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A multifactorial approach to the treatment and ward management of a self-multilating patient
J Behav Ther & Fxp P~vchtat Vol. 3. pp. 189-193 Pergamon Press, 19"/2 Printed m Great Br,tam
A M U L T I F A C T O R I A L APPROACH TO THE T R E A T M E N T AND WARD M A N A G E M E N T OF A SELF-MUTILATING PATIENT HOWARD ROBACK,* DOUGLAS FRAYN, LINDA GUNBY and KASPAR TUTFRS Clarke Institute of Psychiatry. Toronto, Ontarto Surnmary--Thls arttcle describes the treatment procedures employed m altering the self-burmng behavior of a 19-yr-old female patient with a long standing htstory of selfmutdations. During her first 17 days in the hospital she burned herself on six occaslon~ and an addiuonal burning attempt was interrupted by hospital staff During the 44 days of the behavioral modtficatlon program which focused on teaching the patzent adapuve anger responses, the patient burned herself only on the first day of the program The patient's ~mprovement was maintained during a 4-month follow-up period. Tins case is of interest because of the successful diminution of a patient's self-mutilating behavior. From a scientific point of view, it ~s a travesty; from a management point of view, it is an exciting success.
CASE H I S T O R Y Miss A. was a 19-yr-old, unmarried patient, with a history of repeated self-mutilations since 14. These self-destructive acts were expressed by self-cuttings and burnings of the arms, forearms and facial areas. Miss A. had been hospitalized for 1 week at age 5 because of repeated nightmares. When she was 12, her parents noticed an increasing withdrawal from people. At 14 she began slashing herself with a razor blade and burning herself whenever she showed anger. At 15, she developed a "school phobia" and would write on the school walls with the apparently deliberate aim of being expelled from school. She entered into individual psychotherapy with a psychiatrist but stopped seeing him after very few sessions. This experience failed to alter her self-injurious behavior. At this time, the patient's parents would attempt to stop her from burning herself by taking away her cigarettes and matches, but she responded by using sharp pieces of glass to inflict wounds
on her thighs and arms. At 17, Miss A. took an overdose of aspirins while in a depressed state and had her first psychiatric hospitalization. During the next 2 yr, the patient had 7 readmissions to hospital. She made frequent selfmutilating attempts with no endurmg change in her self-destructive behavior, despite treatment which included E.C.T. (which brought about brief periods of improvement in her behavior). group psychotherapy, individual psychotherapy, behavior therapy (specific techniques were not described in her file), and chemotherapy (large doses of phenothiazines and tricychc antidepressants). Miss A. was then referred to this hospital for assessment and recommendations. Her psychological test findings indicated average intelhgence, considerable interpersonal anxiety, and depressive and paranoid features. There were no clear psychotic elements revealed in her test responses, but they might have been concealed by her relatively limited response productivity. She is a tall, heavy set woman with 2nd and 3rd degree scars over much of her face and arms. At the time of her admission, she seldom spoke spontaneously, seldom changed her facial expression, and was generally a "loner" on the ward. During her first 17 days at the hospital, she burned herself on six separate occasions on
* Requests for reprints should be addressed to Howard Roback, Vanderbilt University Medical Center, Nashville, Tennessee. 189
190
HOWARD ROBACK, DOUGLAS FRAYN, LINDA OUNIIY and KASPAR TUTI~R8
the face and arms.* At this point, it became anhedonic feelings and poor impulse control. painfully apparent to the staff that a treatment Because Parnate (tranylcypromine) has been program which would be immediately effective shown to be helpful when combined with in preventing her from further mutilations anti-psychotic neuroleptics in some stubborn needed to be quickly engineered and im- cases of chronic anhedonia (Hedberg and plemented. Due to the apparent lack of success Giueck, 1971), the patient was given Parnate of earlier treatment interventions, a multi- 10 mgm b.i.d, along with Haldol (haloperidol) factorial treatment program involving the 5 mgm t.i.d. The Haldol was started on the simultaneous application of several procedures patient's second day in hospital and the Parnate was initiated. The conceptualization of the on the fourteenth (see Fig. 1). These drugs were problem and rationale for the individual continued throughout the behavioral modificaprocedures follows. tion program. (B) Emotional labelling. (Dollard and Miller, 1966). Both the psychometrist and nurses CONCEPTUALIZATION OF THE assigned to the case attempted to help the PROBLEM patient to discriminate between her feeling Although the clinical staff involved with states and to label them correctly. For example, Miss A. viewed her self-injurious behavior the staff would state, "You sound angry", when differently (e.g. masochism, attempts at "feeling", Miss A. appeared to be in that state. In addition, counterphobie behavior, distraction behavior), the staff encouraged her to label spontaneously they agreed to put aside speculations about the what she was feeling when she was with them. "dynamics behind the self-burnings", and This procedure was initiated on the first day of attempted to modify directly the patient's self- the behavioral modification program and destructive behavior. In perusing nursing notes continued throughout its