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Behavioral treatment of thunder and lightning phobias
BEHAVIORAL
TREATMENT OF THUNDER LIGHTNING PHOBIAS
AND
LARS-G~RAN &r* Psychiatric
Research
Center.
(Rewired
4 Nocemhrr
University
of Uppsala
1977)
Summary-The
use of four different behavioral techniques in the treatment of six female clients with thunder and lightning phobia IS descrtbed. The techniques (Systematic desensitizatton. Covert reinforcement. Stress inoculation training. and Self administered desensitization with tape recorder) were evaluated in single-case experimental designs. using both self-report. behavioral. and physiological data. The immediate and follow-up results showed that five of the clients were completely recovered and the sixth markedly improved after their respective treatment (IO-14 session). These results and the questions concerning continuous assessment in single-case design and external validity of laboratory assessment in phobic conditions are discussed.
Phobia for thunder and lightning is classified by Marks (1969) as “Miscellaneous specific 14% of the phobic patients seen at Maudsley phobia”, a category which comprised hospital in London during a 10 year period. Although phobias are one of the disorders most frequently treated by behavior therapists, there are only a few reports on behavioral treatment of thunder and lightning phobia in the literature. Hoenig and Reed (1966) described the use of systematic desensitization in the treatment of a 32 year old woman. The client was completely recovered after 11 sessions and the outcome assessment was based both on self-reports and electrodermal responses to a flickering neon light. Furst and Cooper (1970) treated a 44 year old housewife with a long-lasting fear of thunderstorms. This was successfully desensitized in 23 sessions and the client “remained symptom free and had not developed any other signs of neurosis” (Furst and Cooper, 1970. p. 89) at the 1 l-months follow-up. Lubetkin (1975) used a planetarium in the desensitization of a 45 year old woman. The client was trained in progressive relaxation and in the planetarium she first relaxed herself and then the projectionist started a three minute presentation of lightning and thunderstorms. During the presentation the client attempted self-relaxation and afterwards she continued to relax herself for several minutes. The projectionist then started the presentation again. The client had eight sessions at the planetarium with an average of eight presentations on each visit. The 9-month follow-up showed a marked improvement in the client’s condition. Finally Leitenberg. cf ul. (1975) used reinforced practice (praise and feedback) in the treatment of a 43-year old married woman. An artificial situation was devised in which flood lamps were synchronized with a stereotape track of a thunderstorm. In the first phase (praise alone) the client gradually increased the time she stayed in the situation. The rate of improvement was greatly accelerated during the next phase when feedback was added to praise. Her ratings of anxiety however did not show any decline. Therefore the client was required to remain in the testing situation for a maximum of 30 min during the third phase of treatment, which led to a decrease in her anxiety rating. No follow-up data were presented on this client. In summary then. these four case studies (all middle-aged women) show that desensitization has been the primary treatment for thunderstorm phobias. It is, however, impossible to draw any conclusions as to the effectiveness of behavioral methods for this * Requests for reprints should of
Uppsala.
Ulleraker
Hospital.
be addressed to Lars-Goran S-750 I7 Uppsala. Sweden. 197
6st.
Psychiatric
Research
Center.
Untversity
LARS-GBRAK6s~
19x
specific phobia since only one study (Leitenberg er al., 1975) applied an experimental single-case design, albeit without followup data. The purpose of the present study was to explore (a) the applicability of different techniques in the treatment of thunder and lightning phobia. and (b) the use of assessment methods in all three response systems of interest with phobic clients, i.e. verbalcognitive. overt behavior, and physiological.
METHOD Assessment
AND
RESULTS
and uppuratus
It is, for natural reasons, very difficult to arrange an in-uiuo behavioral test of thunder and lightning phobia. In order to measure the client’s fear of thunderstorms the following laboratory test was designed and applied immediately after each session. ~~~~uio~~~ fesr. For clients A-C, a 6 min tape recording of an actual thunderstorm was played with a cassette recorder (Philips N2209) and two loudspeakers. With the help of one Kodak carousel Model S projector and a slide synchroniser 20 slides of clouds that could develop into a thunderstorm, lightning etc. were presented in a synchronized fashion. This was done so that when the sound of thunder was remote the slides contained clouds at a distance etc. Furthermore, in order to simulate the lightnings a neon lamp was used. This light source was switched on and off by impulses from a second cassette recorder and slide synchroniser and was synchronised to the sound. The slides were projected on a screen 2 m in front of the clients. who were seated in a comfortable armchair during the testing. The loudspeakers were placed on each side of the screen. and the room was darkened during the testings. For clients D-F the following modifications of the test were made. The tape recording of the thunderstorm took 9e min instead of six, an amplifier (2 x 16 W) was connected to the tape recorder. the number of slides were increased to 25, another loudspeaker was added. and the neon lamp was replaced with an electronic flash. The flashlight was recharged in 0.5 set and could thus flash in rapid succession. It was turned towards the white ceiling which gave a dazzling and highly realistic light. In a pilot study this latter form of the test was shown to six persons who were fearful. but not phobic to thunderstorms. The sound, pictures, and flashes were judged to be very realistic except that the subjects did not experience any danger of being hurt by the stroke of lightning or fire in the testing situation. In order to create a high demand situation (cf. Bernstein, 1973) and to urge the clients to endure the test, the following instructions were given: “You are now going to see a combined sound and picture presentation of thunderstorms. During this presentation we will measure your respiration and heart rate. In order to make our measures reliable it is important that you concentrate on the presentation and really try to imagine that you are experiencing an actual thunderstorm. It is important that you try to see the entire presentation. Instead of, e.g. closing your eyes or looking away. you should stop the presentation by pressing the button at your left.” The dependent measures that were obtained from this test are (a) the observation time. and (b) the client’s rating of the degree of anxiety (O-10) experienced during the test. This rating was obtained immediately after the behavioral test. Self-report measures. Before. after, and at follow-ups the clients answered the following questionnaires: (a) Fear Survey Schedule-122 (Tasto and Hickson, 1970), and (b) Thunder and Lightning Phobia Scale. which was constructed for this study and consists of 15 items to be rated on a 5-point scale. The reliability of the scale was 0.85 (Cronbath’s Alpha). With regards to validity the scale was able to differentiate (p = 0.001) between thunderstorm phobics (n = 17) and a non-phobic group (n = 12). Physiological measures. During the behavioral test the clients heart-rate (D-F only) and respiration-rate were continuously monitored. (a) H-R was assessed by measuring the bloodflow of the right index finger through a finger-stall equipped with a photocell.
