11

Exposure Procedures

E xposure procedures are used to reduce undesirable behaviours, particularly conditioned avoidance
responses such as phobias, obsessions, and compulsions by exposing the client to the stimuli that
provoke such responses. Three principal procedures of exposure are used by behaviour therapists
such as: (i) flooding, (ii) implosion, and (iii) aversion relief. These are also called anxiety-induction
procedures. Systematic desensitisation is considered as a variant of exposure technique, although it does
not fit entirely into the approach. Relaxation training is used as a major component in the systematic
desensitisation procedure. Anxiety-inducing component, if any, is minimal.

FLOODING
The term ‘flooding’ was first used by Polin (1959) while reporting on the effects of exposure to anxiety-
provoking stimuli and physical suppression of anxiety-motivated locomotor response on avoidance
behaviour in animals. The method is also called response prevention. It involves therapist-controlled
prolonged exposure to anxiety-provoking conditioned stimuli (CS) simultaneously blocking the indi-
vidual’s chance of escape and avoidance. It helps him to habituate to the anxiety-provoking conditioned
stimuli. In a natural setting, instrumental responses such as running away from the situation help in
relieving the individual from the stress. The responses that occur prior to it may include instrumental
and autonomic responses such as crying, increased palpitation, sweating, fainting, repetitive washing,
cleaning, checking and so on. When these responses are frequently associated with a feeling of relief,
they are negatively reinforced. This is how many phobic, anxious, obsessive or compulsive responses
are maintained over time. Literally, ‘We are afraid as we run away from the situation.’ In order to
eliminate fear, we must encounter the fear-provoking stimulus. Lack of opportunity to do so ‘incubates’
the ‘neurotic’ response. The response continues to be negatively reinforced.
110 BEHAVIOUR THERAPY

During flooding, the therapist presents a conditioned stimulus (e.g. dog) that usually elicits a strongly
conditioned emotional response (fear) without being followed by the unconditional stimuli (e.g. physical
injury or pain due to dog bite). Prolonged exposure to the stimulus (dog) extinguishes the avoidance
response (fear). By preventing avoidance behaviour in presence of the anxiety-provoking stimulus,
extinction is allowed to occur at a faster rate. Flooding may involve actual exposure to the real-life situations
(flooding in vivo) through films, or computer-generated images (virtual reality therapy) or they could
even be imaginary.

Flooding and Systematic Desensitisation

Although both systematic desensitisation and flooding procedures are classified under exposure-based
treatment methods (Kazdin 2001), in the former method, the client is trained to be deeply relaxed, then
the acquired relaxation is paired with the anxiety-provoking stimulus gradually and step by step; whereas
in flooding, the client is ‘flooded’ with the anxiety-provoking stimulus until the avoidance response
habituates. There is considerable evidence that response blocking is an effective method of speeding
up the extinction of avoidance response (e.g. Baum 1966, 1970; Black 1958). Thus, slow extinction
of avoidance response (as it is done in systematic desensitisation), is not seen in flooding. However,
reviewing a number of studies comparing flooding and systematic desensitisation, Morganstern (1973)
observed that both the procedures are equally effective. Occasionally when systematic desensitisation
is not effective, flooding may successfully reduce avoidance response.

Yule et al. (1974) demonstrated the case of an 11-year-old boy who was afraid of a number of events
such as loud noise of a balloon bursting, guns, motorcycles and so on. Several weeks of systematic
desensitisation could not bring a change in the behaviour. At last, flooding was used. The procedure was
as follows: In the first session, the child along with the therapist entered into a room full of balloons. The
mere sight of balloon made the child anxious and he started crying when the therapist started breaking
them one after another. He then persuaded the child, too, to break the balloons with his legs, and then
with his hands. Initially, the therapist covered his (child’s) ears with hands. Like this, the child was
made to burst several dozens of balloons. At the beginning of the second session, he was still anxious,
but after bursting another hundreds of balloons, he seemed to enjoy it. Finally, he had no fear of loud
noises. A 25-months follow-up study revealed complete extinction of fear of loud noise.