duration. from the current and previous hospitalizations, (C) Modeling (Bandura, 1969). A female it appeared that Miss A.'s in-hospital self- psychometrist met with the patient for 20 min burnings were contingent upon specific stimulus daily (total sessions = 25) in order to model conditions which provoked anger in her. These various kinds of anger responses (ranging from stimulus conditions included visits from her telling someone a firm "No!" to punching a aunt and long distance telephone conversations pillow with her first). She discussed with the with her parents. Miss A. seemed unable to label patient the various methods of anger expression clearly the feeling states she had experienced and their appropriateness or inappropriateness. previous to, and during, her self-destructive acts. These sessions had the purpose of enabling The staff agreed to consider her self-mutilation Miss A. to acquire alternative anger responses as maladaptive anger responses and to develop through observation of the psychometrist's and test out a therapeutic program designed to behavior. The psychometrist also modeled affectionate teach Miss A. adaptive and appropriate responses to the stimuli which had previously responses (e.g. how to let people know that you like them) in order to increase the patient's evoked these responses. social skills which appeared to be relatively minimal at the outset of the program. TREATMENT AND RATIONALE (D) Role playing. The same psychometrist The following interventions were included in spent an additional 20 rain daily with Miss A. during which time the patient would role-play the patient's program: (A) Chemotherapy. The prime targets for the anger responses earlier modeled for her--in symptomatic relief appeared to be the patient's the "safe" environment of the psychometrist's *A burning attempt on day 8 of the baseline period was interrupted by the nursing staff.
A MULTIFACTORIAL APPROACH TO THE TREATMENT AND WARD MANAGEMENT office. The content included both current real life s~tuations (such as demanding of her hospital physician that he give her an exact discharge date) and situations that Miss A. would be confronted with when she left the hospital (e.g. situations involving her family). The trainer would reinforce, by positive statements or head nodding, Miss A.'s appropriate anger responses. Miss A. also role-played positive social responses m a format similar to that utilized na the role playing of anger responses. (E) Modified assertive training (Woipe, 1969). The psychometrist also encouraged and reinforced the patient when she tested out her newly acquired anger and socially oriented responses in "real" situations involving members of the hospital community and hospital visitors. As the hospital staff became aware of angerprovoking situations or other situations in which Miss A. appeared socially awkward, they would pass this information on to the psychometrist who would model the behaviors that seemed relevant for coping with the situation at her next meeting with Miss A. The trainer would also have the patient role-play the appropriate behavior which Miss A. would be encouraged to re-enact in her "psychodrama" session (see below). When she appeared to acquire the necessary behaviors she was encouraged to test them out in reality and to discuss the consequences of her actions with the psychometrist later in the day. (F) "'Psychodrama". The patient attended weekly "psychodrama" sessions in order to provide her with a "safety valve" for releasing pent-up emotions. These sessions were started on the first day of the behavioral modification program. The leader had Miss A. re-enact upsetting emotional events and the patient was encouraged to act out what she would like to have said or done in those situations. During the enactment of the scenes, a staff member acted as a "double" for Miss A. (e.g. the double reflected the emotions aroused in the patient and labelled the resultant feelings). Each scene was terminated when Miss A. appeared to reach an emotional peak or when
191
the scene had reached a satisfactory conclusion. At the end of every session, all the "psychodrama" group members discussed what they felt had transpired and their personal reactions to the experience. In addition, Miss A.'s psychiatric resident met with her after each session to discuss her feelings about the experience. (G) Grouppsychotherapy. The patient attended weekly group therapy sessions which stressed interpersonal interactmn and "cris~s intervention". The therapists in the group attempted to model spontaneity for the patient and socially reinforced all positwe social responses she performed. These sessions were initiated at the end of the first week of the behavioral modification program. (H) Withholding of privileges. The patient was informed by her physician at the start of the program that if she were to burn herself or use other inappropriate anger responses (e.g. hitting staff), she would lose all plivileges for the next 24 hr. In summary, it was hoped that the patient's self-mutilating behavior could be controlled by (a) teaching her to discriminate and label her emotional states including anger, (b) modeling appropriate anger responses for her, (c) having her role-play these observed behaviors m "safe" situations, (d) encouraging her to test out her newly developed behaviors in "live" situations on the ward, (e) providing her with a "safe" environment to re-enact emotionally upsetting situations and to release pent up emotions, and (f) taking away privileges when she engaged in self-mutilating behaviors. The overlapping treatment techniques were intended to increase adaptive assertive behavior.
