Covert sensitization is a form of behavior therapy in which an undesirable behavior is paired with an unpleasant image in order to eliminate that behavior.
As with other behavior modification therapies, covert sensitization is a treatment grounded in learning theory—one of the basic tenets being that all behavior is learned and that undesirable behaviors can be unlearned under the right circumstances. Covert sensitization is one of a group of behavior therapy procedures classified as covert conditioning, in which an aversive stimulus in the form of a nausea- or anxiety-producing image is paired with an undesirable behavior to change that behavior. It is best understood as a mixture of both the classical and the operant conditioning categories of learning. Based on research begun in the 1960s, psychologists Joseph Cautela and Albert Kearney published the 1986 classic The Covert Conditioning Handbook , which remains a definitive treatise on the subject.
The goal of covert sensitization is to directly eliminate the undesirable behavior itself, unlike insight-oriented psychotherapies that focus on uncovering unconscious motives in order to produce change. The behaviors targeted for modification are often referred to as "maladaptive approach behaviors," which includes behaviors such as alcohol abuse, drug abuse, and smoking, pathological gambling, overeating, sexual deviations, and sexually based nuisance behaviors such as obscene phone calling. The type of behavior to be changed and the characteristics of the aversive imagery to be used influence the treatment, which is usually administered in an outpatient setting either by itself or as a component of a multimodal program. Self-administered homework assignments are almost always part of the treatment package. Some therapists incorporate covert sensitization with hypnosis in the belief that outcome is enhanced.
The patient being treated with covert sensitization can expect a fairly standard set of procedures. The therapist begins by assessing the problem behavior, and will most likely measure frequency, severity, and the environment in which it occurs. Depending upon the type of behavior to be changed, some therapists may also take treatment measures before, during, and after physiological arousal (such as heart rate) to better assess treatment impact. Although the therapeutic relationship is not the focus of treatment, the behavior therapist believes that good rapport will facilitate a more successful outcome and strives to establish positive but realistic expectations. Also, a positive relationship is necessary to establish patient confidence in the rationale for exposure to the discomfort of unpleasant images.
The therapist will explain the treatment rationale and protocol. Patient understanding and consent are important, since, by intention, he or she will be asked to experience images that arouse unpleasant and uncomfortable physical and psychological associations. The therapist and patient collaborate in creating a list of aversive images uniquely meaningful to the patient that will be applied in the treatment. Standard aversive images include vomiting, snakes, spiders, vermin, and embarrassing social consequences. An aversive image is then selected appropriate to the target problem behavior. Usually, the image with the most powerful aversive response is chosen. The patient is instructed on how to relax—an important precursor to generating intense imagery. The patient is then asked to relax and imagine approaching the situation where the undesirable behavior occurs (for example, purchasing donuts prior to overeating).
If the patient has a difficult time imagining the scene, the image may be presented verbally by the therapist. As the patient imagines getting closer to the situation (donut store), he or she is asked to clearly imagine an unpleasant consequence (such as vomiting) just before indulging in the undesirable behavior (purchasing donuts and overeating). The scene must be imagined with sufficient vividness so that a sense of physiological discomfort or high anxiety is actually experienced. Then the patient imagines leaving the situation and experiencing considerable relief. The patient learns to associate unpleasant sensations (nausea and vomiting) with the undesirable behavior, leading to decreased desire and avoidance of the situation in the future. An alternative behavior incompatible with the problem behavior may be recommended (eat fruit when hungry for a donut).
The patient is given the behavioral homework assignment to practice self-administering the treatment. The patient is told to alternate the aversive scenes with scenes of self-controlled restraint in which he or she rejects the undesirable behavior before indulging in it, thus avoiding the aversive stimulus. The procedure is practiced several times with the therapist in the office, and the patient practices the procedure ten to 20 times during each home session between office sessions. The patient is then asked to practice in the actual situation, imagining the aversive consequences and avoiding the situation. With much variation, and depending upon the nature of the behavior targeted for change, the patient may see the therapist anywhere from five to 20 sessions over a period of a few weeks to several months. The treatment goal is to eliminate the undesirable behavior altogether.
Patients completing covert sensitization treatment are likely to be asked by the therapist to return periodically over the following six to twelve months or longer, for booster sessions to prevent relapse.
Covert sensitization is comparatively risk-free. This is in contrast to the medical and ethical concerns raised by some other aversive procedures such as aversion therapy , in which potent chemical and pharmacological stimulants may be used as aversants.
Depending upon the objectives established at the beginning of treatment, patients successfully completing covert sensitization might expect to stop the undesirable behavior. And, if they practice relapse prevention techniques, they can expect to maintain the improvement. Although this treatment may appear to be relatively simple, it has been found to be quite effective for treating many problem behaviors.
Cautela, Joseph and Albert Kearney. The Covert Conditioning Handbook. New York: Springer, 1986.
Kaplan, Harold and Benjamin Sadock, eds. Synopsis of Psychiatry. 8th ed. Baltimore: Williams and Wilkins,1998.
Plaud, Joseph and Georg Eifert, eds. From Behavior Theory to Behavior Therapy. Boston: Allyn and Bacon, 1998.
Association for Advancement of Behavior Therapy. 305 seventh Ave.—16th Floor, New York, NY 10001-6008. <http://www.aabt.org> .
John Garrison, Ph.D.
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