Psychotherapy

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Systematic Densensitization

Systematic desensitization, a procedure developed by South African psychiatrist Joseph Wolpe in the 1950s, gradually teaches people to be relaxed in a situation that would otherwise frighten them. It is often used to treat phobias and other anxiety disorders. The word desensitization refers to making people less sensitive to or frightened of certain situations.

In the first step of desensitization, the therapist and client establish an anxiety hierarchy—a list of fear-provoking situations arranged in order of how much fear they provoke in the client. For a man afraid of spiders, for example, holding a spider may rank at the top of his anxiety hierarchy, whereas seeing a small picture of a spider may rank at the bottom. In the second step, the therapist has the client relax using one of the relaxation techniques described above. Then the therapist asks the client to imagine each situation on the anxiety hierarchy, beginning with the least-feared situation and moving upward. For example, the man may first imagine seeing a picture of a spider, then imagine seeing a real spider from far away, then from a short distance, and so forth. If the client feels anxiety at any stage, he or she is instructed to stop thinking about the situation and to return to a state of deep relaxation. The relaxation and the imagined scene are paired until the client feels no further anxiety. Eventually the client can remain free of anxiety while imagining the most-feared situation.

Asking a client to encounter the feared situation is a technique called in vivo exposure. For the man who is afraid of spiders, a therapist might arrange to go to a park or zoo where visitors can touch large spiders. The therapist would model for the client how to approach a spider and how to handle it. The therapist may also encourage the man to walk gradually closer to the spider, reinforcing his progress with praise and reassurance as he does so. The goal for the therapist and patient would be for the man to pick up the spider.

Problems are rarely as clear and simple as fear of spiders. Therapists may spend considerable time deciding on appropriate goals, which ones to pursue first, and then reevaluating or changing goals as therapy progresses. Systematic desensitization typically takes from 10 to 30 sessions, depending on the severity of the problem. In vivo therapies are more direct and may take less time.

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Exposure and Response Prevention

Exposure and response prevention is a behavioral technique often used to treat people with obsessive-compulsive disorder. In this technique, the therapist exposes the client to the situation that causes obsessive thoughts, but then prevents the client from acting on these thoughts. For example, to treat people who compulsively wash their hands because they fear contamination from germs, a therapist might have them handle something dirty and then prevent them from washing their hands. Therapists have also experimented with exposure and response prevention to treat people with bulimia nervosa, an eating disorder in which people engage in binge eating and afterward force themselves to vomit or, more occasionally, take laxatives (see Bulimia). The therapist feeds the bulimic patients small amounts of food but prevents them from binging, taking laxatives, or vomiting.

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Aversive Conditioning

Behavioral therapists occasionally use a technique called aversive conditioning or aversion therapy. In this method, clients receive an unpleasant stimulus, such as an electric shock, whenever they perform an undesirable behavior. For example, therapists treating patients with alcoholism may have them ingest the drug disulfiram (Antabuse). The drug makes the patients violently sick if they drink alcohol. Many therapists have found that aversive conditioning is not as effective as other behavioral techniques, and as a result, they use this technique very infrequently. For some problems, however, aversive conditioning can work when all other techniques have failed. For example, therapists have found that immediate application of an unpleasant stimulus can eliminate self-mutilation and other self-destructive behaviors in children with autism.

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Social Skills Training

Social skills training is a method of helping people who have problems interacting with others. Clients learn basic social skills such as initiating conversations, making eye contact, standing at the appropriate distance, controlling voice volume and pitch, and responding to questions. The therapist first describes and models the behavior. Then the patient or client practices the behavior in skits or role-playing exercises. The therapist watches the exercises and provides constructive criticism and further modeling. Therapists often conduct this kind of training with groups of people with similar problems. Social skills training often can help people with schizophrenia function more easily in public situations and reduce their risk of relapse or rehospitalization.

One popular form of social skills training is assertiveness training, another technique pioneered by Joseph Wolpe. This technique teaches people, often those who are shy, to make appropriate responses when someone does something to them that seems inappropriate or offensive or violates their rights. For example, if a woman has trouble saying no to a coworker who inappropriately asks her to handle some of his job responsibilities, she may benefit from learning how to become more assertive. In this example, the therapist would model assertive behavior for the client, who would then role-play and rehearse appropriate responses to her coworker.

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Cognitive Therapies

Cognitive therapies are similar to behavioral therapies in that they focus on specific problems. However, they emphasize changing beliefs and thoughts, rather than observable behaviors. Cognitive therapists believe that irrational beliefs or distorted thinking patterns can cause a variety of serious problems, including depression and chronic anxiety. They try to teach people to think in more rational, constructive ways.

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