OUTPATIENT TREATMENT RECOMMENDATIONS Upon discharge from the hospital, the patient returned to her home town (approximately 2000 miles from the Clarke Institute) for outpatient care. The treatment recommendations sent to Miss A'.s home therapist included:
192
HOWARD ROBACK, DOUGLAS FRAYN, LINDA GUNBY and KASPAR TUTERS
(a) continuation of her chemotherapy regime in order to prevent a return of her anhedonia, (b) activity group therapy with peers focusing on physical exercise to help the patient with her weight problem and to provide her with peer group involvement, (c) family therapy focusing on helping the family members to develop a more open communication with one another, and (d) supportive individual psychotherapy. Reports we have received indicate that these recommendations have been implemented. A description of the behavior therapy program was also sent to the patient's home therapist in case she resumed her self-burning responses. RESULTS A. Self-mutilating Behavwr The number of self-burning episodes was recorded by nursing and medical staff who treated the patient's wounds. As the patient's burnings were confined to uncovered areas (face, arms and hands), fresh burnings were readily identifiable to nursing staff. The patient also habitually reported her self-burnings immediately after their occurrence. It is possible,
6
but unlikely, that any self-burnmgs went unnoticed. Figure I shows that during the patient's first 17 days in the hospital she burned herself on six different occasions* while during the 44 days of the behavioral modification program she burned herself only once. That particular self-mutilation occurred on the first day of the program. During her stay in the hospital, Miss A, experienced a number of emotionally upsetting events in which she expressed her anger in ways that she had acquired during the treatment program. For example, when the psychiatric resident in the case refused to give her an exact date of discharge, she called him a "bastard" to his face. On another occasion, when she was extremely upset, she went to her room and pounded a pillow. There were several such events, and although she was able to verbalize that she wanted to burn herself, she expressed her anger in ways that were less maladaptive. Immediately after such incidents, the psychometrist would discuss with Miss A. alternattve methods for dealing with the situation, model them for her and have her role-play the modeled
Parnat( (14)
r
5 4 3
Z 0
NF i
2
I , , BEHAVI?RALMODIFICATIONPROGRAM 3 4 5 6 l 8 9 1o 11 BLOCKSOf SIX DAYS
Flo. 1. Rate of self-burnings. * A burning attempt on day 8 o f the baseline period was interrupted by the nursing staff.
A M U L T I F A C T O R I A L A P P R O A C H TO THE T R E A T M E N T A N D W A R D M A N A G E M E N T
behavior. Other staff members would encourage her to label the feelings which she was experiencing and to discuss them. The patient's home therapist reports that Miss A. has engaged in two self-burning incidents durmg the first 4 months after her return. Both of these incidents occurred within the first month of outpatient care and were reported by the patient to the therapist. As the family situation that previously evoked her self-burnings is present m her current environment, the small number of burnings indicates that her improvement has been maintained.
