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response equivalence and reactivity in the assessment and treatment of obsessive-compulsive neurosis
Problems with stimulus/response equivalence and reactivity in the assessment and treatment of obsessive-compulsive neurosis
SummarypSelf-recording was used as part of a comprehensive package of interventions to treat a case of obsessive-compulsive neurosis. The discrepancy between the self-recording data and other indices of improvement provoked consideration of the value of self-monitoring in light of Rachman’s (1976) typology of obsessive-compulsives and the three major theoretical explanations of the reactivity of self-monitoring (Nelson and Hayes. 1981). It is hypothesized that self-monitoring may be countertherapeutic and misleading when there is stimulusresponse equivalence or a checker type of obsessive compulsive client.
INTRODUCTION
Although obsessive thinking and compulsive rituals are not common problems, for they account for only I”,, of the inpatient and outpatient population (Leitenberg, 1976) these behaviors are particularly interesting and difficult to assess and treat. Leitenberg’s (1976) and Walen. Hauserman and Laven’s (1977) reviews of the behavioral treatment of obsessive~-compulsive neurosis indicate that behavior therapists have been successful in treating this problem with ItI-cia flooding and response prevention. Behavioral assessment of the problem has employed various creative and idiosyncratic self-monitoring and therapist-monitored methods to evaluate individual clients‘ obsessiveecompulsive thinking, rituals and discomfort. For example, Hodgson and Rachman (1976) measured the closest point reached by their subject in his attempts to touch different ‘contaminating’ items and minutes of time and number of times the client spent in the toilet and washing once he became ‘contaminated’. Charting the frequency of the targeted compulsive behavior is one of the most common assessments, whether it is the amount of time engaged in the behavior or the number of behaviors performed (e.g. Le Boeuf. 1974; Melamed and Siegel, 1975; Turner, Hersen. Bellack and Wells, 1979). Another method of behavioral assessment has focused on the subjective or cognitive effects of the neurotic behavior. For example, Rainey (1972) used an Anxiety Rating Scale which ranged from I (no anxiety) to 5 (panic) to monitor pre-compulsive and post-compulsive feelings of a client and Foa (1979) used Subjective Units of Discomfort to describe changes in anxiety within treatment sessions. In two controlled studies of behavioral treatment of obsessiveecompulsive neurosis, Rachman and his collaborators (Hodgson. Rachman and Marks, 1972; Rachman, Hodgson and Marks, 1971) used multiple dependent measures (clinical rating scales. attitude measures, avoidance tests. a fear thermometer and two personality inventories) to investigate changes in subjects’ obsessiveecompulsive behavior. Multiple measures also were used by Boulougouris and Bassiakos (1973). who measured changes in total obsessions. free-floating anxiety and depression, rated by the patient, therapist and an independent assessor, in their study of prolonged flooding with three obsessive compulsives. Despite the theoretical and empirical foundations that have been established, the behavioral assessment. treatment and conceptualization of obsessiveecompulsive neurosis clearly is not complete, This is especially true of the assessment issue. and the present study is presented as an illustration of several problems that need to be addressed. First, because the stimulus that ‘triggered’ this client’s obsession was the same event as the compulsive behavior that ‘corrected’ it, this case may represent a different type of obsessiveecompulsive client, one for whom self-monitoring IS contra-indicated and a misleading source of data. Second, consideration of Nelson and Hayes’ (1981) recent review of the major theoretical explanations for the reactivity of self-monitoring, combined with Rachman’s (1976) theoretical distmction between ‘cleaner’ and ‘checker’ types of obsessiveecompulsives, suggests the need for further study of the value of self-recording in the behavioral assessment of the checker type of disorder.
SUBJECI
The subject. a middle-aged. employed, married (no children). high-school educated male. entered the psychiatric institution following a deterioration in his ability to work and carry out the activities of daily functioning. Although this case was similar to many other obsessivecompulsives (e.g. the obsessive thoughts and compulsive actions were recurrent, excessive and stereotyped; the client realized the thoughts were silly and was embarrassed by them although he felt helpless to control them; he was aware of the anxiety and worry he experienced; the thoughts and actions interfered with social, occupational and marital functioning; there was no evidence of psychosis in pre-treatment traditional personality testing or during the months of therapy contact), his obsession was particularly interesting. The specific problem was an obsession that his face, and especially his nose, had changed whenever he accidentally touched it or saw it reflected in a mirror or his eyeglasses. The compulsive component consisted of several stereotyped behaviors that served to restore his belief that his nose was unchanged and undamaged. The process of checking his nose might last from several minutes to over an hour depending upon the strength of the obsession. The only apparent health problem related to the neurosis was frequent weight loss which the client noted occurred after particularly disruptive incidents. 177
178
CASE HlSTDKlES
AND
SHORTtR
COMMUNICATIONS
The S traced his obsessive thinking and concern to seif-conscious feelings following the failure of two grades m elementary school and parental discord at home. He recalled having looked at a class picture at the beginning of adolescence in which ‘my nose stuck out’. The client reported increased feelings of self-consciousness at that point. and it appeared that he had been checking for changes in his nose and face in mirrors since the beginning of adolescence. The only extended break in the behavior pattern occurred during Army service. apparently because there were few mirrors available and the presence of other people inhibited his self-observation. After discharge from service, the behavior increased again. The S had been married for 13 years, and the problem had continued tllrollg~lout the marriage with greater or lesser intensity. although the client had never been symptom-free. Approximately I year prior to seeking hospital admission. the S experienced a particularly disruptive period of obsessions, and sought professional help. He received diazepam (Valium) and insight-oriented therapy with no relief.
