The enclosed techniques and procedures were developed with materials from a workbook of cognitive behavior techniques titled ‘Thoughts & Feelings’ and written by Matthew McKay, Martha Davis and Patrick Fanning. The workbook was published by New Harbinger Publications, Inc. In 1997.
NOTE: Make sure you have an informed commitment from the child.
Flooding is a simple technique in which the client intentionally imagines a feared situation or entertains an obsessive train of thought. The person holds this situation or thought in mind for a long time, at high intensity and without avoiding or neutralizing the images, until they finally grow bored and the images lose their power to upset.
Flooding grew out of Thomas Stampfl’s Implosion Therapy. Stampfl found that the fears of phobic patients would disappear, or “implode,” after the patients were bombarded with six to nine hours of continuous verbal descriptions of their feared situations (1967). Most clinicians and clients found this technique too time- consuming and exhausting until Zev Wanderer (1991) devised Physiologically Monitored Implosion Therapy in the early 1980s. He used blood pressure biofeedback to pinpoint the most disturbing phrases and images in a client’s hierarchy of fear. By intensifying the imagery, he reduced the average time needed for an initial flooding session to two hours. Subsequent sessions could be as short as thirty minutes.
Still, this took up quite a few office hours and didn’t fit into neat, fifty-minute modules. So Wanderer took advantage of another technological aid, the loop tape. He asked clients to record their fearful imagery on a three-minute constant-loop cassette tape while hooked up to a blood pressure monitor. When the monitor indicated that a client had reached a sustained maximum arousal, Wanderer would stop the tape recorder. The client would take the loop tape home and do the actual flooding session as homework. Wanderer later found that many clients could self-monitor their arousal and make their own loop tapes at home.
Paul Salkovskis and Joan Kirk (1980) use a thirty-second loop tape to treat obsessional thinking. They instruct clients to stay away from thoughts that avoid or neutralize the obsession while they listen to the tape. This technique, is based on the Wanderer, as well as the Salkovskis and Kirk methods for self-monitored loop-tape flooding.
Flooding is often the treatment of last resort because it is upsetting and because of a lingering false impression that it is too time-consuming. This limitation is unfortunate, because flooding is quite effective for treating simple phobias, such as fear of snakes, heights, small spaces, freeways, and so on. It is also very effective for reducing obsessional thinking that is not accompanied by compulsive behavior, such as fear of losing control, being hurt, or going crazy. For this reason, however, the Flooding Technique should not be used without the express authority of the Clinical Supervisor.
Because flooding will elevate the blood pressure for an extended period, you should not attempt the technique without the child having had a compete physical or if s/he has high blood pressure or a family history of heart attack or stroke. Flooding is also contraindicated if there is any chance at all that the child might perform a feared action such as suicide or harming others (McMullin 1986).
Time for Mastery
Flooding is intense, but it’s relatively simple and fast. For each phobia or obsession, it will take you about an hour to make a loop tape, and three to ten sessions of at least one hour’s duration to reduce the anxiety level to near zero.
Before you begin the procedure, read all of the instructions, and photocopy the Discomfort Rating Chart [CBT#07-001].
Since the procedure is very traumatic, you will need to assure that a) the child understands that it will be very difficult, b) that enduring this difficulty will result in an end to their ongoing distress, and c) that you will be there at all time. You probably should not utilize the technique with a child who is half hearted about commitment to it. If s/he would rather live with the ongoing problem than face it, this is his/her choice. You don’t make a child do something they don’t want to do. Certainly you should include the Clinical Supervisor in any decisions in this regard.
Step 1. Obtain a Loop Cassette Tape.
This is the type of tape used for message machines, available at most office-supply and electronics stores. A thirty-second tape is sufficient for most obsessional thoughts. For phobias, you might need a longer tape, up to three minutes.
Loop tapes are more expensive and delicate than standard cassette tapes. Don’t fast forward or rewind the child’s loop tape. Don’t put it in a car stereo or any auto-reverse player.
Step 2. Record Intense Fear Images.
Have the child sit in a comfortable chair with the tape recorder handy. S/he might also need a pencil and paper to make a list of frightening images.
The child can put on earphones if s/he chooses to use them. Put the loop tape in the machine and press the record button. The loop tape will record endlessly. When it gets full, it will continuously record over the oldest material.
Have the child close his/her eyes and tune into their body for a moment to take a “base line” reading. Ask the child: How do you feel? How fast and deeply are you breathing? Can you feel your heart beating? How cold or warm are various parts of your body? Do you have any aches or pains, hunger pangs, nausea, or other internal sensations? The child needs to notice how s/he feels now so that s/he will know more clearly when conditions change in his/her body later.
The child can keep his/her eyes open or leave them closed as you ask them these questions:
- What is the most important thing you wish to overcome?
- What are you avoiding that you want to approach?
- What do you want to do that you’re afraid of?
- What is holding you back?
- What are you afraid will happen to you in this situation?
- What thoughts continually prey on your mind?
- What worries can’t you put out of your mind?
When the child has a clear idea of the phobia or obsession s/he wants to work on, s/he starts talking about it. If s/he has a hard time, suggest that s/he just start to talk, s/he may have to use a pencil and paper to jot down some frightening situations or phrases to get them started. Encourage the child to try reading each scene or thought out loud. Help the child elaborate on it and see how scary it feels.
