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.
Clinical Prompt
Step 1: Learning Progressive Relaxation
Step 2: Analyzing Your Destructive Habit
Step 3: Creating a Pleasure Hierarchy
- List five/ten scenes
- Articulate completely
- Pleasure Hierarchy Form
Step 4: Creating an Aversion Scene
- Aversive Suggestions
Step 5: Combining Pleasurable and Aversive Scenes
- Start with a detailed description of that particular item on the hierarchy.
- Introduce the aversive scene so that you feel turned off to whatever you were just enjoying.
- Imagine yourself feeling better as soon as you stop whatever you were doing.
Step 6: Altering the Aversive Scene
Step 7: Practicing Covert Sensitization in Real Life.
- Covert Sensitization of Distressing Thoughts
- Have the child lie down, close your eyes, and relax.
- From material developed in “Uncovering Automatic Thoughts,” have the child imagine a typical problem situation in which the negative reflex thoughts typically occur. See the people involved, the setting, the sounds, smells, and textures.
- Think your distressing thought. Use the words and images that typically present themselves.
- Immediately “punish” the thought by an aversive image. Use the same kind of aversive images described earlier: vomiting, social ostracism, and so on.
- Repeat Steps 3 and 4 several times, alternating the distressing thought with increasingly aversive images.
- Escape from the final and worst aversive image by thinking an alternative, more balanced thought. It’s important that the child not remove the aversive image until s/he has an alternative thought firmly in mind.
- Immediately “reward” the alternative thought with a pleasurable image of yourself successfully coping with the situation.
Special Considerations:
- Actual aversive stimulus by smelling real rotten meat, rotten eggs, or ammonia. S/he can also try holding his/her breath, doing pushups, or making harsh, unpleasant sounds.
- Time aversive stimulus to coincide exactly with the moment s/he begins to engage in the destructive habit.
- Go through the hierarchy again and resensitize him/herself to the aversive scenes.
Forms & Charts
Pleasure Hierarchy Form CBT#18-001 | preparing for upload.
Introduction
Among the greatest sources of painful emotions are destructive habits. These are your vices, the things you have learned to do that feel good for the moment and for which you later pay dearly. The hallmark of destructive habits is short-term gain coupled with long-term loss.
Covert sensitization was developed and popularized by Joseph Cautela (1967) as a treatment for destructive habits. It is called “covert” because the basic treatment takes place inside the mind. The theory behind covert sensitization is that behaviors that have become strong habits are learned because they are consistently reinforced by a great deal of pleasure. One way to eliminate the habit is to begin associating the habitual behavior with some very unpleasant, imagined stimulus. As a result, the old habit no longer evokes images of enjoyment, but becomes associated with something noxious and repulsive. This association is formed by pairing the pleasurable images of the habit with painful images of nausea, physical injury, social ostracism, or other unpleasant experience. Covert sensitization can help the old habit lose most, if not all, of its appeal.
Once an old pleasurable habit has become painful, you can escape its unpleasantness by imagining doing something more appropriate that is associated with enjoyable feelings.
Symptom Effectiveness
Covert sensitization has had significant success in the treatment of sexual deviations such as sadistic fantasies, pedophilia, transvestism, and exhibitionism. It has also been used to reduce stealing, fingernail biting, compulsive gambling, compulsive lying, and compulsive shopping. It has been helpful in curtailing use of nonaddictive drugs such as marijuana.
Covert sensitization has been used with mixed results on alcohol, obesity, and smoking problems. The weight of research evidence indicates that it is not particularly effective with smoking. It’s not effective in treating alcoholism per se, but has been used to treat a habit of alcohol indulgence on particular occasions and in particular environments. Although it is not the final answer to obesity, covert sensitization can be used to treat a weight problem that is exacerbated by a few particular foods or by a certain eating environment.
In short, covert sensitization is effective when the habit is confined to a particular substance, setting, or situation. It is not very effective with generalized habits such as smoking and compulsive eating or drinking. The reason appears to lie in the word sensitization. You become sensitized to something unpleasant, which you associate with the habit in particular settings and situations. A sensitization to one particular food, drink, or setting does not seem to generalize. It is nearly impossible to become sensitized to all food, all drink, or all situations associated with compulsive eating, drinking, and smoking. And thus the technique has diminished effectiveness with such pervasive habits.
