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Gone with the wind: Role-reversed desensitization for a wind phobic client
BEHAVIOR THERAPY 7, 405407 (1976)
Gone with the Wind: Role-Reversed Desensitization for a Wind Phobic Client JAY R . ALPERSON
University of Oregon A wind phobia was eliminated by a series of behavioral interventions. After the application of imaginal and in-vivo desensitization techniques, the therapist changed roles with the client so that the client presented scenes and devised strategies for lessening anxiety. A 2V2 yr follow-up revealed no anxiety reaction to moderate winds.
The flexibility of behavioral techniques enables the clinician to adapt standardized procedures to a variety of clients and problems. In this case report, desensitization procedures have been modified by reversing the roles of client and therapist, so that the client is encouraged to find solutions to stress situations. METHOD Mrs. L., the 34-yr-old wife of a university professor, sought help at our clinic for her fear of wind. She stated that her first anxiety attack occurred during a hurricane lfi years earlier, when gusts reached 90 mph and several people were killed. Eight months pregnant, Mrs. L. was caught with her 2-yr-old daughter in a mountain cabin. She recalled hearing huge trees crashing about her; she panicked and hid in the cellar of the cabin until the storm abated. Since then, she closely monitored weather reports and became nervous when storming was predicted. When winds went above 10 mph, she became increasingly panicky and occasionally had anxiety attacks, consisting of dryness in her mouth, thumping heartbeats, and tightness in her stomach. During the first few attacks, her husband responded in a consoling manner, but he became gradually less sympathetic and let her handle the attacks alone. This was the modal reaction at the beginning of therapy: The whole family left her when she panicked. Excluding the phobia, Mrs. L. found her life enjoyable; she said that her marriage was satisfying, and that she took great pride in her children. An intelligent, competent woman, she was involved in many activities outside of, as well as in her home. A Minnesota Multiphasic Personality Inventory (MMPI) profile revealed no indication of pathology.
TREATMENT After two intake sessions, Mrs. L. was seen by the therapist for 17 meetings on a once-aweek basis. These meetings usually were composed of an inquiry into any problems that had occurred during the past week, and some segment of desensitization procedures. The sessions with Mrs. L. were divisable into four programs: relaxation training and hierarchy building (three sessions); imaginal desensitization (five sessions); in-vivo desensitization (seven sessions); and finally, role-reversed imaginal desensitization (two sessions). The Requests for reprints should be addressed to Jay R. Alperson, Psychology Department, University of Oregon, Eugene, OR 97405. 405 CopyrightEl 1976by Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any form reserved.
406
CASE REPORTS AND STUDIES
first three procedures have been described elsewhere (Lang & Lazovik, 1963;Agras, 1972,pp. 151-153).
Role-Reversed Desensitization If Mrs. L. were to relax herself in anxiety-producing situations, she had to decide which relaxation methods were most appropriate. Within the therapy session, it seemed useful to create these situations and have Mrs. L. determine appropriate procedures. The therapist decided that a role-reversal would accomplish these ends; the client as a therapist would be encouraged to find her own solutions. Mrs. L. changed chairs with the therapist, in order to try something "unusual": she presented the anxiety cards to the therapist, who would signal anxiety as though he were Mrs. L. The real Mrs. L. then restructured the scene, giving the "client" instructions to lower anxiety. An example follows: Mrs. L.: Now I'd like you to imagine this scene. You are going for a walk and have to pass an area where there are tall trees. They are in the distance, but you are approaching them. You're getting closer and closer, and they're getting larger. Therapist: I'm beginning to feel tense. Mrs. L.: Well, OK . . . . As you're walking, you decide to think about the upcoming PTA elections and what your chances are for re-election . . . . Within one session, five cards on the hierarchy were considered, and Mrs. L. posed a Couple of "solutions" for each. Following an additional session of role-reversed desensitization, a joint decision was made to terminate therapy.
