exists for substituting new behavior or for changing a lifestyle by encouraging more adaptive alternative patterns that will prove reinforcing in themselves. This point is particularly important because otherwise a client may simply refrain from maladaptive responses in “unsafe” therapy situations, where such behavior leads to immediate aversive results, but kept making them in “safe” real-life situations, where here is no fear of immediate discomfort. Also, there is little likelihood that a previously gratifying but maladaptive behavior pattern will be permanently relinquished unless alternative forms of gratification are learned during the aversion therapy. A therapist who believes it possible to “take away” something without “giving something back” is likely to be disappointed. This is an important point in regard to the treatment of addictions and paraphilias, one often not appreciated in otherwise well-designed treatment programs.

4. Conclusions

Hope this module gave an insight into the principles and strategies of Systematic Desensitization, Aversion therapy and flooding, and the application of these principles and strategies in assisting clients to replace maladaptive behaviours with adaptive behaviour. Behaviourism is a philosophical approach to life, as well as a psychological discipline built on a precise scientific orients to the problems of man and to her living organism. Behaviourisms represents reality and therefore views behaviour that is outside of the expected social norms as maladaptive, not as a symptom of disease, a form of deviance or deficit. These behavioural techniques have wide applications in clinical, therapeutic, organizational and personal development, encompassing communications, management, personality, relationships and behaviour.

Web links

• https://www.simplypsychology.org/Systematic-Desensitisation.html
• http://www.guidetopsychology.com/sysden.htm
• http://study.com/academy/lesson/systematic-desensitization-definition-treatment-examples.html