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A modified thought stopping procedure for the treatment of agoraphobia
ooo5.7908/79/0601-0121
J. Behov. The-r. & Exp. Psychid. Vol. 10, pp. 121-124. 0 Pergamon Press Ltd.. 1979. Printed in Great Britain.
A MODIFIED
THOUGHT STOPPING PROCEDURE TREATMENT OF AGORAPHOBIA JOHN
Tufts Medical
School,
Department
%02.00/0
FOR THE
S. O’BRIEN
of Psychiatry,
St. Elizabeth’s
Hospital
of Boston
Summary-A modified form of thought stopping was used to overcome anxiety in two adult clients. The clients, a 52-year-old male and a 23-year-old female, were trained to use the modified thought stopping procedure because they were unable to relax or visualize scenes. The clients were successfully treated in one year and three months respectively and were free of anxiety at one-year
follow-up.
Agoraphobic clients, who in many cases have proven difficult to treat with standard desensitization procedures (Butler, 1975) and other treatment methods (Emmelkamp, 1974), frequently report fear of fear, a common neurotic pattern in which certain components of the anxiety response have themselves become conditioned stimuli that lead to further anxiety (Goldstein and Chambliss, 1978; Latimer, 1977). The use of standard desensitization with this type of client is often complicated by the client’s inability to relax and/or to visualize anxiety-evoking stimuli. Some clients of this type have been successfully treated with variants of desensitization which use responses antagonistic to anxiety other than relaxation. Induced anger (Goldstein, Serber and Piaget, 1970; Butler, 1975); laughter (Ventis, 1973); carbon dioxide inhalation (Wolpe, 1958; Latimer, 1977) and reading (Stoffelmeyer, 1970) have been used in this way. These procedures, however, may still require the client to visualize ‘scenes from the anxiety hierarchy which may or may not include relevant introceptive stimuli. The current paper reports the successful use of a thought stopping procedure with two “complex” agoraphobic clients (Goldstein and Chambliss, 1978) who were unable to follow the standard desensitization procedure. A Requests for reprints should be addressed 736 Cambridge St., Boston, MA 02135.
to John
modified form of thought stopping (Taylor, 1963) was used by the clients to eliminate anxiety to both external and introspective stimuli.
CASE HISTORIES Client 1 was a 52-year-old male, married, with two children and working full-time. Over the past 20 years he had frequently experienced overwhelming anxiety. Both introceptive stimuli and external events served as stimuli for his anxiety response. Over the last two years his increasing anxiety was associated with the fear that he “was losing his mind”. He experienced heart palpitations, sweaty palms, dizziness and overall weakness much of the time, but in particular, when he walked outdoors or thought about walking. As his work involved frequent walking, he experienced the anxiety daily. Although he continued to work, his absenteeism was high and he virtually isolated himself at home most of his non-working hours. He also reported that sitting in church or thinking about church produced overwhelming anxiety similar to that associated with walking, In fact, he indicated that he had lost consciousness in church several years ago. As a result, he avoided church and was overwhelmed with “guilt” about this. He also experienced
S. O’Brien, 121
Department
of Psychiatry,
St. Elizabeth’s
Hospital,
122
JOHNS.
intense anxiety in the presence of dogs, in movies, or most public places. He reported that when he was not in an anxiety-producing situation, he was, frequently unable to keep from thinking about being anxious. He was acutely aware of changes in his heart rate and of his palms sweating; both of these appeared to serve as introceptive stimuli to elicit further anxiety. He pictured himself as a weak man and a failure. He felt that people knew he was anxious and often laughed at him. Initially, his lowest reported “suds” level (Wolpe, 1969) was 50. During his interviews he was rigid, appeared angry and felt he had been slighted by the world. He had been hospitalized for this problem approximately fifteen years previously; hospital records described him as paranoid. During that hospitalization he was treated without success with antipsychotic medication and traditional psychotherapy. After hospitalization, he received psychotherapy for about a year and a half without a reduction in anxiety. Client 2 was a 22-year-old female college student. Before being referred for behavior therapy she had been seen for traditional psychotherapy. Following the death of both of her parents (within one year) she developed fear and anxiety which limited her life style. Both introceptive stimuli and external events served as stimuli for her anxiety response. She felt she “was losing her mind” and experienced heart palpitations, sweaty palms and blurred vision much of the time. The anxiety was strongest when she anticipated driving over certain routes (to school), entering certain stores and church, or going on dates. In attempts to reduce the anxiety she made “panic” phone calls to friends and strangers (police, etc.) and pressured people to come to her aid. She angered school officials with her persistent demands to miss tests and classes. She had also angered many of her friends as a result of pressure which she applied to get people to help her. Despite the psychotherapy and two years of transcendental meditation, she had stopped going to school, refused to drive most places
O’BRIEN
alone and often made up to ten panic phone calls daily. Because of her school absenteeism and incomplete courses, she was refused graduation. Her involvement in traditional psychotherapy was terminated upon referral for behavior therapy.
