Current Medical Diagnosis & Treatment in Psychiatry

Applications to Clinical Treatment

Applications to Clinical Treatment

Joseph Wolpe provided the first coherent set of clinical procedures, based on principles of classical conditioning, that had a major impact on the field. Wolpe had studied experimental neuroses in cats. In the course of his studies, which involved shocking animals when they tried to feed and observing the results of the conflict this produced, Wolpe replicated the essential features of Jones’s earlier attempt to reduce a learned fear via the process of counterconditioning. He soon extended his work to people with phobic disorders and was able to reduce his patients’ distress by pairing the object of their fear with an activity that reliably produced an incompatible response. Like Salter, he experimented with the induction of anger and sexual arousal before finally settling on a set of isometric exercises developed to help reduce stress in patients with heart conditions. This procedure, called progressive relaxation, consists of having patients alternately tense and relax different muscle groups in a systematic fashion and can lead to a state of profound relaxation. The isometric exercises could be paired with the presumably conditioned stimulus (whatever the patient feared) in order to have the new conditioned response (relaxation) override the existing arousal and distress that patients experienced in the presence of the phobic stimulus.

Wolpe called his approach systematic desensitization. In addition, in progressive relaxation training a hierarchy is developed that represents successive degrees of exposure to the feared object or stimulus. For example, a patient with a fear of flying might be asked to visualize a variety of scenes that induce differing amounts of anxiety. Simply watching someone else board an airplane might induce only a minimal amount of anxiety, whereas boarding a plane oneself and flying through a thunderstorm would be expected to elicit more anxiety. Wolpe worked with the patient to develop a hierarchy of such imagined experiences and grade them on a scale from 0 to 100 in terms of how much distress they produced. He would then expose the patient to these stimuli (typically in imagination), proceeding on to the next item in the hierarchy only when the client could tolerate a particular image without experiencing distress. If the patient started to become upset while visualizing an image, Wolpe would instruct the patient to stop the image and reinitiate the relaxation exercises until the feelings of arousal had passed. In this fashion, he systematically worked the patient through the hierarchy of representations of the feared object, going only as rapidly as the patient could go without experiencing distress until the stimulus no longer elicited any anxiety.

Hundreds of studies have suggested that systematic desensitization (or its variants) is effective in the treatment of phobia and related anxiety-based disorders. Systematic desensitization has been applied widely to a host of problems and represents a safe and effective way of reducing anxious arousal in both adults and children. Major variations include substituting meditation or biofeedback for progressive relaxation as a means of producing the relaxation response (some people don’t respond well to muscular isometrics) or arranging experiences in a graduated fashion. The basic approach appears to be robust to these minor modifications and is one of the few examples of a treatment intervention that is truly more effective than are other interventions.

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