RESULTS AND DISCUSSION F o u r days after t e r m i n a t i o n , a w i n d s t o r m with gusts to 40 m p h p r o v i d e d a n u n e x p e c t e d f o l l o w - u p . Mrs. L. r e p o r t e d that, while the f o r e c a s t s did n o t m a k e her n e r v o u s , the actual s t o r m did. She d e c i d e d to try the r e l a x a t i o n p r o c e d u r e ; the t e c h n i q u e q u i c k l y c a l m e d her. P l e a s e d with the results, she felt c o n f i d e n t that she w o u l d e v e n t u a l l y be o b l i v i o u s to w i n d s t o r m s . A 2 ½ yr t e l e p h o n e f o l l o w - u p r e v e a l e d that o n e a n x i e t y a t t a c k had occ u r r e d in the m i d s t of a h u r r i c a n e . S i n c e t e r m i n a t i o n , she had r e t u r n e d to the m o u n t a i n c a b i n t h r e e t i m e s , w i t h o u t a n y p a n i c r e a c t i o n s . She r e p o r t e d no n e w p r o b l e m . I n this case s t u d y , it is difficult to d e t e r m i n e w h a t the o p e r a t i v e t h e r a p e u tic t e c h n i q u e s were. T h e i m p r o v e m e n t c o u l d have b e e n a result o f i m a g i n a l or in-vivo d e s e n s i t i z a t i o n , r o l e - r e v e r s e d d e s e n s i t i z a t i o n , d i s c u s s i o n s of family p r o b l e m s , or s o m e t h i n g e x t e r n a l to t h e r a p y . Mrs. L . ' s p r o g r e s s s e e m e d g r a d u a l , s u g g e s t i n g that n o o n e t e c h n i q u e was e n t i r e l y r e s p o n s i b l e for her c h a n g e . R o l e - r e v e r s e d d e s e n s i t i z a t i o n might be a useful a d d i t i o n to a b e h a v i o r m o d i f i e r ' s p r o c e d u r e s for e l i m i n a t i o n p h o b i a s . T h r o u g h its e m p h a s i s on c o p i n g strategies, r o l e - r e v e r s e d d e s e n s i t i z a t i o n e n a b l e s clients to l e a r n g e n e r a l i z a b l e a n d a d a p t i v e b e h a v i o r s ( M e i c h e n b a u m & C a m e r o n , 1974, pp. 263-290). It s e e m s to be a n efficient t h e r a p y ; it r e q u i r e s little t h e r a p i s t time, a n d c a n be easily a d a p t e d to a g r o u p p r e s e n t a t i o n f o r m a t .
CASE REPORTS AND STUDIES
407
REFERENCES Agras, W. Behavior modification: Principles and clinical applications. Boston: Little, Brown & Co., 1972. Lang, P. J., and Lazovik, A. D. Experimental desensitization of a phobia. Journal o f Abnormal and Social Psychology, 1963, 66, 519-525. Meichenbaum, D., & Cameron, R. The clinical potential of modifying what clients say to themselves. In M. Mahoney, & C. Thoresen (Eds.), Self-control: power to the person. Belmont, CA: Wadsworth, 1974.
Gone with the Wind: Role-Reversed Desensitization for a Wind Phobic Client JAY R . ALPERSON
University of Oregon A wind phobia was eliminated by a series of behavioral interventions. After the application of imaginal and in-vivo desensitization techniques, the therapist changed roles with the client so that the client presented scenes and devised strategies for lessening anxiety. A 2V2 yr follow-up revealed no anxiety reaction to moderate winds.
The flexibility of behavioral techniques enables the clinician to adapt standardized procedures to a variety of clients and problems. In this case report, desensitization procedures have been modified by reversing the roles of client and therapist, so that the client is encouraged to find solutions to stress situations. METHOD Mrs. L., the 34-yr-old wife of a university professor, sought help at our clinic for her fear of wind. She stated that her first anxiety attack occurred during a hurricane lfi years earlier, when gusts reached 90 mph and several people were killed. Eight months pregnant, Mrs. L. was caught with her 2-yr-old daughter in a mountain cabin. She recalled hearing huge trees crashing about her; she panicked and hid in the cellar of the cabin until the storm abated. Since then, she closely monitored weather reports and became nervous when storming was predicted. When winds went above 10 mph, she became increasingly panicky and occasionally had anxiety attacks, consisting of dryness in her mouth, thumping heartbeats, and tightness in her stomach. During the first few attacks, her husband responded in a consoling manner, but he became gradually less sympathetic and let her handle the attacks alone. This was the modal reaction at the beginning of therapy: The whole family left her when she panicked. Excluding the phobia, Mrs. L. found her life enjoyable; she said that her marriage was satisfying, and that she took great pride in her children. An intelligent, competent woman, she was involved in many activities outside of, as well as in her home. A Minnesota Multiphasic Personality Inventory (MMPI) profile revealed no indication of pathology.
TREATMENT After two intake sessions, Mrs. L. was seen by the therapist for 17 meetings on a once-aweek basis. These meetings usually were composed of an inquiry into any problems that had occurred during the past week, and some segment of desensitization procedures. The sessions with Mrs. L. were divisable into four programs: relaxation training and hierarchy building (three sessions); imaginal desensitization (five sessions); in-vivo desensitization (seven sessions); and finally, role-reversed imaginal desensitization (two sessions). The Requests for reprints should be addressed to Jay R. Alperson, Psychology Department, University of Oregon, Eugene, OR 97405. 405 CopyrightEl 1976by Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any form reserved.