Time for Mastery
It will take four days to master progressive relaxation and an additional two weeks to begin getting results from the covert sensitization procedure.
Instructions
Step 1: Learning Progressive Relaxation
The first step in covert sensitization is to become relaxed. Progressive muscle relaxation, outlined in Technique #04 – “Relaxation,” is the quickest and most effective way to let go of muscular tension. Have the child practice progressive muscle relaxation in two fifteen-minute sessions daily. Once s/he has mastered the four-step shorthand procedure, s/he will be capable of deep muscle relaxation throughout his/her entire body in less than two minutes.
Step 2: Analyzing Your Destructive Habit
Ask the child: ‘What environment are you typically in when the destructive habit occurs?’ ‘Who is with you?’ How did you set the situation up? What’s the first thing you do as you prepare to launch into your old habit?
Step 3: Creating a Pleasure Hierarchy
Have the child make a short list of five to ten scenes in which s/he enjoys the destructive habit. Have him/her then rank them from the least to the most pleasurable, and assign pleasure ratings on a scale from one to ten. If the destructive habit is overeating, s/he could base the hierarchy on a few of the favorite foods, always being certain to include the settings in which they are consumed.
Other hierarchies are more complex and contain items revolving around anticipation of or preparation for the destructive habit.
Still other hierarchies focus on various elements of a particular pleasurable situation. When the child is developing a pleasure hierarchy, s/he should write it out completely The items in the examples are abbreviated, but your child’s should be much more detailed. S/he might include where s/he is, who she is with, what she is doing, what s/he is thinking, and what is going on inside his/her body. A typical item in the hierarchy might read like this:
“The cards are dealt and I pick each one up. I am excited and nervous. Green felt over the kitchen table at Jack’s house. A couple of strangers, but mostly the same crowd. The fifth card goes around and we’re ready for the first bets. I’m to the left of dealer, I bet a buck.”
The more detail s/he has articulated, the easier it will be for the child to imagine the scene. If s/he has difficulty getting a mental image of an item in the hierarchy, s/he can spice it up with a variety of sense impressions. In addition to what is seen, encourage him/her to notice how it smells, what s/he hears, whether s/he feels warm or cold, and so on.
While creating the hierarchy, make sure the first item is no more than a 1 or 2 on the ten-point pleasure scale. In other words, select something barely pleasurable to start off with, and then have the child work his/her way up to the intensely delightful aspects of habit. Try not to let the child’s hierarchy have more than two points separating consecutive items. Use the Pleasure Hierarchy Form [CBT#18-001] to create the hierarchy
Step 4: Creating an Aversion Scene
Find something the thought of which deeply repulses or frightens the child. Have the child rate the following for degree of repulsion or fear experienced when imagining the item:
Have the child select the two or three items that distress him/her most when s/he thinks about them. Nausea is the most commonly used aversive item for covert sensitization. Social ostracism and rejection have also been used extensively. The aversive item should be sufficiently repulsive so that thinking about it generates a very explicit bodily sensation. Have the child really feeling the repulsion or fear bodily will be very important to the success of this procedure. For example, the thought of nausea should be accompanied by a very specific memory of something that really nauseated the child – until you begin to feel a little of the old nausea returning.
Step 5: Combining Pleasurable and Aversive Scenes
Once the child is able to clearly imagine and experience the aversive scene, s/he is ready to begin pairing it with items on the pleasure hierarchy.
Have the child pair each item of the pleasure hierarchy with the aversive scene in just this manner:
- Start with a detailed description of that particular item on the hierarchy.
- Introduce the aversive scene so that you feel turned off to whatever you were just enjoying.
- Imagine yourself feeling better as soon as you stop whatever you were doing.
Have the child write out this three-step scenario for each item on the hierarchy The aversive scene should be as disgusting as possible, full of detail, and completely eradicate any experience of pleasure. Be sure to have the child turn off the aversive scene as soon as the s/he ceases the destructive habitual behavior. S/he should have immediate feelings of relief, comfort, and relaxation.
