Covert sensitisation and covert conditioning

1. Introduction

Version followed: Cautela & Kearney, The Covert Conditioning Handbook (1986), as reproduced in open chapter excerpts, supplemented by the SAGE Encyclopedia of Behavior Modification and Cognitive Behavior Therapy (2005) entries by Wisocki, Plaud, and Mullins & Van Pelt. Where the handbook is not drawn on, the earlier journal papers (Cautela 1967, 1970; Cautela & Wisocki 1977) are cited as described in secondary sources and marked [uncertain].

Covert conditioning is a family of imagery-based procedures, not a single therapy. Joseph Cautela developed it in the USA from the mid-1960s. Each procedure is the imagined version of an operant procedure: reinforcement, negative reinforcement, extinction, response cost, punishment (covert sensitisation) and modelling. The client imagines a target behaviour, then imagines a consequence, in a structured trial. The core idea of change is that imagined behaviours and imagined consequences obey the same learning laws as overt ones. Imagined consequences can therefore raise or lower how often a real behaviour occurs, and the change then carries over to the natural setting. [source: Cautela & Kearney 1986 via coachsci excerpts; Mullins & Van Pelt 2005; Wikipedia, Covert conditioning]

Scope and a non-negotiable exclusion. Covert sensitisation and related aversive conditioning were historically used in "conversion therapy" to try to change sexual orientation (clients imagined vomiting or shocks paired with same-sex imagery). That use is ineffective and harmful, and professional bodies condemn it. This guide does not cover, and the procedures must never be applied to, sexual orientation, gender identity or consensual adult sexual behaviour. Legitimate targets are behaviours the client wants to change: substance use, smoking, gambling, body-focused habits, avoidance, deficits in assertive or coping behaviour, and (in specialist forensic programmes) offending behaviour. [source: Wikipedia, Conversion therapy; Gale/encyclopedia.com, Covert sensitization] See Section 5.

The procedures are usually delivered individually, often as one component in a multi-part programme (skills training, relapse prevention, education). [source: Plaud 2005; encyclopedia.com]

2. Framework

The handbook does not set out formal named phases. The structure below arranges the handbook's implementation guidelines into a working sequence. [synthesis, built on Cautela & Kearney 1986 guidelines via coachsci "Guidelines for implementing procedures involving imagery"]

Phase A: Behavioural analysis and goal setting (sessions 1–2).

Goals: define the target behaviour in observable terms; record its frequency, severity and settings; identify antecedents (discriminative stimuli) and the reinforcers that maintain it; decide whether the aim is to increase a behaviour (covert positive or negative reinforcement, covert modelling) or decrease it (covert extinction, response cost, sensitisation, self-control triad). [source: Wisocki 2005; Plaud 2005; encyclopedia.com]
In forensic and sexual-behaviour work, a full functional analysis must come first. [source: Plaud 2005]
Move on when: the target is operationally defined, a baseline exists, and the client agrees to the goal.

Phase B: Rationale, consent and imagery training (sessions 1–3).

Goals: explain how imagery works and why the procedure is expected to help; secure informed consent, especially for aversive procedures; confirm the client believes the target behaviour is possible; train imagery clarity, control and involvement; identify reinforcers (or aversive stimuli). [source: coachsci "Prerequisite for effective imagery" and "Guidelines"; Wisocki 2005; encyclopedia.com]
Move on when: the client rates clarity and involvement at 4–5 on a 0–5 scale for practice scenes. [source: coachsci "Guidelines"]

Phase C: Scene construction.

Goals: write target scenes that cover every relevant antecedent situation; for sequences, build chains (usually trained backwards); pick consequence scenes; for strongly disruptive material, fade elements in gradually. [source: coachsci "Guidelines" and "How to develop covert positive reinforcement"]

Phase D: In-session conditioning trials.

Goals: therapist-led trials, then client-led trials, with clarity checks after each new scene. The handbook suggests roughly 30 seconds between trials for covert positive reinforcement and at least 5 seconds for covert sensitisation. [source: coachsci "Guidelines"]

Phase E: Homework and in vivo transfer.

Goals: daily home practice; the client then uses the procedure in real situations and records the behaviour. [source: encyclopedia.com; Fisher & Roget 2009]
Dose conflict [uncertain]: the handbook excerpt caps homework at 10 scenes of the same situation per day per technique. The Gale entry and the SAGE substance-use entry describe 10–20 repetitions per home session or per day for covert sensitisation. This guide follows the handbook cap for any one situation and lets the total rise across situations.