The child should describe what s/he fears in the most vivid detail possible, as if it were actually happening. For example, don’t let him/her describe the fear of heights in an abstract way, as s/he might relate them to a therapist. Instead, s/he should describe what s/he fears as if it were happening in a movie. Likewise, if the child is recording a train of obsessional thoughts, s/he should describe the worst nightmare as if it were happening right now.
The child should not include any descriptions of avoidance of fear, such as “I turn away so I won’t have to see…. I try not to think about it…. I run from the room,” and so on.
Likewise, s/he should not describe any “neutralizing” thoughts. Neutralizing can take several forms. In the case of obsessions, neutralizing can be compulsive mental rituals like counting, repeating nonsense syllables, magical thinking, reciting prayers or affirmations—anything the child typically does in his/her mind to neutralize the obsessive thoughts.
In the case of phobias, neutralizing might be reminding the child that the fears are out of proportion – that s/he really know the bridge won’t collapse. Or s/he may use phrases such as “Whatever happens, happens,” or “Forget it, and let go.” Such thoughts may have a coping value in other applications of cognitive interventions, but for flooding you need for the child to wallow in the worst, craziest, most unrelieved and unmitigated fear images s/he can muster. Leave no escape and no respite from the fear.
Include sights, sounds, smells, tastes, and physical sensations of pain, textures, and temperatures. Using all five senses makes the tape much more vivid. See Changing Core Beliefs with Visualization, for more help with vivid imagery.
Your responsibility is to keep the child on focus with the most difficult thoughts and statements, interrupt if avoidance or neutralization occurs and have the child tape over these statements.
The child should keep talking and adding details until s/he starts to get scared. Encourage him/her to keep track of physical reactions. The breathing should speed up and become more shallow. You might notice that they are breathing from the middle of the chest instead of deeply from the belly. They might start sweating. The hands may feel clammy and the stomach queasy. They might start to cry or feel like crying. They might tremble or get a headache.
Don’t let them stop talking, even if they are shaking and crying. Keep asking them, “What could be worse than what you are describing?” Use the physical reactions to get them just as scared and upset as they can be.
When they have reached what feels like the peak of arousal and they can’t get any more upset, they can stop the tape. Depending on the length of the loop tape, there will be thirty seconds to three minutes of the thoughts and images that scare the child the most.
Some people have stage fright when it comes to talking into a tape recorder, even though there is no audience beyond themselves. If this is the case, the child may have to practice a long time before they get a usable tape. S/he may have to write out a script for the tape and read it.
Depending upon the level of distress the child has had in recording, you may want to go directly to relaxation techniques to help the child calm down. If it had such an impact, you will probably consider delaying Step 3 until the following day. However, you must be cautious not to allow the child to avoid dealing with the stress. This will be a best judgment situation.
Step 3. Listen to the Loop Tape.
The child should get comfortable in a chair and have a pencil and photocopies of the rating chart from Step 4 handy. They may put the earphones on if they want. Hit the play button and turn up the volume until it’s nice and loud, filling the consciousness and really affecting them.
The child should listen attentively for at least an hour. S/he should try to stay with it and avoid the usual magical thinking, mental rituals of counting or nonsense syllables, favorite prayers or sayings and the like. When flooding yourself with phobic images, you must stay with them. Advise the child not to argue [internally] against the images with positive counter statements like, “This could never happen…. It will be over soon…. It really wouldn’t be this bad,” and so on. The idea is that the child should really feel the distress.
Just like preparing an athlete, you have to coach them to ‘hang in there’. Statements like ‘when the going gets tough, the tough get going’ and other cliches may help to encourage them stick it out.
Step 4. Rate the Discomfort Every Five Minutes.
The child should use the Discomfort Rating Chart [Form CBT#07-001] to rate the discomfort from one to ten, with one representing no discomfort and ten representing the worst you’ve ever felt. Have them put a check mark or an X next to the appropriate discomfort level at each five-minute interval.
Flooding is so unpleasant that the child will probably be peeking at a clock frequently enough to know when each five-minute interval is up. If they have trouble keeping track of the time, use an egg timer and keep resetting it for five minutes after each rating.
You’ll notice that the discomfort rating often increases during the first ten to twenty minutes. Don’t let the child become discouraged by that – it’s normal.
Step 5. Stop When Peak Discomfort is Halved.
Instruct the child that s/he can stop the tape when the discomfort has declined to 50 percent of the highest level reached during the session. S/he should keep listening until they reach 50 percent improvement, and never quit prematurely. Stopping early is a form of avoidance, and successful avoidance will act like a reward, reinforcing the fear or obsession. It could make it more intense next time.
Step 6. Repeat Steps 3 through 5.
Give the child a few hours or a day to recover, then have him/her listen to the tape again, following the directions for Steps 3, 4, and 5. The next time they listen to the tape, s/he will probably find that the discomfort level is greater at the start than it was at the end of the previous session, but not as high as the peak of the previous session. This is a normal discomfort “rebound. ”
You should schedule flooding sessions every day and keep working with the same loop tape until the child can start a session at a minimal level of discomfort that drops quickly to near zero. It will take from three to ten sessions to get near zero discomfort for each phobia or obsession.