( B) hTterpersonal behavior Miss A.'s newly-acquired "social behavior" imtmlly seemed quite mechanical. However, it became increasingly spontaneous, both on the ward and at her group therapy sessions. Although she became able to smile and laugh appropriately and answered questions with longer statements than her initial "yes" or "no", she seldom mttmted mterpersonal behavior. DISCUSSION The disadvantage of employing a multiplicity of therapeutic techniques to a given case is the
193
impossibility of determining afterwards which of the treatment interventions had the most impact on modifying the behavior. The expression of newly acquired anger responses during emotionally disturbing events suggests that modeling, role-playing and assertive training were important in altering the previously intractable self-mjurous behavior of this severely disturbed patient However, it m~ght also be argued that the chemotherapy facdltated her ab.hty to find words to label her feelings. Those on the staff who wewed the pattent's self-mutdatlon as attempts "to feel something" have argued that the combination of Parnate and Haldol reduced the necessity of the patient having to injure herself m order to experience feelings. The authors acknowledge that staff "enthusiasm" and the "'attention factor" also contributed to the effectiveness of the treatment program. However, since Miss A. had been subject to considerable individual attention and staff involvement during her prewous hospitalizations without alteration in her ineffective coping behavior, it ~s extremely doubtful that these factors alone can account for the results obtained.
Acknowledgements--The authors would like to acknowledge tile helpful suggest,ons of Ronald Langevm and Douglas Qu,rk in the planning of the treatment program, and the invaluable assistance of Dorothy Burwell, Lorram Massey, Judy Slater and other members of the nursing staff m its implementation
REFERENCES BANDURA A. (I 969) Principlesof Behavioral Modification, Holt, Rinehart and Winston, New York. DOLLArD J. and MILLER N. (1966) Reinforcement theory and counselhng, Theories of Counselling and Psychotherapy (Edited by PATTERSON C. H ), pp 179-215, Harper and Row, New York.
HEDBERG D. L. and GLUECK B. (1971) Tranylcypromine --Trifluoperazme combination m the treatment of Schizophrema, Am J. Psychiat. 127, 211-216. WOLPE J. (1969) The Practwe of Behavior Therapy, Pergamon Press, New York.
(First received 16 December 1971; in revised form 17 March 1972)
A M U L T I F A C T O R I A L APPROACH TO THE T R E A T M E N T AND WARD M A N A G E M E N T OF A SELF-MUTILATING PATIENT HOWARD ROBACK,* DOUGLAS FRAYN, LINDA GUNBY and KASPAR TUTFRS Clarke Institute of Psychiatry. Toronto, Ontarto Surnmary--Thls arttcle describes the treatment procedures employed m altering the self-burmng behavior of a 19-yr-old female patient with a long standing htstory of selfmutdations. During her first 17 days in the hospital she burned herself on six occaslon~ and an addiuonal burning attempt was interrupted by hospital staff During the 44 days of the behavioral modtficatlon program which focused on teaching the patzent adapuve anger responses, the patient burned herself only on the first day of the program The patient's ~mprovement was maintained during a 4-month follow-up period. Tins case is of interest because of the successful diminution of a patient's self-mutilating behavior. From a scientific point of view, it ~s a travesty; from a management point of view, it is an exciting success.