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(b) Respiration-rate was measured with a bellows stretched around phragm. The signals were fed into a Gilson four-channel polygraph.
the client’s dia-
Client A Background. Client A is a 64 year old married female, who has been afraid of thunderstorms since her early childhood. She has acquired her phobia through modelling on the part of her parents who always took extraordinary measures of precaution when there was a forecast of a thunderstorm. The client is handicapped by her fear in many ways. She cannot stay alone in her summerhouse, or enjoy sunshine and good weather due to the risk of a thunderstorm. During the summer her thoughts center around thunder and lightning and she compulsively listens to the weather forecasts on the radio and TV, checking to see if there is any risk of a thunderstorm. During a thunderstorm she experiences strong anxiety, headache, palpitation and urge to urinate. She cannot sit in a chair but must be on her feet and occupied all the time. Procedure. An A-B design (Hersen and Barlow 1976) was used with three and 13 sessions in each phase respectively. The treatment method applied in this case is called self-administered desensitization with tape recorder. In this technique two tape-recorders. one playing the client’s favourite music and the other playing a IO min tape with the sound of thunder, are used. The favourite music was played continuously but the client controlled the tape recorder with the thunder. When she felt calm and ready to start she turned on the sound of thunder and gradually increased the volume to as much as she could stand. She was instructed that as soon as she felt the slightest discomfort she was to decrease the volume (or turn the tape-recorder off) until she once again was calm and then to gradually increase the volume again. When she managed to listen to the sound of thunder (at a preset maximum level) the volume of her favourite music was lowered somewhat and she started with the *‘thunder-tape” all over again. This was repeated several times until at the 13th treatment session she could listen to the whole thunder-tape without any help from her favourite music and without any discomfort. Results. The client’s results on the behavioral test is shown in Fig. 1. During baseline she stopped the presentation of the “thunder and lightning slide show” after 5’20” on the average, which was concurrent with maximum anxiety. Immediately after the first treatment session she could watch the whole presentation and this was the case during the remainder of this phase. Her rating of anxiety decreased steadily and after the last treatment session she experienced no anxiety. The mean for this phase was 5.4. The results were also the same at a 4-month follow-up occasion. Concerning the s&report measures client A had increased her scores on FSS-122 from 288 before to 343 after treatment. There was however a decrease at follow-up Self-administered dbrensitization wrth tape-recorder 0
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on the laboratory
test
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to 274 points. The same trend was noticed on the “thunder and lightning phobia scale”; 61-64-48 before, after and follow-up respectively. At the follow-up (4 months after therapy) a summer had passed and the client had experienced several thunderstorms without her former difficulties and physiological reactions. For the first time for as long as she could remember. the summer had been enjoyable instead of potentially fear-arousing. Ciierlr B Backgrourrd. This client is a 37 year old married female. Until recently she lived in the countryside but has moved into town due to her fear of thunderstorms. She has been phobic for thunderstorms as long as she can remember and her fear seems to have been modeled by her grandparents who were extremely afraid of thunderstorms according to the client. The client was handicapped by her phobia in different ways. During hot. stuffy summer days she was very uncomfortable due to the possibility of a thunderstorm. Immediately before a thunderstorm she was panicky and during it she experienced headaches, tremor. sweating and sometimes nausea. Procedure. In this case, an A-B design was also used with systematic desensitization (Wolpe, 1969) as treatment method. Relaxation training was completed in three sessions and a hierarchy of 1 l-items was desensitized in eight sessions. Results. As can be seen from Fig. 2 client B was able to watch the whole presentation at the first baseline testing. She experienced medium anxiety while doing so (mean = 5.3). During the treatment phase her anxiety rating fluctuated somewhat but showed a tendency to decrease during the last third of this phase (mean for the B-phase 4.8). At follow-up she experienced only minimal anxiety (1) while watching the presentation. As for the self-report measures her scores on FSS-122 did not change after treatment (183 vs. 183) but there was a small decrease at follow-up (170). There was however a marked decrease of her scores on the TLPS (6844-45) before. after and at follow-up. At the follow-up after the summer-season client B did not consider herself completely recovered from the phobia but was greatly improved. The anticipation anxiety had vanished and during a thunderstorm she could look out the window. watch the lightning and listen to the thunder. Clirrlr C Background. Client C is a 27 year old married woman living in the countryside. She has been thunder-phobic since early childhood and recalls certain episodes when lightning struck where she has been staying. She often has a headache when she notices that there is thunder in the air and at the risk of a thunderstorm she has difficulty concentrating and checks constantly for thunderclouds or distant sounds of thunder.
Fig. 2. Chent B. Ohservatlon
time -0
and selfrating
of anxiety
e--o
on the laboratory
test.
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This difficulty in concentrating increases as the thunderstorm approaches and she cannot do anything but walk around in the house, look out the window and count the time between the lightning and the thunder clap. When the thunderstorm is close to her house she cannot stay in the house any longer but persuades the family go out and sit in the car until the thunderstorm is over. Procedure. An A-B design was used with a baseline of four and a B-phase of 14 sessions. The treatment applied was covert reinforcement (Cautela, 1970) in which a behavior incompatible (mostly approach behaviors) to the phobic behavior is covertly reinforced by letting the client imagine a positive scene contingently upon an approach behavior. In this case normally high frequency and anxiety-incompatible behaviors (weaving, reading, talking to friends) were reinforced. The therapist instructed the client to perform these different behaviors in a calm and concentrated way. Each sequence of a thunderstorm was divided into small steps, and at each step the client was covertly reinforced for imagining herself performing the incompatible behaviors (e.g. weaving) while the thunderstorm came closer and finally vanished. Results. As can be seen in Fig. 3 this client also could watch the entire presentation of the thunderstorm at the first baseline testing and every time thereafter. There was a tendency for the anxiety rating to decrease during baseline (mean = 6.0) and this continued during the treatment phase (mean = 1.4). For the last 10 sessions and at follow-up (4 M) she experienced minimal anxiety (1) but was never completely free from discomfort while watching the presentation. Her scores on the self-report measures decreased somewhat on FSS-122 (244-196-167) and very much on TLPS (61-3(3-22). At the follow-up client C described having experienced five thunderstorms during the summer season, and reported that she no longer had any fear of thunderstorms. When a thunderstorm started she could continue with whatever she was doing without any di~culty. Client
D
Background. The client is a 23 year old married woman who had been fearful of thunderstorms for as long as she could remember. She had never encountered any traumatic situations with thunderstorms, but instead acquired her phobia through modeling. Her mother was very afraid of thunderstorms and used to take her children and sit under the kitchen-table whenever one occurred. The client’s fear of thunderstorms necessitates many precautionary steps e.g. disconnecting electric apparatuses, not talking on the telephone etc. During a thunderstorm she ruminates about the worst thing that could happen and this increases her anxiety. Furthermore she has difficulty concentrating and motor& uneasiness. She walks around the house checking that every precaution has been taken.