Meyer et al. (1975) reported the case of an obsessive woman who used to engage in elaborate washing
rituals after the death of her husband. She used to wash all objects ‘contaminated’ with death. The in vivo
flooding technique used to treat this case included touching a dead body in the hospital mortuary in
presence of the therapist. Turner et al. (1994) successfully used a combination of in vivo flooding in treat-
ment of social phobias. People suffering from social phobia often report physiological symptoms like
increased heartbeat, trembling or sweating in social situations that others do not find disturbing. The
authors compared the effects of three treatment conditions: (i) flooding therapy, (ii) drug (atenol) therapy,
and (iii) placebo (where the clients consumed tablets thought to be atenol). All were exposed to three
months each of these treatments. The clients were assessed through psychological tests measuring
anxiety and through verbal interaction, where they were asked to speak to an audience of three persons.
Flooding was found to be more effective than drug or placebo conditions. The gain from the treatment
was maintained in six months follow-up.
Exposure Procedures 111

Operationally, there is a subtle difference between in vivo flooding and in vivo exposure. They are
similar except that the in vivo exposure can be conducted on a graduated or hierarchical basis and not
desired to maximise the fear/anxiety reaction, whereas flooding always aims at maximising these
responses in order to extinguish them faster.

Conducting a long series of studies on confronting real life exposures in phobic and obsessive
compulsive disorders, Marks (1981) suggested that anxiety disorders are not necessarily caused by
conditioning. Instead, he described the fear situation as an ‘evoking stimulus’ (ES) and the avoidance
behaviour that follows (e.g. phobic or compulsive response) as ‘evoking response’ (ER). In flooding
exposure in vivo, the therapist’s task is to identify the ES and present it until the ER is reduced. Stronger
the evoking stimulus, longer would be the required duration of exposure to extinguish the response.
The relationship between stimulus intensity and stimulus duration in flooding will determine whether
it will be sensitising or desensitising (Reiss, 1980). However, Yule and his associates cautioned that if
the flooding session is terminated prematurely, it might even increase the phobic response. Indeed Staub
(1968) reported some similar cases where fears worsened after a short duration of flooding. Systematic
desensitisation is considered as a rather pleasant procedure; therefore, it is more popular. It does not allow
the person to experience high degree of anxiety/fear, whereas flooding does. Therefore, Mazur (1986)
even stated that there is little justification for using flooding. This may be an over generalised view of
the technique. In many situations, flooding is found to be more effective than imaginary desensitisation
(Marshall et al. 1977). On the other hand, there are real life situations (e.g. natural disaster, accidents,
rape or a terrorist attack) that cannot be simulated to create a situation for flooding in vivo. Thus, there
are limitations and advantages of both the procedures.

Regardless of which theory best explains this phenomenon, flooding and exposure in vivo have
been used by behaviour therapists successfully for treatment of a number of disorders including
phobias (Jones 1924; Kandel et al. 1977; Kolko 1984; Yule et al. 1974), anxiety disorders (Girodo 1974),
obsessive-compulsive disorder (Hackmann and McLean 1975; Levy and Meyer 1971; Meyer et al.
1975; Rachman et al. 1873; Rainey 1972), children’s agitated depression (Hannie and Adams 1974);
somatic complaints (Stambaugh 1977) and psychogenic urinary retention (Glasgow 1975; Lamontagne
and Marks 1973).

Flooding is not a fixed technique but there are different parameters involved it. When a client is not
able to tolerate extremely intense stimulation, the therapist is required to present the stimuli in a graded
manner. This method is called graded exposure. One has to proceed in short hierarchies, depicting smaller
level of anxiety (Borden 1992). Failure to modify the procedure by downgrading the level of anxiety
through limited or graded exposure may lead the client to drop out. The therapist should also be careful to
see that the threatening stimulus (CS) is not accompanied by unpleasant stimuli (US) like pain or injury.

Flooding may also involve a wide range of allied procedures. Sinha and Jalan (2001) successfully
used a combined method that included relaxation, exposure and cognitive restructuring in the treatment
of social phobia. Recently, Abramowitz et al. (2002) treated obsessive-compulsive disorders in 14 males
and 14 females using exposure and ritual prevention. The therapists were asked to rate the treatment
compliance of these clients. Results showed that understanding of the treatment rationale and compliance
with in-session and homework exposure instruction were more closely linked with the treatment outcome,
than with ritual prevention and self-monitoring.
112 BEHAVIOUR THERAPY

Is flooding a safe method of response elimination? This is an important question. For that matter,
acceptability of any form of therapy depends on the safety of the client under treatment. Exposure
to the fearful situations in real life may have serious side effects. This may perhaps even worsen the
client’s condition. However, a survey conducted by Shipley and Boudewyns (1980), negative outcomes
were only in nine out of 3500 cases. Thus, most therapists consider the procedure to be quite safe.
The second question, which is often asked is that whether it is necessary for a therapist to accompany
the client. Research findings reveal that presence of the therapist during flooding does not enhance its
effectiveness (Al-Khubaisy et al. 1992). In spite of controversies, flooding has been used successfully
in many clinical conditions.