CASE H I S T O R Y Miss A. was a 19-yr-old, unmarried patient, with a history of repeated self-mutilations since 14. These self-destructive acts were expressed by self-cuttings and burnings of the arms, forearms and facial areas. Miss A. had been hospitalized for 1 week at age 5 because of repeated nightmares. When she was 12, her parents noticed an increasing withdrawal from people. At 14 she began slashing herself with a razor blade and burning herself whenever she showed anger. At 15, she developed a "school phobia" and would write on the school walls with the apparently deliberate aim of being expelled from school. She entered into individual psychotherapy with a psychiatrist but stopped seeing him after very few sessions. This experience failed to alter her self-injurious behavior. At this time, the patient's parents would attempt to stop her from burning herself by taking away her cigarettes and matches, but she responded by using sharp pieces of glass to inflict wounds
on her thighs and arms. At 17, Miss A. took an overdose of aspirins while in a depressed state and had her first psychiatric hospitalization. During the next 2 yr, the patient had 7 readmissions to hospital. She made frequent selfmutilating attempts with no endurmg change in her self-destructive behavior, despite treatment which included E.C.T. (which brought about brief periods of improvement in her behavior). group psychotherapy, individual psychotherapy, behavior therapy (specific techniques were not described in her file), and chemotherapy (large doses of phenothiazines and tricychc antidepressants). Miss A. was then referred to this hospital for assessment and recommendations. Her psychological test findings indicated average intelhgence, considerable interpersonal anxiety, and depressive and paranoid features. There were no clear psychotic elements revealed in her test responses, but they might have been concealed by her relatively limited response productivity. She is a tall, heavy set woman with 2nd and 3rd degree scars over much of her face and arms. At the time of her admission, she seldom spoke spontaneously, seldom changed her facial expression, and was generally a "loner" on the ward. During her first 17 days at the hospital, she burned herself on six separate occasions on
* Requests for reprints should be addressed to Howard Roback, Vanderbilt University Medical Center, Nashville, Tennessee. 189
190
HOWARD ROBACK, DOUGLAS FRAYN, LINDA OUNIIY and KASPAR TUTI~R8
the face and arms.* At this point, it became anhedonic feelings and poor impulse control. painfully apparent to the staff that a treatment Because Parnate (tranylcypromine) has been program which would be immediately effective shown to be helpful when combined with in preventing her from further mutilations anti-psychotic neuroleptics in some stubborn needed to be quickly engineered and im- cases of chronic anhedonia (Hedberg and plemented. Due to the apparent lack of success Giueck, 1971), the patient was given Parnate of earlier treatment interventions, a multi- 10 mgm b.i.d, along with Haldol (haloperidol) factorial treatment program involving the 5 mgm t.i.d. The Haldol was started on the simultaneous application of several procedures patient's second day in hospital and the Parnate was initiated. The conceptualization of the on the fourteenth (see Fig. 1). These drugs were problem and rationale for the individual continued throughout the behavioral modificaprocedures follows. tion program. (B) Emotional labelling. (Dollard and Miller, 1966). Both the psychometrist and nurses CONCEPTUALIZATION OF THE assigned to the case attempted to help the PROBLEM patient to discriminate between her feeling Although the clinical staff involved with states and to label them correctly. For example, Miss A. viewed her self-injurious behavior the staff would state, "You sound angry", when differently (e.g. masochism, attempts at "feeling", Miss A. appeared to be in that state. In addition, counterphobie behavior, distraction behavior), the staff encouraged her to label spontaneously they agreed to put aside speculations about the what she was feeling when she was with them. "dynamics behind the self-burnings", and This procedure was initiated on the first day of attempted to modify directly the patient's self- the behavioral modification program and destructive behavior. In perusing nursing notes continued throughout its duration. from the current and previous hospitalizations, (C) Modeling (Bandura, 1969). A female it appeared that Miss A.'s in-hospital self- psychometrist met with the patient for 20 min burnings were contingent upon specific stimulus daily (total sessions = 25) in order to model conditions which provoked anger in her. These various kinds of anger responses (ranging from stimulus conditions included visits from her telling someone a firm "No!" to punching a aunt and long distance telephone conversations pillow with her first). She discussed with the with her parents. Miss A. seemed unable to label patient the various methods of anger expression clearly the feeling states she had experienced and their appropriateness or inappropriateness. previous to, and during, her self-destructive acts. These sessions had the purpose of enabling The staff agreed to consider her self-mutilation Miss A. to acquire alternative anger responses as maladaptive anger responses and to develop through observation of the psychometrist's and test out a therapeutic program designed to behavior. The psychometrist also modeled affectionate teach Miss A. adaptive and appropriate responses to the stimuli which had previously responses (e.g. how to let people know that you like them) in order to increase the patient's evoked these responses. social skills which appeared to be relatively minimal at the outset of the program. TREATMENT AND RATIONALE (D) Role playing. The same psychometrist The following interventions were included in spent an additional 20 rain daily with Miss A. during which time the patient would role-play the patient's program: (A) Chemotherapy. The prime targets for the anger responses earlier modeled for her--in symptomatic relief appeared to be the patient's the "safe" environment of the psychometrist's *A burning attempt on day 8 of the baseline period was interrupted by the nursing staff.