202
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Procedure. After a three-session baseline this client’s phobia was treated with systematic desensitization which required 10 sessions (six for relaxation training and four for desensitization proper). Results. In the behavioral test (Fig. 4) the client could watch the whole presentation during the baseline phase, but was rather anxious (M = 7.0) while doing so. Physiologically she reacted with an elevated heart-rate (M = 72.6) compared to a resting value of 63 b/m. Her respiration-rate was however fairly normal (M = 12.8). In the treatment phase her anxiety rating decreased steadily (M = 2.2). As for the heart-rate there was a decrease during the first half and an increase during the last half of phase B. The average (M = 63.5) was however substantially lower than the baseline value. There was no change in respiration-rate during the treatment phase. Her results on the self-report scales showed a large decrease on FSS-I22 (207-165-158) and a rather small decrease on TPLS (42-40-34) before, after. and at follow-up respectively. Both at the 3 and 9 months foltow-up she could watch the entire thunder presentation without any discomfort at all. Physiologically she reacted at baseline levels on both these occasions. She also reported that none of the pre-treatment problem behaviors described above were present during the thunderstorms she had experienced during the summer season.
Clietlt E Buckground. Client E was a 77 year old woman (retired teacher), who dated her phobia back to her childhood. As a child and during her teens she had experienced some very traumatic thunderstorms, i.e. the lightning had struck and set the house she lived in on fire. In the spring the client starts to worry about the thunderstorms that will come during the summer, which in turn leads to difficulty in sleeping. She avoids listening to weather forecasts, so she does not have to know if a thunderstorm is predicted, knowledge which makes her more anxious. During a thunderstorm she has very strong physiological reactions. She experiences pain in her chest, trembles and feels panic-stricken. When the. thunderstorm is close to her house she crawls someplace where she does not hear the thunder or see the lightning. In order to further exclude these stimuli she buries her face in a pillow.
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If possible she seeks the company of other people. Although she is still scared and panicky, she feels safer than being on her own. Procedure. An A-B-C design was applied in which the client, after a four session baseline, received relaxation training (five sessions) and self-administered desensitization with tape recorder (eight sessions). The latter method was similar to the treatment of client A but divided into two parts. In the first part relaxation and listening to her favourite music were used as activities incompatible to the anxiety aroused by the sound of thunder. No assessment was made during this part of phase C as this was likely to influence the treatment result negatively. In the second part the client’s fear of lightning was treated. A tape was prepared so that 20 artificial lightning flashes were followed by the sound of thunder with intervals of l-10 set, according to the principle that the closer the sound was perceived to be the shorter the interval. The order of these pairs of lightning and sound was randomized on the tape. In this part no music was used but the client could stop the tape-recorder whenever she felt anxious and turn it on again when she was calm. During this part of phase C, assessment was made with the behavioral test. Results. In the behavioral test (Fig. 5) client E observed the entire presentation at all sessions. During the baseline phase she was rather anxious (M = 8.0) while doing so. Her heart-rate and respiration-rate were 75.6 and 17.5 respectively. The first treatment phase resulted in decreases of anxiety-rating (M = 40), respiration rate (M = 14.6), and heart-rate (M = 71.7). During the self-administration desensitization there was a further small decrease of her anxiety (M = 3.0) and heart-rate (M = 69.7) while the respiration-rate remained unchanged. At the follow-ups 3 and 9 months after the end of therapy, the results on the test were on the whole unchanged. Of the self-report questionaires there was a large decrease on FSS-122 (383-293-256) and a smaller on TPLS (64-60-52). At the 9 months follow-up, after the summer, this client described that she had, for the first time in decades, been able to enjoy her summer stay in Italy in spite of several encounters with thunderstorms. The anticipation worries, tension, and sleeping difficulty had also vanished and she considered herself as completely recovered.
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Client F Background. This client was a 23 year old nurse who had acquired her phobia only seven months prior to treatment. At that time she experienced a thunderstorm that started with a whirlwind which brought a lot of dust and pebbles with it. The client’s mother. a very religious person. cried out “It is Doomsday”. which frightened the client and she ran into the bedroom. The ensuing thunderstorm was a very unpleasant experience. After that occasion she considered each thunderstorm as increasingly more unpleasant. During a thunderstorm she moves around continually and cries occasionally. She compulsively looks out the windows, cannot concentrate on anything or talk to anyone. She has a strange feeling in her body and experiences strong palpitations. After the first traumatic experience she has been tense and fearful most of the time. She is less fearful at work when she is busy but at home she listens to all weather reports and often checks the sky for signs of thunderstorms. During the warmest period of the summer she was on sick-leave for a week because of her fear. Procedure. Using an A-B-C design this client’s phobia was treated with relaxation and stress-inoculation training (SIT; Meichenbaum 1977). SIT is focused on changing the client’s cognitive behavior in connection with the phobic stimulus. Instead of the negative self-statements and catastrophic thoughts that usually dominates, the client is taught to apply different coping self-statements. The treatment consists of three phases: (1) education phase, (2) training phase. and (3) application phase. In the first phase the purpose is to give the client a reasonable explanation for her phobia and to make her accept it. The actual training in coping and positive self-statements takes place in the second phase and in the third the client is given different opportunities to apply her new-learned skill in stressful situations. Results. In the behavioral test (Fig. 6) this client could watch the whole presentation from the first testing. She experienced medium anxiety while doing this (M = 5.2 during baseline). Her anxiety diminished in the relaxation phase (M = 3.3) and further still in the SIT-phase (M = 1.8).
