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Chapter 28: Psychotherapies
Table 28.8-1
Hierarchy Construction (Least Anxious to Most Anxious): Fear of Water and Heights
1. Taking a bath at home.
2. Taking a shower at home.
3. Going into the shallow end of the swimming pool.
4. Starting to swim at the shallow end of the swimming pool,
breaststroke only.
5. Swimming at the shallow end, doing the crawl.
6. Jumping into the swimming pool at the shallow end.
7. Jumping into the pool and then doing the crawl.
8. Swimming at the shallow end, first breaststroke, then the crawl.
9. Pushing away from the bars and causing a splash.
10. Swimming in the middle of the pool at a depth of 5 feet 3 inches.
11. Swimming at the shallow end and then at the deep end
(10 feet 3 inches).
12. Going into the deep end of the swimming pool.
13. Watching people jump from the diving boards.
14. Standing on a step at the deep end of the pool and making a
little jump into the water.
15. Backstroke at the shallow end of the pool.
16. Jumping into the water at the shallow end of the pool
(belly-flop dive).
17. Belly-flop dive at the deep end of the pool.
18. Racing dive at the shallow end of the pool.
19. Racing dive at the deep end of the pool.
20. Swimming three times across the deep end of the pool
without stopping:
a. breaststroke
b. crawl
c. backstroke
21. Jumping into the pool at a depth of:
a. 5 feet 3 inches
b. 6 feet
c. 7 feet
22. Several jumps at 6 feet and 7 feet, alternating them, and then
remaining at the 7-foot depth.
23. Going onto the first diving board and jumping into the water.
24. Jumping off the first diving board, then diving from the first
board.
25. Diving off the first board.
26. Jumping from the first diving board, jumping from the second
diving board, then diving from the first diving board.
27. Jumping off the first, second, and third diving boards, then
diving from the first diving board.
28. Jumping off the first, second, and third diving boards, then
diving from the first and then the second diving board.
29. Jumping off the fourth diving board, then diving off the
second diving board.
30. Jumping off the fifth diving board, then diving off the third
diving board.
31. Jumping off the fifth diving board, then diving off the fourth
diving board.
32. Jumping off the top board, then diving off the fourth diving
board.
33. Jumping off the top board, then diving off the fifth diving
board.
34. Diving off the top diving board.
35. Random stimuli.
36. Looking around before jumping off the third diving board.
37. Looking around before jumping off the fourth diving board.
38. Looking around before jumping off the fifth diving board.
39. Diving from the fifth diving board and looking around before
diving.
40. Diving from the top board and looking around before diving.
(From Kraft T. The use of behavior therapy in a psychotherapeutic context. In: Lazarus AA, ed.
Clinical Behavior Therapy
. New York: Brunner/Mazel;
1972:222, with permission.)
Adjunctive Use of Drugs.
Clinicians have used various
drugs to hasten relaxation, but drugs should be used cautiously
and only by clinicians trained and experienced in potential
adverse effects. Either the ultrarapidly acting barbiturate sodium
methohexital (Brevital) or diazepam (Valium) is given intrave-
nously in subanesthetic doses. If the procedural details are fol-
lowed carefully, almost all patients find the procedure pleasant,
with few unpleasant side effects. The advantages of pharmaco-
logical desensitization are that preliminary training in relaxation
can be shortened, almost all patients can relax adequately, and
the treatment itself seems to proceed more rapidly than without
the drugs.
Indications.
Systematic desensitization works best in cases
of a clearly identifiable anxiety-provoking stimulus. Phobias,
obsessions, compulsions, and certain sexual disorders have
been treated successfully with this technique.
Therapeutic-Graded Exposure
Therapeutic-graded exposure is similar to systematic desen-
sitization, except that relaxation training is not involved and
treatment is usually carried out in a real-life context. This
means that the individual must be brought in contact with (i.e.,
be exposed to) the warning stimulus to learn firsthand that no
dangerous consequences will ensue. Exposure is graded accord-
ing to a hierarchy. Patients afraid of cats, for example, might
progress from looking at a picture of a cat to holding one.
Flooding
Flooding (sometimes called
implosion
) is similar to graded
exposure in that it involves exposing the patient to the feared
object in vivo; however, there is no hierarchy. Flooding is
based on the premise that escaping from an anxiety-provoking
experience reinforces the anxiety through conditioning. Thus,
clinicians can extinguish the anxiety and prevent the condi-
tioned avoidance behavior by not allowing patients to escape
the situation. Clinicians encourage patients to confront feared
situations directly, without a gradual buildup, as in systematic
desensitization or graded exposure. No relaxation exercises are
used, as in systematic desensitization. Patients experience fear,
which gradually subsides after a time. The success of the proce-
dure depends on having patients remain in the fear-generating