Behavioral assessment of the problem began with a description of the client’s typical day and identification of the triggering stimuli and worry-reducing checking behaviors. The client first observed that some days were more troublesome than others. and he called these ‘obsession days’. Although often afraid to arise from bed on these davs. the s always did so. and then began his day by staring at his face and nose in the mirror for 5 minutes both before and after his morning washing. While driving to his job. the S would look at his nose in his automobile rear-view mirror. He reported that he had been doing this for so long that he could safely keep one eye on the road and the other on the mirror. Once at his work place, the client was usually symptom-l&e for the first several hours of work. However. he would soon begin to check his nose by observing his reflection on the inside of his glasses and he might do this so often during the day that he acquired a headache. He also reported using the men’s room mirror at work to look at his nose, and on occasion might go outside to use the sun to cast a shadow so that he could examine the shape of his profile. After returning home from work, the client often spent &l hr examining his Face in the bathroom mirror, and this process might continue throughout the evening with a respite of an hour or two if the S washed his face or took a hot shower during which he touched his nose and found that it appeared unchanged. The client identified a list of stimuli that triggered the obsession. These included, in descending order of their frequency: catching the reflection of his nose in his eyeglasses; looking at his Rice in a mirror; looking down at the side of his nose; touching his nose with his shaving razor, the bridge guard of his eyeglasses. or some other object; breathing too strongly, sniffing too strongly, or blowing his nose too strongly: believing the eye strain caused by looking down at his nose had swollen his nose; and touching the side of his mouth too hard uhilc eating or smoking his pipe. The compulsive behaviors used to check his nose included, in descending order of frequency: looking in the mirror (sometimes for up to several hours at a time); staring at the reflective lines of his eyeglasses; looking down at the side of his nose; duplicatin& the behavior that triggered the obsession (e.g. retouching his nose with the razor, eyeglass bridge guard, coffee cup etc.); touching and retouching his nose with his finger tip; and other less frequent behaviors idiosyncratic to the triggering stimulus. It is important to note that the stimuli that triggered the obsession were almost always the same behaviors used by the client to reduce the obsessive concern and worry, Beginning with the first interview, the client was instructed to carry 3 x 5” index cards and a pen to make daily records of the obsessive--compulsive incidents and their lengths of duration in minutes. He returned these cards to the therapist at the beginning of each weekly session and began a new period of self-recording. At week 12 of the self-recording. the S was instructed to record only those incidents that lasted 1min or more. and to ignore my that lasted for less than 60 sec. This change in the self-recording was instituted because of a concern that stimulus,‘response equivalence was resulting in over-recording of the number of independent incidents. Beginning during the final 4 weeks of his hospit~~liz~ltioll, and contilluin~ on an outpatient basis for the next -l months. the S was seen for weekly and then twice-weekly sessions during which a variety of self-control skills (relaxation, thought-stopping, alternative incompatible behaviors) were taught in combination with ir:+iuo flooding and response prevention. In addition. a home-treatment contract was used to encourage the client and his spouse to practice flooding and response preventioli at home follo~~in~ discharge from the ilistitution. In the final stage of the intervention, sessions focused on discussion ofrational.-emotive therapy principles related to the s’s self-consciousness regarding his nose, and the use of a wallet card for overt and covert rehearsal of positive self-statements during obsessive episodes. The client \vas seen bi-weekly during the final 6 weeks of therapy to facilitate termination. RESCJLTS AND DISCllSSIOh The result that provoked our questioning of the value of self-recording with certain types of obsessive-.~omplilsives was a discrepancy between the self-recording data and the client’s report of improvement. Specifically. the number of self-recorded incidents generally i~~creusrd over the lY weeks of assessment and therapy (mean number of incidents per week = 14.71. 21.29. 24.86, 23.00, 26.29, 27.86. 30.43. 34.29. 58.14, 54.14. 50.29. 2X.14, 32.29, 28.43. 40.29, 3Y.14. 37.3, 58.29. 52.57). However. at termination the subject: (1) spent much less time looking in his bathroom mirror at home to check his face; (2) experienced fewer incidents at work, was more effective on the job and completely stopped using the men’s room mirror to check his nose; and (3) maintained his normal body weight throughout the period of therapy, compared to fluctuations of 3-5 lb per week prior to treatment. This third outcome was described by the client as his best evidence that the obsessions were no longer as severe or troublesome as they had been before the treatment program. As noted above, we examined this discrepancy between the self-recording data and other results in light of: (I) the theoretical confeptunlizations of obsessive-compulsive neurosis (Rachman, 1976) and reactivity of self-recording (Nelson and Hayes. 1981); and (2) the dificulty encountered in a client for whom the stimuli which trigger the obsession are the same as the compulsive behaviors used to restore the status quo. Rachman (1976) described the difference between obsessional checking and cleaning compulsions by suggesting that the former “are predominately attempts at prrcrntion. white most forms of cleaning compulsions are predominately resrorrrfire. Most, but not all checking rituals are intended to forestall some unpleasant event Most
CASE HISTORIES
AN11 SHORTER
COMMUNICATIONS
179
cleaning compulsions however are intended to restore a state of safety (e.g. cleanliness, hygiene) and they are preventive only in the secondary sense that a failure to restore safety is threatening.” (p. 270. original italics) Rachman
writes that the motive for checking
“attempt to avoid punishment guilt.” (p. 270)
rituals
is the
in the form of criticism
either from others,
or self-directed
criticism,
i.e.
