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In vivo desensitization of a paranoid schizophrenic
Jr. Behm.
Thu.
& fip.
Psychid.
Vol.
I. pp. 79-81
Pcrgamon
IN VW0 DESENSITIZATION
Reu,
1970. Printed
in Great
Britain.
OF A PARANOID
SCHIZOPHRENIC*
Temple University (Received
25 August
1969)
Summary-Systematic desensitization and operant conditioning were applied to a paranoid schizophrenic inpatient who for 6 years believed the CIA would kill him outside the hospital. After desensitization the patient spent increasing amounts of time outside the hospital where appropriate social behaviors were reinforced.
in a real life (in Go) situation. The study that follows initially used desensitization to encourage the patient to experience the situations he most feared. Those previously feared situations, having been ‘sampled’ (Ayllon and Azrin, 1968), became powerful reinforcers which were later used in operant conditioning with the patient. The subject (S) was a 36year-old, male, white, single, Protestant, diagnosed as paranoid schizophrenic since 1961. His major complaint was the overwhelming fear and hopelessness he experienced because he felt the CIA had hypnotized his mind and convinced many people to persecute him. S felt the persecution stemmed from the times he made ‘wisecracks’ against the government in 1961. He had been hospitalized almost continuously since then in state and V.A. hospitals. When he was discharged (against his will) he reported actively hallucinating CIA agents’ voices in passing strangers, and was readmitted immediately. The S had been in individual and group psychotherapy over the years, with no apparent gains. Except for tranquilizing him somewhat, chemotherapy had been of little help. During the summer of 1968 when the study was conducted, S was receiving 200 mg of Mellaril four times each day. In the absence of hallucinations, s’s major symptom was his delusion about the CIA. Essentially, S was a
THIS case study was intended to extend the applicability of systematic desensitization to a psychotic adult. Although Wolpe (1961) has stated, “Psychotic patients do not respond to this treatment . . . ,” (p. 198), Cowden and Ford (1962) report two case studies involving desensitization of paranoid schizophrenics. One of their two cases was judged successful after I8 sessions. “The symptom to be removed was his marked fear of talking to other people” (p. 242). The other case involved an obsessional fear of leaving things behind. After 56 sessions, the patient was improved in the presence of the therapist. “However, the behaviors did not generalize to other personnel” (p. 244). Cowden and Ford suggest that some schizophrenics may have a “verbal-behavioral discrepancy,” that is, the schizophrenics’ reports of anxiety may be inaccurate. An alternative explanation is that some schizophrenics have an ‘imaginational behavioral discrepancy.’ With neurotics, there appears to be a close parallel between imagined scenes and real scenes, so that it is sufficient to deal with imagined scenes in the anxiety hierarchy. With schizophrenics, however, reductions in anxiety to imagined scenes may not generalize to real life situations so easily. One way to overcome a failure to generalize (either from the therapy retting or from ‘imagination’) is to conduct the desensitization
shy, passive,
socially
awkward
*The supervision of Lynn Caldwell is gratefully acknowledged. tNow at the Behavioral Research Laboratory, V.A. Hospital, Palo Alto, California 94304. 79
man.
80
F. WEIDNER
The procedures were carried out when S was a neuropsychiatric inpatient at a large V.A. hospital. The major immediate therapeutic goal was to remove enough of S’s anxiety about being outside the hospital to enable him to go on day passes into town. Initially, S said he had no wish to go to town, that there were CIA agents out to get him, and that therapy was hopeless. He refused to be hypnotized or relaxed at first, so the procedures were explained in this way. If the CIA had been controlling his mind and body, but he wished to control his own mind and body, then he would have to begin somewhere. Bodily reactions definitely could be brought under control with relaxation. Therefore, relaxation training was an important first step toward a more hopeful future. After several relaxation sessions in the office, the relaxation sessions were continued while the patient was seated in an automobile. Each week the automobile was driven by the therapist closer to the gate of the hospital grounds, and then farther and farther away from the hospital, until a 5-mile drive took place during the sixth session in the car. During each trip outside the hospital, the patient was let out of the car for increasing lengths of time, going from 1 min to + hr in 3 weeks. Concomitant with therapy sessions outside the hospital grounds, the patient was encouraged to go on trips with other patients. By the tenth week, the patient had been to a county fair in the neighboring state, an art show across the river, a local firemen’s carnival, and a fishing trip. The art show was the only trip on which the therapist accompanied S, and even then, S was alone for half the 2 hr show. After the 10th session it was no longer necessary
to encourage S to go out on day passes, since he signed up for passes and outside activities on his own. Table 1 shows the number of minutes which S spent outside the hospital on his own each week before, during and after the study. It is clear from the data in Table 1 that S has spent more and more time outside the hospital without the presence of the therapist. At the end of desensitization therapy (week IO), those events which the S had come to enjoy were made contingent upon certain ‘social’ behaviors prescribed by the therapist each week. For example, S reported going each Saturday morning to a cafe where there were few people, ordering coffee, and sitting alone. He said he really enjoyed this. After cafe attendance was well established, S was instructed to stop in a crowded news-stand near the cafe, speak to someone about the weather (or whatever they were discussing), and then go on to the cafe. For those situations which the therapist felt S had an inadequate behavioral repertoire, some time was spent before the upcoming Saturday rehearsing appropriate social behaviors. In general S was encouraged to speak to people, act pleasant and interested in the conversation, and accept the content of what was said without reading hidden meanings into it. Although S is still hospitalized at the time of this writing, his sampling of the outside world has reawakened social interests. When S acquires more of the social graces and competencies necessary for outpatient adjustment, discharge plans will be made. This goal can be achieved through continued behavioral rehearsal and in viva practice made possible through eliminating his unadaptive fear of being outside the hospital.
