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Sequential treatments for severe phobia
1. Behav. Ther. & Exp. Psycbiar. Vol. 2, PP. 195-197. Perwnmn Press, 1971. Printed in Great Britain.
SEQUENTIAL TREATMENTS MICHAEL
FOR SEVERE PHOBIA
J. MAHONEY*
Stanford
University
Summary-Sequential treatment involving systematic desensitization and relaxation, symbolic (film), live, and participant modeling were employed in the successful alleviation of a severe snake phobia. Implications are discussed regarding the utility of programs attuned to the needs of individual patients. THE alleviation of maladaptive avoidance behaviors has been a densely researched area in behavior therapy (Franks, 1969; Bandura, 1969). Therapy has typically involved a single technique such as desensitization, implosion, or participant modeling. However, the highly individualized nature of specific behavioral problems makes an inflexible routine of standardized techniques undesirable (Marquis and Morgan, 1968; Yates, 1970). While the relative efficacy of various techniques has been researched in empirical group studies (e.g. Bandura, Blanchard and Ritter, 1969), very little has been reported regarding the utility of treatment combinations. Tooley and Pratt (1967) have employed sequential treatment combinations in the modification of smoking behavior. Gershman (1970) has combined therapeutic techniques in eliminating deviant sexual fantasies. However, neither of these studies involved avoidance behaviors. Fryrear and Werner (1970) have recently employed a treatment combination of modeling plus desensitization in order to meet the specific therapeutic needs of a phobic client. The following report describes another multiple treatment program for a severe phobia.
CASE STUDY The client was a 31-year-old woman who complained of an extreme and incapacitating fear of snakes. She had been referred from an ongoing empirical group study at Stanford University. She had answered a newspaper advertise*Requests California
for reprints 94305.
should
be addressed
ment for participation in that study which was concerned with the treatment of snake fears. She was unable to participate in it, however, because of the severity of her avoidance behavior. During an initial behavioral pre-test, she became hysterical when asked to enter a room which contained a caged harmless snake. Her response to this situation included uncontrollable crying, tremors, and extreme behavioral avoidance. On refusing to continue in the study, she was referred to the author for individual treatment. During the initial interview, the client reported that her severe fear of snakes was long-standing. She was unable to view pictures of snakes, to watch films or movies containing snake scenes, or to visit reptile houses in zoos. Participation in out-of-doors activities (swimming, camping, hiking) was very infrequent because of possible encounters. On several occasions she had experienced painful social ostracization due to her fears. She was very tearful during this interview, and expressed pessimism regarding the outcome of therapy. She was assured that her fear was surmountable and that the techniques to be employed would be adjusted to her own pacing and abilities. The client was told that the treatment would have both active and passive components. There would be gradual exposure to the feared stimulus that would help alleviate her fear. This exposure would involve both her active participation in increasing the stimulus exposure and her passive
to: Department 195
of Psychology,
Stanford
University,
Stanford,
196
MICHAEL
J. MAHONEY
presence in each stimulus situation. She was then asked to rank the unpleasantness of the following situations : (a) imagining herself in varying degrees of interaction with a snake, (b) watching a film of people interacting with a snake, (c) watching her therapist interact with a snake, and (d) actually engaging in a graded series of interactions with a snake. From her ranking, the following sequential therapeutic strategy was decided upon: (1) training in deep muscular relaxation, (2) systematic desensitization, (3) symbolic modeling, (4) live modeling, and (5) participant modeling. Training in muscular relaxation was begun at the first session and the client was instructed to practice daily at home. A hierarchy was constructed consisting of 21 items. During Sessions 2 and 3 the client was able to complete 15 of these items in systematic desensitization. At that point she requested moving on to the film hierarchy which consisted of 7 scenes of graduated interactions between adults and a 4-ft corn snake. Each scene was presented twice in conjunction with muscular relaxation. A frame-byframe presentation of two of the scenes was initially required due to the client’s fear of snake movements. Gradual increments in the speed of the film allowed movement scenes to be successively approximated. Four sessions were required to complete the film hierarchy. The live modeling phase consisted of the therapist interacting with a 4-ft corn snake while the client watched through a one-way mirror. Self-induced relaxation was employed and the live modeling was paced by client reports. After two sessions, the client graduated to participant modeling. This technique involves a graduated sequence of modeling and guided participation by the client in the operations of the therapist (Bandura, Blanchard and Ritter, 1969; Rimm and Mahoney, 1969). While group studies have questioned the contribution of relaxation to the participant modeling technique (Bandura, Blanchard and Ritter, 1969; Rimm and Medeiros, 1970), the client was encouraged to induce relaxation if she felt that it would be of assistance to her during this phase. She later reported