The background of this subject indicated that he was a combination of the cleaner and checker types outlined above. The clinical history revealed feelings of self-consciousness and guilt concerning failure in school, parental discord and physical appearance. These characteristics indicate that the subject should be a checker type who would he motivated to forestall or prevent further punishment and criticism. And, indeed, the client’s obsessive concern was that he ‘look good to other people and avoid criticism of his appearance. The form of the neurosis, however, was not purely preventative, as it is with certain clients who check for gas leaks, sharp objects and so on in an attempt to prevent an accident. Instead. the checking behaviors in this case were restorative as with the cleaning compulsions. The client sought to restore a feeling of safety and normalcy regarding the shape and position of his face and nose. Nelson and Hayes (1981) reviewed three major theoretical explanations for the reactivity phenomenon in selfrecording (a change in a subject’s behavior, usually a decrease in response frequency, that is produced by selfmonitoring of the target behavior). The first theory reviewed is Kanfer’s application of his three stage model of self-control to reactivity, and two important aspects of Kanfer’s explanation are cited: “First, that the reactive chain begins by self-monitoring recording its occurrence); and, second, that self-monitored as a function of self-administered consequences.” (Nelson
(either noticing one’s own behavior and/or behavior increases or decreases in frequency and Hayes, 198 1, p. 5)
Second, Rachlin’s (1974) explanation of reactivity is compared to Kanfer’s view, and the major difference is that Rachlin sees the self-monitoring act as cueing the environmental consequences that control the frequency of behavior, rather than the self-administered consequences. Third, according to the Nelson and Hayes (1981) expansion of this explanation, “the entire self-monitoring procedure (therapist instructions, training in self-monitoring, the self-recording device. feedback from others, the occurrence of the target behavior and the self-recording response. when the latter two occur), rather than only the self-monitored response. serves to cue the ultimate environmental consequences contingent on the target behavior.” (p. 11) While Rachlin (1974) and Nelson and Hayes (1981) differ on whether it is the self-recording act or the entire self-recording procedure that actually leads to behavior change, both viewpoints agree on the basic chain of eventsenvironmental consequences are cued and the likelihood of performance of the target behavior is decreased. These two viewpoints differ from Kanfer’s primarily because of the latter’s emphasis on wffudministered com~~uer~ces as the agent of change. With obsessive-compulsives. therefore, reactivity would result when self-monitoring of the target (e.g. handwashing, checks for gas leaks. mirror gazing) would serve as a cue to remind the subject of the consequences of the repeated behavior (e.g. sore hands, therapist censure. marital discord). While this anticipation of environmental consequences (or in Kanfer‘s view. serf-~~dministered consequences) may iead to a reactivity-induced reduction of the behavior, another situation can arise. Apparently. self-monitoring can result in an increased. rather than decreased. number of recorded incidents. How can the theorized chain of events (from self-recording to cued consequences to behavior reduction) lead to a different result’? Recalling Rachman’s (I 976) explanation of obsessive- compulsive neurosis, a subject’s anxiety. heightened by repeated observation of the target behavior and anticipation of environmental (or self-administered) consequences. would be the answer. According to Rachman. the checker type of disorder centers on avoiding punishment, whether the criticism comes from others or is self-directed. A subject may well be reactive to the self-recording procedure, but the anticipation of consequences may cause increased anxiety and fear of criticism. leading to an it~c~~sc in the number of obsessiveecompulsive incidents to be recorded. This description of a reactivity-induced increase in the target behavior would only hold for the checker type, however. because the obsessive-compulsive cleaner is concerned with restoring a sense of safety rather than forestalling social censure. This leads to the prediction that self-recording might be a useful procedure for cleaner types. but not for checker types. The subject in our case was an apparent mixture of the two types, but enough of the checker characteristics were present (especially the fear of social criticism) to cause the increase in self-recorded incidents, Whether it is the self-recording act itself or the entire procedure that is actually the active ingredient, it is hypothesized that the obsessive-compulsive checker will experience heightened anxiety when self-recording cues social consequences. and this anxiety will lead to an increased number of recorded incidents. If Kanfer is correct, and it is self-administered consequences rather than environmental consequences that cause reactivity, it seems likely that the anticipated consequences of ftor performing the compulsive ritual may outweigh the self-administered negative consequences cued by self-monitoring or that self-criticism may result in increased anxiety and increased checking, In either case. seIf-monitoring may not lead to a reduction in the number of monitored incidents. The second issue castmg doubt on the value of self-recording relates to the equivalence between the cues that triggered the obsession and the behaviors engaged in to counter the obsession. Although self-monitoring has been used previously with a variety of disorders, it may not be useful with clients or problems where the clinician is attempting to extinguish a potentially self-perpetuating target behavior. In this case, there was so much similarity between the stimulus and the compulsive ritual. the process had the quality of a vicious cycle in which the obsession was triggered. the compulsive ritual was performed, the obsession was re-rriggyered by the compulsive act. and so on, ff a client has dithculty distinguishing between one obsessive-compulsive incident and another due to the stimulus
