Covert sensitization is a specific form of aversion therapy. Also known as verbal aversion therapy, this behavior modification approach is often used in the treatment of various types of addiction as well as other undesirable or self-destructive behaviors, desires, and habits. Overeating, alcohol and drug abuse, and smoking are good examples of the types of behaviors that can respond well to covert sensitization.
Based upon the behavioral analysis principles of classical conditioning, covert sensitization relies on the assumption that most problem behaviors are learned and, therefore, can be unlearned. The process of unlearning or changing the behavior requires proper conditioning. Covert sensitization involves eliminating the unwanted behavior by creating a profound and lasting association between the behavior and a highly disturbing “covert” (i.e., imagined) stimulus or consequence. Once the association is firmly established, engaging in the behavior is no longer appealing.
Covert sensitization was first introduced in the 1960s as a form of treatment for unwanted behaviors by American psychologist Dr. Joseph Cautela.
How Covert Sensitization Works
You see, just about everything you do in life on a regular basis – whether it’s brushing your teeth, going to work every day, or abusing alcohol – has a “payoff”. If it didn’t, you wouldn’t do it. For example, the payoff for brushing your teeth is better oral health and fresher breath, while the payoff for abusing alcohol may be the temporary numbing of painful emotions or to feel more relaxed and confident in social situations. Of course, going to work every day – even if it’s to a job you hate – has the obvious payoff of providing an income, which, for most people, is a necessity in order to have food on the table and keep a roof overhead. Payoffs serve to reinforce the behavior – whether it’s an adaptive behavior or a problematic one.
With aversion therapy, the payoff for an unwanted behavior needs to be thwarted or undermined in some way in order for the behavior to stop. This is accomplished by creating a strong association between the behavior you want to change and a highly unpleasant stimulus. In order for the stimulus to be effective, it has to be very unpleasant. In fact, the more uncomfortable, painful, or disgusting it is, the more effective it will be.
The negative impact of the stimulus must also occur immediately or very soon after the unwanted behavior in order for the association to be made. For example, children quickly learn that touching a hot burner on the stove immediately results in a very painful and unpleasant sensation. They will rarely repeat the behavior because a powerful association was created between touching the hot burner and pain.
Even though problematic behaviors and bad habits, such as overeating or drug abuse, have negative consequences as well, those consequences often don’t occur immediately or soon after. As a result, a powerful association isn’t made. People who overeat or smoke regularly know, intellectually at least, that they’re going to gain excess weight or seriously damage their health. But a consequence that won’t occur until some point in the future – or especially, the very distant future – often isn’t enough to offset the power of an immediate – and highly gratifying – reward or payoff. That’s why something like compulsive overeating can be so difficult to overcome. The immediate gratification serves as a powerful reinforcement. The flip side of stopping the behavior – for example, losing weight – is a nice reward but it occurs over time rather than immediately. As humans, instant gratification can be hard to resist even when we know there will be a payoff in the future.
Covert Sensitization versus Overt Sensitization
Many people are familiar with overt sensitization methods. One of the most well-known is the use of the drug disulfiram (the generic name for Antabuse) to help stop alcoholics from drinking. Disulfiram is an “overt” chemical stimulus. When alcoholics are being treated with this drug they experience some very unpleasant side effects – such as nausea, vomiting, headache, and dizziness – within a few minutes of consuming any alcohol. These side effects serve as deterrent to drinking. Electrical shocks are also frequently used in overt sensitization.
Covert sensitization works very similarly to overt sensitization, except with one major difference – the “covert” stimulus (in the form of something extremely unpleasant or a powerful negative consequence) is imagined by the recipient. In other words, rather than experiencing actual physical consequences such as pain from an electric shock or the nasty physical side effects of a drug like disulfiram, the consequences are vividly pictured in the person’s mind.
For example, rather than using disulfiram, alcoholics using covert sensitization would imagine themselves drinking alcohol and then, as vividly as possible, imagine a very unpleasant consequence as they’re taking the drink. An example of an imagined consequence could be intense nausea followed by throwing up all over their clothing, the bar or table, and the floor, as well as the humiliation they would experience while others watched.
An example of using covert sensitization to overcome emotional overeating – which typically involves turning to unhealthy “comfort” foods during times of stress – could be vividly imagining taking a bit of the desired food, only to find that it’s covered in something revolting such as hair, feces, or vomit.
The goal with covert sensitization – as with all types of aversion therapy – is to form such a solid and powerful association over time that the unwanted behavior is eventually completely eliminated. At the very least, the behavior becomes increasingly less pleasant and less appealing.
