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A multiple impact program for the treatment of injection phobias
J. Behav. The?. & Exp. Psych&t. Vol. 5, pp. 257-258. Pergamon Press, 1974. Printed in Great Britain.
A MULTIPLE IMPACT PROGRAM FOR THE TREATMENT OF INJECTION PHOBIAS WILLIAM
H. NIMMER* and RICHARDA. KAPPA
Mental Health Program and Department
of Psychology, University of Cincinnati
Summary-Three female college students with longstanding histories of aversive reactions to injections were treated by a multifaceted program consisting of prolonged presentations of hierarchical stimuli, in vivo work, modeling, and “homework”. An average of five sessions was needed to complete therapy. Follow-up contacts 6 months after therapy indicated that there had been no return of the original aversive reactions.
between systematic desensitization and flooding in the context of fear of receiving injections. Basically, an in vivo hierarchical progression toward the phobic situation was coupled with the demand that the anxieties attendant on each particular item be fully experienced until no further discomfort could be generated by it. This procedure is in contrast to the brief hierarchical presentations of systematic desensitization, and to the high prolonged anxious arousal of flooding. The combination was felt to represent the sum of the most useful features of these two techniques, a premise which finds some support in the work of Gelder et al. (1973). Procedures bearing some similarity to the present one have been described by Goldfried (1971) and Davison (1965). THIS paper
offers
a compromise
METHOD Subjects
Three women seen at a university health service each presented a lifelong history of aversive reactions to injections. Two Ss typically fainted either before or after receiving injections. The third had on occasion fainted or “blacked out” and also experienced nausea in conjunction with injections. Each had responded adversely to “shots” at least once during the previous 10 months. Procedure
The Ss, seen separately, all received the same basic therapeutic procedures. They were first asked to provide
oral and written descriptions of their reactions to injections. Particular attention was devoted to elucidating the most disturbing aspects of the situation (medicinal odors, sights of injection equipment etc.) in order to locate pertinent phobic cues. This assignment was designed to increase feelings of control over the anxiety-producing events, as well as to foster contact with thoughts about stimuli which might typically be avoided. The therapeutic operations were (a) work with the hierarchy, (b) extra-therapy practice, (c) assignments tailored to individual requirements, and (d) receiving an injection as a culmination of therapy. One-hour therapy appointments were scheduled two or three times weekly. (a) The hierarchy (shown in Table 1) was based on information derived from the first S and was used for all Ss. The gradual nature of the hierarchy was explained, and it was suggested that the gradualness would ward off fainting during therapy. At each hierarchical stage, the Ss were required to describe their anxious reactions to the task being considered. Their descriptions not only provided a guide to the degree of discomfort experienced, but also served to assure focusing upon the hierarchical item and maintaining contact with their reactions. Their verbal commentaries typically consisted initially of apprehensive, anxiety-laden statements, which gradually diminished and eventually ceased to reflect discomfort. When a stimulus was no longer capable of evoking fearful responses, Ss were directed to try to reinstate their original apprehensivereactions. These efforts met with only limited success. When it became apparent that no anxiety could be induced, we proceeded to the next highest item in the hierarchy. (b) A second major part of this therapeutic program involved “homework” assignments in which the Ss practiced exactly that which had been accomplished during the preceding session. Daily 15min rehearsal periods were conducted with the aid of a friend. Ss were
*Currently with the Psychology Service Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas 78234. 7Requests for reprints should be addressed to Richard A. Kapp, Director of Training, Mental Health Program, 102 Scioto Hall, University of Cincinnati, Cincinnati, Ohio 45221. 257
258
WILLIAM
H. NIMMER
TABLE 1. STANDARD HIERARCHY USED FOR ALL 'IHREE Ss. ITEMS ARE RANKED IN DESCENDING ORDER OF THEIR ANTICIPATED ANXIETY-AROUSAL POTENTIAL