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CASE HISTORIESAIU’DSHORTEzRCOMMUNICATIONS
trigger’compulsive ritual equivalence. this could lead to over-recording of the actual number of independent incidents. Therefore, self-recording would enable the client to observe that he or she experienced many incidents and thus the individual might become discouraged about the prospect of progress or success in decreasing the problem. or confused about the discrepancy between the self-recording data and perceived progress decreasing the problem. While the pervasiveness and often subtle performance of our client’s ritual (e.g. looking down at his nose, catching the reflection of his nose in his eyeglasses), combined with his primarily outpatient status, prevented valid observation and recording by any individual other than the subject himself, asking this type of client to self-record his or her obsessivecompulsive incidents may bring counter-therapeutic attention to a behavior that should not be the focus of selfrecording. By whatever mechanism it works. and we are writing to provoke more theoretical and empirical attention to this issue. it is clear that behavioral assessment of obsessiveecompulsive neurosis via self-recording of the target thoughts and actions may not always be a useful or valid indicator of the client’s baseline or outcome status. If self-recording is not appropriate in these cases, then what forms of behavioral assessment can be used‘? In this particular case. body weight was a stable indicator of the client’s distress. His anecdotal report indicated that his weight consistently fluctuated several pounds per week prior to treatment, and rarely rose above 150 lb. After treatment began, the client’s regular self-weighings indicated that his weight no longer fluctuated and had risen to a stable 154 lb. Although weight may not be a valid or useful indicator for every or even most obsessiveecompulsives. other idiosyncratic or unobtrusive behavioral measures may be used to monitor response to treatment. Given the potential for counter-therapeutic effects that self-monitoring of the target behaviors can cause, therapist or peer momtoring of unobtrusive or seemingly tangential or irrelevant behaviors may be useful. Obviously, adequate assessment must be undertaken to establish the valid links between unobtrusive or tangential behaviors and the target outcome. The purpose here is not to suggest that behavioral assessors revert to the use of speculation or unwarranted inference in their documentation of therapeutic change. Rather, the purpose is to provoke clinicians engaged in the behavioral assessment of obsessiveecompulsive neurosis. especially the checker type and those with stimulus/response equivalence, to be sensitive to the effect of self-recording on the target behaviors themselves, and to the potential usefulness of less reactive and multiple measures of outcome. HAROLD
ROSFYBERG*
DENXIS
UPPERt
REFERENCES BOLXOUGOURISJ. C. and BASSAKIOSL. (1973) Prolonged flooding in cases with obsessiveecompulsive neurosis. Brlltrr. Res. Thu. 1 I, 227-23 1. FOA E. B. (1979) Failure in treating obsessive-compulsives. Behav. Res. Thrr. 17, 169-176. H~DGS~N R. and RACHMAN S. (1976) The modification of compulsive behavior. In CLIS~ Studies irl Behtrcior Tllrrtrp~ (Edited by EYSENCK H. J.). Routledge & Kegan Paul, London. HCKKWN R., RACHMAN S. and MARKS I. M. (1972) The treatment of chronic obsessiveecompulsive neurosis: follow-up and further findings. Behuu. Res. Thu. 10, 181-189. Lt BOEUF A. (1974) An automated aversion device in the treatment of a compulsive handwashing ritual. J. EMtro. Thw. mp. Psychiut. 5, 267-270. LFITENH~RG H. (Ed.) (1976) Behavioral approaches to treatment of neuroses. In Hmdhod of‘&hu~~ior Modific~rrtim cm/ Behtrrior Therapy. Prentice-Hall, Englewood Cliffs, New Jersey. MELAMED B. and SIEGEL L. (1975) Self-directed in cico treatment of an obsessiveecompulsive checking ritual. J. Eehtrl~. Thrr. e-up. Ps)chiut. 6, 3 I-35. NELSON R. 0. and HAYES S. C. (1981) Theoretical explanations for reactivity in self-monitoring. Brlztrr. ,Vod$ 5, ?- 14. RACHLIN H. (1974) Self-control. Behaciorism 2, 94-107. RACHMAI\; S. (1976) Obsessional~compulsive checking. Brhao. Res. Thu. 14, 269-277. RACHMAYXS., HOIXXX R. and MARKS I. M. (1971) The treatment of chronic obsessiveecompulsive neurosis. Brhclr. Rex Thu. 9, 237-247. RAINEY A. (1972) An obsessive+compulsive neurosis treated by flooding in vice. J. Brhuu. Thw. up. PsychI’ur. 3, I 17. TURUFR S. M., HERSEN M., BELLACK A. S. and WELLS K. C. (1979) Behavioral treatment of obsessive~compulsive neurosis. B&c. Res. Thu. 17, 95-106. WALI;F; S., HAUSFRMAS N. M. and LAVIN P. J. (1977) Clirlkul Guide to Behurior Therapy. Williams & Wilkins. Baltimore.