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F: Observation
time.
selfrating of anxiety. the laboratory test.
heart-rate.
and
respiration
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Physiologically she fluctuated somewhat during baseline with means for heart-rate and respiration-rate of 68.2 and 14.5 respectively. During the relaxation phase her heartrate dropped considerably (M = 59.0). but it increased to the baseline level during the SIT-phase (M = 68.6). There were however only small changes in her respiration rate during these phases; the means were 14.0 and 15.5 respectively. In the self-report measures there was a small increase in the FSS-122 (161-l 75-181) and a very large decrease on the TPLS (67-30-27). At the six-months follow-up testing (after a summer) the client rated her anxiety to I while watching the presentation. Her heart-rate was 75.0 and respiration rate 17.5. At no time did she dwell on the possibility of a thunderstorm and during actual storms she had looked out the window. and then continued with her job or house-work. DISCUSSION
There are a large number of behavioral techniques that have been applied in the treatment of phobias: Marks (1975) describes more than 20 different methods. Phobia for thunderstorms, however, limits the range of possible methods, as the technique based on in-km exposure are not applicable to this disorder. In the six single-case studies presented in this paper four different treatment techniques (systematic desensitization, covert reinforcement, self-administered desensitization with tape recorder and stress inoculation training) were applied to thunder and lightning phobia. The tentative conclusion that can be drawn from these cases is that all of the techniques used appeared to be equally applicable to this condition. It is however not possible to conclude that one is more effective than the other as in no case was more than one technique applied. The overall conclusion concerning the outcome is that all clients (except A) reduced their degree of fear after treatment as measured by self-report questionnaires and selfrating of anxiety. These results were corroborated by the physiological (heart-rate and respiration rate) data for clients D-F. At the follow-ups (4-9 months after therapy) a summer had passed and all clients had experienced several thunderstorms. All but client B considered themselves as completely recovered from the phobia and reported that during a thunderstorm they continued with the on-going activity instead of the different avoidance behaviors which they engaged in before treatment. The second purpose of this study was to try out assessment methods in the different response-systems of interest in anxiety clients. The self-report measures (FSS-122 and Thunder and Lightning Phobia scale) functioned satisfactorily for this study. The changes were rather small on FSS-122, which was expected, as the treatment of a specific phobia hardly would generalize to other fears. The changes on the TPLS were larger and in agreement with the clients’ own overall ratings of the outcome. The behavioral test. which for obvious reasons could not be administered in-viva, was an artificial laboratory test. In order to avoid artifacts, high demands (Bernstein, 1973) on the clients’ performance were presented in the instructions. This led to a ceiling-effect, and all clients (except A) could watch the entire presentation from the very first trial during baseline. This, in turn, meant that only an impairment as result of treatment could be reliably evaluated. As a consequence, the conclusive power of the, designs applied was weakened. as only the self-reports of anxiety remained, and could be expected to change in a predictable direction. Of the physiological measures obtained (from clients D-F) heart-rate showed rather large decreases. Compared to baseline client C had 9.1 b/m. lower on the average during the treatment, client E reduced her heart-rate with 3.9 b/m during the first and 5.9 b/m during the second treatment phase, and finally client F showed a reduction of 9.2 b/m during her first treatment period. At follow-ups the heart rate had increased again to the pretreatment level but this should be regarded with caution as it is based on only one testing while the treatment values were means of 5-10 testings. The changes in respiration-rate were generally much smaller and as the pre-treatment values were within the normal range no extensive changes could be expected.
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This study raises some important questions concerning the assessment of phobias in single-case experimental designs. According to Hersen and Barlow (1976) continuous assessment is one defining characteristic of these designs. Generally speaking there are two types of continuous measures, (a) the assessment and treatment method are closely linked together. e.g. as in most of Leitenberg and his coworkers’ studies of reinforced practice with different phobias (Leitenberg, 1976), and (b) the assessment is made independent of the treatment method in question, e.g. Liberman and Smith (1972) multiple baseline design where SD was used with a multiphobic woman. For reasons described earlier the second type of assessment was used immediately after each treatment session. The same sound and slide presentation of thunderstorms was used on every occasion and this makes the question of reactivity more pertinent. The possibility exists that the gradual decline in the clients’ self-ratings of anxiety was not an effect of treatment but rather habituation, i.e. the clients became used to and more familiar with the presentation. This hypothesis is however contradicted by the fact that all clients reported very marked changes in their in-uiuo behaviors during a thunderstorm. and five of the six clients considered themselves as totally recovered from the phobia. One way to reduce the risk of reactive effects is to make a new slide show for each testing. This would have meant 20 different slide shows for the present study, which is virtually impossible for both practical and economical reasons. Another important question concerning the assessment of this phobia is what Lick and Unger (1975) have called external validity, i.e. to what extent do changes on a laboratory test of fear correlate with changes in the client’s behavior during an in-uivo confrontation with the phobic stimuli? The most obvious difference between a laboratory test of fear (as in this study) and an in-u&o anxiety situation is the degree of control and predictability of the situation. The laboratory test situation is “safe” in the respect that the clients know that nothing really harmful can happen to them. In a real confrontation with the phobic stimulus however the client is uncertain of the exact nature of the stimulus because it is often vague and ambiguous. Consequently the responses that the client has to perform in order to efficiently cope with the anxiety is unclear and this often intensifies the fear (Borkovec. Weerts and Bernstein, 1977). Unfortunately it was impossible to arrange pre-and post in-uiuo assessments of the clients’ thunderstorm phobia in a way that permitted sufficient control over the situation. This is however a very important area for future investigations in order to find out if the correlation between an anxiety provoking situation in-aiuo and in the laboratory is high enough to allow the use of laboratory tests of fear in clinical phobias. The thunder and lightning phobia per se does not seem to be different from most other phobias, either in regard to acquisition, or treatment. Clients A, B and D seem to have acquired their fear through modeling from parents or grandparents, while clients C. E and F have experienced traumatic incidents in connection with thunderstorms. As for treatment the techniques applied in the different cases were chosen on the basis of the behavior analysis performed during the baseline phase. Judging from our experiences this type of phobia does not seem to require a specific type of behavioral treatment. Instead the clinical procedure of adjusting the treatment technique to the characteristics of the individual client appears to be as valid for thunder and lightning phobia as for most other types of phobias. AcknoH:/~dg~r,ltnrs-Leif
Havneskcld. Anita Jerremalm. Jan Johansson. and Rolf Olofsson served as therapists. suggestions on the manuscript. Their assistance is gratefully acknowledged.
and Sandra Bates gave valuable
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HERSENM. and BARLOWD. H. (1976) Single Case Experimental Designs. Pergamon Press, New York. HOENK J. and REEDG. F. (1966) The objective assessment of desensitization. Br. J. Psychiat. 112, 1279-1283. LE~TENBERG H. (1976) Behavioral approaches to the treatment of neuroses. In Handbook ofBehaciorModification and Behavior Therapy (Ed. H. LEITENBERG). Prentice-Hall. Englewood Cliffs. LE~TENBERG H., AGRASW. S., ALLEN R., B~TZ R. and EDWARDSJ. (1975) Feedback and therapist praise during treatment of a phobia. J. cot&r. c/in. Psycho/. 43. 396-404. L~BERMAN R. P. and SMITHV. (1972) A multiple baseline study of systematic desensitization in a patient with multiple phobias. B&au. Therap. 3, 597-603. LICK J. R. and UNGER T. E. (1975) External validity of laboratory fear assessment: Implications from two case studies. J. consult. c/in. Psychol. 43, 864-866. LUBETK~N B. (1975) The use of a planetarium in the desensitization of a case of bronto- and astra-phobia. Behau. Therap. 6, 276277.