TREATMENT The behavior analyses were conducted separately to determine all the circumstances in which the clients were experiencing anxiety, the levels of anxiety and the consequences of the anxiety responses; both clients were trained in the use of Wolpe’s (1969) “suds” scale to rate anxiety. The behavior analysis included instructing the clients to keep a diary of anxiety-associated experiences and anxiety-free periods. Client 2 was also asked to record the number of panic phone calls she made. Only Client 1 complied in keeping written records. The general principle of counterconditioning was explained to each client. Many misconceptions were clarified during this process, such as disease concepts of anxiety, ideas of lack of character and of religious commitment being responsible for the anxiety, as well as other individual misconceptions about the causes of the anxiety. Following this, they were exposed to progressive relaxation training (Jacobson, 1938) and scenevisualization trials. Repeated attempts to train each client with the progressive relaxation procedure and scene visualization failed, both clients claiming that they were not able to stop thinking about anxiety. After a series of unsuccessful trials with Taylor’s (1963) thought stopping procedure, both clients were taught a modified thought stopping procedure which was intended to induce anger or another response antagonistic to anxiety. The procedure consisted of three phases of practice. (1) The clients were instructed to clench both fists and raise both arms above their heads. Following this, they were instructed to strike their fists against their thighs and shout “stop, anxiety,
MODIFIED THOUGHT
STOPPING
PROCEDURE
FOR TREATING
AGORAPHOBIA
123
cknt I
100=u) 3 i 3
z
5o Weddmq 20
sh._& 0
(See
written
text)
/ 5
IO
20
15 Weeks
25
e follow-up
Fig. 1. Plotted is the mean daily self-rated “suds” (Wolpe, 1969) levels reported by the client in his written journal during therapy and at a one-year foliow-up. He was instructed to record each day the anxiety level and the major activity that occurred every four hours while awake.
stop”. Other choice verbal selections were often elected by the clients. (2) Step 2 consisted of shouting loud anger words, no longer hitting the thighs. but still clenching fists. (3) Step 3 consisted of producing “thoughts” incompatible with anxiety while clenching fists. The clients were given freedom to choose the content of the thoughts which seemed to stop anxiety best. This was to be used when they experienced anxiety in public places where they could not shout or strike themselves without being conspicuous. The clients were told that they could use any of these steps as they preferred. They were not instructed to arrange events according to their anxiety intensity. Instead they were encouraged to use the modified thought stopping procedure every time they experienced anxiety. Both clients found the procedure worked best with daily practice. They also found Step 1 to be more effective with higher “suds” and stronger obsessions, while Step 3 could be sufficient with lower “suds” events. During therapy sessions and telephone contacts, the therapist verbally reinforced the client’s progress. RESULTS Client 1 Results were dramatic with Client 1. His anxiety was greatly reduced and obsessions
controlled within a 6-8 week period. However, for several more months, he continued to “request” verbal reassurance that his progress would last. Generally his “suds” ratings after 8 weeks of treatment ranged from 0 to 15. These data, as rated by the client in his diary, are presented in Fig. 1. The client felt that his major accomplishment during treatment was to be able to prepare for and finally attend his daughter’s church wedding. During the wedding he reported that he felt like he “owned the world”. Freedom from anxiety while working and control of “fear of fear” thoughts were also considered major accomplishments by this client. Following this major accomplishment, follow-up sessions were conducted to monitor and verbally support the client’s progress over a period of one year. The total treatment time involved 22 half-hour sessions. He reported that he had maintained the progress, was getting along better at home, and that he was going to church and to ball games. He felt much better about himself, and never felt people were laughing at him. He had also lost his pre-therapy appearance of anger and was ‘able to laugh appropriately. Client 2 After only two weeks of therapy, this client began travelling between her home and school and re-enrolled in courses. The number of “panic” phone calls the client reported (before therapy, during therapy and during
124
JOHNS.