* To whom all reprint requests should be addressed. t Lahey Clinic Medical Center, Burlington, Massachusetts
and Harvard
Medical
School. CambrIdge.
Massachusetts.
SummarypSelf-recording was used as part of a comprehensive package of interventions to treat a case of obsessive-compulsive neurosis. The discrepancy between the self-recording data and other indices of improvement provoked consideration of the value of self-monitoring in light of Rachman’s (1976) typology of obsessive-compulsives and the three major theoretical explanations of the reactivity of self-monitoring (Nelson and Hayes. 1981). It is hypothesized that self-monitoring may be countertherapeutic and misleading when there is stimulusresponse equivalence or a checker type of obsessive compulsive client.
INTRODUCTION
Although obsessive thinking and compulsive rituals are not common problems, for they account for only I”,, of the inpatient and outpatient population (Leitenberg, 1976) these behaviors are particularly interesting and difficult to assess and treat. Leitenberg’s (1976) and Walen. Hauserman and Laven’s (1977) reviews of the behavioral treatment of obsessive~-compulsive neurosis indicate that behavior therapists have been successful in treating this problem with ItI-cia flooding and response prevention. Behavioral assessment of the problem has employed various creative and idiosyncratic self-monitoring and therapist-monitored methods to evaluate individual clients‘ obsessiveecompulsive thinking, rituals and discomfort. For example, Hodgson and Rachman (1976) measured the closest point reached by their subject in his attempts to touch different ‘contaminating’ items and minutes of time and number of times the client spent in the toilet and washing once he became ‘contaminated’. Charting the frequency of the targeted compulsive behavior is one of the most common assessments, whether it is the amount of time engaged in the behavior or the number of behaviors performed (e.g. Le Boeuf. 1974; Melamed and Siegel, 1975; Turner, Hersen. Bellack and Wells, 1979). Another method of behavioral assessment has focused on the subjective or cognitive effects of the neurotic behavior. For example, Rainey (1972) used an Anxiety Rating Scale which ranged from I (no anxiety) to 5 (panic) to monitor pre-compulsive and post-compulsive feelings of a client and Foa (1979) used Subjective Units of Discomfort to describe changes in anxiety within treatment sessions. In two controlled studies of behavioral treatment of obsessiveecompulsive neurosis, Rachman and his collaborators (Hodgson. Rachman and Marks, 1972; Rachman, Hodgson and Marks, 1971) used multiple dependent measures (clinical rating scales. attitude measures, avoidance tests. a fear thermometer and two personality inventories) to investigate changes in subjects’ obsessiveecompulsive behavior. Multiple measures also were used by Boulougouris and Bassiakos (1973). who measured changes in total obsessions. free-floating anxiety and depression, rated by the patient, therapist and an independent assessor, in their study of prolonged flooding with three obsessive compulsives. Despite the theoretical and empirical foundations that have been established, the behavioral assessment. treatment and conceptualization of obsessiveecompulsive neurosis clearly is not complete, This is especially true of the assessment issue. and the present study is presented as an illustration of several problems that need to be addressed. First, because the stimulus that ‘triggered’ this client’s obsession was the same event as the compulsive behavior that ‘corrected’ it, this case may represent a different type of obsessiveecompulsive client, one for whom self-monitoring IS contra-indicated and a misleading source of data. Second, consideration of Nelson and Hayes’ (1981) recent review of the major theoretical explanations for the reactivity of self-monitoring, combined with Rachman’s (1976) theoretical distmction between ‘cleaner’ and ‘checker’ types of obsessiveecompulsives, suggests the need for further study of the value of self-recording in the behavioral assessment of the checker type of disorder.
SUBJECI
The subject. a middle-aged. employed, married (no children). high-school educated male. entered the psychiatric institution following a deterioration in his ability to work and carry out the activities of daily functioning. Although this case was similar to many other obsessivecompulsives (e.g. the obsessive thoughts and compulsive actions were recurrent, excessive and stereotyped; the client realized the thoughts were silly and was embarrassed by them although he felt helpless to control them; he was aware of the anxiety and worry he experienced; the thoughts and actions interfered with social, occupational and marital functioning; there was no evidence of psychosis in pre-treatment traditional personality testing or during the months of therapy contact), his obsession was particularly interesting. The specific problem was an obsession that his face, and especially his nose, had changed whenever he accidentally touched it or saw it reflected in a mirror or his eyeglasses. The compulsive component consisted of several stereotyped behaviors that served to restore his belief that his nose was unchanged and undamaged. The process of checking his nose might last from several minutes to over an hour depending upon the strength of the obsession. The only apparent health problem related to the neurosis was frequent weight loss which the client noted occurred after particularly disruptive incidents. 177
178
CASE HlSTDKlES
AND
SHORTtR
COMMUNICATIONS
The S traced his obsessive thinking and concern to seif-conscious feelings following the failure of two grades m elementary school and parental discord at home. He recalled having looked at a class picture at the beginning of adolescence in which ‘my nose stuck out’. The client reported increased feelings of self-consciousness at that point. and it appeared that he had been checking for changes in his nose and face in mirrors since the beginning of adolescence. The only extended break in the behavior pattern occurred during Army service. apparently because there were few mirrors available and the presence of other people inhibited his self-observation. After discharge from service, the behavior increased again. The S had been married for 13 years, and the problem had continued tllrollg~lout the marriage with greater or lesser intensity. although the client had never been symptom-free. Approximately I year prior to seeking hospital admission. the S experienced a particularly disruptive period of obsessions, and sought professional help. He received diazepam (Valium) and insight-oriented therapy with no relief.
