Covert Conditioning for Persistent Aggressive Behaviors: A Case Illustration

Abstract

In psychotherapy practice and training, single case study design plays an indispensable role by effectively articulating the application of textbook knowledge, thereby bridging the gap between theory and practice. This article, on similar lines, illustrates one such successful example of the application of the classical behavioral technique of covert conditioning modified with a component of verbal challenging. A woman in her late-thirties reported with long-standing seemingly-resistant-to-treat symptoms of aggressive behavior of beating children. The client had a total of 10 daily sessions of 60–90 minutes each. By the end of one week, she reported not beating children in this period. She felt extremely relieved because it had happened for the first time in 10 years. The intensity of anger had decreased drastically, and she was not shouting any longer. She had to discontinue sessions abruptly due to unavoidable circumstances. Although she was suggested to follow up the intensive sessions again, she was not able to do it due to feasibility issues. The improvement was maintained on follow-up visits after two weeks, four weeks, and three months.

Behaviors that are resistant to change posit a substantial burden on mental health care services and increase the chances of dropout from therapy. From the vantage point of social interaction theory, the onus for resistance is on the therapist–client interaction and the theory calls for adaptive modifications by the therapist. ¹ This requires the therapist to identify the most appropriate technique and customize it to suit the idiosyncratic needs of the client, based on the conceptualization.

Single case study design in psychotherapy has immense potential to highlight the link between theory and practice. Existing work using the single case study design is evidence of the utility of this method.^2–5 This article describes the use of covert conditioning in combination with verbal challenge to overcome the symptoms of aggressive behavior in a woman. Covert conditioning is a procedure that utilizes classical and operant conditioning principles. While overt behaviors refer to observable behaviors, covert behaviors include thinking, imaging responses, feeling, and self-talk. Joseph R. Cautela is credited with this technique based on the assumptions of homogeneity, interaction, and learning. ⁶

Background and the Relevant History

A married working woman in her late thirties came with the chief complaints of aggressive behavior and feelings of guilt for more than 10 years. She was distraught over her aggressive behavior towards her family. Every morning, when getting the children ready for school, she would resolve to not shout at them but invariably end up doing so, only to regret later and resolve again, in vain. She would end up slapping her sons or pulling them. When things went against her plan, she would be unable to regulate her emotions. She contrasted her lack of control with her husband’s “cool, controlled” attitude and berated herself for her lack thereof. She expressed dismay and frustration over her poor management of daily chores. She blamed herself for the always tense environment at home. She had sought treatment in the past. It was a combination of medical and psychological treatments. She had also tried religion-based treatment. The past treatments, however, were not effective in handling her aggressive behaviors.

History taking revealed that she has been single-handedly taking care of the household chores and responsibilities since the marriage. The significant other did not believe in her abilities to independently take care of her kids. She too believed the same. Hence, she and her family of procreation were staying near her parents’ home so that her parents could help in the child care. As a result, they could not shift to stay closer to her husband’s workplace. Her husband’s workplace was very far off from her parents’ home. It meant long travelling hours for him, which prevented him from participating in the household responsibilities. All these factors—her dependence on her parents for upbringing the kids, frustration because of being responsible for the entire household work, absence of husband, negative self-view, aggressive behavior with children—made her feel very guilty about herself, and her day remained filled with depreciating self-talk.

During her developmental years, she had faced constant hostility and severe criticality at home. She had engaged in repeated self-talk of inferiority during those years. She had a poor interpersonal relationship with her brother and parents. Over those years, her parents almost always held her responsible whenever things went wrong. After the marriage also, she got blamed for the interpersonal issues with her husband and children. It led to symptoms of dysthymia in her. She and her significant others had accepted everything as her fate. However, she wanted to bring some changes in herself, to at least stop beating up her children.

In therapy, while a formulation was taking shape for the long term goals based on these developmental (such as hostility and criticality, feelings of inferiority, stigma) and systemic (such as absent husband, dependence on extended family, blaming) factors, a short-term goal focus was needed to bring change in her aggressive behaviors. It was considered of utmost importance because it entailed physical abuse of children, apart from the intense guilt and distress it caused to the client. It was also seen that to achieve the probable long-term goals, she needed to learn self-management skills. In this case, the probable long-term goal would be to help her overcome the impact of exposure to expressed emotions since her childhood. It was evident in the form of poor self-efficacy, poor self-esteem, stigma, and extreme self-blame.