TABLE 1. MINUTES SPENT OUTSIDE HOSPITAL Baseline Week Time alone Time with
01 0
therapist
*Some of the more some trust.
recent
In
oeriod 20 0
03 0
‘time alone’
4 1:
5 ::
vivo
Follow-up
desensitization
6 :oo
has been in the company
7 1:
685 55
of another
6: 20
:: 10
patient
with whom
S has established
IN
DESENSITIZATION
VIVO
0
OF A PARANOID
16
12345678910
SCHIZOPHRENIC
,rr(f,~r,rll 20 24
30
81
36
Weeks
FIG. 1. Number of hours spent outside of the hospital by a paranoid schizophrenic inpatient without the therapist present. Weeks 1 to 3 are baseline. weeks 4 to 10 in vivu desensitization, and weeks II to 16 the operant conditioning period. Subsequent weeks show follow-up data when there were no regular therapy sessions.
CONCLUSIONS One of the unique contributions which psychology can make to the field of mental health, is the control of human behavior through learning techniques. This case study attempted to show how two techniques of behavioral control, systematic desensitization and operant conditioning, can be combined to alleviate human suffering with a case that had been previously treated by a variety of therapies, with no apparent therapeutic gains. The study’s major implication is that a clinical psychologist need not feel bound by his office walls or by
P
traditional methods when dealing with extremely difficult cases. In addition, it appears that systematic desensitization used in vivo is appropriate and useful with psychotic as well as neurotic patients. REFERENCES T. and ABUN N. H. (1968) Reinforcer sampling: a technique for increasing the behavior of
AYLLON
mental patients, 1. uppl. Behuv. Ad. 1, 13-20. R. C. and FORD L. I. (1962) Systematic desensitization with phobic schizophrenia, Am. J. Psychiar. 119.241-245. WOLPE J. (1961) The systematic desensitization treatment of neuroses, J. nerv. men. Dis. 132, 189-203. COWDEN
Thu.
& fip.
Psychid.
Vol.
I. pp. 79-81
Pcrgamon
IN VW0 DESENSITIZATION
Reu,
1970. Printed
in Great
Britain.
OF A PARANOID
SCHIZOPHRENIC*
Temple University (Received
25 August
1969)
Summary-Systematic desensitization and operant conditioning were applied to a paranoid schizophrenic inpatient who for 6 years believed the CIA would kill him outside the hospital. After desensitization the patient spent increasing amounts of time outside the hospital where appropriate social behaviors were reinforced.
in a real life (in Go) situation. The study that follows initially used desensitization to encourage the patient to experience the situations he most feared. Those previously feared situations, having been ‘sampled’ (Ayllon and Azrin, 1968), became powerful reinforcers which were later used in operant conditioning with the patient. The subject (S) was a 36year-old, male, white, single, Protestant, diagnosed as paranoid schizophrenic since 1961. His major complaint was the overwhelming fear and hopelessness he experienced because he felt the CIA had hypnotized his mind and convinced many people to persecute him. S felt the persecution stemmed from the times he made ‘wisecracks’ against the government in 1961. He had been hospitalized almost continuously since then in state and V.A. hospitals. When he was discharged (against his will) he reported actively hallucinating CIA agents’ voices in passing strangers, and was readmitted immediately. The S had been in individual and group psychotherapy over the years, with no apparent gains. Except for tranquilizing him somewhat, chemotherapy had been of little help. During the summer of 1968 when the study was conducted, S was receiving 200 mg of Mellaril four times each day. In the absence of hallucinations, s’s major symptom was his delusion about the CIA. Essentially, S was a
THIS case study was intended to extend the applicability of systematic desensitization to a psychotic adult. Although Wolpe (1961) has stated, “Psychotic patients do not respond to this treatment . . . ,” (p. 198), Cowden and Ford (1962) report two case studies involving desensitization of paranoid schizophrenics. One of their two cases was judged successful after I8 sessions. “The symptom to be removed was his marked fear of talking to other people” (p. 242). The other case involved an obsessional fear of leaving things behind. After 56 sessions, the patient was improved in the presence of the therapist. “However, the behaviors did not generalize to other personnel” (p. 244). Cowden and Ford suggest that some schizophrenics may have a “verbal-behavioral discrepancy,” that is, the schizophrenics’ reports of anxiety may be inaccurate. An alternative explanation is that some schizophrenics have an ‘imaginational behavioral discrepancy.’ With neurotics, there appears to be a close parallel between imagined scenes and real scenes, so that it is sufficient to deal with imagined scenes in the anxiety hierarchy. With schizophrenics, however, reductions in anxiety to imagined scenes may not generalize to real life situations so easily. One way to overcome a failure to generalize (either from the therapy retting or from ‘imagination’) is to conduct the desensitization
shy, passive,
socially
awkward
*The supervision of Lynn Caldwell is gratefully acknowledged. tNow at the Behavioral Research Laboratory, V.A. Hospital, Palo Alto, California 94304. 79
man.