Phase F: Overlearning, thinning and follow-up.

Goals: keep running scenes after the target is reached (overlearning); stretch the covert reinforcement schedule before ending; schedule booster sessions to prevent spontaneous recovery and relapse. [source: coachsci "Guidelines" and "Covert extinction"; encyclopedia.com]
End when: the target has been stable in vivo across the full range of situations, and the client runs the procedure alone.

Typical dose. About 5–20 therapist sessions over a few weeks to several months for covert sensitisation, with boosters over the following 6–12 months. [source: encyclopedia.com] The SAGE substance-use entry gives 6–40 sessions. [source: Fisher & Roget 2009] Weekly individual sessions of about 50 minutes are typical. [synthesis]

3. Guiding principles

[source for principles 1–3: Mullins & Van Pelt 2005; Cautela & Kearney 1986 as cited there. The labels homogeneity, interaction and learning are commonly attributed to the handbook; exact wording not verified: uncertain]

Homogeneity (continuity). Overt behaviour, covert behaviour (images, self-talk, feelings) and physiology are behaviours of one kind. Practice: treat an imagined act as a real response that can be conditioned.
Interaction. Covert and overt behaviour influence each other. Practice: expect imagery change to show up in real behaviour, and use real behaviour to strengthen imagery.
Same laws of learning. Imagined events follow the same operant contingencies as overt ones. Practice: use operant rules for timing, schedules, satiation, extinction bursts and spontaneous recovery when designing covert trials.
Behaviour analysis first. Practice: no scene is written until antecedents, behaviour and maintaining consequences are mapped and measured. [source: Plaud 2005; Wisocki 2005]
Operational, measured targets. Practice: define behaviours observably, chart them, and judge progress by the data, not impressions. [source: Plaud 2005]
Explain and obtain cooperation. Practice: the client must understand the procedure and believe the target behaviour is possible, or imagery is "minimally effective". [source: coachsci "Prerequisite"]
Imagery quality is the active ingredient. Practice: accept only clarity and involvement ratings of 4–5 out of 5, and check after every new scene. [source: coachsci "Guidelines"]
Be in the scene, not watching it. Practice: coach first-person, multisensory imagery; the client should feel "there". [source: Wisocki 2005; coachsci "Guidelines"]
Emotion is required. Practice: scenes should evoke the feelings that go with the real behaviour. [source: coachsci CPR and CNR excerpts]
Immediacy. Practice: the imagined consequence follows the target behaviour within about 5 seconds. [source: Wisocki 2005]
Cover every antecedent. Practice: write scenes for all the situations that trigger the behaviour, and vary them to aid generalisation. [source: coachsci "Guidelines" and "Covert extinction"]
Avoid satiation. Practice: rotate several different reinforcers. [source: coachsci "Guidelines"]
Relaxation only when needed. Practice: use relaxation when anxiety interferes with imagery, not as a routine step. [source: coachsci "Guidelines" and CPR excerpt] The Gale and substance-use entries treat relaxation as a standard preliminary for covert sensitisation, which conflicts with the handbook excerpt. [uncertain]
Build what replaces the problem. Practice: pair any decreasing procedure with reinforcement of an alternative or incompatible behaviour and with skills training. [source: encyclopedia.com; Plaud 2005]
Prefer positive procedures, especially with children. Practice: with children, use covert modelling, covert reinforcement and covert extinction; avoid aversive procedures. [source: coachsci "Guidelines"; Mullins & Van Pelt 2005]
Overlearn, thin, then stop. Practice: continue past criterion and stretch the schedule before ending. [source: coachsci "Guidelines"]
Client-directed aims and consent. Practice: aversive procedures need explicit informed consent, a client-chosen target and a right to stop at any time. They are never used to change identity or orientation. [source: encyclopedia.com on consent; Wikipedia, Conversion therapy; the identity exclusion is synthesis]

4. Intervention inventory

All example language is illustrative unless quoted and cited. Cautela & Kearney's handbook and the original papers are not drawn on in full; step detail comes from the open handbook excerpts and the SAGE and Gale encyclopedia entries, and anything beyond them is marked.