18 17 16 15 14 13 12 11 t0 9 8 7 6 5 4 3 2 I
Receiving injection by physician Syringe, shield off, held by T/I and darted quickly to s’s arm Syringe, shield on, held by Th and darted quickly to s’s arm Syringe, shield off, held by S and darted quickly to 7%‘~arm Syringe, shield on, held by S and darted quickly to Th’s arm Syringe, shield off, held by Th and touched to s’s arm Syringe, shield on, held by Th and touched to S’s arm Syringe, shield off, held by Sand touched to her own arm Syringe, shield on, held by Sand touched to her own arm Syringe, shield off, held by Sand touched to Th’s arm Syringe, shield on, held by S and touched to therapist’s (Th) arm Syringe is placed leaning against s’s arm, shield off Syringe is placed leaning against S’s arm, shield on Being prepared for an injection (sleeve up, rubbed with swab) Handling syringe with shield off Handling syringe with shield on Viewing syringe on table with shield off the needle Viewing hypodermic syringe on table with shield on the needle
allowed to take the various materials (syringe, alcohol and swabs, smelling salts) home with them for the rehearsals. These assignments reinforced feelings of success and self-control by maintaining Ss in non-threatening contact with customarily avoided stimuli. (c) The third element of the program was the opportunity to work directly with pertinent phobic stimuli, Since all reported experiencing anxiety arousal when viewing others receiving injections, one common assignment was to witness such occurrences. This was accomplished in cooperation with university health service staff, some of whom received injections expressly for the Ss to observe models who did not react aversively to injections. Medicinal odors were especially likely to trigger fear responses for one S. She was given vials of alcohol, ether, and nail polish and directed to practice experiencing her discomfort with them in the same manner as used for the hierarchy. Another S’s anxiety was often cued by the presence of a medical person in a white
and RICHARD
A. KAPP
coat; a nurse was used to work on the latter stages of the hierarchy with this individual. (d) When all but the last hierarchy item had been completed, the Ss selected a time to receive an injection (isotonic saline solution). No cancellations of these appointments were permitted. No specific instructions were given in preparation for the injection for two of the Ss, although it was suggested that it might be helpful for each to reflect upon the progress made to this point. The third S rehearsed exactly how she would behave during the injection while present in the room where she would eventually get the “shot”. A real-life test of the therapeutic success was considered essential, since only this type of encounter could provide behavioral evidence of amelioration of the phobic state.
RESULTS None of the Ss offered any resistance to receiving their injections. Each watched the injection being administered and reported an absence of premonitions of fainting or nausea. Follow-up contacts 6 months after therapy indicated that there had been no return of the customary aversive reactions for any of them. During the follow-up interviews, all Ss indicated a willingness to receive an injection to demonstrate their continuing success, although they were not required to receive one at this time. One S was donating blood periodically, another had uneventfully received a cortisone shot, and the third was scheduled for dental surgery involving injections. These procedures combined a hierarchical approach, in viva work, anxiety-evocation, modeling, and “homework”. Accordingly, it is not possible to determine to what degree each of the components contributed to the outcome. The inherent flexibility of the present approach would seem to make it applicable to a broad range of phobic symptomatology, particularly when the aversive reactions are cued by distinct objects or settings.
Acknowledgements-Special thanks to the medical staff of the Student Health Service for their cooperation in this research, and to Drs. Paul Karoly and John Steffen, Psychology Department, for their critical reading of the manuscript. REFERENCES DAVISON G. (1965) Relative
contributions
of differential
relaxation and graded exposure to desensitization of a neurotic fear, Proc. of the 73rd Ann. Conv. Amer. Psychol. Assoc., pp. 209-210. GELDER
M.,
BANCROFT
J.,
GATH
D.,
JOHNSTON D.,
MATHEWS A. specific factors
and SHAW P. (1973) Specific and nonin behaviour therapy, &it. J. Psychiut.
123,445-462. GOLDFRIED
M.
(1971)
training in self-control, 228-234.