15 r m
I
Client 2
E0
5
IO
15 Weeks
‘e f&w-up
Fig. 2. Plotted is the mean daily number of “panic” phone calls made by the client each week during therapy and at one-year follow-up. These data were gathered from the client’s verbal reports.
follow-up) are plotted in Fig. 2. Since talking about her anxiety experiences in therapy elicited high anxiety for her, she was seen as infrequently as possible. She did, however, seek instructions and reported her progress via the telephone to the therapist during the beginning of her last school semester. After graduating from school, the client called the therapist with symptoms of anxiety at the time she relocated for employment. The therapist reassured her that she was experiencing normal anxiety caused by her new job situation and that this anxiety was not a sign that her problems had returned. She was instructed to use the original procedure of thought stopping if and when she obsessed or felt anxious. She wrote about six months later (over one year after treatment) to indicate that she had maintained her progress.
O’BRIEN
While the theoretical basis for the modified thought stopping procedure is not clear from the results obtained in the current investigation, it most probably served both to interrupt anxiety producing cognitions and to reciprocally inhibit anxiety to both external and introceptive stimuli. Although the clients’ anecdotal reports seemed to indicate that most progress coincided with the use of the modified thought stopping procedures, the value of a written diary (Wolpe, 1973), discussion of misconceptions and verbal reinforcement of progress cannot be overlooked. The procedure is easily taught and seems to eliminate the need for relaxation training, scene visualization and the cumbersome task of establishing and following hierarchies.
REFERENCES Butler P. (1975) The treatment of severe agoraphobia employing induced anger a\ an anxiety inhibitor: A case study, J. Behav. Ther. & Exp. Psychial. 6, 327.330. Emmelkamp P. (1974) Self-observation vcrsw flooding in the treatment of agoraphobia, Behav. Rer. & Ther. 12,
229-237. Goldstein A. J., Serber M. and Piaget G. (1970) Induced anger as a reciprocal inhibition of fear, J. Behav. Ther.
& Exp. Psychial. I, 67.71. Goldstein A. J. and Chambliss D. L. (1978) A reanaiyjis of agoraphobia, Behav. Therapy9.47.59. Jacobson E. (1938) Progressive Relaxation, University of Chicago Press, Chicago. Latimer P. (1977) Carbon dioxide as a reciprocal inhibitor in the treatment of neurosis, J. Behav. Ther. & Exp.
fsychia/.
8,83-85
Stoffelmeyer B. E. (1970) The treatment of a retching response to dentures by counteractive reading aloud,
DISCUSSION The data clearly indicated successful elimination of obsessional thinking and anxiety caused by both introceptive and external stimuli while using the modified thought stopping procedure with two agoraphobic clients. The complex interrelationship of variables uncovered in the present cases underscores the need for a careful behavior analysis.
J. Behav. Ther. & Exp. Psychial. 1, 163-l 64. Taylor J. G. (1963) A behavioral interpretation of obsessivecompulsive neurosis, Behav. Kes. & Ther. I, 237-244. Ventis L. W. (1973) Ca\e history: The use of laughter as an alternative responw in \y\tematic dcccnsitiration, Behav.
Therapy4,
120-122.
Wolpe J. (1958)Psycholherapy by Reciprocul Inhibition, Stanford Univcr\ity Prcs\, Stanford. Wolpe J. (1969) The Praclice of Behavior Therapy, Pcrgamon Prc\\, New York. Wolpe J. (1973) The Practice q/ Brhovror Therapy, Pergamon Press, New York.
Acknowledgemen&-The author is grateful to Paul W. Yost M D., for referral of the current two clients and for his support during discussions of the current cases.