MARKSI. M. (1969) Fears and Phobias. Heineman. London. MARKSI. M. (1975) Behavioral treatments of phobic and obsessive-compulsive disorders: A critical appraisal. In Progress in Behavior Modijcation (Eds. M. HERSEN,R. M. ESLER and P. M. MILLER).Vol. 1. Academic Press, New York. MEKHENBAUMD. (1977) Cognitive-Behavior Modification. Plenum, New York. TASTOD. L. and HICKSONR. (1970) Standardization and scaling of the 122-item fear survey schedule. Behac. Therap. 1, 473-484.
WOLPE,J. (1969) The Pracrice
ofBehaviorTherapy.
Pergamon, New York.
TREATMENT OF THUNDER LIGHTNING PHOBIAS
AND
LARS-G~RAN &r* Psychiatric
Research
Center.
(Rewired
4 Nocemhrr
University
of Uppsala
1977)
Summary-The
use of four different behavioral techniques in the treatment of six female clients with thunder and lightning phobia IS descrtbed. The techniques (Systematic desensitizatton. Covert reinforcement. Stress inoculation training. and Self administered desensitization with tape recorder) were evaluated in single-case experimental designs. using both self-report. behavioral. and physiological data. The immediate and follow-up results showed that five of the clients were completely recovered and the sixth markedly improved after their respective treatment (IO-14 session). These results and the questions concerning continuous assessment in single-case design and external validity of laboratory assessment in phobic conditions are discussed.
Phobia for thunder and lightning is classified by Marks (1969) as “Miscellaneous specific 14% of the phobic patients seen at Maudsley phobia”, a category which comprised hospital in London during a 10 year period. Although phobias are one of the disorders most frequently treated by behavior therapists, there are only a few reports on behavioral treatment of thunder and lightning phobia in the literature. Hoenig and Reed (1966) described the use of systematic desensitization in the treatment of a 32 year old woman. The client was completely recovered after 11 sessions and the outcome assessment was based both on self-reports and electrodermal responses to a flickering neon light. Furst and Cooper (1970) treated a 44 year old housewife with a long-lasting fear of thunderstorms. This was successfully desensitized in 23 sessions and the client “remained symptom free and had not developed any other signs of neurosis” (Furst and Cooper, 1970. p. 89) at the 1 l-months follow-up. Lubetkin (1975) used a planetarium in the desensitization of a 45 year old woman. The client was trained in progressive relaxation and in the planetarium she first relaxed herself and then the projectionist started a three minute presentation of lightning and thunderstorms. During the presentation the client attempted self-relaxation and afterwards she continued to relax herself for several minutes. The projectionist then started the presentation again. The client had eight sessions at the planetarium with an average of eight presentations on each visit. The 9-month follow-up showed a marked improvement in the client’s condition. Finally Leitenberg. cf ul. (1975) used reinforced practice (praise and feedback) in the treatment of a 43-year old married woman. An artificial situation was devised in which flood lamps were synchronized with a stereotape track of a thunderstorm. In the first phase (praise alone) the client gradually increased the time she stayed in the situation. The rate of improvement was greatly accelerated during the next phase when feedback was added to praise. Her ratings of anxiety however did not show any decline. Therefore the client was required to remain in the testing situation for a maximum of 30 min during the third phase of treatment, which led to a decrease in her anxiety rating. No follow-up data were presented on this client. In summary then. these four case studies (all middle-aged women) show that desensitization has been the primary treatment for thunderstorm phobias. It is, however, impossible to draw any conclusions as to the effectiveness of behavioral methods for this * Requests for reprints should of
Uppsala.
Ulleraker
Hospital.
be addressed to Lars-Goran S-750 I7 Uppsala. Sweden. 197
6st.
Psychiatric
Research
Center.
Untversity
LARS-GBRAK6s~
19x
specific phobia since only one study (Leitenberg er al., 1975) applied an experimental single-case design, albeit without followup data. The purpose of the present study was to explore (a) the applicability of different techniques in the treatment of thunder and lightning phobia. and (b) the use of assessment methods in all three response systems of interest with phobic clients, i.e. verbalcognitive. overt behavior, and physiological.
METHOD Assessment
AND
RESULTS
and uppuratus
It is, for natural reasons, very difficult to arrange an in-uiuo behavioral test of thunder and lightning phobia. In order to measure the client’s fear of thunderstorms the following laboratory test was designed and applied immediately after each session. ~~~~uio~~~ fesr. For clients A-C, a 6 min tape recording of an actual thunderstorm was played with a cassette recorder (Philips N2209) and two loudspeakers. With the help of one Kodak carousel Model S projector and a slide synchroniser 20 slides of clouds that could develop into a thunderstorm, lightning etc. were presented in a synchronized fashion. This was done so that when the sound of thunder was remote the slides contained clouds at a distance etc. Furthermore, in order to simulate the lightnings a neon lamp was used. This light source was switched on and off by impulses from a second cassette recorder and slide synchroniser and was synchronised to the sound. The slides were projected on a screen 2 m in front of the clients. who were seated in a comfortable armchair during the testing. The loudspeakers were placed on each side of the screen. and the room was darkened during the testings. For clients D-F the following modifications of the test were made. The tape recording of the thunderstorm took 9e min instead of six, an amplifier (2 x 16 W) was connected to the tape recorder. the number of slides were increased to 25, another loudspeaker was added. and the neon lamp was replaced with an electronic flash. The flashlight was recharged in 0.5 set and could thus flash in rapid succession. It was turned towards the white ceiling which gave a dazzling and highly realistic light. In a pilot study this latter form of the test was shown to six persons who were fearful. but not phobic to thunderstorms. The sound, pictures, and flashes were judged to be very realistic except that the subjects did not experience any danger of being hurt by the stroke of lightning or fire in the testing situation. In order to create a high demand situation (cf. Bernstein, 1973) and to urge the clients to endure the test, the following instructions were given: “You are now going to see a combined sound and picture presentation of thunderstorms. During this presentation we will measure your respiration and heart rate. In order to make our measures reliable it is important that you concentrate on the presentation and really try to imagine that you are experiencing an actual thunderstorm. It is important that you try to see the entire presentation. Instead of, e.g. closing your eyes or looking away. you should stop the presentation by pressing the button at your left.” The dependent measures that were obtained from this test are (a) the observation time. and (b) the client’s rating of the degree of anxiety (O-10) experienced during the test. This rating was obtained immediately after the behavioral test. Self-report measures. Before. after, and at follow-ups the clients answered the following questionnaires: (a) Fear Survey Schedule-122 (Tasto and Hickson, 1970), and (b) Thunder and Lightning Phobia Scale. which was constructed for this study and consists of 15 items to be rated on a 5-point scale. The reliability of the scale was 0.85 (Cronbath’s Alpha). With regards to validity the scale was able to differentiate (p = 0.001) between thunderstorm phobics (n = 17) and a non-phobic group (n = 12). Physiological measures. During the behavioral test the clients heart-rate (D-F only) and respiration-rate were continuously monitored. (a) H-R was assessed by measuring the bloodflow of the right index finger through a finger-stall equipped with a photocell.