Systematic
desensitization
as
J. consult. clin. Psychol. 37,
A MULTIPLE IMPACT PROGRAM FOR THE TREATMENT OF INJECTION PHOBIAS WILLIAM
H. NIMMER* and RICHARDA. KAPPA
Mental Health Program and Department
of Psychology, University of Cincinnati
Summary-Three female college students with longstanding histories of aversive reactions to injections were treated by a multifaceted program consisting of prolonged presentations of hierarchical stimuli, in vivo work, modeling, and “homework”. An average of five sessions was needed to complete therapy. Follow-up contacts 6 months after therapy indicated that there had been no return of the original aversive reactions.
between systematic desensitization and flooding in the context of fear of receiving injections. Basically, an in vivo hierarchical progression toward the phobic situation was coupled with the demand that the anxieties attendant on each particular item be fully experienced until no further discomfort could be generated by it. This procedure is in contrast to the brief hierarchical presentations of systematic desensitization, and to the high prolonged anxious arousal of flooding. The combination was felt to represent the sum of the most useful features of these two techniques, a premise which finds some support in the work of Gelder et al. (1973). Procedures bearing some similarity to the present one have been described by Goldfried (1971) and Davison (1965). THIS paper
offers
a compromise
METHOD Subjects
Three women seen at a university health service each presented a lifelong history of aversive reactions to injections. Two Ss typically fainted either before or after receiving injections. The third had on occasion fainted or “blacked out” and also experienced nausea in conjunction with injections. Each had responded adversely to “shots” at least once during the previous 10 months. Procedure
The Ss, seen separately, all received the same basic therapeutic procedures. They were first asked to provide
oral and written descriptions of their reactions to injections. Particular attention was devoted to elucidating the most disturbing aspects of the situation (medicinal odors, sights of injection equipment etc.) in order to locate pertinent phobic cues. This assignment was designed to increase feelings of control over the anxiety-producing events, as well as to foster contact with thoughts about stimuli which might typically be avoided. The therapeutic operations were (a) work with the hierarchy, (b) extra-therapy practice, (c) assignments tailored to individual requirements, and (d) receiving an injection as a culmination of therapy. One-hour therapy appointments were scheduled two or three times weekly. (a) The hierarchy (shown in Table 1) was based on information derived from the first S and was used for all Ss. The gradual nature of the hierarchy was explained, and it was suggested that the gradualness would ward off fainting during therapy. At each hierarchical stage, the Ss were required to describe their anxious reactions to the task being considered. Their descriptions not only provided a guide to the degree of discomfort experienced, but also served to assure focusing upon the hierarchical item and maintaining contact with their reactions. Their verbal commentaries typically consisted initially of apprehensive, anxiety-laden statements, which gradually diminished and eventually ceased to reflect discomfort. When a stimulus was no longer capable of evoking fearful responses, Ss were directed to try to reinstate their original apprehensivereactions. These efforts met with only limited success. When it became apparent that no anxiety could be induced, we proceeded to the next highest item in the hierarchy. (b) A second major part of this therapeutic program involved “homework” assignments in which the Ss practiced exactly that which had been accomplished during the preceding session. Daily 15min rehearsal periods were conducted with the aid of a friend. Ss were
*Currently with the Psychology Service Brooke Army Medical Center, Fort Sam Houston, San Antonio, Texas 78234. 7Requests for reprints should be addressed to Richard A. Kapp, Director of Training, Mental Health Program, 102 Scioto Hall, University of Cincinnati, Cincinnati, Ohio 45221. 257
258
WILLIAM
H. NIMMER
TABLE 1. STANDARD HIERARCHY USED FOR ALL 'IHREE Ss. ITEMS ARE RANKED IN DESCENDING ORDER OF THEIR ANTICIPATED ANXIETY-AROUSAL POTENTIAL
18 17 16 15 14 13 12 11 t0 9 8 7 6 5 4 3 2 I