Behavioral assessment of the problem began with a description of the client’s typical day and identification of the triggering stimuli and worry-reducing checking behaviors. The client first observed that some days were more troublesome than others. and he called these ‘obsession days’. Although often afraid to arise from bed on these davs. the s always did so. and then began his day by staring at his face and nose in the mirror for 5 minutes both before and after his morning washing. While driving to his job. the S would look at his nose in his automobile rear-view mirror. He reported that he had been doing this for so long that he could safely keep one eye on the road and the other on the mirror. Once at his work place, the client was usually symptom-l&e for the first several hours of work. However. he would soon begin to check his nose by observing his reflection on the inside of his glasses and he might do this so often during the day that he acquired a headache. He also reported using the men’s room mirror at work to look at his nose, and on occasion might go outside to use the sun to cast a shadow so that he could examine the shape of his profile. After returning home from work, the client often spent &l hr examining his Face in the bathroom mirror, and this process might continue throughout the evening with a respite of an hour or two if the S washed his face or took a hot shower during which he touched his nose and found that it appeared unchanged. The client identified a list of stimuli that triggered the obsession. These included, in descending order of their frequency: catching the reflection of his nose in his eyeglasses; looking at his Rice in a mirror; looking down at the side of his nose; touching his nose with his shaving razor, the bridge guard of his eyeglasses. or some other object; breathing too strongly, sniffing too strongly, or blowing his nose too strongly: believing the eye strain caused by looking down at his nose had swollen his nose; and touching the side of his mouth too hard uhilc eating or smoking his pipe. The compulsive behaviors used to check his nose included, in descending order of frequency: looking in the mirror (sometimes for up to several hours at a time); staring at the reflective lines of his eyeglasses; looking down at the side of his nose; duplicatin& the behavior that triggered the obsession (e.g. retouching his nose with the razor, eyeglass bridge guard, coffee cup etc.); touching and retouching his nose with his finger tip; and other less frequent behaviors idiosyncratic to the triggering stimulus. It is important to note that the stimuli that triggered the obsession were almost always the same behaviors used by the client to reduce the obsessive concern and worry, Beginning with the first interview, the client was instructed to carry 3 x 5” index cards and a pen to make daily records of the obsessive--compulsive incidents and their lengths of duration in minutes. He returned these cards to the therapist at the beginning of each weekly session and began a new period of self-recording. At week 12 of the self-recording. the S was instructed to record only those incidents that lasted 1min or more. and to ignore my that lasted for less than 60 sec. This change in the self-recording was instituted because of a concern that stimulus,‘response equivalence was resulting in over-recording of the number of independent incidents. Beginning during the final 4 weeks of his hospit~~liz~ltioll, and contilluin~ on an outpatient basis for the next -l months. the S was seen for weekly and then twice-weekly sessions during which a variety of self-control skills (relaxation, thought-stopping, alternative incompatible behaviors) were taught in combination with ir:+iuo flooding and response prevention. In addition. a home-treatment contract was used to encourage the client and his spouse to practice flooding and response preventioli at home follo~~in~ discharge from the ilistitution. In the final stage of the intervention, sessions focused on discussion ofrational.-emotive therapy principles related to the s’s self-consciousness regarding his nose, and the use of a wallet card for overt and covert rehearsal of positive self-statements during obsessive episodes. The client \vas seen bi-weekly during the final 6 weeks of therapy to facilitate termination. RESCJLTS AND DISCllSSIOh The result that provoked our questioning of the value of self-recording with certain types of obsessive-.~omplilsives was a discrepancy between the self-recording data and the client’s report of improvement. Specifically. the number of self-recorded incidents generally i~~creusrd over the lY weeks of assessment and therapy (mean number of incidents per week = 14.71. 21.29. 24.86, 23.00, 26.29, 27.86. 30.43. 34.29. 58.14, 54.14. 50.29. 2X.14, 32.29, 28.43. 40.29, 3Y.14. 37.3, 58.29. 52.57). However. at termination the subject: (1) spent much less time looking in his bathroom mirror at home to check his face; (2) experienced fewer incidents at work, was more effective on the job and completely stopped using the men’s room mirror to check his nose; and (3) maintained his normal body weight throughout the period of therapy, compared to fluctuations of 3-5 lb per week prior to treatment. This third outcome was described by the client as his best evidence that the obsessions were no longer as severe or troublesome as they had been before the treatment program. As noted above, we examined this discrepancy between the self-recording data and other results in light of: (I) the theoretical confeptunlizations of obsessive-compulsive neurosis (Rachman, 1976) and reactivity of self-recording (Nelson and Hayes. 1981); and (2) the dificulty encountered in a client for whom the stimuli which trigger the obsession are the same as the compulsive behaviors used to restore the status quo. Rachman (1976) described the difference between obsessional checking and cleaning compulsions by suggesting that the former “are predominately attempts at prrcrntion. white most forms of cleaning compulsions are predominately resrorrrfire. Most, but not all checking rituals are intended to forestall some unpleasant event Most
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AN11 SHORTER
COMMUNICATIONS
179
cleaning compulsions however are intended to restore a state of safety (e.g. cleanliness, hygiene) and they are preventive only in the secondary sense that a failure to restore safety is threatening.” (p. 270. original italics) Rachman
writes that the motive for checking
“attempt to avoid punishment guilt.” (p. 270)
rituals
is the
in the form of criticism
either from others,
or self-directed
criticism,
i.e.