A MULTIFACTORIAL APPROACH TO THE TREATMENT AND WARD MANAGEMENT office. The content included both current real life s~tuations (such as demanding of her hospital physician that he give her an exact discharge date) and situations that Miss A. would be confronted with when she left the hospital (e.g. situations involving her family). The trainer would reinforce, by positive statements or head nodding, Miss A.'s appropriate anger responses. Miss A. also role-played positive social responses m a format similar to that utilized na the role playing of anger responses. (E) Modified assertive training (Woipe, 1969). The psychometrist also encouraged and reinforced the patient when she tested out her newly acquired anger and socially oriented responses in "real" situations involving members of the hospital community and hospital visitors. As the hospital staff became aware of angerprovoking situations or other situations in which Miss A. appeared socially awkward, they would pass this information on to the psychometrist who would model the behaviors that seemed relevant for coping with the situation at her next meeting with Miss A. The trainer would also have the patient role-play the appropriate behavior which Miss A. would be encouraged to re-enact in her "psychodrama" session (see below). When she appeared to acquire the necessary behaviors she was encouraged to test them out in reality and to discuss the consequences of her actions with the psychometrist later in the day. (F) "'Psychodrama". The patient attended weekly "psychodrama" sessions in order to provide her with a "safety valve" for releasing pent-up emotions. These sessions were started on the first day of the behavioral modification program. The leader had Miss A. re-enact upsetting emotional events and the patient was encouraged to act out what she would like to have said or done in those situations. During the enactment of the scenes, a staff member acted as a "double" for Miss A. (e.g. the double reflected the emotions aroused in the patient and labelled the resultant feelings). Each scene was terminated when Miss A. appeared to reach an emotional peak or when
191
the scene had reached a satisfactory conclusion. At the end of every session, all the "psychodrama" group members discussed what they felt had transpired and their personal reactions to the experience. In addition, Miss A.'s psychiatric resident met with her after each session to discuss her feelings about the experience. (G) Grouppsychotherapy. The patient attended weekly group therapy sessions which stressed interpersonal interactmn and "cris~s intervention". The therapists in the group attempted to model spontaneity for the patient and socially reinforced all positwe social responses she performed. These sessions were initiated at the end of the first week of the behavioral modification program. (H) Withholding of privileges. The patient was informed by her physician at the start of the program that if she were to burn herself or use other inappropriate anger responses (e.g. hitting staff), she would lose all plivileges for the next 24 hr. In summary, it was hoped that the patient's self-mutilating behavior could be controlled by (a) teaching her to discriminate and label her emotional states including anger, (b) modeling appropriate anger responses for her, (c) having her role-play these observed behaviors m "safe" situations, (d) encouraging her to test out her newly developed behaviors in "live" situations on the ward, (e) providing her with a "safe" environment to re-enact emotionally upsetting situations and to release pent up emotions, and (f) taking away privileges when she engaged in self-mutilating behaviors. The overlapping treatment techniques were intended to increase adaptive assertive behavior.
