Covert Sensitization

Sensitization refers to a behavioral treatment designed for myriad problem behaviors including alcohol and drugs as well as obesity, sexual deviance, delinquent behavior, stealing, and compulsions. Sensitization describes building up avoidance to an aversive stimulus, and covert distinguishes this treatment in that neither the stimulus nor the consequence is actually presented. This entry includes the history, rationale and assumptions, implementation, examples, and advantages and disadvantages of covert sensitization.

When covert sensitization is used for alcohol or drug treatment, the client imagines a problem behavior, such as drinking alcohol, and then imagines a negative consequence, such as nausea. The therapist guides the participant through a series of specific situations, increasing the intensity of the consequence based on the proximity to the behavior while at the same time reinforcing escape and avoidance alternatives.

Joseph Cautela developed covert sensitization in the 1960s. It is based on classical and operant conditioning theories, which posit that the problem behaviors evolve from the accidental pairings of stimuli, which are then reinforced by accidental pairings of responses. In covert sensitization, the goal of treatment is to pair an aversive unconditioned stimulus (UCS) with the conditioned stimulus (CS), resulting in negative conditioned responses (CR) as well as unconditioned responses (UCR).

The rationale of covert sensitization posits that the problem behavior is a strongly learned habit, so unlearning can occur through pairing the learned habit with a negative consequence. In this process, cues and urges actually become stimuli to avoid the situations and consequences. The assumptions of covert sensitization include that imaginary actions are homogenous with overt behaviors, that there will be an interaction between the imagined and actual behaviors, and that learning will occur to pair the new consequences to the original stimulus.

To implement covert sensitization, an initial interview takes place between the client and therapist to assess the problem behavior, gather further information about specific settings and cues, create a hierarchy of situations, describe the rationale, and introduce relaxation training. Therapy sessions tend to follow an agenda of relaxation, visualization of the behavior, visualization of the negative consequence, and alternative escape scenarios. Treatment can last between 6 to 40 sessions and is specific to the client's behaviors and negative consequences. In addition, the therapist may assign homework to continue the visualizations between sessions as often as 10 to 20 times per day. Some therapists use audiotapes to record the session so [Page 247]that the client has the therapist's voice as a guide, while others encourage the client to continue the imagination exercises independently. After termination, the client may schedule follow-up or booster sessions to maintain the pairing of the consequence with the stimulus.

When defining the targeted behavior, the therapist identifies a specific behavior that is particular to the client. The client describes the highest risk first, including a specific location, setting, atmosphere, and time of day if applicable. The client describes the visualization in the first-person view, with the goal of depicting the scenario exactly as he or she experiences it. The therapist pays special attention to the experience of temptation and any reinforcing feelings. The therapist then identifies a hierarchy of negative consequences, each specific to the client. The consequences increase in severity as the proximity to the behavior increases and decrease as the client chooses escape or avoidant techniques. The outcome of this intervention is that the problem behavior now elicits a paired negative consequence, and escape from the consequence is negatively reinforced.

...