The background of this subject indicated that he was a combination of the cleaner and checker types outlined above. The clinical history revealed feelings of self-consciousness and guilt concerning failure in school, parental discord and physical appearance. These characteristics indicate that the subject should be a checker type who would he motivated to forestall or prevent further punishment and criticism. And, indeed, the client’s obsessive concern was that he ‘look good to other people and avoid criticism of his appearance. The form of the neurosis, however, was not purely preventative, as it is with certain clients who check for gas leaks, sharp objects and so on in an attempt to prevent an accident. Instead. the checking behaviors in this case were restorative as with the cleaning compulsions. The client sought to restore a feeling of safety and normalcy regarding the shape and position of his face and nose. Nelson and Hayes (1981) reviewed three major theoretical explanations for the reactivity phenomenon in selfrecording (a change in a subject’s behavior, usually a decrease in response frequency, that is produced by selfmonitoring of the target behavior). The first theory reviewed is Kanfer’s application of his three stage model of self-control to reactivity, and two important aspects of Kanfer’s explanation are cited: “First, that the reactive chain begins by self-monitoring recording its occurrence); and, second, that self-monitored as a function of self-administered consequences.” (Nelson
(either noticing one’s own behavior and/or behavior increases or decreases in frequency and Hayes, 198 1, p. 5)
Second, Rachlin’s (1974) explanation of reactivity is compared to Kanfer’s view, and the major difference is that Rachlin sees the self-monitoring act as cueing the environmental consequences that control the frequency of behavior, rather than the self-administered consequences. Third, according to the Nelson and Hayes (1981) expansion of this explanation, “the entire self-monitoring procedure (therapist instructions, training in self-monitoring, the self-recording device. feedback from others, the occurrence of the target behavior and the self-recording response. when the latter two occur), rather than only the self-monitored response. serves to cue the ultimate environmental consequences contingent on the target behavior.” (p. 11) While Rachlin (1974) and Nelson and Hayes (1981) differ on whether it is the self-recording act or the entire self-recording procedure that actually leads to behavior change, both viewpoints agree on the basic chain of eventsenvironmental consequences are cued and the likelihood of performance of the target behavior is decreased. These two viewpoints differ from Kanfer’s primarily because of the latter’s emphasis on wffudministered com~~uer~ces as the agent of change. With obsessive-compulsives. therefore, reactivity would result when self-monitoring of the target (e.g. handwashing, checks for gas leaks. mirror gazing) would serve as a cue to remind the subject of the consequences of the repeated behavior (e.g. sore hands, therapist censure. marital discord). While this anticipation of environmental consequences (or in Kanfer‘s view. serf-~~dministered consequences) may iead to a reactivity-induced reduction of the behavior, another situation can arise. Apparently. self-monitoring can result in an increased. rather than decreased. number of recorded incidents. How can the theorized chain of events (from self-recording to cued consequences to behavior reduction) lead to a different result’? Recalling Rachman’s (I 976) explanation of obsessive- compulsive neurosis, a subject’s anxiety. heightened by repeated observation of the target behavior and anticipation of environmental (or self-administered) consequences. would be the answer. According to Rachman. the checker type of disorder centers on avoiding punishment, whether the criticism comes from others or is self-directed. A subject may well be reactive to the self-recording procedure, but the anticipation of consequences may cause increased anxiety and fear of criticism. leading to an it~c~~sc in the number of obsessiveecompulsive incidents to be recorded. This description of a reactivity-induced increase in the target behavior would only hold for the checker type, however. because the obsessive-compulsive cleaner is concerned with restoring a sense of safety rather than forestalling social censure. This leads to the prediction that self-recording might be a useful procedure for cleaner types. but not for checker types. The subject in our case was an apparent mixture of the two types, but enough of the checker characteristics were present (especially the fear of social criticism) to cause the increase in self-recorded incidents, Whether it is the self-recording act itself or the entire procedure that is actually the active ingredient, it is hypothesized that the obsessive-compulsive checker will experience heightened anxiety when self-recording cues social consequences. and this anxiety will lead to an increased number of recorded incidents. If Kanfer is correct, and it is self-administered consequences rather than environmental consequences that cause reactivity, it seems likely that the anticipated consequences of ftor performing the compulsive ritual may outweigh the self-administered negative consequences cued by self-monitoring or that self-criticism may result in increased anxiety and increased checking, In either case. seIf-monitoring may not lead to a reduction in the number of monitored incidents. The second issue castmg doubt on the value of self-recording relates to the equivalence between the cues that triggered the obsession and the behaviors engaged in to counter the obsession. Although self-monitoring has been used previously with a variety of disorders, it may not be useful with clients or problems where the clinician is attempting to extinguish a potentially self-perpetuating target behavior. In this case, there was so much similarity between the stimulus and the compulsive ritual. the process had the quality of a vicious cycle in which the obsession was triggered. the compulsive ritual was performed, the obsession was re-rriggyered by the compulsive act. and so on, ff a client has dithculty distinguishing between one obsessive-compulsive incident and another due to the stimulus
