BEHAVIOR MODIFICATION TECHNIQUES TABLE OF CONTENTS SYSTEMATIC DESENSITIZATION……………………………………….. 1 RELAXATION TRAINING………………………………………………….. 55 IMPLOSIVE THERAPY AND FLOODING…………….………………….. 83 ASSERTIVE TRAINING………………………………….………………….. 101 AVERSION THERAPY……………………………………………………….. 117 POSITIVE REINFORCEMENT…………………………..………………….. 127 RESPONSE-SHAPING…………………………………….………………….. 150 INTERMITTENT REINFORCEMENT…………………..………………….. 158 EXTINCTION……………………………………………….………………….. 164 MODELING…………………………………………………………………….. 178 TOKEN ECONOMIES…………………………………….………………….. 194 QUIZZES…………………………………………………….………………….. 206 ANSWER KEY…………………………………………………………………. 237 REFERENCES………………………………………………………………….. 244 EVALUATION & SUMMARY OF QUIZZES……………………………….. 251 SYSTEMATIC DESENSITIZATION ADIGUE, MARY LOU BUENASFLORES, MA. FE FERRAN, KIMBERLY G. GOMEZ, MARA CASSANDRA NACIONAL, CHRISTELLE JAN 3 | P a g e SYSTEMATIC DESENSITIZATION Systematic Desensitization is a procedure for the treatment of phobias originally developed by Joseph Wolpe (1958). Systematic desensitization was originally a treatment for phobias in individuals with generally adequate cognitive functioning and required their organized assistance in implementing the several components of the treatment plan. Since Wolpe’s original publication, systematic desensitization has been successfully used to reduce a wide variety of phobias, and a number of elaborations and variations on the procedure have been developed. Systematic desensitization is when the client is exposed to the anxiety-producing stimulus at a low level, and once no anxiety is present a stronger version of the anxiety-producing stimulus is given. This continues until the individual client no longer feels any anxiety towards the stimulus. There are three main steps in using systematic desensitization. The first step is to teach the client relaxation techniques. HISTORY (JOSEPH WOLPE’S SHORT BACKGROUND) Joseph Wolpe (20 April 1915 in Johannesburg, South Africa – 4 December 1997 in Los Angeles) was a South African psychiatrist, one of the most influential figures in Behavior Therapy. One of the most influential experiences in Wolpe’s life was when he enlisted in the South African army as a medical officer. Wolpe was entrusted to treat soldiers who were diagnosed with what was then called "war neurosis" but today is known as post-traumatic stress disorder. The mainstream treatment of the time for soldiers was drug therapy. Doctors would use a type of "truth serum" to get soldiers to talk about their experiences. It was believed that by having the soldiers talk about their experiences openly it would effectively cure their neurosis. However, this was not the case. It was this lack of successful treatment outcomes that forced Wolpe, once a dedicated follower of Freud, to question psychoanalytic therapy and search for more effective treatments options. Wolpe is most well-known for his Reciprocal Inhibition techniques, the most heralded being Systematic Desensitization, which revolutionized behavioral therapy. Systematic desensitization is what Wolpe is most famous for. However, he was not the first to happen upon such an idea. Mary Cover Jones had used similar techniques in treating phobias in younger children. But it was Wolpe who coined and perfected it. Wolpe received the idea of relaxation from Edmund Jacobson, modifying his muscle relaxation techniques to take less time. Wolpe’s rationale was that you cannot be both relaxed and anxious at the same time. The second step is for the client and the therapist to create a hierarchy 2 | P a g e of anxieties. The therapist normally has the client make a list of all the things that produce anxiety in all its different forms. Then together, with the therapist, the client makes a hierarchy, starting with what produces the lowest level of anxiety to what produces the most anxiety. Next is to have the client be fully relaxed while imaging the anxiety producing stimulus. Depending on what their reaction is, whether they feel no anxiety or a great amount of anxiety, the stimulus will then be changed to a stronger or weaker one. Systematic desensitization, though successful, has flaws as well. The patient may give misleading hierarchies, have trouble relaxing, or not be able to adequately imagine the scenarios. Despite this possible flaw, it seems to be most successful. COMPONENTS/STEPS OF SYSTEMATIC DESENSITIZATION Systematic desensitization, as developed by Wolpe, consisted of three primary components. The first was to develop with the individual a hierarchy of anxiety promoting stimuli. The client was asked to imagine a variety of objects and/or situations that induced anxiety, and to rank these in degree of anxiety from one to ten. The therapist worked with the client to develop a list of anxiety provoking stimuli at all levels of the continuum, so that there were only small increments of additional anxiety between each item on the hierarchy. The second component was to teach the client how to relax (a state considered incompatible with