J. Behov. The-r. & Exp. Psychid. Vol. 10, pp. 121-124. 0 Pergamon Press Ltd.. 1979. Printed in Great Britain.
A MODIFIED
THOUGHT STOPPING PROCEDURE TREATMENT OF AGORAPHOBIA JOHN
Tufts Medical
School,
Department
%02.00/0
FOR THE
S. O’BRIEN
of Psychiatry,
St. Elizabeth’s
Hospital
of Boston
Summary-A modified form of thought stopping was used to overcome anxiety in two adult clients. The clients, a 52-year-old male and a 23-year-old female, were trained to use the modified thought stopping procedure because they were unable to relax or visualize scenes. The clients were successfully treated in one year and three months respectively and were free of anxiety at one-year
follow-up.
Agoraphobic clients, who in many cases have proven difficult to treat with standard desensitization procedures (Butler, 1975) and other treatment methods (Emmelkamp, 1974), frequently report fear of fear, a common neurotic pattern in which certain components of the anxiety response have themselves become conditioned stimuli that lead to further anxiety (Goldstein and Chambliss, 1978; Latimer, 1977). The use of standard desensitization with this type of client is often complicated by the client’s inability to relax and/or to visualize anxiety-evoking stimuli. Some clients of this type have been successfully treated with variants of desensitization which use responses antagonistic to anxiety other than relaxation. Induced anger (Goldstein, Serber and Piaget, 1970; Butler, 1975); laughter (Ventis, 1973); carbon dioxide inhalation (Wolpe, 1958; Latimer, 1977) and reading (Stoffelmeyer, 1970) have been used in this way. These procedures, however, may still require the client to visualize ‘scenes from the anxiety hierarchy which may or may not include relevant introceptive stimuli. The current paper reports the successful use of a thought stopping procedure with two “complex” agoraphobic clients (Goldstein and Chambliss, 1978) who were unable to follow the standard desensitization procedure. A Requests for reprints should be addressed 736 Cambridge St., Boston, MA 02135.
to John
modified form of thought stopping (Taylor, 1963) was used by the clients to eliminate anxiety to both external and introspective stimuli.
CASE HISTORIES Client 1 was a 52-year-old male, married, with two children and working full-time. Over the past 20 years he had frequently experienced overwhelming anxiety. Both introceptive stimuli and external events served as stimuli for his anxiety response. Over the last two years his increasing anxiety was associated with the fear that he “was losing his mind”. He experienced heart palpitations, sweaty palms, dizziness and overall weakness much of the time, but in particular, when he walked outdoors or thought about walking. As his work involved frequent walking, he experienced the anxiety daily. Although he continued to work, his absenteeism was high and he virtually isolated himself at home most of his non-working hours. He also reported that sitting in church or thinking about church produced overwhelming anxiety similar to that associated with walking, In fact, he indicated that he had lost consciousness in church several years ago. As a result, he avoided church and was overwhelmed with “guilt” about this. He also experienced
S. O’Brien, 121
Department
of Psychiatry,
St. Elizabeth’s
Hospital,
122
JOHNS.
intense anxiety in the presence of dogs, in movies, or most public places. He reported that when he was not in an anxiety-producing situation, he was, frequently unable to keep from thinking about being anxious. He was acutely aware of changes in his heart rate and of his palms sweating; both of these appeared to serve as introceptive stimuli to elicit further anxiety. He pictured himself as a weak man and a failure. He felt that people knew he was anxious and often laughed at him. Initially, his lowest reported “suds” level (Wolpe, 1969) was 50. During his interviews he was rigid, appeared angry and felt he had been slighted by the world. He had been hospitalized for this problem approximately fifteen years previously; hospital records described him as paranoid. During that hospitalization he was treated without success with antipsychotic medication and traditional psychotherapy. After hospitalization, he received psychotherapy for about a year and a half without a reduction in anxiety. Client 2 was a 22-year-old female college student. Before being referred for behavior therapy she had been seen for traditional psychotherapy. Following the death of both of her parents (within one year) she developed fear and anxiety which limited her life style. Both introceptive stimuli and external events served as stimuli for her anxiety response. She felt she “was losing her mind” and experienced heart palpitations, sweaty palms and blurred vision much of the time. The anxiety was strongest when she anticipated driving over certain routes (to school), entering certain stores and church, or going on dates. In attempts to reduce the anxiety she made “panic” phone calls to friends and strangers (police, etc.) and pressured people to come to her aid. She angered school officials with her persistent demands to miss tests and classes. She had also angered many of her friends as a result of pressure which she applied to get people to help her. Despite the psychotherapy and two years of transcendental meditation, she had stopped going to school, refused to drive most places
O’BRIEN
alone and often made up to ten panic phone calls daily. Because of her school absenteeism and incomplete courses, she was refused graduation. Her involvement in traditional psychotherapy was terminated upon referral for behavior therapy.