4.1 Behavioural analysis and target definition (preparatory)

Purpose / when: Every case, before any scene is built. It determines which covert procedure fits: increasing or decreasing, and which consequence. [source: Plaud 2005; Wisocki 2005]
Steps: (1) Agree goals and the problems blocking them. (2) Define the target behaviour in observable terms: what, where, when, how often. (3) Collect a baseline with a daily log or frequency count, and in forensic or addiction work add collateral or physiological measures where available. (4) Map antecedents: places, people, times, internal states, urges. (5) Identify the maintaining reinforcer, which covert extinction will need. (6) Identify a competing or alternative behaviour to strengthen. (7) Choose the procedure. [source: Wisocki 2005; Plaud 2005; encyclopedia.com]
Example language (illustrative): "Let's pin down exactly what happens: where you are, what you notice just before, what you do, and what you get out of it right afterwards."
Watch for: vague targets ("be less stressed"); a target set by a third party and not the client; any request to change orientation or identity, which is excluded (Section 5).

4.2 Reinforcer identification (Reinforcement Survey Schedule)

Purpose / when: Before covert positive reinforcement, covert reinforcer sampling or covert modelling, to find several strong imaginable reinforcers. [source: Wisocki 2005]
Steps: (1) Ask the client to complete the Reinforcement Survey Schedule (Cautela & Kastenbaum, 1967). It is a self-report rating of how pleasurable many activities and items are; items are not reproduced here. Interview, observation and family input are alternatives. [source: Wisocki 2005, covert reinforcer sampling entry] (2) Pick the highest-rated, most vivid items, including tangible, social, activity and purely imagined ones. (3) Test each as an image and keep only those rated clear and pleasant. (4) Hold 4 or more in rotation to prevent satiation. [source: coachsci "Guidelines"; the number 4 is synthesis]
Example language (illustrative): "Of everything on this list, which ones give you a real lift when you picture them, so you can almost feel it?"
Watch for: depressed clients who cannot produce any pleasant images. Cautela designed covert negative reinforcement for them (4.7). [source: coachsci CNR excerpt]

4.3 Imagery assessment and training

Purpose / when: Every case, before conditioning trials. Imagery control and clarity are the core requirement. [source: coachsci "Guidelines"]
Steps: (1) Explain the procedure. [source: coachsci "Prerequisite"] (2) Start with neutral, non-relevant scenes such as a familiar room or a walk, to train the components of imagery skill. (3) Describe each scene in multisensory detail: sights, sounds, smells, body sensations, emotions. (4) The client closes their eyes and raises an index finger when the image is clear. (5) Afterwards, the client rates clarity 0–5 and involvement 0–5; continue only at 4–5. Also check speed of forming the image, duration and pleasantness, or ask the client to narrate the scene aloud. (6) Coach first-person experience ("as if it is happening now"), not watching oneself on a screen. (7) With each new scene, re-check clarity, enjoyment or involvement. [source: coachsci "Guidelines"; Wisocki 2005]
Example language (illustrative): "Picture yourself at your kitchen table. Notice the light, the sound of the fridge, the feel of the chair. Raise your finger when you're really there. Now, 0 to 5, how clear was it? How much did you feel you were in it?"
Watch for: ratings stuck below 4 (add sensory detail, shorten the scene, let the client describe it in their own words); intrusive distressing material (see 5.3).

4.4 Relaxation (adjunct)

Purpose / when: Only when anxiety is high enough to disrupt imagery, or early in imagery training. [source: coachsci "Guidelines" and CPR excerpt] Several encyclopedia entries treat it as a routine preliminary for covert sensitisation. [source: encyclopedia.com; Fisher & Roget 2009] [uncertain: the sources conflict]
Steps: Use any brief standard method, for example abbreviated progressive muscle relaxation or slow breathing, for 5–10 minutes before trials. Teach it for home use. [synthesis: the specific method is not prescribed in the sources]
Watch for: relaxation used as avoidance of the target scene; relaxation-induced anxiety.