anxiety). This was accomplished did by teaching the client to take long deep breaths, and to tighten and relax different muscle groups throughout the body. The third component was the systematic pairing of the relaxation response to the stimuli on the anxiety hierarchy, starting with the lowest level of anxiety. After repeated pairings of the relaxation response with the anxiety response, typically the anxiety was extinguished, and the relaxation procedure was applied to the next item on the anxiety hierarchy. If the anxiety was not eliminated at a particular step, additional stimuli of lesser anxiety level were developed to bridge the gap. This procedure was repeated through all items on the hierarchy, thereby leading to elimination of the phobia. In most cases systematic desensitization was done in an office setting and involved the client imagining objects or situations, but the technique could also be used in real life situations. In general, this procedure was effective in reducing phobias and is an often used treatment option for phobias. The desensitization procedure makes use of the fact that a person’s anxiety response (tensing of muscles, feeling of discomfort, uptightness, etc.,) to the imagined situation resembles his anxiety response to the real situation. So, when you can feel entirely comfortable and relaxed when thinking of your target behavior, your real-life target situation will shortly begin to be 3 | P a g e progressively less anxiety-producing. Experience with patients has proven this method of relaxing while imagining to be quite effective in reducing anxiety. The purpose of the first half of this manual is to teach you precisely how to construct an anxiety hierarchy, learn deep muscle relaxation, and desensitize yourself to the steps in your hierarchy, thereby helping you reduce the anxiety you experience in your target situation. The number of sessions required depends on the severity of the phobia. Usually 4-6 sessions, up to 12 for a severe phobia. The therapy is complete once the agreed therapeutic goals are met (not necessarily when the person’s fears have been completely removed). Exposure can be done in two ways: · In vitro – the client imagines exposure to the phobic stimulus. · In vivo – the client is actually exposed to the phobic stimulus. APPLICATION OF THE PROGRAM STEP 1: Creating your Anxiety Hierarchy You should attempt to create about 16 or 17 situations at the beginning. Most people tend to discard some items in the sorting process, so you can expect to end up with about 10 to 15 items in your final hierarchy. To aid in sorting the items, write each one on a separate index card. As was mentioned earlier, the situations or scenes in your hierarchy should represent a fairly well-spaced progression of anxiety. The best way to achieve this goal is to first grade the anxiety of each item by assigning it a number on a scale from 0 to 100, where 100 is the highest level of anxiety imaginable and 0 is no anxiety (complete relaxation). Write this number on the back of the index card for the item being graded. At this point, you need not worry about how well- spaced the items are; just give each item the first number grade that “pops into your head.” When each item has an anxiety grade, your next step will be to sort the cards into 5 piles. Each pile will represent a different category of anxiety, as follows: Pile Anxiety Grade Low Anxiety 1–19 Medium Low Anxiety 20–39 Medium Anxiety 40–59 4 | P a g e Medium High Anxiety 60–79 High Anxiety 80–100 The goal here is to end up with at least two items in each pile. If this happens, congratulations. If not, you will have to go back and re-evaluate some items or create some new items. When you have finished, combine all the cards into one pile that is ordered from lowest to highest anxiety. This is your personal Fear of Flying anxiety hierarchy. Set the cards aside for one day. It helps to check the accuracy of your ordering by shuffling the cards the next day or so. Without looking at the grades on the back of the cards, re-order them. Then check the grades to see if your second ordering is the same as the first. If not, make some adjustments. You don’t have to waste a lot of time with this; just try to get an order that feels right and that represents a fairly smooth progression from low to high anxiety. The anxiety hierarchy is a list of situations relating to your target behavior to which you react with varying degrees of anxiety. The most disturbing item is placed at the bottom of the list and the least disturbing at the top. In working on the hierarchy, you will begin with the top item on the list (that is, the least disturbing item) and work step by step through the hierarchy to the last item (the one which produces the greatest anxiety affecting your target behavior). Thus, the hierarchy provides a framework for desensitization, through relaxation, of progressively more anxiety-producing situations. CONSTRUCTION OF AN ANXIETY HIERARCHY CAN AID YOU IN THREE WAYS: 1.