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(b) Respiration-rate was measured with a bellows stretched around phragm. The signals were fed into a Gilson four-channel polygraph.
the client’s dia-
Client A Background. Client A is a 64 year old married female, who has been afraid of thunderstorms since her early childhood. She has acquired her phobia through modelling on the part of her parents who always took extraordinary measures of precaution when there was a forecast of a thunderstorm. The client is handicapped by her fear in many ways. She cannot stay alone in her summerhouse, or enjoy sunshine and good weather due to the risk of a thunderstorm. During the summer her thoughts center around thunder and lightning and she compulsively listens to the weather forecasts on the radio and TV, checking to see if there is any risk of a thunderstorm. During a thunderstorm she experiences strong anxiety, headache, palpitation and urge to urinate. She cannot sit in a chair but must be on her feet and occupied all the time. Procedure. An A-B design (Hersen and Barlow 1976) was used with three and 13 sessions in each phase respectively. The treatment method applied in this case is called self-administered desensitization with tape recorder. In this technique two tape-recorders. one playing the client’s favourite music and the other playing a IO min tape with the sound of thunder, are used. The favourite music was played continuously but the client controlled the tape recorder with the thunder. When she felt calm and ready to start she turned on the sound of thunder and gradually increased the volume to as much as she could stand. She was instructed that as soon as she felt the slightest discomfort she was to decrease the volume (or turn the tape-recorder off) until she once again was calm and then to gradually increase the volume again. When she managed to listen to the sound of thunder (at a preset maximum level) the volume of her favourite music was lowered somewhat and she started with the *‘thunder-tape” all over again. This was repeated several times until at the 13th treatment session she could listen to the whole thunder-tape without any help from her favourite music and without any discomfort. Results. The client’s results on the behavioral test is shown in Fig. 1. During baseline she stopped the presentation of the “thunder and lightning slide show” after 5’20” on the average, which was concurrent with maximum anxiety. Immediately after the first treatment session she could watch the whole presentation and this was the case during the remainder of this phase. Her rating of anxiety decreased steadily and after the last treatment session she experienced no anxiety. The mean for this phase was 5.4. The results were also the same at a 4-month follow-up occasion. Concerning the s&report measures client A had increased her scores on FSS-122 from 288 before to 343 after treatment. There was however a decrease at follow-up Self-administered dbrensitization wrth tape-recorder 0
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on the laboratory
test
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to 274 points. The same trend was noticed on the “thunder and lightning phobia scale”; 61-64-48 before, after and follow-up respectively. At the follow-up (4 months after therapy) a summer had passed and the client had experienced several thunderstorms without her former difficulties and physiological reactions. For the first time for as long as she could remember. the summer had been enjoyable instead of potentially fear-arousing. Ciierlr B Backgrourrd. This client is a 37 year old married female. Until recently she lived in the countryside but has moved into town due to her fear of thunderstorms. She has been phobic for thunderstorms as long as she can remember and her fear seems to have been modeled by her grandparents who were extremely afraid of thunderstorms according to the client. The client was handicapped by her phobia in different ways. During hot. stuffy summer days she was very uncomfortable due to the possibility of a thunderstorm. Immediately before a thunderstorm she was panicky and during it she experienced headaches, tremor. sweating and sometimes nausea. Procedure. In this case, an A-B design was also used with systematic desensitization (Wolpe, 1969) as treatment method. Relaxation training was completed in three sessions and a hierarchy of 1 l-items was desensitized in eight sessions. Results. As can be seen from Fig. 2 client B was able to watch the whole presentation at the first baseline testing. She experienced medium anxiety while doing so (mean = 5.3). During the treatment phase her anxiety rating fluctuated somewhat but showed a tendency to decrease during the last third of this phase (mean for the B-phase 4.8). At follow-up she experienced only minimal anxiety (1) while watching the presentation. As for the self-report measures her scores on FSS-122 did not change after treatment (183 vs. 183) but there was a small decrease at follow-up (170). There was however a marked decrease of her scores on the TLPS (6844-45) before. after and at follow-up. At the follow-up after the summer-season client B did not consider herself completely recovered from the phobia but was greatly improved. The anticipation anxiety had vanished and during a thunderstorm she could look out the window. watch the lightning and listen to the thunder. Clirrlr C Background. Client C is a 27 year old married woman living in the countryside. She has been thunder-phobic since early childhood and recalls certain episodes when lightning struck where she has been staying. She often has a headache when she notices that there is thunder in the air and at the risk of a thunderstorm she has difficulty concentrating and checks constantly for thunderclouds or distant sounds of thunder.
Fig. 2. Chent B. Ohservatlon
time -0
and selfrating
of anxiety
e--o
on the laboratory
test.
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Bortiine ‘-
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and lightning
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reinforcemen+
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time W--+
and selfrating of anxiety O--
-0 on the laboratory
test.
This difficulty in concentrating increases as the thunderstorm approaches and she cannot do anything but walk around in the house, look out the window and count the time between the lightning and the thunder clap. When the thunderstorm is close to her house she cannot stay in the house any longer but persuades the family go out and sit in the car until the thunderstorm is over. Procedure. An A-B design was used with a baseline of four and a B-phase of 14 sessions. The treatment applied was covert reinforcement (Cautela, 1970) in which a behavior incompatible (mostly approach behaviors) to the phobic behavior is covertly reinforced by letting the client imagine a positive scene contingently upon an approach behavior. In this case normally high frequency and anxiety-incompatible behaviors (weaving, reading, talking to friends) were reinforced. The therapist instructed the client to perform these different behaviors in a calm and concentrated way. Each sequence of a thunderstorm was divided into small steps, and at each step the client was covertly reinforced for imagining herself performing the incompatible behaviors (e.g. weaving) while the thunderstorm came closer and finally vanished. Results. As can be seen in Fig. 3 this client also could watch the entire presentation of the thunderstorm at the first baseline testing and every time thereafter. There was a tendency for the anxiety rating to decrease during baseline (mean = 6.0) and this continued during the treatment phase (mean = 1.4). For the last 10 sessions and at follow-up (4 M) she experienced minimal anxiety (1) but was never completely free from discomfort while watching the presentation. Her scores on the self-report measures decreased somewhat on FSS-122 (244-196-167) and very much on TLPS (61-3(3-22). At the follow-up client C described having experienced five thunderstorms during the summer season, and reported that she no longer had any fear of thunderstorms. When a thunderstorm started she could continue with whatever she was doing without any di~culty. Client
D
Background. The client is a 23 year old married woman who had been fearful of thunderstorms for as long as she could remember. She had never encountered any traumatic situations with thunderstorms, but instead acquired her phobia through modeling. Her mother was very afraid of thunderstorms and used to take her children and sit under the kitchen-table whenever one occurred. The client’s fear of thunderstorms necessitates many precautionary steps e.g. disconnecting electric apparatuses, not talking on the telephone etc. During a thunderstorm she ruminates about the worst thing that could happen and this increases her anxiety. Furthermore she has difficulty concentrating and motor& uneasiness. She walks around the house checking that every precaution has been taken.