IMPLOSION
Implosion or implosive therapy is a variant of flooding but it takes place at the imaginary level. The
technique was developed by Thomas Stampfl (Hogan 1968; Stampfl 1966, 1970; Stampfl and Levis
1967). It involves prolonged exposure of the client to relevant negative fantasies connected with an
anxiety-provoking event. The therapist’s task is to describe the scenes in an involved and dramatic manner
repeatedly with variation in order to arouse maximal anxiety, maintaining it almost at an intolerable
level, so that the stress/anxiety caused by it dissipates. The scenes are usually unrealistic, exaggerated
or physically damaging events, that are unlikely to happen in real life (Morganstern 1973; Stampfl and
Levis 1967). For instance, a snake phobic client is asked to imagine a snake coiling around his body
and starting to bite his finger. He is trying to put his finger out, feeling the fangs going right down into
the finger. The terrible pain is spreading throughout the shoulder and the body, and blood dripping out
of his finger. At the next stage, the animal begins to attack his face and other vital organs of the body.
The therapist may also assist the client in doing so, instead of directly being engaged in description of the
scenes. It is based on the hypothesis that neurotic and avoidance responses are perpetuated because they
reduce anxiety. Stampfl theorised that the cues from early traumatic experiences caused by punishment,
rejection, deprivation, or humiliation are retained throughout the lifetime of an individual. Everything
associated with these events tends to elicit anxiety. These ‘neurotic’ behaviours can be treated by re-
creating the original trauma, or something quite similar to it in the absence of real punishment, deprivation
or rejection. If intense emotional reactions are made to occur in absence of primary reinforcement,
extinction of neurotic behaviour perpetuated by anxiety would occur (Hogan 1968). While explaining
implosion, Stampfl combined psychodynamic principles with behaviour therapy. The unique aspect of
this therapy is that the client avoids not only the real situations or objects but also the thoughts and ideas
concerning the event. Implosion is useful in changing the catastrophic ideas concerning an anxiety-
provoking stimulus directly.

Implosion differs from flooding in that in flooding, the client is exposed to the fear-provoking
stimuli either in real life or in imagination, whereas in implosion these scenes are presented verbally in
an exaggerated and dramatic manner. The descriptions are rather unrealistic. The length of imagining
anxiety-provoking scenes may be upto two or more hours, although 40 to 60 minutes sessions are more
common (Marks 1972).
Exposure Procedures 113

Research does not indicate that implosion therapy is better than systematic desensitisation (Morganstern
1973, 1974). Inclusion of implosion like material in flooding either has no effect or the outcome of it is
poor (Wilson 1982). Looking at these findings, some authors do not recommend the use of implosive
therapy in clinical practice (e.g. Martin and Pear 1992).

AVERSION RELIEF
Aversion relief is an avoidance learning method in which the individual is required to perform a response
to avoid punishment. The response is generally the one which is desirable. For instance, in laboratory
setting, an individual is continuously exposed to aversive stimulation like a mild electric shock or painful
imagery until he/she actively engages in some response to avoid it. A ‘deviant stimulus’ may occur prior
to either the aversive stimulation or following such stimulation. In order to terminate it, he switches
on to a ‘relief stimulus’. For instance, an alcoholic may be administered a low-level shock in presence of
a preferred brand of alcohol (deviant stimulus), until he/she chooses to switch over to a relief stimulus
such as pleasant slides of nutritious food, a soft drink or a relaxing scene. In case of a homosexual client,
he is administered the deviant stimuli consisting of those homosexual stimuli, which elicit sexual arousal.
The aversive stimulation terminates as soon as the client switches over to either a neutral or heterosexual
stimulus. Kazdin (1978) viewed aversion relief as a special case of escape training in which escape is
associated with a particular stimulus.