When the child has rewritten the hierarchy to include the aversive scene, s/he can begin practicing covert sensitization. Have the child read over the first item of the hierarchy until s/he has it clearly in mind. Close the eyes and relax using progressive relaxation. Relaxation helps to form clearer images. When the tension is out of his/her body, s/he is ready to imagine the first item. Remind the child to notice what s/he sees, smells, and hears. Have him/her notice everything s/he is doing. Then have him/her move right into the aversive scene until s/he feel uncomfortable and repulsed.
Step 6: Altering the Aversive Scene
Now have the child change the scene so that s/he avoids vomiting, being ostracized, or whatever was chosen for an aversion. Avoid the aversion by avoiding the destructive habit. At the first sign of feeling queasy, put the food down, get up and leave the bar, quit the card game, etc. and start to feel better.
For example, the stout housepainter rewrote the fifth item of his hierarchy to reflect this change: “I’m relaxed. The TV is on. There’s a blue glow. I’m slumped in the chair and I think of getting a little something to eat. I go into the kitchen and butter five pieces of cinnamon bread. I start to bring a piece to my mouth, but I have that queasy feeling and put it down right away. I immediately feel relieved and relaxed again.”
Have the child go through the hierarchy again, avoiding rather than experiencing the aversive scene. As s/he did initially, s/he should limit him/herself to one or two items a day, practicing each item three to five times before going on to the next one.
Step 7: Practicing Covert Sensitization in Real Life.
Once the child has mastered covert sensitization with imagined scenes, have him/her practice the procedure in the presence of tempting objects or situations when his/her desire for them is low. As s/he becomes more confident about controlling a destructive habit, s/he can begin using covert sensitization when the temptation is stronger.
Covert Sensitization of Distressing Thoughts
Covert sensitization can be used not only to inhibit destructive habits but also to reduce the frequency of negative thoughts – that precipitate painful emotions. You simply pair a recurrent negative thought or irrational belief with an aversive covert stimulus such as an image of spiders, vomiting, or being socially ostracized. If the stimulus is aversive enough and it is paired with the distressing thought frequently enough, the thought is eventually experienced as unpleasant and it is less likely to recur. For instance, when the belief “I can’t cope with life on my own; I need someone to help me” is paired with sufficiently vivid images of having a tooth drilled, it becomes aversive and is less likely to occur.
McMullin (1986) calls this use of covert sensitization cognitive aversive conditioning. He recommends combining it with cognitive escape conditioning, in which you “escape” the aversive image by replacing it with a positive alternative thought, followed by images of relief. For example, you would replace the image of a tooth being drilled with the alternative thoughts, “I can take care of myself, I can solve my own problems” and images of yourself successfully handling your problems and feeling relieved, free of pain, relaxed, and competent.
Instructions
Step 1. Have the child lie down, close the eyes, and relax.
Step 2. From material developed in “Uncovering Automatic Thoughts,” have the child imagine a typical problem situation in which the negative reflex thoughts typically occur. See the people involved, the setting, the sounds, smells, and textures.
Step 3. Think your distressing thought. Use the words and images that typically present themselves.
Step 4. Immediately “punish” the thought by an aversive image. Use the same kind of aversive images described earlier: vomiting, social ostracism, and so on.
Step 5. Repeat Steps 3 and 4 several times, alternating the distressing thought with increasingly aversive images.
Step 6. Escape from the final and worst aversive image by thinking an alternative, more balanced thought. It’s important that the child not remove the aversive image until s/he has an alternative thought firmly in mind.
Step 7. Immediately “reward” the alternative thought with a pleasurable image of yourself successfully coping with the situation.
To assist the child’s practice, you can tape-record the description of your scene, the hot thought, aversive images, alternative thought, and pleasant image. Have the child listen to the tape two or three times a day for about a week.
Special Considerations
- If the child has difficulty visualizing or feeling an aversive stimulus, s/he can provide him/herself with an actual aversive stimulus by smelling real rotten meat, rotten eggs, or ammonia. S/he can also try holding his/her breath, doing pushups, or making harsh, unpleasant sounds.
- The child should always time the nausea or other aversive stimulus to coincide exactly with the moment s/he begins to engage in the destructive habit. S/he should cut off the aversion as soon as s/he abandons the destructive habit.
- The effects of covert sensitization can be strengthened with booster sessions. When the child feels stronger or more frequent impulses to engage in destructive habit, s/he can go through the hierarchy again and resensitize him/herself to the aversive scenes.