Covert Assertion

Covert assertion, a cognitive- behavioral approach, is the method which allowed her to
understand and manage pain and its related behaviors.
Covert sensitization

Introduction

 Covert sensitization is a form of behavior therapy in which an undesirable behavior is

paired with an unpleasant image in order to eliminate that behavior.
 “Covert sensitization is an aversion therapy that reduces unwanted behaviors by
repeated, imagined associations with an unpleasant consequence.”

 Covert sensitization was first described in the mid-1960s by psychologist Joseph

Cautela as a new treatment for people who engage in undesirable behaviors. In the
past 30 years it has been researched as a treatment for alcoholism, smoking, obesity,
and various sexual deviations including pedophilia and exhibitionism.
 Covert sensitization discourages people from engaging in unwanted behaviors by
creating an association between those behaviors and an unpleasant consequence.
Because of this, it is classified as a type of aversion therapy.
 What is unique about covert sensitization, however, is that the unwanted consequence
is never actually present in therapy. This is best illustrated with an example. If a
person was undergoing covert sensitization to stop using alcohol, for instance, a
typical therapy session would involve the therapist instructing the client to imagine
himself drinking and becoming very nauseous. Then the client would be encouraged
to imagine himself becoming so nauseous that he starts vomiting all over himself, the
room he is in, and in the beer mug from which he was drinking. By imagining this
 disgusting scene over and over again, the client starts associating alcohol with vomit,
and drinking becomes much less appealing. Finally, the therapist would instruct the
client to imagine accepting a drink, becoming nauseous again, and then deciding to
refuse the drink. In the imagined scene, the nausea (which is an unpleasant stimulus
for almost everyone) goes away as a consequence of the client's choice not to drink.

Rationale

The goal of covert sensitization is to directly eliminate the undesirable behavior itself, unlike
insight-oriented psychotherapies that focus on uncovering unconscious motives in order to
produce change. The behaviors targeted for modification are often referred to as
“maladaptive approach behaviors,” which includes behaviors such as alcohol abuse, drug
abuse, and smoking; pathological gambling; overeating; sexual deviations, and sexually
based nuisance behaviors such as obscene phone calling. The type of behavior to be changed
and the characteristics of the aversive imagery to be used influence the treatment, which is
usually administered in an outpatient setting either by itself or as a component of a
multimodal program. Self-administered homework assignments are almost always part of the
treatment package. Some therapists incorporate covert sensitization with hypnosis in the
belief that outcome is enhanced.

Procedure

The patient being treated with covert sensitization can expect a fairly standard set of
procedures. The therapist begins by assessing the problem behavior, and will most likely
measure frequency, severity, and the environment in which it occurs. Depending upon the
type of behavior to be changed, some therapists may also take treatment measures before,
during, and after physiological arousal (such as heart rate) to better assess treatment impact.
Although the therapeutic relationship is not the focus of treatment, the behavior therapist
believes that good rapport will facilitate a more successful outcome and strives to establish
positive but realistic expectations. Also, a positive relationship is necessary to establish
patient confidence in the rationale for exposure to the discomfort of unpleasant images.

The therapist will explain the treatment rationale and protocol. Patient understanding and
consent are important, since, by intention, he or she will be asked to experience images that
arouse unpleasant and uncomfortable physical and psychological associations. The therapist
and patient collaborate in creating a list of aversive images uniquely meaningful to the patient
that will be applied in the treatment. Standard aversive images include vomiting, snakes,
spiders, vermin, and embarrassing social consequences. An aversive image is then selected
appropriate to the target problem behavior. Usually, the image with the most powerful
aversive response is chosen. The patient is instructed on how to relax—an important
precursor to generating intense imagery. The patient is then asked to relax and imagine
approaching the situation where the undesirable behavior occurs (for example, purchasing
donuts prior to overeating).

If the patient has a difficult time imagining the scene, the image may be presented verbally by
the therapist. As the patient imagines getting closer to the situation (donut store), he or she is
asked to clearly imagine an unpleasant consequence (such as vomiting) just before indulging
in the undesirable behavior (purchasing donuts and overeating). The scene must be imagined
with sufficient vividness that a sense of physiological discomfort or high anxiety is actually
experienced. Then the patient imagines leaving the situation and experiencing considerable
relief. The patient learns to associate unpleasant sensations (nausea and vomiting) with the
undesirable behavior, leading to decreased desire and avoidance of the situation in the future.
An alternative behavior incompatible with the problem behavior may be recommended (eat
fruit when hungry for a donut).

The patient is given the behavioral homework assignment to practice self-administering the
treatment. The patient is told to alternate the aversive scenes with scenes of self-controlled
restraint in which he or she rejects the undesirable behavior before indulging in it, thus
avoiding the aversive stimulus. The procedure is practiced several times with the therapist in
the office, and the patient practices the procedure ten to 20 times during each home session
between office sessions. The patient is then asked to practice in the actual situation,
imagining the aversive consequences and avoiding the situation. With much variation, and
depending upon the nature of the behavior targeted for change, the patient may see the
therapist anywhere from five to 20 sessions over a period of a few weeks to several months.
The treatment goal is to eliminate the undesirable behavior altogether.

Clinical Applications

Covert sensitization most frequently has been used to treat paraphilias, overeating, alcohol
abuse, and smoking, and it is used almost exclusively with adults.
It has also been commonly applied to the treatment of obesity. Additional applications have
included the treatment of alcoholism and other drug use, nail biting, and self-injurious
behavior.

Advantages

Covert sensitization has four advantages over other aversion therapies: (1) no equipment,
such as a shock apparatus, is needed; (2) unlike some drug-induced aversion, covert
sensitization can be safely carried out without medical supervision; (3) with an aversive
image, clients can easily self-administer covert sensitization in vivo; and (4) clients may
consider it more acceptable, which is an important consideration because of the high dropout
rate with aversion therapy

The major advantage covert sensitization has over other methods of aversion therapy is that it
works without the presence of the unwanted behavior and the unpleasant consequence. This
has practical and ethical advantages. For example, when treating exhibitionists, it would be
difficult to justify encouraging people to expose themselves to others while a therapist
administered a shock or some other unpleasant stimulus. It is important to note that aversion
therapy is not the only way to break bad habits. Large-scale studies comparing several
methods have found that other techniques, such as behavioral family counseling and self-
management techniques are also effective.