In one of the earliest studies, Thorpe et al. (1964) provided a detailed description of the use of aversion
relief method in case of homosexuals. The treatment combined both aversion therapy and aversion relief
methods (i.e. relief from electric shock). One client reported that his reaction to homosexuals changed
from pleasure to ‘aggression and disgust’. This method also brought substantial cognitive changes in
the clients. Attitude towards women, which was assessed through the ‘Osgood Semantic Differential
Test’, also changed. The client started considering women as desirable ‘sexual partners’. Another potent
homosexual reported that his thoughts of homosexuality had become ‘frightening and sickening’. He
preferred to spend more time on heterosexual fantasies. Still another client reported about disappearance of
motorcycle fetish too. Apart from aversion therapy and aversion relief, the authors also asked the
clients to masturbate to heterosexual fantasies to enhance the treatment effect. Although the treatment
was successful, it was difficult to establish which aspect of this treatment programme was effective in
behaviour change.
12

Relaxation and Systematic Desensitisation

RELAXATION

A wide range of distressing behaviours such as anxiety, fears, phobias, aggression and psychosomatic
disorders are caused by maladaptive learning that triggers undesirable autonomic arousal. These
responses can be unlearned effectively through acquisition of antagonistic responses generally labelled
as relaxation response. Relaxation training is a self-control procedure that requires the client to develop a
set of responses to modify autonomic arousal. Apart from mental and physical relaxation, the individual
develops a feeling of control and starts assuming responsibility for management of his life and health
(Beech et al. 1982). Different forms of relaxation techniques have been used by behaviour therapists.
Edmund Jacobson’s progressive muscle relaxation (JPMR) technique is one of the most commonly
used techniques.

In his classic book Progressive Relaxation, Jacobson (1938) explained that an individual experiences
anxiety when there is a marked degree of muscular tension. Conversely, exercises that reduce muscular
tension would reduce anxiety. This technique involves successive flexing and relaxing of voluntary
muscles. The individual experiences a very marked reduction in anxiety. The progressive relaxation
technique begins with alternately flexing and relaxing the muscles to appreciate the difference between
relaxed and tense muscles. Next, the client is asked to shake his arms and let them flop beside the body;
then to relax the shoulders, he is asked to slowly roll them up and down. Then it proceeds to the neck,
forehead, eyes, mouth, chest, abdomen, thighs, calf muscles, feet, toes, and at last, the entire body until
the client is completely relaxed.

Cue-controlled relaxation is an anxiety reduction technique based on self-control. It involves two

components: (i) deep muscle relaxation training, and (ii) establishing a conditioned stimulus as a cue
Relaxation and Systematic Desensitisation 115

for relaxation. This can be accomplished by repeated use of a cue word like ‘relax’, ‘quiet’ or any word
associated with deep relaxing experience.

Guided somato-psychic relaxation was another technique of relaxation, which was developed by
Sreedhar (1996). The method consisted of a brief rehearsal of physical relaxation and mental relaxation.
The total duration of the session is about 30 minutes. It was found to be effective in reducing blood
pressure, both systolic and diastolic pulse rate, improving the quality of sleep, anxiety, depression mania,
inferiority feelings and paranoia (Anjana and Sreedhar 2000).

Vipassana is one of the most ancient techniques of relaxation. It is a concentrative form of meditation.
Purohit and Chowdhary (1999) used it in a group setting with 106 subjects. Pre- and post-Vipassana
measures included co-dependence and self-rated anxiety. Co-dependence means the extent to which
the individuals organise their lives, decision-making, perception, beliefs and values around something
(Brown 1988). Comparison of scores revealed that both Indian as well as foreign clients benefited from
Vipassana. However, there was very little change in the co-dependence scores of the foreign participants.
This was attributed to differences in cultural beliefs.

Rangaswami’s (1990) deep relaxation training as an adjunct to Anger Control Training (Feindler
and Ecton 1986; Feindler et al. 1984) was used for a child who exhibited uncontrolled aggression,
quarrelling with children in school and neighbourhood. The client was treated in 15 sessions spread
over four weeks time, each session lasting for about an hour. The post-treatment assessment indicated a
significant decrease in self-destructive tendencies, conflict with parents, regressive anxiety, and fighting
and isolation behaviour. Jacobson’s progressive relaxation technique was also used along with lifestyle
modifications such as, developing positive attitude and thinking, cessation of brooding, morning
exercise, deep breathing and break from monotonous work for 20 students suffering from various
stress-related problems (e.g. obsessive brooding, insomnia, stammering and somatoform disorders).
The therapy could decrease these problems significantly along with a decrease in the GSR activity.
Follow-up did not reveal any relapse.