Covert Conditioning: Use of Imagery and Conditioning Principles

Her dysfunctional thought record reflected that getting her children ready for school created a tremendous disturbance and made her very irritable every morning. She had a fair understanding that most children find it difficult to wake up and take time to get ready for school. However, this understanding did not translate into action, as her behaviors had acquired a certain automaticity. Consequently, the cycle of her aggressive behaviors and resultant guilt had become an iterative loop. Breaking this loop was crucial not just for her children’s well-being but also for her mental health.

Based on her past treatment history, it was clear that techniques like verbal challenging, distractions, or insight orientation alone would not yield results in her case as she had already tried them unsuccessfully over the years. History also revealed that insight was not a cure in her case. For instance, she reported feeling intensely angry when her husband reached home late, causing a planned outing to be postponed. This was an uncommon occurrence happening at the most two out of ten times. In the sessions, she had the insight that “two out of ten times” is a reasonable occurrence by all means but was unable to control her anger despite this insight.

It was observed that she continuously engaged in maladaptive covert self-critical verbalizations. Her maladaptive thoughts would overpower her adaptive thoughts in these “hot” situations. Hence, intense practice was deemed essential to break the automaticity of the self-critical maladaptive thoughts and replace them with adaptive self-efficacious thoughts. She was able to describe her feelings and conveyed the intensity of their behavioral manifestations. Her capacity to identify her thoughts, however, was limited. In such a scenario, visual imagery was considered a suitable alternative modality for identifying and modifying the underlying assumptions. ⁷ Imagery has been an integral part of the psychotherapy process as it adds a different dimension for understanding and working with clients’ problems. A wide array of therapeutic approaches have documented the benefits of working with imagery.^{8, 9} In applying this technique, the therapist can read the script aloud and help the clients visualize the situation to be mastered in the session. Gradually, the clients can imagine it themselves without the help of the therapist. Mass practice and homework assignments are key to its application.

Considering all these factors, the covert conditioning methods were found useful for management. These methods make use of visual imagery. They are based on the application of classical and operant conditioning and follow the principles of self-management. It assumes that the replacement of critical self-talk with adaptive and appropriate self-talk leads to the learning of new adaptive behaviours. ¹⁰ It also assumes that proper control of covert activities results in better self-management skills. These adaptive changes in behavior can trigger the positive change cycle in the interrelated aspects of cognition, emotion, behavior, and physiology ¹¹ —the core of every psychotherapy process.

The formulation was discussed with the client. She was educated about the nature of the complaints and the management plan. She was explained about the need for frequent sessions and her active participation in therapy. Although she could understand the formulation, she was reluctant for frequent sessions, due to feasibility issues. The management plan was “sold off” to her to motivate her to apply for leave. She was made aware of the possible benefits outweighing the costs and the necessity to work on the physical abuse involved. Other feasibility issues were resolved after discussions based on problem-solving principles. She agreed to apply for two weeks’ leave from the workplace for daily sessions. On the therapist’s part, he agreed to make all efforts to utilize these two weeks for maximum benefits in terms of intensity and frequency.

After discussion with the client, a separate team of two young cotherapists was assigned the responsibility of frequent sessions for aggressive behavior, based on covert conditioning principles. The cotherapists were specifically chosen to be two in number to reduce the possibility of canceling the session; if one is absent, the other can continue the session and when both are present, one of them can lead the session. The parallel sessions, twice in a week, with the primary therapist continued to shape the formulation for the long-term goals. For any psychotherapy, the ultimate aim is to work towards behaviors responsible for the person’s overall growth. Following the principle of parsimony, the parallel assessment shall continue for the overall growth if the client is willing to spare more time or comes back for therapy at a later point in time.

Therapy Details

In step 1, the scripts of the “hot” situations as they happened in daily life were prepared. In step 2, undesirable self-critical verbalizations were replaced with alternative adaptive, desirable self-verbalization, followed by a reduction in negative consequences. In step 3, mass practice was done using imagery to strengthen the association between desirable self-verbalization and reduction in negative consequences (negative reinforcement). It was assumed that replacing critical self-talk with adaptive and appropriate self-talk would reduce aggressive behaviors. In final step 4, she would imagine herself handling these situations effectively and experiencing positive emotions about herself. Step 4 could not be done because she had to leave therapy midway due to unavoidable reasons.