TREATMENT The behavior analyses were conducted separately to determine all the circumstances in which the clients were experiencing anxiety, the levels of anxiety and the consequences of the anxiety responses; both clients were trained in the use of Wolpe’s (1969) “suds” scale to rate anxiety. The behavior analysis included instructing the clients to keep a diary of anxiety-associated experiences and anxiety-free periods. Client 2 was also asked to record the number of panic phone calls she made. Only Client 1 complied in keeping written records. The general principle of counterconditioning was explained to each client. Many misconceptions were clarified during this process, such as disease concepts of anxiety, ideas of lack of character and of religious commitment being responsible for the anxiety, as well as other individual misconceptions about the causes of the anxiety. Following this, they were exposed to progressive relaxation training (Jacobson, 1938) and scenevisualization trials. Repeated attempts to train each client with the progressive relaxation procedure and scene visualization failed, both clients claiming that they were not able to stop thinking about anxiety. After a series of unsuccessful trials with Taylor’s (1963) thought stopping procedure, both clients were taught a modified thought stopping procedure which was intended to induce anger or another response antagonistic to anxiety. The procedure consisted of three phases of practice. (1) The clients were instructed to clench both fists and raise both arms above their heads. Following this, they were instructed to strike their fists against their thighs and shout “stop, anxiety,
MODIFIED THOUGHT
STOPPING
PROCEDURE
FOR TREATING
AGORAPHOBIA
123
cknt I
100=u) 3 i 3
z
5o Weddmq 20
sh._& 0
(See
written
text)
/ 5
IO
20
15 Weeks
25
e follow-up
Fig. 1. Plotted is the mean daily self-rated “suds” (Wolpe, 1969) levels reported by the client in his written journal during therapy and at a one-year foliow-up. He was instructed to record each day the anxiety level and the major activity that occurred every four hours while awake.
stop”. Other choice verbal selections were often elected by the clients. (2) Step 2 consisted of shouting loud anger words, no longer hitting the thighs. but still clenching fists. (3) Step 3 consisted of producing “thoughts” incompatible with anxiety while clenching fists. The clients were given freedom to choose the content of the thoughts which seemed to stop anxiety best. This was to be used when they experienced anxiety in public places where they could not shout or strike themselves without being conspicuous. The clients were told that they could use any of these steps as they preferred. They were not instructed to arrange events according to their anxiety intensity. Instead they were encouraged to use the modified thought stopping procedure every time they experienced anxiety. Both clients found the procedure worked best with daily practice. They also found Step 1 to be more effective with higher “suds” and stronger obsessions, while Step 3 could be sufficient with lower “suds” events. During therapy sessions and telephone contacts, the therapist verbally reinforced the client’s progress. RESULTS Client 1 Results were dramatic with Client 1. His anxiety was greatly reduced and obsessions
controlled within a 6-8 week period. However, for several more months, he continued to “request” verbal reassurance that his progress would last. Generally his “suds” ratings after 8 weeks of treatment ranged from 0 to 15. These data, as rated by the client in his diary, are presented in Fig. 1. The client felt that his major accomplishment during treatment was to be able to prepare for and finally attend his daughter’s church wedding. During the wedding he reported that he felt like he “owned the world”. Freedom from anxiety while working and control of “fear of fear” thoughts were also considered major accomplishments by this client. Following this major accomplishment, follow-up sessions were conducted to monitor and verbally support the client’s progress over a period of one year. The total treatment time involved 22 half-hour sessions. He reported that he had maintained the progress, was getting along better at home, and that he was going to church and to ball games. He felt much better about himself, and never felt people were laughing at him. He had also lost his pre-therapy appearance of anger and was ‘able to laugh appropriately. Client 2 After only two weeks of therapy, this client began travelling between her home and school and re-enrolled in courses. The number of “panic” phone calls the client reported (before therapy, during therapy and during
124
JOHNS.