Receiving injection by physician Syringe, shield off, held by T/I and darted quickly to s’s arm Syringe, shield on, held by Th and darted quickly to s’s arm Syringe, shield off, held by S and darted quickly to 7%‘~arm Syringe, shield on, held by S and darted quickly to Th’s arm Syringe, shield off, held by Th and touched to s’s arm Syringe, shield on, held by Th and touched to S’s arm Syringe, shield off, held by Sand touched to her own arm Syringe, shield on, held by Sand touched to her own arm Syringe, shield off, held by Sand touched to Th’s arm Syringe, shield on, held by S and touched to therapist’s (Th) arm Syringe is placed leaning against s’s arm, shield off Syringe is placed leaning against S’s arm, shield on Being prepared for an injection (sleeve up, rubbed with swab) Handling syringe with shield off Handling syringe with shield on Viewing syringe on table with shield off the needle Viewing hypodermic syringe on table with shield on the needle
allowed to take the various materials (syringe, alcohol and swabs, smelling salts) home with them for the rehearsals. These assignments reinforced feelings of success and self-control by maintaining Ss in non-threatening contact with customarily avoided stimuli. (c) The third element of the program was the opportunity to work directly with pertinent phobic stimuli, Since all reported experiencing anxiety arousal when viewing others receiving injections, one common assignment was to witness such occurrences. This was accomplished in cooperation with university health service staff, some of whom received injections expressly for the Ss to observe models who did not react aversively to injections. Medicinal odors were especially likely to trigger fear responses for one S. She was given vials of alcohol, ether, and nail polish and directed to practice experiencing her discomfort with them in the same manner as used for the hierarchy. Another S’s anxiety was often cued by the presence of a medical person in a white
and RICHARD
A. KAPP
coat; a nurse was used to work on the latter stages of the hierarchy with this individual. (d) When all but the last hierarchy item had been completed, the Ss selected a time to receive an injection (isotonic saline solution). No cancellations of these appointments were permitted. No specific instructions were given in preparation for the injection for two of the Ss, although it was suggested that it might be helpful for each to reflect upon the progress made to this point. The third S rehearsed exactly how she would behave during the injection while present in the room where she would eventually get the “shot”. A real-life test of the therapeutic success was considered essential, since only this type of encounter could provide behavioral evidence of amelioration of the phobic state.
RESULTS None of the Ss offered any resistance to receiving their injections. Each watched the injection being administered and reported an absence of premonitions of fainting or nausea. Follow-up contacts 6 months after therapy indicated that there had been no return of the customary aversive reactions for any of them. During the follow-up interviews, all Ss indicated a willingness to receive an injection to demonstrate their continuing success, although they were not required to receive one at this time. One S was donating blood periodically, another had uneventfully received a cortisone shot, and the third was scheduled for dental surgery involving injections. These procedures combined a hierarchical approach, in viva work, anxiety-evocation, modeling, and “homework”. Accordingly, it is not possible to determine to what degree each of the components contributed to the outcome. The inherent flexibility of the present approach would seem to make it applicable to a broad range of phobic symptomatology, particularly when the aversive reactions are cued by distinct objects or settings.
Acknowledgements-Special thanks to the medical staff of the Student Health Service for their cooperation in this research, and to Drs. Paul Karoly and John Steffen, Psychology Department, for their critical reading of the manuscript. REFERENCES DAVISON G. (1965) Relative
contributions
of differential
relaxation and graded exposure to desensitization of a neurotic fear, Proc. of the 73rd Ann. Conv. Amer. Psychol. Assoc., pp. 209-210. GELDER
M.,
BANCROFT
J.,
GATH
D.,
JOHNSTON D.,
MATHEWS A. specific factors
and SHAW P. (1973) Specific and nonin behaviour therapy, &it. J. Psychiut.
123,445-462. GOLDFRIED
M.
(1971)
training in self-control, 228-234.
Systematic
desensitization
as
J. consult. clin. Psychol. 37,