FLOODING
A BEHAVIOURAL THERAPY FOR TREATING PHOBIAS

Remember Watson & Rayner (1920)? John Watson intended to cure Baby Albert of the fear of white furry animals but never got the chance, because Albert's mother withdrew from the study.

One way to do this might have been exposure therapy. Exposure therapy involves presenting the phobia-sufferer with the object they fear and forcing them to confront it.

This idea is based on classical conditioning and biological theory. The biology is the body's stress response - the fight-or-flight response. When there is a threat, the body goes into the "alarm stage": the heart beats faster, blood pressure increase, perspiration begins and adrenalin is released into the blood.

The body can only stay in the alarm stage for quite a short amount of time. After that, the heart rate slows back down, breathing becomes regular again and adrenaline levels drop.

The phobia sufferer finds that they are no longer panicking, despite being exposed to the object they fear. They relax and learn to associate the feared object with neutral emotions instead.

This certainly sounds cruel - like this classic "Far Side" cartoon

Exposure has been shown to work. Joseph Wolpe (1970) took a girl who was scared of cars and drove her around for 4 hours. At first, the girl was hysterical but she calmed down when she realised that she was in no danger. Afterwards, her phobia disappeared: she learned to enjoy car rides.

Exposure therapy might work with children and simple phobias (like Baby Albert's fear of the white rat), but you can't lock a grown adult in a room full of snakes and leave them in there for hours.

We are NOT looking at simple exposure theory here. We're looking at flooding, which is more complicated and more ethical than locking people in rooms full of snakes.

What this lady describes is exposure therapy in general, rather than flooding

Flooding is based on classical conditioning and has two components:

1. Unavoidable exposure: this involves introducing you to the thing you fear in the most immediate and unavoidable way.
   
2. Extinction: this involves learning to associate the thing you fear with something neutral
   

In the 1960s, Thomas Stampfl developed"implosion therapy" but flooding is the more common name today. Stampfl bombarded his phobia patients with detailed descriptions of the situations that they feared for 6-9 hours. Afterwards, they lost their fear of those situations. Getting patients to imagine the fearful situation is known as in vitro therapy.

Zev Wanderer (1991) used biofeedback machines to monitor patients' blood pressure, perspiration and heart rate while they listened to descriptions of what they most feared. Wanderer identified the phrases that sparked the most intense reactions. By just using these phrases, he reduced the time needed for the flooding session from 9 hours to 2 hours. Later sessions could be as short as half an hour. Wanderer's patients would take the tape recordings home and listen to them as 'homework'.

Flooding is a type of exposure therapy. Normally, flooding is an in vitro therapy, whereas exposure therapy is an in vivo therapy

Unavoidable Exposure

Normally, phobia-sufferers run away from the thing they fear, so they never work through the body's "alarm stage" and learn to end the association with fear and anxiety. If the patient can be prevented from escaping the object they fear, then they can learn to stop fearing it.

In Stampfl's flooding therapy, the patients are bombarded with tape-recorded descriptions of what they fear. They can't stop the tape recorder or block out the descriptions.

Other types of flooding involve being surrounded by images of the feared object (imaginal flooding) or immersed in virtual reality.

Extinction

When the body's "alarm phase" comes to an end, you feel emotionally drained but unafraid. If the feared object is still present, you will learn to associate it with a lack of emotion, rather than fear. This is called "extinction" or "Pavlovian extinction".

The idea is that the feared object stops being a conditioned stimulus (CS) producing a fearful conditioned response (CR); it goes back to being a neutral stimulus (NS) which doesn't produce any response at all.

FLOODING
CODA

Behavioural therapies in general are evaluated on Therapies for Phobias. Systematic Desensitisation is another therapy with its own page.

CREDIBILITY

Flooding is based on classical conditioning, which is a well-established psychological theory supported by a huge amount of research (eg Pavlov's dogs, Baby Albert). Research suggests that phobias are learned in the first place through association and can be un-learned by forming different associations.

The main advantage of flooding is that it is fast, realistic and relatively ethical.

Exposure therapy can have immediate results: the alarm stage only lasts about 10-15 minutes and the fear response can be extinguished within an hour. Flooding takes longer, with the first session lasting several hours but later ones getting shorter.

Exposure therapy and flooding present the sufferer with unavoidable exposure and this is what often happens in real life. It is argued that this therapy better prepares sufferers for occasions when they may be confronted unexpectedly with the object they fear, with no way to get away from it.

Exposure therapy has ethical problems but flooding is an in vitro technique that causes less intense distress. Although exposure therapy works best on simple phobias, like animals or objects, flooding can be used for more complex phobias, like social situations. This is because the patient is listening to descriptions or looking at images, rather than physically touching the object they fear.

Keane et al. (1989) studied 24 Vietnam veterans with PTSD (post-traumatic stress disorder). PTSD is experienced by people who have survived traumatic events like wars, disasters or crimes; it involves panic attacks and phobias as well as other symptoms like "numbing" (the inability to feel normal emotions) and social avoidance (breaking off relationships).

The soldiers received 14 to 16 sessions of flooding therapy and they were tested before, after and 6 months later for symptoms of PTSD. Compared to a control group who didn't receive therapy, the flooding group had fewer terrifying flashbacks as well as less anxiety and depression. The other symptoms of PTSD ("numbing" and social avoidance) didn't change. This study supports the idea that flooding can extinguish phobias.

OBJECTIONS

It can be unethical to expose a patient to something they find distressing. In fact, it could backfire and make the patient even more frightened of that thing. This is particularly true of exposure therapy, which can backfire badly, but even the tape recordings or constant flow of images involved in flooding can be too much for some patients.

Wolpe (1969) reported the case of a client who had to be hospitalised because flooding made her so anxious. This is one reason why Wolpe preferred systematic desensitisation to flooding.

For the same reason, although it has been shown to work, psychiatrists are often reluctant to suggest flooding as a therapy.

There's also a danger of spontaneous recovery, when the extinguished phobia suddenly returns. This is because the flooding sessions aren't very long and the therapy doesn't replace the fear-response with a different response, it just replaces it with no response.

DIFFERENCES

Systematic desensitisation involves gradual exposure to the object you fear, but with flooding you are completely exposed to it, all at once. It's like going directly to the end of the stimulus hierarchy and skipping all the stages in between.

Systematic desensitisation is much more ethical than flooding, because the participants are only exposed gradually to the thing that they fear and they only move on to greater exposure when they feel ready. With flooding, the patient is exposed to the object they fear all at once, in a very intense way. This can be distressing.

Both therapies can be carried out in vitro rather than in vivo. Imagining exposure to the feared object is less distressing. However, in vitro flooding is still more upsetting that in vitro systematic desensitisation.

Neither systematic desensitisation nor flooding tackle the possible underlying problem behind the phobia. They are both behavioural therapies that only deal with the symptoms, not the cause. If there is an underlying problem behind the phobia (like trauma in the patient's past), then that will still be there and will carry on causing difficulties, even if the phobia is temporarily eased.

APPLICATIONS

It's quite common for flooding to form a part of cognitive-behavioural therapy (CBT).

In the video (right), Prof. Lars-Göran Öst uses exposure therapy to overcome Mariam's fear of snakes, but he also challenges Mariam's false beliefs about what the snake will do when it is released. HIs approach also uses some elements of systematic desensitisation because Mariam is gradually exposed to the snake (although much faster than in SD and with less control on her part). This shows how the different therapies blend together.

Mariam overcomes her phobia of snakes in an afternoon through exposure therapy