OUTPATIENT TREATMENT RECOMMENDATIONS Upon discharge from the hospital, the patient returned to her home town (approximately 2000 miles from the Clarke Institute) for outpatient care. The treatment recommendations sent to Miss A'.s home therapist included:
192
HOWARD ROBACK, DOUGLAS FRAYN, LINDA GUNBY and KASPAR TUTERS
(a) continuation of her chemotherapy regime in order to prevent a return of her anhedonia, (b) activity group therapy with peers focusing on physical exercise to help the patient with her weight problem and to provide her with peer group involvement, (c) family therapy focusing on helping the family members to develop a more open communication with one another, and (d) supportive individual psychotherapy. Reports we have received indicate that these recommendations have been implemented. A description of the behavior therapy program was also sent to the patient's home therapist in case she resumed her self-burning responses. RESULTS A. Self-mutilating Behavwr The number of self-burning episodes was recorded by nursing and medical staff who treated the patient's wounds. As the patient's burnings were confined to uncovered areas (face, arms and hands), fresh burnings were readily identifiable to nursing staff. The patient also habitually reported her self-burnings immediately after their occurrence. It is possible,
6
but unlikely, that any self-burnmgs went unnoticed. Figure I shows that during the patient's first 17 days in the hospital she burned herself on six different occasions* while during the 44 days of the behavioral modification program she burned herself only once. That particular self-mutilation occurred on the first day of the program. During her stay in the hospital, Miss A, experienced a number of emotionally upsetting events in which she expressed her anger in ways that she had acquired during the treatment program. For example, when the psychiatric resident in the case refused to give her an exact date of discharge, she called him a "bastard" to his face. On another occasion, when she was extremely upset, she went to her room and pounded a pillow. There were several such events, and although she was able to verbalize that she wanted to burn herself, she expressed her anger in ways that were less maladaptive. Immediately after such incidents, the psychometrist would discuss with Miss A. alternattve methods for dealing with the situation, model them for her and have her role-play the modeled
Parnat( (14)
r
5 4 3
Z 0
NF i
2
I , , BEHAVI?RALMODIFICATIONPROGRAM 3 4 5 6 l 8 9 1o 11 BLOCKSOf SIX DAYS
Flo. 1. Rate of self-burnings. * A burning attempt on day 8 o f the baseline period was interrupted by the nursing staff.
A M U L T I F A C T O R I A L A P P R O A C H TO THE T R E A T M E N T A N D W A R D M A N A G E M E N T
behavior. Other staff members would encourage her to label the feelings which she was experiencing and to discuss them. The patient's home therapist reports that Miss A. has engaged in two self-burning incidents durmg the first 4 months after her return. Both of these incidents occurred within the first month of outpatient care and were reported by the patient to the therapist. As the family situation that previously evoked her self-burnings is present m her current environment, the small number of burnings indicates that her improvement has been maintained.
( B) hTterpersonal behavior Miss A.'s newly-acquired "social behavior" imtmlly seemed quite mechanical. However, it became increasingly spontaneous, both on the ward and at her group therapy sessions. Although she became able to smile and laugh appropriately and answered questions with longer statements than her initial "yes" or "no", she seldom mttmted mterpersonal behavior. DISCUSSION The disadvantage of employing a multiplicity of therapeutic techniques to a given case is the
193
impossibility of determining afterwards which of the treatment interventions had the most impact on modifying the behavior. The expression of newly acquired anger responses during emotionally disturbing events suggests that modeling, role-playing and assertive training were important in altering the previously intractable self-mjurous behavior of this severely disturbed patient However, it m~ght also be argued that the chemotherapy facdltated her ab.hty to find words to label her feelings. Those on the staff who wewed the pattent's self-mutdatlon as attempts "to feel something" have argued that the combination of Parnate and Haldol reduced the necessity of the patient having to injure herself m order to experience feelings. The authors acknowledge that staff "enthusiasm" and the "'attention factor" also contributed to the effectiveness of the treatment program. However, since Miss A. had been subject to considerable individual attention and staff involvement during her prewous hospitalizations without alteration in her ineffective coping behavior, it ~s extremely doubtful that these factors alone can account for the results obtained.
Acknowledgements--The authors would like to acknowledge tile helpful suggest,ons of Ronald Langevm and Douglas Qu,rk in the planning of the treatment program, and the invaluable assistance of Dorothy Burwell, Lorram Massey, Judy Slater and other members of the nursing staff m its implementation
REFERENCES BANDURA A. (I 969) Principlesof Behavioral Modification, Holt, Rinehart and Winston, New York. DOLLArD J. and MILLER N. (1966) Reinforcement theory and counselhng, Theories of Counselling and Psychotherapy (Edited by PATTERSON C. H ), pp 179-215, Harper and Row, New York.
HEDBERG D. L. and GLUECK B. (1971) Tranylcypromine --Trifluoperazme combination m the treatment of Schizophrema, Am J. Psychiat. 127, 211-216. WOLPE J. (1969) The Practwe of Behavior Therapy, Pergamon Press, New York.
(First received 16 December 1971; in revised form 17 March 1972)