Singh and Kaushik (2000) taking an across-subject design attempted to compare the effects of
the shortened version of deep muscle relaxation (Phillips and Judd 1978), mindfulness meditation
technique used by Kabat-Zinn (1990), and cognitive therapy that focused on corrective self-talk method
(Meichenbaum and Cameron 1973) in enhancing coping skills of three middle-aged women at the risk
of depression. Results revealed that relaxation and cognitive therapy reduced their problems to some
extent but meditation was found to be the most effective among all techniques. In order to examine the
cognitive effects of relaxation and other related techniques, Nathawat and Kumar (1999) exposed 40
subjects, 10 in each group, to one of these treatments: JPMR and transcendental meditation. All subjects
were assessed on their perceptions of life situations, satisfaction with life, positive and negative affects,
depression, hostility and aggression. After exposure to 10 sessions of therapy, post-treatment evaluation
revealed that there were significant cognitive changes. Negative mental health measures such as
negative affect, depression, hostility and aggressive tendency declined, whereas positive mental health
measures increased significantly in all the experimental groups as compared to a control group. The
psychobiological change that takes place under Jacobson’s progressive muscle relaxation was studied
by Chinnian et al. (1975) on 11 subjects. The results revealed significant reduction in pulse pressure
and rate of respiration.
116 BEHAVIOUR THERAPY

In one of the early applications of relaxation technique, Kaliapan and Murthy (1970) demonstrated
its effects in tension headache. In a study of Jacobson’s progressive relaxation technique with 21 psy-
chogenic headache cases, Kumaraiah and Murthy (1975a) reported improvement in 19 cases. Kaliappan
and Murthy (1973) used a modification of Yate’s procedure and standard procedure of JPMR in the
treatment of a case with tics and headache. Three and half years of follow-up revealed maintenance of
the treatment effects. Mishra (1974) used JPMR for controlling reflex epileptic seizure such as hot water
epilepsy and acoustic epilepsy. With other techniques, like assertive training and aversion, relaxation
training was used for the treatment of addiction (Kumaraiah 1979b). Relaxation technique was used
along with (electromyograph) EMG biofeedback for treatment of tension headache (Kumaraiah 1980).
Bhargava (1983) also successfully used JPMR along with assertive training in case of headache in a
25-year-old male. In obstetrical and gynaecological problems also, behaviour therapy has been used.
Mathur, Sharma and Likhari (1983) studied 60 cases of spasmodic dysamenorrhea. 30 of them were
administered progressive muscle relaxation and 30 acted as the control group. Pre- and post-treatment
measures revealed significant reduction of pain in the experimental group. Effects of relaxation on
premenstrual psychological variables were studied by Mohan and Chopra (1985). The investigators
observed significant reduction in neuroticism and anxiety scores. Singh (1986, 1989) treated a case
of abdominal pain and functional fit using behaviour therapy techniques. Prasad and Sitholey (1988)
also reported successful use of behaviour therapy in treatment of conduct disorder of a retarded child.
Cognitive-behaviour therapy started appearing in 1990s. Rangaswami (1995) conducted one of the
earliest intervention studies on panic disorder. After that, there has been an upsurge of interest in
the application of cognitive-behaviour therapy for various conditions. Suvadarshani (1994) used JPMR
and cognitive restructuring in order to reduce premenstrual tension. There is an extensive use of relaxation
either as an independent technique or as an adjunct in a wide variety of other behavioural disorders like
insomnia (Reynolds et al. 1984), duodenal ulcer (Thankachan 1993), anxiety, insomnia, fear, pain, and
indigestion in HIV patients (Prachi 1996), and writer’s cramp (Rangaswami 1982).