It should be noted that the reason covert sensitization is also referred to as “verbal” aversion therapy is because the therapist guides the client’s imagination with verbal instructions. Using the alcoholic treatment example above, the therapist would instruct the alcoholic to picture himself choosing to drink alcohol, followed by the instruction to imagine the intensely negative consequences described earlier (i.e. nausea, vomiting, and humiliation). The therapist would have the client do this process again and again in order to strengthen the association between taking a drink and very unpleasant consequences. The therapist would then have the client imagine the scene again, except now the client chooses to not take a drink. By not engaging in the undesired behavior – taking a drink – the client avoids the negative consequences of intense nausea, vomiting, and humiliation.
Therapists using covert sensitization instruct their clients to use as much detail as possible when imagining negative consequences. Since the covert stimulus needs to be suitable for the client, the therapist will take some time getting to know the client – i.e. “what makes the client tick”, so to speak. The more well-suited the image, the more effective it will be in terms of successfully eliminating the behavior. For example, the idea of being humiliated may work well for some clients, but not be much of a deterrent for others. It’s the therapist’s role to make sure that the selected image will have a profound impact on the client.
Advantages of Covert Sensitization
There are several advantages to covert sensitization, particularly when compared to overt sensitization. Perhaps the most salient advantage is that many people regard covert sensitization as a more ethical approach to treatment. Overt sensitization is often criticized because participants experience actual physical consequences. Some argue that it’s unethical to use a chemical stimulus like disulfiram to induce nausea and vomiting (among other nasty side effects), even if it can be an effective way to curb or eliminate problem drinking in some people. Many have argued against the often controversial use of electrical shock in overt sensitization, which can be construed as punitive and potentially cause psychological damage to recipients. The bottom line is that overt sensitization methods almost always involve some sort of physical suffering as a means to eliminate problem behaviors, whereas covert sensitization does not.
Other advantages of covert sensitization include:
- The client – rather than the therapist – has full control over the imagined stimulus.
- There are no potential physical risks (e.g. an adverse reaction to a chemical stimuli)
- The client isn’t required to actually engage in the undesired behavior in most cases (e.g. actually taking a drink). The therapy can be effective by only imagining engaging in the behavior. This is especially important for behaviors that would involve and be harmful to others, such as pedophilia or exhibitionism.
- It’s less expensive. Some overt sensitization techniques, particularly those that involve the use of chemical stimuli such as Antabuse, can be quite cost prohibitive. This is because (in addition to the cost of the drug itself) medical supervision is required – at least on an outpatient basis and sometimes on an inpatient basis. Since there are no physical risks involved with covert sensitization, the primary cost is for the therapy sessions.
- It’s relatively risk free. Overt sensitization methods almost always involve some degree of risk, such as serious side effects or an unexpected adverse response.
Disadvantages of Covert Sensitization
Like all therapies, covert sensitization isn’t without disadvantages:
- Like other behavior modification therapies, covert sensitization focuses on the learned aspect of unwanted behaviors. As such, it fails to address other psychological factors that often drive such behaviors. Many behaviors treated with covert sensitization, such as addiction or paraphilias, are highly complex. Failure to address the underlying issues that led to the problem in the first place may be a set up for failure. In the case of addiction, it may also leave individuals at risk for developing another addiction even if the addiction being treated is eliminated.
- The imagined consequence must be extremely disturbing in order to be effective. Without this component, treatment will likely fail.
- It doesn’t work for everyone.
- Therapy clients who aren’t highly motivated usually won’t benefit from covert sensitization.
- More research needs to be done in order to determine the effectiveness of covert sensitization with various problems and disorders, particularly compared to other types of therapy.
Uses of Covert Sensitization
Since covert sensitization is used to put a stop to problematic behaviors and unwanted desires, there are limitations to what it can be used for, especially when compared to more traditional forms of psychotherapy. Disorders, conditions, and problems for which covert sensitization is sometimes used include:
- Alcohol abuse and addiction
- Drug abuse and addiction
- Other types of paraphilia / sexually deviant behavior
- Pathological gambling
- Compulsive nail biting
- Weight loss / obesity
- Compulsive overeating
Covert sensitization can be a viable, relatively low-risk and cost-effective treatment option for the types of disorders listed above. While it won’t work for everyone, it may be worth considering, particularly if you’re interested in aversion therapy without the potential drawbacks associated with overt sensitization methods. It should be noted that covert sensitization is most likely to have lasting positive effects when proper relapse prevention techniques are taught and practiced, and periodic aftercare sessions take place up to a year (or more, if needed) once treatment ends.