IX0
CASE HISTORIESAIU’DSHORTEzRCOMMUNICATIONS
trigger’compulsive ritual equivalence. this could lead to over-recording of the actual number of independent incidents. Therefore, self-recording would enable the client to observe that he or she experienced many incidents and thus the individual might become discouraged about the prospect of progress or success in decreasing the problem. or confused about the discrepancy between the self-recording data and perceived progress decreasing the problem. While the pervasiveness and often subtle performance of our client’s ritual (e.g. looking down at his nose, catching the reflection of his nose in his eyeglasses), combined with his primarily outpatient status, prevented valid observation and recording by any individual other than the subject himself, asking this type of client to self-record his or her obsessivecompulsive incidents may bring counter-therapeutic attention to a behavior that should not be the focus of selfrecording. By whatever mechanism it works. and we are writing to provoke more theoretical and empirical attention to this issue. it is clear that behavioral assessment of obsessiveecompulsive neurosis via self-recording of the target thoughts and actions may not always be a useful or valid indicator of the client’s baseline or outcome status. If self-recording is not appropriate in these cases, then what forms of behavioral assessment can be used‘? In this particular case. body weight was a stable indicator of the client’s distress. His anecdotal report indicated that his weight consistently fluctuated several pounds per week prior to treatment, and rarely rose above 150 lb. After treatment began, the client’s regular self-weighings indicated that his weight no longer fluctuated and had risen to a stable 154 lb. Although weight may not be a valid or useful indicator for every or even most obsessiveecompulsives. other idiosyncratic or unobtrusive behavioral measures may be used to monitor response to treatment. Given the potential for counter-therapeutic effects that self-monitoring of the target behaviors can cause, therapist or peer momtoring of unobtrusive or seemingly tangential or irrelevant behaviors may be useful. Obviously, adequate assessment must be undertaken to establish the valid links between unobtrusive or tangential behaviors and the target outcome. The purpose here is not to suggest that behavioral assessors revert to the use of speculation or unwarranted inference in their documentation of therapeutic change. Rather, the purpose is to provoke clinicians engaged in the behavioral assessment of obsessiveecompulsive neurosis. especially the checker type and those with stimulus/response equivalence, to be sensitive to the effect of self-recording on the target behaviors themselves, and to the potential usefulness of less reactive and multiple measures of outcome. HAROLD
ROSFYBERG*
DENXIS
UPPERt
REFERENCES BOLXOUGOURISJ. C. and BASSAKIOSL. (1973) Prolonged flooding in cases with obsessiveecompulsive neurosis. Brlltrr. Res. Thu. 1 I, 227-23 1. FOA E. B. (1979) Failure in treating obsessive-compulsives. Behav. Res. Thrr. 17, 169-176. H~DGS~N R. and RACHMAN S. (1976) The modification of compulsive behavior. In CLIS~ Studies irl Behtrcior Tllrrtrp~ (Edited by EYSENCK H. J.). Routledge & Kegan Paul, London. HCKKWN R., RACHMAN S. and MARKS I. M. (1972) The treatment of chronic obsessiveecompulsive neurosis: follow-up and further findings. Behuu. Res. Thu. 10, 181-189. Lt BOEUF A. (1974) An automated aversion device in the treatment of a compulsive handwashing ritual. J. EMtro. Thw. mp. Psychiut. 5, 267-270. LFITENH~RG H. (Ed.) (1976) Behavioral approaches to treatment of neuroses. In Hmdhod of‘&hu~~ior Modific~rrtim cm/ Behtrrior Therapy. Prentice-Hall, Englewood Cliffs, New Jersey. MELAMED B. and SIEGEL L. (1975) Self-directed in cico treatment of an obsessiveecompulsive checking ritual. J. Eehtrl~. Thrr. e-up. Ps)chiut. 6, 3 I-35. NELSON R. 0. and HAYES S. C. (1981) Theoretical explanations for reactivity in self-monitoring. Brlztrr. ,Vod$ 5, ?- 14. RACHLIN H. (1974) Self-control. Behaciorism 2, 94-107. RACHMAI\; S. (1976) Obsessional~compulsive checking. Brhao. Res. Thu. 14, 269-277. RACHMAYXS., HOIXXX R. and MARKS I. M. (1971) The treatment of chronic obsessiveecompulsive neurosis. Brhclr. Rex Thu. 9, 237-247. RAINEY A. (1972) An obsessive+compulsive neurosis treated by flooding in vice. J. Brhuu. Thw. up. PsychI’ur. 3, I 17. TURUFR S. M., HERSEN M., BELLACK A. S. and WELLS K. C. (1979) Behavioral treatment of obsessive~compulsive neurosis. B&c. Res. Thu. 17, 95-106. WALI;F; S., HAUSFRMAS N. M. and LAVIN P. J. (1977) Clirlkul Guide to Behurior Therapy. Williams & Wilkins. Baltimore.
* To whom all reprint requests should be addressed. t Lahey Clinic Medical Center, Burlington, Massachusetts
and Harvard
Medical
School. CambrIdge.
Massachusetts.