80
F. WEIDNER
The procedures were carried out when S was a neuropsychiatric inpatient at a large V.A. hospital. The major immediate therapeutic goal was to remove enough of S’s anxiety about being outside the hospital to enable him to go on day passes into town. Initially, S said he had no wish to go to town, that there were CIA agents out to get him, and that therapy was hopeless. He refused to be hypnotized or relaxed at first, so the procedures were explained in this way. If the CIA had been controlling his mind and body, but he wished to control his own mind and body, then he would have to begin somewhere. Bodily reactions definitely could be brought under control with relaxation. Therefore, relaxation training was an important first step toward a more hopeful future. After several relaxation sessions in the office, the relaxation sessions were continued while the patient was seated in an automobile. Each week the automobile was driven by the therapist closer to the gate of the hospital grounds, and then farther and farther away from the hospital, until a 5-mile drive took place during the sixth session in the car. During each trip outside the hospital, the patient was let out of the car for increasing lengths of time, going from 1 min to + hr in 3 weeks. Concomitant with therapy sessions outside the hospital grounds, the patient was encouraged to go on trips with other patients. By the tenth week, the patient had been to a county fair in the neighboring state, an art show across the river, a local firemen’s carnival, and a fishing trip. The art show was the only trip on which the therapist accompanied S, and even then, S was alone for half the 2 hr show. After the 10th session it was no longer necessary
to encourage S to go out on day passes, since he signed up for passes and outside activities on his own. Table 1 shows the number of minutes which S spent outside the hospital on his own each week before, during and after the study. It is clear from the data in Table 1 that S has spent more and more time outside the hospital without the presence of the therapist. At the end of desensitization therapy (week IO), those events which the S had come to enjoy were made contingent upon certain ‘social’ behaviors prescribed by the therapist each week. For example, S reported going each Saturday morning to a cafe where there were few people, ordering coffee, and sitting alone. He said he really enjoyed this. After cafe attendance was well established, S was instructed to stop in a crowded news-stand near the cafe, speak to someone about the weather (or whatever they were discussing), and then go on to the cafe. For those situations which the therapist felt S had an inadequate behavioral repertoire, some time was spent before the upcoming Saturday rehearsing appropriate social behaviors. In general S was encouraged to speak to people, act pleasant and interested in the conversation, and accept the content of what was said without reading hidden meanings into it. Although S is still hospitalized at the time of this writing, his sampling of the outside world has reawakened social interests. When S acquires more of the social graces and competencies necessary for outpatient adjustment, discharge plans will be made. This goal can be achieved through continued behavioral rehearsal and in viva practice made possible through eliminating his unadaptive fear of being outside the hospital.
TABLE 1. MINUTES SPENT OUTSIDE HOSPITAL Baseline Week Time alone Time with
01 0
therapist
*Some of the more some trust.
recent
In
oeriod 20 0
03 0
‘time alone’
4 1:
5 ::
vivo
Follow-up
desensitization
6 :oo
has been in the company
7 1:
685 55
of another
6: 20
:: 10
patient
with whom
S has established
IN
DESENSITIZATION
VIVO
0
OF A PARANOID
16
12345678910
SCHIZOPHRENIC
,rr(f,~r,rll 20 24
30
81
36
Weeks
FIG. 1. Number of hours spent outside of the hospital by a paranoid schizophrenic inpatient without the therapist present. Weeks 1 to 3 are baseline. weeks 4 to 10 in vivu desensitization, and weeks II to 16 the operant conditioning period. Subsequent weeks show follow-up data when there were no regular therapy sessions.
CONCLUSIONS One of the unique contributions which psychology can make to the field of mental health, is the control of human behavior through learning techniques. This case study attempted to show how two techniques of behavioral control, systematic desensitization and operant conditioning, can be combined to alleviate human suffering with a case that had been previously treated by a variety of therapies, with no apparent therapeutic gains. The study’s major implication is that a clinical psychologist need not feel bound by his office walls or by
P
traditional methods when dealing with extremely difficult cases. In addition, it appears that systematic desensitization used in vivo is appropriate and useful with psychotic as well as neurotic patients. REFERENCES T. and ABUN N. H. (1968) Reinforcer sampling: a technique for increasing the behavior of
AYLLON
mental patients, 1. uppl. Behuv. Ad. 1, 13-20. R. C. and FORD L. I. (1962) Systematic desensitization with phobic schizophrenia, Am. J. Psychiar. 119.241-245. WOLPE J. (1961) The systematic desensitization treatment of neuroses, J. nerv. men. Dis. 132, 189-203. COWDEN