SYSTEMATIC DESENSITISATION
Many maladaptive responses learned due to prior conditioning with aversive events can be effectively
eliminated by developing antagonistic responses. The process is termed as counter-conditioning or
reciprocal inhibition. Wolpe (1958) names this technique as systematic desensitisation. In 1924, Watson
explicitly endorsed the idea that, for decreasing the maladaptive response (e.g. fear), the individual
should be brought into contact with the fear-provoking stimulus and associated with a ‘rival’ stimulus
that does not elicit fearful response. During the same year, Jones (1924a and 1924b) demonstrated the
usefulness of this procedure with a 3-year-old boy, Peter, who was afraid of rabbits. The laboratory
procedure included the following steps:

1. Rabbit anywhere in the room in a cage causes fear reaction

2. Rabbit 12 feet away in cage tolerated
3. Rabbit 4 feet away in cage tolerated
4. Rabbit 3 feet away in cage tolerate
5. Rabbit close in the cage tolerated
Relaxation and Systematic Desensitisation 117

6. Rabbit free in the room tolerated

7. Rabbit touched when experimenter holds it
8. Rabbit touched when free in the room
9. Rabbit defied by spitting at it, throwing things at it, imitating it
10. Rabbit allowed to tray on high chair
11. Squats in defenseless position beside rabbit
12. Helps experimenter to carry rabbit to its cage
13. Holds rabbit on the lap
14. Stays alone in the room with rabbit
15. Allows rabbit in play-pen with him
16. Fondles rabbit affectionately
17. Lets rabbit nibble his fingers (Jones 1924b, 310–11).

However, this procedure could not be fully adopted with Peter as he discontinued the treatment for
about two months and perhaps encountered a large dog in the mean time. The procedure was made more
direct and objective by using food as a rival stimulus to reduce fear. Jones stated, ‘Through presence of
pleasant stimulus, whenever the rabbit was shown, the fear was eliminated in favour of positive practice’
(Jones 1924b: 313).

In 1958, Joseph Wolpe developed it more systematically as a clinical technique of counter-conditioning

to use it for treating anxiety. He called it systematic desensitisation (SD). Counter-conditioning was the
basic operational concept underlying SD. It is defined as the use of learning procedure to substitute one
type of response for another. Systematic desensitisation attempts to substitute relaxation for anxiety.
Although anxiety is one of the numerous reactions to experimental neurosis and a major component,
there are other reactions, too, like aggression, inactivity, stupor, stereotyped movement, psychosomatic
disorder, or displacement of existing conditioned response. Wolpe considered behaviour as neurotic
when it is maladaptive and acquired through learning. Over excitation of the nervous system can produce
maladaptive behaviour. In systematic desensitisation, the therapist attempts to present one element of
stimulus to fear under conditions where an alternative response to fear is being evoked. This is what
roughly resembles ‘transference’ in psychoanalytic approach.

THEORETICAL BASIS
Reciprocal Inhibition Theory

Wolpe explained SD through the concept of reciprocal inhibition. The term was first introduced by
Charles Sherrington (1906) who intended the inhibition of one spinal reflex by another. Wolpe extended
this concept to clinical conditions and beyond its original definitions. He stated the general principles
of reciprocal inhibition in the following words, ‘if a response antagonistic to anxiety can be made
to occur in presence of anxiety-provoking stimuli, so that it is accompanied by a complete or partial
suppression of the anxiety responses, the bond between these stimuli and the anxiety responses will be
weakened’ (Wolpe 1958: 71). He assumed that most neurotic patterns are fundamentally conditioned
118 BEHAVIOUR THERAPY

anxiety responses and attempted to train the clients to remain calm and relaxed in situations that formerly
produced anxiety. Thus neurotic responses declined, as the autonomic effects that accompanied deep
relaxation were diametrically opposed to those characteristics of anxiety (Wolpe 1969: 96). In laboratory
setting, Wolpe produced neurotic responses in cats either by presenting shock alone or in conjunction
with presence of food, while the cat approached the food. The neurotic responses included symptoms
like resistance to be placed in the cage, refusal to eat even after 1–3 days of starvation. Thereafter, he
attempted to reduce these anxiety responses by feeding the animal in rooms resembling the original room
in which the neurotic behaviours were introduced. Once the animal ate in the given room it was given
several opportunities to eat until all signs of anxiety decreased in that room. Then it was successively
placed in more similar rooms until the anxiety was eliminated. This was continued until the neurotic
responses were fully eliminated in the original room that included the same. In human subjects, the
relaxation component of systematic desensitisation produces muscular relaxation, which is incompatible
with the state of anxiety triggered by anxiety or fear provoking stimulus. The reinforcement due to
reciprocal inhibition leads to conditioned inhibition.