4.5 Covert positive reinforcement (CPR)

Purpose / when: To increase a desired behaviour, overt or covert: assertive refusal, approaching a feared situation, coping statements, study behaviour, resisting temptation. It is the procedure the handbook describes as "imperative" for behaviour change. [source: coachsci CPR excerpt; Wisocki 2005]
Steps:
1. Define the target response and the situation it should occur in (4.1).
2. Select and rehearse reinforcing images until each is clear on cue (4.2, 4.3).
3. Write a target scene: the usual context, then the client performing the desired behaviour, with the feelings involved (fear, anger, temptation, shyness).
4. Therapist-led trial: describe the scene; the client raises a finger when clearly performing the behaviour; immediately, within about 5 seconds, the therapist cues the reinforcing scene; the client holds it and signals. [source: Wisocki 2005 for the 5-second rule] Using the spoken cue word "reinforcement" to switch scenes is the procedure as usually attributed to Cautela (1970). [uncertain: original paper]
5. Leave about 30 seconds between trials. [source: coachsci "Guidelines"]
6. Alternate therapist-led trials with client-led trials, where the client runs the whole sequence silently and signals at the end. [synthesis consistent with handbook emphasis on client independence]
7. Rotate reinforcers to prevent satiation. [source: coachsci "Guidelines"]
8. For complex sequences, chain scenes and train backwards (4.15).
9. Homework: practise the scenes daily, up to 10 per situation, then perform the behaviour in vivo. [source: coachsci "Guidelines"]
10. Before ending, thin the schedule so not every trial is followed by a reinforcer (4.17).
Example language (illustrative): "You're at the meeting. Your manager adds another project to your list. You feel your chest tighten. You say calmly, 'I can take it on if we move the deadline on the report.' Signal when you've said it... Now switch: you're on the beach at sunset, warm sand, the sound of the waves. Signal when you're there."
Watch for: the client imagining failure instead of success (re-script, or use covert modelling first); a reinforcer losing its pull (rotate it); the client watching from outside (re-coach first-person). It is working when in-scene ratings stay high and the logged frequency of the real behaviour rises.

4.6 Covert modelling

Purpose / when: To teach new behaviour, or increase or decrease existing behaviour, by imagining another person perform it and receive a consequence. Use it when the client cannot yet picture themselves succeeding, or when self-imagery is negative. It is suitable for children. [source: coachsci "Covert modeling"; Mullins & Van Pelt 2005]
Steps:
1. Choose a model similar to the client in age, sex and initial difficulty. Use a coping model (struggles, then manages) rather than a mastery model in early stages. The model should be someone the client can admire and emulate. [source: coachsci "Model characteristics", Lowe 1978]
2. The client imagines the model performing the target behaviour, like watching a film.
3. The model receives a favourable consequence. Reinforcing the model strengthens the effect. [source: coachsci "Model characteristics"; Kazdin 1976 as cited by Uhlemann & Koehn 1989]
4. Gradually change the model into the client. [source: coachsci "Covert modeling"]
5. Make the scene progressively more realistic, shaping and fading along a stimulus dimension.
6. The client imagines performing successfully, followed by CPR.
7. Transfer to the real situation. [source: coachsci "Covert modeling"]
8. Scene length in studies ranges roughly 15–40 seconds, with a period of silent imagining after each description. [source: Uhlemann & Koehn 1989]
9. Using several different models, and having the client elaborate the scene in their own words, are features of Kazdin's research programme. [uncertain: Kazdin's papers]
Example language (illustrative): "Picture a woman about your age, nervous, standing at the counter. Her voice shakes a little, but she says, 'This isn't what I ordered; could you change it?' The server smiles and apologises. Notice her shoulders drop... Now let her face become yours."
Watch for: a model too competent for the client to identify with; the client's fear rising when the switch to self comes too early (go back to the model stage).

4.7 Covert negative reinforcement (CNR)

Purpose / when: To increase a target behaviour by having it end an aversive image. It was developed for clients, such as depressed clients, who cannot form positive images. Reported uses include tantrums, social anxiety, alcohol problems, agoraphobia and a specific fear. [source: coachsci CNR excerpt] It is difficult with children and rarely used there. [source: Mullins & Van Pelt 2005]
Steps:
1. Identify an aversive scene that is strongly unpleasant, can be imagined in clear detail, evokes emotions similar to those around the overt behaviour, and "can be terminated immediately". [source: coachsci CNR excerpt]
2. Exclude scenes that cause nausea or disrupt cooperation. [source: same]
3. Trial: the client imagines the aversive scene and signals. On the therapist's cue, the client switches immediately to the target scene (performing the desired behaviour). The aversive scene must be fully eliminated. [source: same] If it lingers, choose a different aversive scene.
4. Repeat. Expect the aversive scene to lose potency with repetition; replace it when it does. [source: same]
5. Only escape conditioning has been described for CNR. [source: same]
Example language (illustrative): "Picture the dentist's drill starting... Signal... Now, straight away: you're walking into the party, saying hello to Sam, feeling steady."
Watch for: the aversive image persisting into the target scene, which pairs the target with distress instead of relief. Use mild-to-moderate aversive content chosen by the client, not trauma material [synthesis].