202
S*rrions
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3Y
OY
time. selfrating of anxiety, heart-rate. the laboratory test.
and respiration
rate on
Procedure. After a three-session baseline this client’s phobia was treated with systematic desensitization which required 10 sessions (six for relaxation training and four for desensitization proper). Results. In the behavioral test (Fig. 4) the client could watch the whole presentation during the baseline phase, but was rather anxious (M = 7.0) while doing so. Physiologically she reacted with an elevated heart-rate (M = 72.6) compared to a resting value of 63 b/m. Her respiration-rate was however fairly normal (M = 12.8). In the treatment phase her anxiety rating decreased steadily (M = 2.2). As for the heart-rate there was a decrease during the first half and an increase during the last half of phase B. The average (M = 63.5) was however substantially lower than the baseline value. There was no change in respiration-rate during the treatment phase. Her results on the self-report scales showed a large decrease on FSS-I22 (207-165-158) and a rather small decrease on TPLS (42-40-34) before, after. and at follow-up respectively. Both at the 3 and 9 months foltow-up she could watch the entire thunder presentation without any discomfort at all. Physiologically she reacted at baseline levels on both these occasions. She also reported that none of the pre-treatment problem behaviors described above were present during the thunderstorms she had experienced during the summer season.
Clietlt E Buckground. Client E was a 77 year old woman (retired teacher), who dated her phobia back to her childhood. As a child and during her teens she had experienced some very traumatic thunderstorms, i.e. the lightning had struck and set the house she lived in on fire. In the spring the client starts to worry about the thunderstorms that will come during the summer, which in turn leads to difficulty in sleeping. She avoids listening to weather forecasts, so she does not have to know if a thunderstorm is predicted, knowledge which makes her more anxious. During a thunderstorm she has very strong physiological reactions. She experiences pain in her chest, trembles and feels panic-stricken. When the. thunderstorm is close to her house she crawls someplace where she does not hear the thunder or see the lightning. In order to further exclude these stimuli she buries her face in a pillow.
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heart-rate,
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If possible she seeks the company of other people. Although she is still scared and panicky, she feels safer than being on her own. Procedure. An A-B-C design was applied in which the client, after a four session baseline, received relaxation training (five sessions) and self-administered desensitization with tape recorder (eight sessions). The latter method was similar to the treatment of client A but divided into two parts. In the first part relaxation and listening to her favourite music were used as activities incompatible to the anxiety aroused by the sound of thunder. No assessment was made during this part of phase C as this was likely to influence the treatment result negatively. In the second part the client’s fear of lightning was treated. A tape was prepared so that 20 artificial lightning flashes were followed by the sound of thunder with intervals of l-10 set, according to the principle that the closer the sound was perceived to be the shorter the interval. The order of these pairs of lightning and sound was randomized on the tape. In this part no music was used but the client could stop the tape-recorder whenever she felt anxious and turn it on again when she was calm. During this part of phase C, assessment was made with the behavioral test. Results. In the behavioral test (Fig. 5) client E observed the entire presentation at all sessions. During the baseline phase she was rather anxious (M = 8.0) while doing so. Her heart-rate and respiration-rate were 75.6 and 17.5 respectively. The first treatment phase resulted in decreases of anxiety-rating (M = 40), respiration rate (M = 14.6), and heart-rate (M = 71.7). During the self-administration desensitization there was a further small decrease of her anxiety (M = 3.0) and heart-rate (M = 69.7) while the respiration-rate remained unchanged. At the follow-ups 3 and 9 months after the end of therapy, the results on the test were on the whole unchanged. Of the self-report questionaires there was a large decrease on FSS-122 (383-293-256) and a smaller on TPLS (64-60-52). At the 9 months follow-up, after the summer, this client described that she had, for the first time in decades, been able to enjoy her summer stay in Italy in spite of several encounters with thunderstorms. The anticipation worries, tension, and sleeping difficulty had also vanished and she considered herself as completely recovered.
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Client F Background. This client was a 23 year old nurse who had acquired her phobia only seven months prior to treatment. At that time she experienced a thunderstorm that started with a whirlwind which brought a lot of dust and pebbles with it. The client’s mother. a very religious person. cried out “It is Doomsday”. which frightened the client and she ran into the bedroom. The ensuing thunderstorm was a very unpleasant experience. After that occasion she considered each thunderstorm as increasingly more unpleasant. During a thunderstorm she moves around continually and cries occasionally. She compulsively looks out the windows, cannot concentrate on anything or talk to anyone. She has a strange feeling in her body and experiences strong palpitations. After the first traumatic experience she has been tense and fearful most of the time. She is less fearful at work when she is busy but at home she listens to all weather reports and often checks the sky for signs of thunderstorms. During the warmest period of the summer she was on sick-leave for a week because of her fear. Procedure. Using an A-B-C design this client’s phobia was treated with relaxation and stress-inoculation training (SIT; Meichenbaum 1977). SIT is focused on changing the client’s cognitive behavior in connection with the phobic stimulus. Instead of the negative self-statements and catastrophic thoughts that usually dominates, the client is taught to apply different coping self-statements. The treatment consists of three phases: (1) education phase, (2) training phase. and (3) application phase. In the first phase the purpose is to give the client a reasonable explanation for her phobia and to make her accept it. The actual training in coping and positive self-statements takes place in the second phase and in the third the client is given different opportunities to apply her new-learned skill in stressful situations. Results. In the behavioral test (Fig. 6) this client could watch the whole presentation from the first testing. She experienced medium anxiety while doing this (M = 5.2 during baseline). Her anxiety diminished in the relaxation phase (M = 3.3) and further still in the SIT-phase (M = 1.8).