that her relaxation training was helpful during the initial stages of treatment but became less necessary later. Three sessions of participant modeling were employed. At the end of that time (Session 12) the client reported that she felt very comfortable in handling the snake and that her fear-related problems had been eliminated. She felt no distress at viewing pictures of snakes or at talking about them. At her request, a snake skin was obtained and she expressed the intention of framing it as a decoration for her apartment. A behavioral post-test indicated that she was able to pick up and handle the snake for several minutes. This performance was in marked contrast to her initial avoidance. She neither exhibited nor expressed discomfort when the snake’s head was within 5 in. of her face. These therapeutic gains were still present at a four-month follow-up. DISCUSSION While treatment combinations may complicate functional analysis of the behavior change process, they often provide necessary weaponry for particular problems. The relative contributions of particular treatment components is, of course, hard to evaluate in such cases. However, one can justifiably argue for the practicality of a specific treatment sequence for a specific problem. In the case described here, treatments were applied in the order of their acceptability to the patient. A graduated succession of techniques-relaxation training, systematic desensitization, symbolic modeling, live modeling, and participant modeling-provided an effective strategy for attacking the client’s behavioral problem. The avoidance behavior was initially so extreme as to render impossible the earlier use of methods farther down the 1ist-e.g. participant modeling, which was the technique which ultimately eliminated the avoidance behavior. The gradation of techniques was recognized by the client as a significant factor in her progress. REFERENCES BANDURA A. (1969) Principles of Behavior Modification.
Holt, Rinehart
& Winston,
New York.
SEQUENTIAL
TREATMENTS
BANDURAA., BLANCHARDE. B. and Rrrre~ B. (1969) Relative efficacy of desensitization and modeling approaches for inducing behavioral. affective. and $t_;d$al changes, J. ?ersonaI. Sdc. Psychoi. 13,
_,_ _<<.
FRANKS C. M. (Ed.) (1969) Behavior Therapy: Appraisal and Status. McGraw-Hill. New York. FRYREARJ. L. and WERNER S. 1970) Treatment of a phobia by use of a video-tape 6 modeling procedure: A case study, Behavior Therapy 1, 391-394. GER~HMANL. (1970) Case conference: A transvestite fantasy treated by thought-stopping, covert sensitixation and aversive shock, J. Behav. Ther. Exp. Psychiat. 1, 153-161.
FOR
SEVERE
PHOBIA
197
MARQUISJ. N. and MORGANW. G. (1968) A Guidebook for Systematic Desensitization. Veterans’ Workshop, Palo Alto. California. RIMM D. C. and MAHONEYM. J. (1969) The application of reinforcement and participant modeling procedures in the treatment of snake-phobic behavior, Behav. Res. & Therapy 7, 369-376. RIMM D. C. and MEDEIROSD. C. (1970) The role of muscle relaxation in participant modeling, Behav. Res. & Therapy 8, 127-132. TOOLEYJ. T. and Pa~rr S. (1967) An exoerimental urocedure for the extinction of smoking beha;ior, Psychol. Record 17, 209-218. YATFS A. J. (1969) Behavior Therapy. Wiley, New York.
(Received 11 May 1971)
SEQUENTIAL TREATMENTS MICHAEL
FOR SEVERE PHOBIA
J. MAHONEY*
Stanford
University
Summary-Sequential treatment involving systematic desensitization and relaxation, symbolic (film), live, and participant modeling were employed in the successful alleviation of a severe snake phobia. Implications are discussed regarding the utility of programs attuned to the needs of individual patients. THE alleviation of maladaptive avoidance behaviors has been a densely researched area in behavior therapy (Franks, 1969; Bandura, 1969). Therapy has typically involved a single technique such as desensitization, implosion, or participant modeling. However, the highly individualized nature of specific behavioral problems makes an inflexible routine of standardized techniques undesirable (Marquis and Morgan, 1968; Yates, 1970). While the relative efficacy of various techniques has been researched in empirical group studies (e.g. Bandura, Blanchard and Ritter, 1969), very little has been reported regarding the utility of treatment combinations. Tooley and Pratt (1967) have employed sequential treatment combinations in the modification of smoking behavior. Gershman (1970) has combined therapeutic techniques in eliminating deviant sexual fantasies. However, neither of these studies involved avoidance behaviors. Fryrear and Werner (1970) have recently employed a treatment combination of modeling plus desensitization in order to meet the specific therapeutic needs of a phobic client. The following report describes another multiple treatment program for a severe phobia.