4.8 Covert extinction

Purpose / when: To decrease a behaviour by imagining it occur with its usual reinforcer absent. Use it when extinction is appropriate but people around the client will not withhold the reinforcer. It is suitable for children. [source: coachsci "Covert extinction"; Mullins & Van Pelt 2005]
Steps:
1. From the behaviour analysis, name the specific maintaining reinforcer, such as laughter, attention, relief or the payout.
2. Before starting, tell the client about likely difficulties: a temporary rise in the behaviour (extinction burst) and possible irritation or aggression. [source: coachsci "Covert extinction"]
3. Trial: the client imagines performing the behaviour in a typical setting, then imagines the reinforcer clearly not arriving, with people unmoved and nothing changing. Signal at the end.
4. Vary settings and people across scenes to generalise. [source: same]
5. Make sure real-life reinforcement is not delivered at the same time. Mixing them creates intermittent reinforcement and makes the behaviour more resistant. Work with family or staff where possible. [source: same]
6. Schedule periodic trials and boosters against spontaneous recovery. [source: same]
Example language (illustrative): "You tell the story about the motorbike crash. Everyone keeps eating. Nobody looks up. Someone asks for the salt. Stay with that... Signal."
Watch for: the client spontaneously imagining the reinforcer anyway, which the handbook excerpt notes is a major difficulty (re-script, rehearse the 'no response' ending first); an expected rise in frequency in weeks 1–2.

4.9 Covert response cost

Purpose / when: To decrease a behaviour by imagining it followed by the loss of a specific valued reinforcer. [source: Mullins & Van Pelt 2005; Wikipedia, Covert conditioning] It is aversive, so avoid it with children. [source: Mullins & Van Pelt 2005]
Steps: (1) Identify a reinforcer the client already has and values, such as money, a privilege, a planned outing or a possession. (2) Trial: the client imagines the target behaviour, then immediately imagines losing that specific reinforcer, for example handing over cash or cancelling the outing. (3) Vary the lost reinforcer and settings. (4) Pair it with CPR for the alternative behaviour. [steps 1 and 3–4: synthesis from the definitions; detailed handbook procedure: uncertain]
Example language (illustrative): "You place the bet... and you watch a 50 note being taken from your wallet and put in someone else's hand. That's the money for Saturday's concert, gone."
Watch for: losses so severe they evoke shame or hopelessness, not a contingency (keep them proportionate and concrete).