During the sessions, special attention was given to keep the therapy work collaborative. The rationale for the choice of the technique was explained, and the procedure was detailed to the client in simple terms. In step 1, she was asked to devise the initial script describing the chain of events that would take place in the incidents that triggered her aggressive behavior. She was guided to provide a detailed report of events. She provided vivid descriptions extremely close to reality because she has been living these situations every day for more than 10 years. The preparation of the scripts gave her the confidence of being an active contributor to the process. The draft of the script was refined in the sessions. This entailed working on the tense, pronouns, and descriptiveness of the language used. It was decided to use the present tense for writing the script. Using the present tense helps elicit more detail in the description as it allows one to imagine the event fully. Experimental research in the domain of cognitive science provides evidence that contextual cues facilitate memory recall. ¹² Using the present tense can be thought to provide adequate cues in the narrative to aid recall. In this case, the tense provides a powerful linguistic cue to help recall. The client’s narrative did become richer as she used the present tense in the sessions. Verbal encouragers and directives were used to help the client make the descriptions more detailed. It was decided to change the pronouns in the script so that it had second-person pronouns throughout. The script had to be read out to the client in the sessions so that she could sit back and visualize the events unfolding.

In step 1, the therapists had retained a guiding role thus far, focusing solely on the client’s skill in building and enriching her script. However, in step 2, when modifying the script for covert conditioning sessions, they took a more active role as she was finding it difficult to come up with alternate desirable self-verbalizations. The more active role was also decided because, in the parallel sessions with the primary therapist, structural changes in the family systems were being discussed. The discussions about structural changes can sap tremendous energy of the clients, leaving them with not much energy to focus on other tasks. ¹³

Adaptive self-talk was inserted in the script so as to teach her the use of positive self-statements and verbal challenge. For example, in one excerpt of the script, when her husband says that he would not be able to reach on time to go for an outing as per plan because of being caught in a traffic snarl, she would feel intensely angry, thinking, “No matter what, I will not change my plan. He should not have promised to go out if he could not reach on time.” Despite knowing that they would not be able to go out, she would not change her dress. She would be getting angry and irritated with children. “Despite the knowledge that these kinds of things can happen, I would not be able to control my anger because of the irritation in my abdomen and in my body, and I will push and shove the children while changing their dress.” “The cool attitude of my husband in handling this situation would further irritate me and induce anger.” “Later, I would berate myself for not being able to handle things calmly and getting angry with my children and husband.”

The alternate script in this situation included positive self-statements to relax herself and verbal challenge. For example, the alternate script ran “No matter what, I will not change my plan” “It’s ok, just relax, take a deep breath.” “Does this happen very frequently?” “Can it happen with anyone?” “No, but if he has promised, he should reach on time.” “Take your time, just relax, you can handle this.” “Can we go out some other day?” “Has the plan changed because of me also sometime?” In the script, this reduces her anger somewhat and she begins to feel the abdominal muscles relax a little. This further leads to a reduction in her negative emotion. She gets more self-control in her behavior. She does not engage in the negative behavior of shouting and slapping. Further in the script, while changing the dress of the children, she is repetitively engaged in positive self-talk and verbal challenge. She handles the situation with significant decrease in her angry behavior and without any pushing and shoving. At the end of the script, she experiences significant reduction in her self-berating behavior and guilt feelings. The application of adaptive patterns reduces the negative consequences and hence becomes akin to the reduction or removal of aversive stimuli. The reduction further acts as a negative reinforcement for these adaptive patterns. The change in one aspect (covert/cognition) of the quadrangle has the potential to start off a cycle of change in all the four aspects. ¹¹

The Outcome

For this particular intervention, the client had a total of 10 daily sessions of 60–90 minutes each. She had to abruptly discontinue sessions due to unavoidable circumstances before the planned two weeks. The script was audio-recorded and used for practice as homework, twice daily. The script for one situation considered many different alternatives that could occur, so as to allow for more instances of practice for that one situation. Within one week of therapy, she completely stopped the aggressive behavior of beating up the children, for the first time in 10 years. Her shouting behavior decreased significantly, and her intensity of anger reduced drastically. She felt extremely relieved and spoke of feeling calmer and having better control over her responses to situations that would earlier make her go berserk with anger. Although she was suggested to follow up the intensive sessions again, she was unable to do it due to feasibility issues. The improvement was maintained on follow-up visits after two weeks, four weeks, and three months.

Conclusions

The case study provides many insights. First, identifying client strengths and weaknesses, and then utilizing them is important. Second, the plan of therapy needs to be sold off to the client based on the careful cost–benefit analysis and gravity of the symptoms. The problem of child abuse was brought to the forefront to make her understand the gravity of the situation. Third, sincere efforts are required to be made to overcome feasibility issues. Fourth, insight is not a cure. Action needs to be taken to convert it into concrete results. Fifth, assessment for long-term goals needs to continue while addressing short-term goals. Therapist can continue to work for it if the person has the willingness.