Habituation Theory
The response decrement in systematic desensitisation was explained by Lader and Wing (1966) through
a habituation theory. This was subsequently elaborated by Lader and Mathew (1968) and reformulated
by Watts (1971, 1973 and 1979). Habituation is defined as the waning of a response to a stimulus due
to its repeated presentation. It applies only to unconditional responses. The decremental processes of
anxiety that operate in desensitisation are more closely analogous to those found in habituation, because
both the novel stimuli that elicit orienting responses and the stimuli that have been paired with aversive
stimuli and arouse anxiety, activate the ‘behavioural inhibition system’ (Gray 1975, 1976). This system
produces an inhibition of ongoing behaviour and increases arousal. This system is particularly active
in neurotic introverts (Nicholson and Gray 1972). Reformulation of this theory by Lader and Mathew
(1968), and Lader and Wing (1966) is called the ‘maximal habituation theory’. It postulated that the rate
of observed reduction in the magnitude of fear or anxiety response to aversive stimulus is a habituation
process. Thus, habituation process is maximised by aspects of the procedure (notably relaxation) that
lowers the central arousal. This can be experimentally measured by galvanic skin response (GSR)
changes. Lader and Mathew (1968) viewed that relaxation is instrumental in lowering the central
arousal that increases the rate of response decrement. Physiologically, deep muscle relaxation excites
the parasympathetic division of the autonomic nervous system, whereas the sympathetic division of the
nervous system is involved in anxiety and phobic responses. Thus, excitation of parasympathetic nervous
system has automatic inhibitory effect on the sympathetic division. This state of anxiety inhibition is
conditioned to each step of the hierarchy scenes in graded manner, so that the client learns to relax instead
of getting anxious. In this sense, it is a form of ‘counter-conditioning’. The ‘dual-process habituation
theory’ was proposed by some authors (Groves and Thompson 1970; Thompson et al. 1973). They stated
that the observed response decrement is the summation of two inferred processes: habituation and
sensitisation. Watts (1979) stated that during the imagery and actual exposure phase of systematic
desensitisation, there is initial sensitisation (i.e. incremental response) to specific phobic stimuli in the
hierarchy, which is accompanied by habituation. The combination of short presentation of low intensity
stimuli and relaxation can apparently prevent the development of sensitisation and therefore appear to
facilitate response decrement.
Relaxation and Systematic Desensitisation 119

Cognitive Theory

Ellis (1962) stated that systematic desensitisation discourages the client from engaging in self-
verbalisations that lead to anxiety. Bandura (1977) however, observed that lowering of physiological
arousal in presence of anxiety-provoking stimulus enhances the client’s belief that he/she can cope with
the phobic situation. Weitzman (1967) reinterpreted the process in which SD presumably achieves its
effects. He explained that during the course of SD, the aversive scenes presented by the therapist get
transformed and elaborated by the clients into imaginal content not in line with the usual fearful or
anxiety-provoking ones, leading to newer forms of adaptive responses. Thus the changes are derived
primarily from the associative material that are aroused and eventually integrated into the ‘ego complex’
ego. Thus, active cognitive restructuring is involved in the process of desensitisation. However,
researches have revealed that when clients modify presented scenes by either transforming them into
less threatening events or by introducing unintended anxiety-provoking elements, they are least likely
to benefit from desensitisation (Lazovik and Lang 1960; Weinberg and Zaslove 1963). The above
findings suggest that the associative process invoked by Weitzman can better account for failures of
desensitisation therapy than its success (Bandura 1971). On the other hand, experiments conducted by
Strahley (1966) indicated that much better outcomes were shown when the method was based on real
life exposures to aversive stimuli.

METHOD
Systematic desensitisation involves three phases of training: (a) relaxation training, (b) construction of
hierarchies, and (c) desensitisation procedure.

a. Relaxation Training

During relaxation training, the client is trained to learn to relax himself by using any of the relaxation
procedures. Various methods of relaxation training are used, depending on the suitability for the client and
expertise of the therapist. However, JPMR technique is generally used. The other relaxation techniques
include meditation, yoga, hypnosis and drugs (Bandura 1969; Brady 1967). This is done in about the
first six sessions.

b. Construction of Hierarchy

With relaxation training, the client is given ‘home-work’ to prepare a hierarchy of scenes in descending
order, at the top of which remains the most anxiety arousing scene and at the bottom, the least anxiety-
provoking (neutral) scene. Here, hierarchy of scenes refers to a graded series of events or situations that a
client has to imagine during relaxation. Therefore, the scenes must be as realistic as possible, with vivid
details of the scene which are relevant to the concrete situations that the client either has experienced
or expects to experience. The extent to which a scene or an actual event evokes distress to a client is
called subjective unit of distress (SUD). The hierarchy of events or scenes is marked according to the
120 BEHAVIOUR THERAPY

level of distress they generate in the client. A hierarchy of events can be prepared by asking the clients
to rate each item. When a client experiences a wide range of phobias for different things, each of them
can also be graded sequentially as per the degree of distress involved.