4.10 Covert sensitisation

Purpose / when: To decrease an approach behaviour the client wants to stop and finds rewarding: drinking, drug use, smoking, gambling, overeating episodes, and (in specialist programmes) sexual offending behaviour. The behaviour is paired in imagery with an aversive consequence. It is usually one component of a wider programme that includes skills training and building alternative behaviour. [source: encyclopedia.com; Plaud 2005; Fisher & Roget 2009] Never for sexual orientation, gender identity or consensual adult sexuality (Section 5).
Contraindications and cautions [synthesis unless cited]: Avoid nausea or vomiting imagery with eating disorders (especially purging), emetophobia or pregnancy nausea. Avoid aversive procedures with children. [source: coachsci "Guidelines"; Mullins & Van Pelt 2005] Avoid it in current severe depression, active psychosis, or where the aversive content overlaps with trauma memories. Do not use it where the client is coerced into treatment without real consent; in mandated forensic settings, make consent explicit and documented and follow programme governance.
Consent and safety steps: (1) Explain the rationale, what the imagery will involve and the expected discomfort. (2) Obtain explicit consent, and give the client control of the aversive content and a stop signal. (3) Agree a way to close each session settled (escape scenes, relaxation). [source: encyclopedia.com on rationale, rapport and consent; items 2–3 synthesis]
Steps:
1. Assessment: frequency, severity and settings of the behaviour; build a hierarchy of high-risk situations, often starting with the highest-risk scenario. [source: encyclopedia.com; Fisher & Roget 2009]
2. Choose the aversive image: with the client, list personally aversive consequences. Options include nausea, other strongly disliked sensory experiences, and embarrassing social consequences. Choose the strongest that the client consents to. [source: encyclopedia.com]
3. Relaxation if used (4.4).
4. Approach scene: the client imagines in the first person moving step by step towards the behaviour: setting, time, cues, rising urge. [source: Fisher & Roget 2009]
5. Aversive consequence: as the client gets closer, and just before performing the behaviour, introduce the aversive consequence; it intensifies the closer the client gets. It needs to be vivid enough to evoke real discomfort. [source: encyclopedia.com; Fisher & Roget 2009] Present it verbally, or let the client generate it. [source: Plaud 2005]
6. Escape and relief scene: the client turns away, leaves the situation, and the discomfort fades into marked relief. This negatively reinforces escape. [source: encyclopedia.com; Fisher & Roget 2009]
7. Self-control (avoidance) scenes: alternate with scenes where the client notices the urge or cue, decides not to proceed, and so never experiences the aversive consequence, feeling relief. [source: encyclopedia.com] Cautela's original 1967 procedure alternated aversive and escape/avoidance scenes within each session. [uncertain: original; exact ratio not verified]
8. Inter-trial interval: at least 5 seconds. [source: coachsci "Guidelines"]
9. Alternative behaviour: add CPR for an incompatible behaviour, for example a planned alternative when the urge arises. [source: encyclopedia.com]
10. Homework and in vivo: daily practice (see the dose conflict in Section 2), audio recordings of the therapist's voice if useful, then use in real high-risk situations by imagining the consequence and leaving. [source: encyclopedia.com; Fisher & Roget 2009]
11. Boosters over 6–12 months or more. [source: encyclopedia.com]
Example language (illustrative): "You're walking into the bar. You hear the glasses, smell the beer. As you reach the counter, your stomach turns over, a sour taste rising... You order, and the queasiness surges; as you lift the glass it gets much worse... Now you put the glass down and walk out. Cool air. With every step the sickness eases. You feel clear and relieved. Signal when you're there."
Watch for: genuine nausea or panic beyond the agreed level (reduce intensity, end on escape, reconsider fit); habituation to the aversive image (vary or replace it, with consent); the client using scenes as permission-giving fantasy (keep scenes short and end before the act); urges and in vivo frequency are the measures of progress. Sexual-offending applications belong only in specialist, governed programmes with specific training and multi-component treatment [source: Plaud 2005; Marshall et al. 1991 as cited by Wikipedia].

4.11 Assisted covert sensitisation (variant)

What it is: Covert sensitisation with an actual unpleasant odour presented at the aversive point of the scene, described in the sexual-offending literature (often associated with Maletzky). [uncertain: no primary source is drawn on; listed for completeness only]
Guidance: Use it only within specialist forensic programmes that have their own protocols, governance and consent procedures. It is not a general-practice technique. [synthesis]

4.12 Self-control triad

Purpose / when: A brief, portable self-management sequence used at the moment an unwanted behaviour, thought or urge starts. [source: Mullins & Van Pelt 2005] It is classed with aversive procedures and avoided with children. [source: same]
Steps: (1) The client notices the onset of the target behaviour or thought. (2) The client says "stop", first aloud in session, then subvocally. (3) The client takes a deep breath, exhales slowly and relaxes. (4) The client imagines a pleasant scene. [source: Mullins & Van Pelt 2005] (5) Rehearse it in session to the target scene, then assign it for in vivo use. [synthesis] Fading from overt to covert follows the thought-stopping model. [synthesis]
Example language (illustrative): "The moment you notice your hand going to your hair: 'Stop.' Breathe in deeply... and out slowly, letting your shoulders go... and you're on the hill path in the morning sun."
Watch for: use as a way to suppress obsessional or traumatic intrusions (see 4.13 caution).

4.13 Thought stopping

Purpose / when: To interrupt specific repetitive unwanted thoughts. It was formalised in learning-theory terms by Cautela & Wisocki (1977). [source: Wikipedia, Thought stopping]
Steps: (1) List the target thoughts in the client's words, and agree which to work on and why. (2) Overt phase: the client brings the thought to mind and signals; the therapist says "Stop!" loudly, at varied intervals. (3) Covert phase: the client says "stop" to themselves instead. (4) The client substitutes a pre-agreed positive or task-focused thought. (5) Weekly check of use; the aim is independent use. [source: Wikipedia, Thought stopping, citing Cautela & Wisocki 1977] A rubber-band snap as a cue is described in that source. [source: same] This guide does not recommend it [synthesis].
Example language (illustrative): "Bring the thought 'I'll never get through this' to mind, and lift your finger when it's there... STOP. Now: 'One task at a time; start with the email.'"
Watch for: research on thought suppression shows rebound effects. [source: Wikipedia, Thought stopping, citing Wegner et al. 1987] Current evidence-based treatment of OCD and PTSD relies on exposure and processing, not suppression, so avoid thought stopping for obsessions or trauma memories. [synthesis; uncertain: specific guideline text]

