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Flooding

Description of the Strategy

Flooding procedures can be subdivided according to cues presented (psychodynamic cues vs. symptom-contingent cues). In implosive therapy as originally developed by Stampfl, the therapist presents a complex of conditioned stimuli to the patient without primary reinforcement and without allowing an avoidance response. The therapist tries to maximize anxiety throughout treatment, which eventually leads to extinction. Sessions are continued until a significant reduction in anxiety is achieved. It is essential to the implosive approach that the patient be exposed to aversive stimuli assumed to be underlying the patient's problems (hypothesized-sequential cues). Hypothesized cues are defined as “those which are not directly correlated with symptom onset but which represent ‘guesses’ as to the remaining components of the avoided CS [conditioned stimulus] complex.” These hypothesized cues may concern dynamics such as aggression, guilt, punishment, rejection, loss of control, and oral, anal, or sexual material.

Almost all controlled studies have conducted implosive therapy with symptom-contingent cues without the psychodynamic ones. Since therapeutic procedures used differ considerably from the implosive therapy as originally developed by Stampfl, the term flooding will be used further.

Apart from psychodynamic cues, flooding therapy for phobias got wide attention from behavior therapists. Flooding can be carried out in imagination or in vivo, but the earlier studies and clinical applications consisted of imaginal flooding. With flooding in imagination, patients have to imagine situations and experiences that they find most frightening for a prolonged period of time. One of the most important variables in determining effectiveness of flooding appears to be duration of exposure to the stimulus variable within each session. Too early termination of flooding sessions may lead to exacerbation instead of a reduction of fear. In fact, the patient is then allowed to escape the fearful situation (either in imagination or in vivo), which may lead to an immediate anxiety reduction (negative reinforcement).

Research Basis

Flooding procedures are theoretically founded on animal research into the conditioning and extinction of fear. According to Mowrer, anxiety is attached to previously neutral cues through classical conditioning. In the second stage of learning, the animal terminates the aversive stimulus by making escape responses, thereby reducing the anxiety it experiences. Based on this two-factor theory, flooding is held to work to reduce anxiety by extinction. A number of studies have addressed issues relevant to humans, such as the duration of flooding, and imaginal versus in vivo flooding. Continuous flooding has been shown to be superior to interrupted flooding, both in nonclinical anxious subjects (analog research) and phobic and obsessive-compulsive patients. It is noteworthy that in most studies with clinical patients, much longer exposure duration has been used than has typically been done in analog research. In the analog studies, flooding sessions lasted from 20 to 60 minutes. In contrast, in clinical studies where flooding has been found to be effective, flooding lasted up to several hours.

The process of anxiety reduction during flooding in imagination sessions has been studied in several studies. Results showed that habituation of subjective anxiety occurs within sessions. Most often, it follows a curvilinear pattern. In addition, evidence was provided for habituation across sessions. Several studies investigated whether habituation of physiological arousal occurred during flooding in imagination. Generally, after an initial increase in arousal, arousal decreases, thus showing a curvilinear habituation curve. Such results were found on heart rate and on skin conductance measures.

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