The typical ‘home-work’ assignment requires the client to: (i) prepare index cards depicting the
situation, (ii) arrange them initially in terms of the levels of distress under broad categories like ‘mild’,
‘moderate’, ‘severe’ or ‘profound’ levels of anxiety, and (iii) rearrange them in terms of the subjective
units of distress. The therapist assists the client to provide all necessary details about each event, so that
he can clearly visualise them while relaxing. The total number of scenes will depend on the intensity of
the problem. Marquis and Morgan (1969) suggested that in most cases 10 items are sufficient. Additional
items may be introduced during the desensitisation phase if the hierarchy fails to cover the entire spectrum
of the phobia. There may be possible inconsistencies in the construction of hierarchy. The client may
be again asked to re-rate the same anxiety arousing event(s) in the hierarchy by being independent of
the previous rating. Paul (1969b) made a distinction between thematic and spatial-temporal hierarchies.
The client may be asked to visualise themes of similar events. For example, if one has irrational fear
for spiders, then he/she may be asked to visualise other insects also that cause anxiety and construct a
hierarchy with common themes.

c. Desensitisation Procedure

Desensitisation training is introduced only after the client has mastered the act of relaxation. While
the client relaxes completely in a comfortable chair or couch with his eyes closed, the therapist directs
him to imagine and experience each situation in the hierarchy from the pleasant or neutral to the most
anxiety-provoking one in a graded manner. Initially, the lowest scene in the hierarchy is presented; if the
client relaxes well, the therapist moves progressively up to the next item. The scene at which the client
experiences anxiety is indicated by raising his index finger and the treatment is discontinued and restarted
with the next below item. It continues until the client remains relaxed and vividly imagines the scene.

Lal et al. (1976) treated a 35-year-old stuttering client with 22 sessions of desen-sitisation. The
patient showed 75 per cent improvement in the symptoms. The reciprocal inhibition technique was used
by Majumder (1975) for treatment of pedagophobia in a 14-year-old adolescent. Rangaswami (1982)
used the technique in treatment of writer’s cramp. The hierarchy included steps like (i) drawing with
a brush, (ii) writing alphabets using a chalk, (iii) writing on the writer’s cramp apparatus, (iv) writing
on a blackboard, (v) writing on a paper with felt pen, and finally, (vi) writing with the usual pen. The
method was successful in controlling writer’s cramp. The same author (Rangaswami 1983) also used
three weeks systematic desensitisation programme in vivo to treat school phobia of an 8-year-old child.
Mishra et al. (1970); Shantha et al. (1972), and Kumaraiah and Murthy (1975c) reported successful
use of systematic desensitisation in phobias. In a case of washing compulsion in a female, Kumaraiah
and Murthy (1975) used systematic desensitisation both in vivo and in vitro to eliminate anxiety
for contamination. After 27 sessions, the duration of washing compulsion reduced from 90 to four
minutes. Four months of follow-up study revealed maintenance of the treatment gains. In another study,
Chopra (1974) used the technique successfully in four cases with obsessive-compulsive neurosis. The
group included one male and three females. Their ages were 20, 26, 49 and 41 years. He also used
Relaxation and Systematic Desensitisation 121

thought-stopping in three out of the four cases and suggested that in acute cases of recent onset where
anxiety is still dominant, the technique was effective. However, in cases with long standing obsessive
compulsive symptoms, direct intervention in target behaviour could be more effective than those of
anxiety-reduction techniques alone. The obsessive behaviour was viewed largely as a conditioned
avoidance response. After the 1970s, the progress in behaviour therapy in India was quite remarkable.
Relaxation techniques were used successfully to cure drug addiction (Kumaraiah 1979). Mehta and
Chawla (1985) used the technique in the successful treatment of asthma.