4.14 Covert reinforcer sampling

Purpose / when: To increase the number and variety of pleasant activities a client will actually do, by repeatedly imagining their sensory features. Use it as an adjunct, for example in low mood or after giving up a substance. [source: Wisocki 2005, covert reinforcer sampling entry]
Steps: (1) Explain why varied pleasant activity matters. (2) The client rates items on the Reinforcement Survey Schedule; select action-oriented items rated at least somewhat pleasant. (3) Build a series of multisensory images for them. (4) The client imagines several of them several times a day, in blocks of 10–15 trials, varying content to prevent satiation. (5) No consequences are attached. [source: same]
Example language (illustrative): "Picture phoning Ana to suggest the Thai place: hearing her voice, the clink of the restaurant, the smell of lemongrass."
Watch for: whether imagined activities start appearing in the activity log.

4.15 Covert chaining (backward)

Purpose / when: For complex behaviour sequences, for example an exam day from waking to handing in the paper. [source: coachsci CPR excerpt; Wisocki 2005]
Steps: (1) Break the sequence into links. (2) Train the final link first with CPR. (3) Add the preceding link, run both, and reinforce at the end. (4) Continue backwards until the whole chain runs. [source: coachsci CPR excerpt for backward sequencing; step detail synthesis]
Watch for: weak middle links; isolate them and train them separately.

4.16 Homework, audio recordings and in vivo transfer

Steps: (1) Write a scene card or list for each target situation. (2) Assign daily practice; the handbook excerpt caps it at 10 scenes per situation per technique per day. (3) Optionally record the therapist reading the scenes; CPR instructions have been adapted to audiotape. [source: coachsci CPR excerpt; Fisher & Roget 2009] (4) Use a practice log with clarity ratings. (5) Progress to in vivo use: imagine the consequence at the real cue, then act. (6) Keep a behaviour log. [source: coachsci "Guidelines"; encyclopedia.com; logging is synthesis]
Watch for: low completion (Section 5.4); rote practice with low clarity.

4.17 Overlearning, schedule thinning and booster sessions

Steps: (1) Continue trials after the behaviour reaches target. (2) In CPR, gradually reinforce only some trials before ending. (3) For decreasing procedures, schedule periodic trials and boosters, as covert sensitisation boosters may run 6–12 months or longer. [source: coachsci "Guidelines" and "Covert extinction"; encyclopedia.com]
Watch for: spontaneous recovery after a gap; this is expected, so respond with a booster rather than restarting treatment.

5. Handling problems

The handbook excerpts address extinction bursts, aggression, spontaneous recovery, satiation, habituation to aversive scenes and disruptive scenes. Everything else here is marked [synthesis].

5.1 Stuck: poor imagery. Ratings stay below 4.

Return to neutral training scenes and add sensory channels.
Shorten the scenes.
Let the client describe the scene aloud in their own words. [source: Wisocki 2005]
Use covert modelling with another person before self-imagery. [source: coachsci "Covert modeling"]
If imagery stays weak after about 3 sessions of training, switch to overt or in vivo operant procedures. [synthesis]

5.2 Stuck: no transfer to real life.

Check that scenes cover every real antecedent and are varied. [source: coachsci "Guidelines" and "Covert extinction"]
Check that the environment is not still reinforcing the behaviour intermittently. [source: coachsci "Covert extinction"]
Add in vivo rehearsal, skills training and an alternative behaviour. [source: encyclopedia.com; Plaud 2005]
Re-run the functional analysis: the maintaining reinforcer may have been misidentified. [synthesis]

5.3 Overwhelm and disruptive material.

If a scene is strongly disruptive, fade it in element by element. [source: coachsci "Guidelines"]
If anxiety blocks imagery, add relaxation. [source: same]
If aversive imagery produces real nausea, panic or trauma intrusions: stop the trial, go to the escape/relief scene or a grounding exercise, lower the intensity or change the aversive content, and review consent. If trauma material appears, pause covert aversive work and assess for trauma-focused treatment. [synthesis]
With CNR, never use scenes that cause nausea. [source: coachsci CNR excerpt]