406
CASE REPORTS AND STUDIES
first three procedures have been described elsewhere (Lang & Lazovik, 1963;Agras, 1972,pp. 151-153).
Role-Reversed Desensitization If Mrs. L. were to relax herself in anxiety-producing situations, she had to decide which relaxation methods were most appropriate. Within the therapy session, it seemed useful to create these situations and have Mrs. L. determine appropriate procedures. The therapist decided that a role-reversal would accomplish these ends; the client as a therapist would be encouraged to find her own solutions. Mrs. L. changed chairs with the therapist, in order to try something "unusual": she presented the anxiety cards to the therapist, who would signal anxiety as though he were Mrs. L. The real Mrs. L. then restructured the scene, giving the "client" instructions to lower anxiety. An example follows: Mrs. L.: Now I'd like you to imagine this scene. You are going for a walk and have to pass an area where there are tall trees. They are in the distance, but you are approaching them. You're getting closer and closer, and they're getting larger. Therapist: I'm beginning to feel tense. Mrs. L.: Well, OK . . . . As you're walking, you decide to think about the upcoming PTA elections and what your chances are for re-election . . . . Within one session, five cards on the hierarchy were considered, and Mrs. L. posed a Couple of "solutions" for each. Following an additional session of role-reversed desensitization, a joint decision was made to terminate therapy.
RESULTS AND DISCUSSION F o u r days after t e r m i n a t i o n , a w i n d s t o r m with gusts to 40 m p h p r o v i d e d a n u n e x p e c t e d f o l l o w - u p . Mrs. L. r e p o r t e d that, while the f o r e c a s t s did n o t m a k e her n e r v o u s , the actual s t o r m did. She d e c i d e d to try the r e l a x a t i o n p r o c e d u r e ; the t e c h n i q u e q u i c k l y c a l m e d her. P l e a s e d with the results, she felt c o n f i d e n t that she w o u l d e v e n t u a l l y be o b l i v i o u s to w i n d s t o r m s . A 2 ½ yr t e l e p h o n e f o l l o w - u p r e v e a l e d that o n e a n x i e t y a t t a c k had occ u r r e d in the m i d s t of a h u r r i c a n e . S i n c e t e r m i n a t i o n , she had r e t u r n e d to the m o u n t a i n c a b i n t h r e e t i m e s , w i t h o u t a n y p a n i c r e a c t i o n s . She r e p o r t e d no n e w p r o b l e m . I n this case s t u d y , it is difficult to d e t e r m i n e w h a t the o p e r a t i v e t h e r a p e u tic t e c h n i q u e s were. T h e i m p r o v e m e n t c o u l d have b e e n a result o f i m a g i n a l or in-vivo d e s e n s i t i z a t i o n , r o l e - r e v e r s e d d e s e n s i t i z a t i o n , d i s c u s s i o n s of family p r o b l e m s , or s o m e t h i n g e x t e r n a l to t h e r a p y . Mrs. L . ' s p r o g r e s s s e e m e d g r a d u a l , s u g g e s t i n g that n o o n e t e c h n i q u e was e n t i r e l y r e s p o n s i b l e for her c h a n g e . R o l e - r e v e r s e d d e s e n s i t i z a t i o n might be a useful a d d i t i o n to a b e h a v i o r m o d i f i e r ' s p r o c e d u r e s for e l i m i n a t i o n p h o b i a s . T h r o u g h its e m p h a s i s on c o p i n g strategies, r o l e - r e v e r s e d d e s e n s i t i z a t i o n e n a b l e s clients to l e a r n g e n e r a l i z a b l e a n d a d a p t i v e b e h a v i o r s ( M e i c h e n b a u m & C a m e r o n , 1974, pp. 263-290). It s e e m s to be a n efficient t h e r a p y ; it r e q u i r e s little t h e r a p i s t time, a n d c a n be easily a d a p t e d to a g r o u p p r e s e n t a t i o n f o r m a t .
CASE REPORTS AND STUDIES
407
REFERENCES Agras, W. Behavior modification: Principles and clinical applications. Boston: Little, Brown & Co., 1972. Lang, P. J., and Lazovik, A. D. Experimental desensitization of a phobia. Journal o f Abnormal and Social Psychology, 1963, 66, 519-525. Meichenbaum, D., & Cameron, R. The clinical potential of modifying what clients say to themselves. In M. Mahoney, & C. Thoresen (Eds.), Self-control: power to the person. Belmont, CA: Wadsworth, 1974.