15 r m
I
Client 2
E0
5
IO
15 Weeks
‘e f&w-up
Fig. 2. Plotted is the mean daily number of “panic” phone calls made by the client each week during therapy and at one-year follow-up. These data were gathered from the client’s verbal reports.
follow-up) are plotted in Fig. 2. Since talking about her anxiety experiences in therapy elicited high anxiety for her, she was seen as infrequently as possible. She did, however, seek instructions and reported her progress via the telephone to the therapist during the beginning of her last school semester. After graduating from school, the client called the therapist with symptoms of anxiety at the time she relocated for employment. The therapist reassured her that she was experiencing normal anxiety caused by her new job situation and that this anxiety was not a sign that her problems had returned. She was instructed to use the original procedure of thought stopping if and when she obsessed or felt anxious. She wrote about six months later (over one year after treatment) to indicate that she had maintained her progress.
O’BRIEN
While the theoretical basis for the modified thought stopping procedure is not clear from the results obtained in the current investigation, it most probably served both to interrupt anxiety producing cognitions and to reciprocally inhibit anxiety to both external and introceptive stimuli. Although the clients’ anecdotal reports seemed to indicate that most progress coincided with the use of the modified thought stopping procedures, the value of a written diary (Wolpe, 1973), discussion of misconceptions and verbal reinforcement of progress cannot be overlooked. The procedure is easily taught and seems to eliminate the need for relaxation training, scene visualization and the cumbersome task of establishing and following hierarchies.
REFERENCES Butler P. (1975) The treatment of severe agoraphobia employing induced anger a\ an anxiety inhibitor: A case study, J. Behav. Ther. & Exp. Psychial. 6, 327.330. Emmelkamp P. (1974) Self-observation vcrsw flooding in the treatment of agoraphobia, Behav. Rer. & Ther. 12,
229-237. Goldstein A. J., Serber M. and Piaget G. (1970) Induced anger as a reciprocal inhibition of fear, J. Behav. Ther.
& Exp. Psychial. I, 67.71. Goldstein A. J. and Chambliss D. L. (1978) A reanaiyjis of agoraphobia, Behav. Therapy9.47.59. Jacobson E. (1938) Progressive Relaxation, University of Chicago Press, Chicago. Latimer P. (1977) Carbon dioxide as a reciprocal inhibitor in the treatment of neurosis, J. Behav. Ther. & Exp.
fsychia/.
8,83-85
Stoffelmeyer B. E. (1970) The treatment of a retching response to dentures by counteractive reading aloud,
DISCUSSION The data clearly indicated successful elimination of obsessional thinking and anxiety caused by both introceptive and external stimuli while using the modified thought stopping procedure with two agoraphobic clients. The complex interrelationship of variables uncovered in the present cases underscores the need for a careful behavior analysis.
J. Behav. Ther. & Exp. Psychial. 1, 163-l 64. Taylor J. G. (1963) A behavioral interpretation of obsessivecompulsive neurosis, Behav. Kes. & Ther. I, 237-244. Ventis L. W. (1973) Ca\e history: The use of laughter as an alternative responw in \y\tematic dcccnsitiration, Behav.
Therapy4,
120-122.
Wolpe J. (1958)Psycholherapy by Reciprocul Inhibition, Stanford Univcr\ity Prcs\, Stanford. Wolpe J. (1969) The Praclice of Behavior Therapy, Pcrgamon Prc\\, New York. Wolpe J. (1973) The Practice q/ Brhovror Therapy, Pergamon Press, New York.
Acknowledgemen&-The author is grateful to Paul W. Yost M D., for referral of the current two clients and for his support during discussions of the current cases.