Baseline
Stress-lnoculotlon troinrng -Time *eRoting
75
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Fig.
6. Client
F: Observation
time.
selfrating of anxiety. the laboratory test.
heart-rate.
and
respiration
rate
on
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Physiologically she fluctuated somewhat during baseline with means for heart-rate and respiration-rate of 68.2 and 14.5 respectively. During the relaxation phase her heartrate dropped considerably (M = 59.0). but it increased to the baseline level during the SIT-phase (M = 68.6). There were however only small changes in her respiration rate during these phases; the means were 14.0 and 15.5 respectively. In the self-report measures there was a small increase in the FSS-122 (161-l 75-181) and a very large decrease on the TPLS (67-30-27). At the six-months follow-up testing (after a summer) the client rated her anxiety to I while watching the presentation. Her heart-rate was 75.0 and respiration rate 17.5. At no time did she dwell on the possibility of a thunderstorm and during actual storms she had looked out the window. and then continued with her job or house-work. DISCUSSION
There are a large number of behavioral techniques that have been applied in the treatment of phobias: Marks (1975) describes more than 20 different methods. Phobia for thunderstorms, however, limits the range of possible methods, as the technique based on in-km exposure are not applicable to this disorder. In the six single-case studies presented in this paper four different treatment techniques (systematic desensitization, covert reinforcement, self-administered desensitization with tape recorder and stress inoculation training) were applied to thunder and lightning phobia. The tentative conclusion that can be drawn from these cases is that all of the techniques used appeared to be equally applicable to this condition. It is however not possible to conclude that one is more effective than the other as in no case was more than one technique applied. The overall conclusion concerning the outcome is that all clients (except A) reduced their degree of fear after treatment as measured by self-report questionnaires and selfrating of anxiety. These results were corroborated by the physiological (heart-rate and respiration rate) data for clients D-F. At the follow-ups (4-9 months after therapy) a summer had passed and all clients had experienced several thunderstorms. All but client B considered themselves as completely recovered from the phobia and reported that during a thunderstorm they continued with the on-going activity instead of the different avoidance behaviors which they engaged in before treatment. The second purpose of this study was to try out assessment methods in the different response-systems of interest in anxiety clients. The self-report measures (FSS-122 and Thunder and Lightning Phobia scale) functioned satisfactorily for this study. The changes were rather small on FSS-122, which was expected, as the treatment of a specific phobia hardly would generalize to other fears. The changes on the TPLS were larger and in agreement with the clients’ own overall ratings of the outcome. The behavioral test. which for obvious reasons could not be administered in-viva, was an artificial laboratory test. In order to avoid artifacts, high demands (Bernstein, 1973) on the clients’ performance were presented in the instructions. This led to a ceiling-effect, and all clients (except A) could watch the entire presentation from the very first trial during baseline. This, in turn, meant that only an impairment as result of treatment could be reliably evaluated. As a consequence, the conclusive power of the, designs applied was weakened. as only the self-reports of anxiety remained, and could be expected to change in a predictable direction. Of the physiological measures obtained (from clients D-F) heart-rate showed rather large decreases. Compared to baseline client C had 9.1 b/m. lower on the average during the treatment, client E reduced her heart-rate with 3.9 b/m during the first and 5.9 b/m during the second treatment phase, and finally client F showed a reduction of 9.2 b/m during her first treatment period. At follow-ups the heart rate had increased again to the pretreatment level but this should be regarded with caution as it is based on only one testing while the treatment values were means of 5-10 testings. The changes in respiration-rate were generally much smaller and as the pre-treatment values were within the normal range no extensive changes could be expected.
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This study raises some important questions concerning the assessment of phobias in single-case experimental designs. According to Hersen and Barlow (1976) continuous assessment is one defining characteristic of these designs. Generally speaking there are two types of continuous measures, (a) the assessment and treatment method are closely linked together. e.g. as in most of Leitenberg and his coworkers’ studies of reinforced practice with different phobias (Leitenberg, 1976), and (b) the assessment is made independent of the treatment method in question, e.g. Liberman and Smith (1972) multiple baseline design where SD was used with a multiphobic woman. For reasons described earlier the second type of assessment was used immediately after each treatment session. The same sound and slide presentation of thunderstorms was used on every occasion and this makes the question of reactivity more pertinent. The possibility exists that the gradual decline in the clients’ self-ratings of anxiety was not an effect of treatment but rather habituation, i.e. the clients became used to and more familiar with the presentation. This hypothesis is however contradicted by the fact that all clients reported very marked changes in their in-uiuo behaviors during a thunderstorm. and five of the six clients considered themselves as totally recovered from the phobia. One way to reduce the risk of reactive effects is to make a new slide show for each testing. This would have meant 20 different slide shows for the present study, which is virtually impossible for both practical and economical reasons. Another important question concerning the assessment of this phobia is what Lick and Unger (1975) have called external validity, i.e. to what extent do changes on a laboratory test of fear correlate with changes in the client’s behavior during an in-uivo confrontation with the phobic stimuli? The most obvious difference between a laboratory test of fear (as in this study) and an in-u&o anxiety situation is the degree of control and predictability of the situation. The laboratory test situation is “safe” in the respect that the clients know that nothing really harmful can happen to them. In a real confrontation with the phobic stimulus however the client is uncertain of the exact nature of the stimulus because it is often vague and ambiguous. Consequently the responses that the client has to perform in order to efficiently cope with the anxiety is unclear and this often intensifies the fear (Borkovec. Weerts and Bernstein, 1977). Unfortunately it was impossible to arrange pre-and post in-uiuo assessments of the clients’ thunderstorm phobia in a way that permitted sufficient control over the situation. This is however a very important area for future investigations in order to find out if the correlation between an anxiety provoking situation in-aiuo and in the laboratory is high enough to allow the use of laboratory tests of fear in clinical phobias. The thunder and lightning phobia per se does not seem to be different from most other phobias, either in regard to acquisition, or treatment. Clients A, B and D seem to have acquired their fear through modeling from parents or grandparents, while clients C. E and F have experienced traumatic incidents in connection with thunderstorms. As for treatment the techniques applied in the different cases were chosen on the basis of the behavior analysis performed during the baseline phase. Judging from our experiences this type of phobia does not seem to require a specific type of behavioral treatment. Instead the clinical procedure of adjusting the treatment technique to the characteristics of the individual client appears to be as valid for thunder and lightning phobia as for most other types of phobias. AcknoH:/~dg~r,ltnrs-Leif
Havneskcld. Anita Jerremalm. Jan Johansson. and Rolf Olofsson served as therapists. suggestions on the manuscript. Their assistance is gratefully acknowledged.
and Sandra Bates gave valuable
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