5.4 Non-adherence with homework.

Agree a smaller daily dose; the handbook cap is 10 scenes per situation. [source: coachsci "Guidelines"]
Provide audio recordings. [source: coachsci CPR excerpt; Fisher & Roget 2009]
Link practice to an existing daily routine, use a simple log, and reinforce completion in session (overt reinforcement of practice). [synthesis]
Treat repeated non-completion as data: ask what it costs the client and whether they still want the goal. [synthesis]

5.5 Resistance and ambivalence about giving up the behaviour. Common with substances and gambling, where the behaviour is still rewarding.

Revisit the rationale and the client's own reasons. [source: coachsci "Prerequisite"]
Without the client's belief that change is possible, imagery is minimally effective. [source: same] Confirm that the goal is the client's own.
Consider a motivational-interviewing phase before aversive work.
Start with CPR for alternatives, which is less aversive, before sensitisation. [synthesis]

5.6 Ruptures. Aversive procedures can make the therapist feel punitive or controlling.

Name this openly.
Hand control of intensity and the stop signal to the client.
End every session on a relief or reinforcing scene.
Repair any rupture by validating the client's experience and adjusting the procedure, not by insisting on it. [synthesis]

5.7 Modality-specific difficulties.

Extinction burst (early increase) and extinction-induced aggression: warn the client in advance and keep going; monitor safety where aggression is possible. [source: coachsci "Covert extinction"]
Client imagines the reinforcer anyway during covert extinction: re-script the scene and rehearse the 'non-response' ending on its own first. [source: difficulty named in coachsci "Covert extinction"; response synthesis]
Reinforcer satiation: rotate reinforcers. [source: coachsci "Guidelines"]
Aversive image loses potency: replace it, with consent. [source: coachsci CNR excerpt]
Aversive image lingers into the target scene (CNR): choose a different aversive scene. [source: same]
Spontaneous recovery after ending: run boosters and periodic trials. [source: coachsci "Covert extinction"; encyclopedia.com]
Depressed client cannot form pleasant images: use CNR or covert reinforcer sampling. [source: coachsci CNR excerpt; Wisocki 2005]
Children: use only CPR, covert modelling and covert extinction. [source: Mullins & Van Pelt 2005]

5.8 Risk: suicide, self-harm and deterioration.

Depressed clients and clients withdrawing from substances are at higher risk. Screen for suicidal ideation at intake and when mood drops, using your service's standard risk assessment and a collaborative safety plan. Lethal-means counselling covers safe storage or removal only.
Suspend aversive procedures during a crisis, because aversive self-imagery can feed hopelessness.
Never use aversive imagery about self-harm itself as a "consequence". [synthesis, following standard practice]

5.9 Requests to change sexual orientation or gender identity, or historic harm.

Covert sensitisation was one of the methods of conversion therapy: imagined vomiting or shocks paired with same-sex arousal. It was found ineffective, and conversion therapy is associated with higher depression, substance use and suicide attempts. Professional bodies including the American Psychiatric and American Psychological Associations oppose it; the UN Independent Expert called for a global ban in 2020, and several countries ban it in law. [source: Wikipedia, Conversion therapy]
Legal status varies by jurisdiction and was in flux in 2026, including US court rulings described on that page. Professional ethical positions do not depend on the legal position. [uncertain: legal details not verified beyond that page]
If a client asks for this: decline to target orientation or identity. Explore the distress underneath, such as family or religious conflict, minority stress or shame. Offer affirmative psychotherapy (for example, the APA guidelines for practice with sexual minority, transgender and gender-nonconforming people), or refer to an affirming specialist. [synthesis; guideline names are standard references]
If a client discloses past conversion therapy that used these methods: assess for trauma, shame and suicidality; do not use aversive conditioning with this client; consider trauma-focused and affirmative work. [synthesis]
In forensic sexual-offending work, the target is offending behaviour, defined by the functional analysis, never orientation. [source: Plaud 2005 on functional analysis; boundary synthesis]

5.10 Mandated clients. Consent obtained under pressure is not free consent. Use positive procedures first, document informed consent for any aversive component, and follow programme governance. [synthesis]

Sources

Sources: