The Story of Psychology (113 page)

After some years of experimenting and reading, Wolpe found a method he thought would work; it became the basis of most of his practice from then on. He would induce a pleasant trancelike state in the patient, link its agreeable feelings by associative training with the fear-inducing stimulus, and thereby overcome the fear. (This pertains only to a neurotic fear; the procedure would be useless against fear aroused by a real and continuing danger, like living in a city under enemy bombardment.)

Wolpe would begin such treatment by spending a few hours taking a new patient’s history and indoctrinating him or her with the theory that the neurosis was only one or more habits induced by experience and easily replaceable by new habits, without any need to dig into the unconscious or childhood traumas.

He would then teach the patient deep muscle relaxation, which involves the “letting go” of muscle groups first in the forehead, then the face, and so on down to the toes, until a fully relaxed, half-trancelike state is achieved. While the patient was becoming adept at achieving this, he or she and Wolpe would construct a “hierarchy,” or graded list of stimuli, according to their power to arouse anxiety. Wolpe would have the patient envision the feeblest of them while in the relaxed state. Once it no longer caused any discomfort, they would tackle the next one. The patient would become progressively deconditioned, until the last and worst stimulus was associated with the relaxed state and rendered innocuous.

In a typical case report, Wolpe told of Mrs. C.W., a fifty-two-year-old Johannesburg housewife, who came to him because of overpowering fears of rejection, illness, and death, along with fears of the symptoms created by these feelings. He and she assembled a hierarchy for each of her fears. That for physical symptoms comprised nine items, the mildest of which was fear of pain in the left hand (caused by an old injury); the most severe, fear of irregular heartbeats. By her eighteenth desensitization session, he had deconditioned her to all but the three most severe items on the list, and at that session worked on her third worst fear, that of pain in her left shoulder. First, he got her deeply relaxed and had her concentrate on her pleasant feelings. Then he proceeded as follows:

By this method, Wolpe claimed, he had been able to cure not only phobias but neuroses of many sorts—usually in about one-twentieth the
number of therapeutic sessions required by psychoanalytic therapy. Many of his cases were more dramatic than that of Mrs. C.W.; they ranged from an extreme fear of driving to an equally extreme fear of urine (by a youth who had been a bedwetter). Even when the presenting symptoms sounded like the kind of neurosis that would require dynamic therapy, Wolpe found explanations based on simple phobias. A twenty-seven-year-old woman came to him complaining of frigidity (Wolpe’s word) and serious problems in her marriage, notably an inability to assert herself. Wolpe, rather than searching for deep psychological fears of domination, as Freudians might have, concluded after questioning that her anxiety was triggered by situations involving the sight or touch of a penis, which she found revolting.

He and she then worked up a hierarchy in which the least fearful situation, for her, was seeing a nude male statue in a park thirty feet away. After she overcame anxiety at imagining this scene, he brought her closer and closer, until she could imagine herself handling the stone penis. He then switched to a series of scenes in which she imagined herself at one end of the bedroom, seeing her husband’s penis from a distance of fifteen feet. Through desensitization, she was brought closer and closer until she could imagine herself briefly touching the penis, and then doing so for longer periods of time. By about the twentieth session she reported that she was enjoying sexual relations with her husband and having orgasm about half the time.
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Such systematic desensitization, according to Wolpe, proved to be the method of choice for about 70 percent of his patients; for the other 30 percent he worked out other techniques. During the early 1950s, he began making his work known through journal articles, and in 1958 presented a full-scale treatment of it in the book
Psychotherapy by Reciprocal Inhibition.

By then, a handful of other therapists had followed suit and begun practicing desensitization and developing other forms of behavior therapy. The most influential were Arnold Lazarus, another South African, who had come to the United States and was the first person to use the term “behavior therapy,”
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and H. J. Eysenck in England. For a while, behavior therapy of neurotic conditions remained a novelty and rarity. Few clinicians practiced it, because it was diametrically opposed to the dominant dynamic tradition, and, in any case, there was no place in the United States to get training in it. But in 1966, Wolpe, by then at Temple University School of Medicine in Philadelphia, launched a program
of research and training in behavior therapy. The same year, a nonprofit clinic and training center called the Behavior Therapy Institute opened in Sausalito, California; a new book,
Behavior Therapy Techniques
, by Wolpe and Lazarus (by then his colleague at Temple), appeared; and the following year Wolpe and behavior therapy were introduced to the nation’s intelligentsia by an article in the
New York Times Magazine.
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From that point on, research on behavior therapy and publication of articles about it increased rapidly; by the 1970s it had become a leading method of therapy and has remained so, though it has never supplanted dynamic therapy, as Joseph Wolpe felt it should. Some psychotherapists practice it exclusively; many more use it in combination with cognitive therapy (which we will look at shortly and which they call cognitive behavioral therapy); and a number of others, including some whose primary allegiance is to dynamic therapy, use behavior therapy now and then for the treatment of specific phobias such as fear of driving, flying, cats, or crowded places, which often can be cured without concomitant dynamic treatment.

A particularly interesting use of the desensitization technique is in treating sexual dysfunctions, especially impotence and female lack of orgasm. In the late 1960s, William Masters and Virginia Johnson, both sex researchers but neither one a psychologist, developed what has ever since been one of the key treatments of such difficulties when they result from anxiety, not from an organic condition. The method pioneered by Masters and Johnson involved instruction in, and the practice of, step-by-step desensitization—the procedures were carried out by the couple at home over a period of days or weeks—starting with the partners touching each other’s bodies, gradually coming to fondle each other’s genitals (intercourse is barred, to prevent performance anxiety), eventually inserting the penis in the vagina but without coital movement, and finally, when that condition is anxiety-free, proceeding to full coition. Unlike treatment of the simpler phobias, however, sex therapy generally required discussion of and education in the couple’s relationship.
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The Masters and Johnson form of sex therapy was rapidly adopted and used by a wide variety of therapists. The results, however, were often less than hoped for, and over a number of years sex therapists modified the basic desensitization therapy into more of a cognitive-behavioral process, often including bibliotherapy. In one form or another, it continued to be one of the techniques used by some psychotherapists, especially those who specialize in treating sexual dysfunctions.
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Desensitization remains the most frequently used technique of behavior therapy, but for certain conditions different techniques developed by Wolpe and others work better. They are:

Aversive conditioning:
The goal of this technique is to eliminate undesired behavior, such as alcoholism, drug use, or deviant sexuality. According to behaviorist theory, when a response to a stimulus is linked with pain or punishment, the response becomes weakened or inhibited. As a treatment, it calls for causing the patient discomfort when he or she does, or thinks of doing, whatever act is to be eliminated.

In an early form of aversive conditioning used with hospitalized alcoholics, mentioned earlier in this chapter, the patient would take a nausea-producing drug along with an alcoholic drink; the drink was followed by nausea and vomiting. After a number of such experiences, the patient might find the sight or even the thought of a drink repellent.

Later, electric shock became the preferred method for treating motivated alcoholics, heavy smokers, overeaters, persons plagued by obsessive-compulsive routines, and sexual deviants. An example: A thirty-three-year-old man sought treatment for his lifelong interest in women’s undergarments and his impotence with women. He would buy panties or steal them from clotheslines, put them on, and masturbate. In treatment, he would look at a pair of panties or a picture of them or would think of them; as he did so, the therapist would give him a brief but painful shock. After forty-one sessions and 492 shocks over a fourteen-week period, the patient said that panties no longer aroused him; with this obstacle cleared away, he and his therapist were able to treat his impotence by other methods.
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Some therapists used aversive conditioning to treat male homosexuals, delivering a shock to them when they looked at pictures of nude males but not when they looked at pictures of nude females.
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There were reports of modest success with this method, but when homosexuality came to be redefined during the 1970s as a sexual preference rather than a mental disorder, this use of aversive therapy was abandoned.

A mild form of aversive conditioning is called covert sensitization. Patients are trained to punish themselves by thinking some loathsome thought when they are about to do whatever it is they want to stop doing. A drinker, for instance, may be taught that as soon as he walks into a bar to buy a drink, he should visualize himself becoming nauseated, vomiting
all over his hands, shirt, and suit, and on the bar and the bartender, but, as soon as he turns away and heads out, feeling better. Evidence of this method’s usefulness has been scanty.

By and large, the stronger aversive methods have fallen into disfavor and now are rarely used. Not only did they involve risks to health, but aroused ethical concerns, patient resistance, and negative public perception of procedures that customarily (and intentionally) cause extremely uncomfortable consequences. These effects often lead to poor compliance with treatment, high dropout rates, potentially hostile and aggressive patients, and public relations problems. Social critics and members of the general public alike often consider this type of treatment punitive and morally objectionable.
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The benefits, moreover, have not proven long-lasting unless alternative ways of behaving replace the inhibited one. For such reasons, most psychotherapists consider aversive therapy a last resort.

Assertiveness training:
This is not a single technique but several; all aim to help patients overcome social anxieties and inhibitions and act more assertively in situations in which they have been timid and passive. Treatment begins with education: The therapist and patient discuss threatening situations and identify appropriate responses. The patient is then encouraged to try out those behaviors in mildly threatening situations, and, as he begins to feel some control, extend them to more severe ones.

An important part of assertion training is “behavior rehearsal.” The patient enacts his or her role in a threatening situation, with the therapist playing the part of the threatening person (employer, spouse, neighbor). The patient has the opportunity to practice saying and doing whatever he or she needs to do in real life, with feedback and direction coming from the therapist, until the patient is skilled in the role and comfortable with the new behavior, and begins to see himself or herself in different terms.
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Modeling:
Albert Bandura of Stanford University developed this technique based on his theory that most human behavior is learned by identifying with and imitating others of personal importance. The heart of the treatment consists of the patient’s watching the therapist behave in a particular way, learning by imitation, and modifying his or her behavior accordingly. As Bandura has pointed out, this is the process by which millions of people, watching and imitating others at Toastmasters Clubs, have overcome their fear of public speaking.
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