CASE STUDY The client was a 31-year-old woman who complained of an extreme and incapacitating fear of snakes. She had been referred from an ongoing empirical group study at Stanford University. She had answered a newspaper advertise*Requests California
for reprints 94305.
should
be addressed
ment for participation in that study which was concerned with the treatment of snake fears. She was unable to participate in it, however, because of the severity of her avoidance behavior. During an initial behavioral pre-test, she became hysterical when asked to enter a room which contained a caged harmless snake. Her response to this situation included uncontrollable crying, tremors, and extreme behavioral avoidance. On refusing to continue in the study, she was referred to the author for individual treatment. During the initial interview, the client reported that her severe fear of snakes was long-standing. She was unable to view pictures of snakes, to watch films or movies containing snake scenes, or to visit reptile houses in zoos. Participation in out-of-doors activities (swimming, camping, hiking) was very infrequent because of possible encounters. On several occasions she had experienced painful social ostracization due to her fears. She was very tearful during this interview, and expressed pessimism regarding the outcome of therapy. She was assured that her fear was surmountable and that the techniques to be employed would be adjusted to her own pacing and abilities. The client was told that the treatment would have both active and passive components. There would be gradual exposure to the feared stimulus that would help alleviate her fear. This exposure would involve both her active participation in increasing the stimulus exposure and her passive
to: Department 195
of Psychology,
Stanford
University,
Stanford,
196
MICHAEL
J. MAHONEY
presence in each stimulus situation. She was then asked to rank the unpleasantness of the following situations : (a) imagining herself in varying degrees of interaction with a snake, (b) watching a film of people interacting with a snake, (c) watching her therapist interact with a snake, and (d) actually engaging in a graded series of interactions with a snake. From her ranking, the following sequential therapeutic strategy was decided upon: (1) training in deep muscular relaxation, (2) systematic desensitization, (3) symbolic modeling, (4) live modeling, and (5) participant modeling. Training in muscular relaxation was begun at the first session and the client was instructed to practice daily at home. A hierarchy was constructed consisting of 21 items. During Sessions 2 and 3 the client was able to complete 15 of these items in systematic desensitization. At that point she requested moving on to the film hierarchy which consisted of 7 scenes of graduated interactions between adults and a 4-ft corn snake. Each scene was presented twice in conjunction with muscular relaxation. A frame-byframe presentation of two of the scenes was initially required due to the client’s fear of snake movements. Gradual increments in the speed of the film allowed movement scenes to be successively approximated. Four sessions were required to complete the film hierarchy. The live modeling phase consisted of the therapist interacting with a 4-ft corn snake while the client watched through a one-way mirror. Self-induced relaxation was employed and the live modeling was paced by client reports. After two sessions, the client graduated to participant modeling. This technique involves a graduated sequence of modeling and guided participation by the client in the operations of the therapist (Bandura, Blanchard and Ritter, 1969; Rimm and Mahoney, 1969). While group studies have questioned the contribution of relaxation to the participant modeling technique (Bandura, Blanchard and Ritter, 1969; Rimm and Medeiros, 1970), the client was encouraged to induce relaxation if she felt that it would be of assistance to her during this phase. She later reported
that her relaxation training was helpful during the initial stages of treatment but became less necessary later. Three sessions of participant modeling were employed. At the end of that time (Session 12) the client reported that she felt very comfortable in handling the snake and that her fear-related problems had been eliminated. She felt no distress at viewing pictures of snakes or at talking about them. At her request, a snake skin was obtained and she expressed the intention of framing it as a decoration for her apartment. A behavioral post-test indicated that she was able to pick up and handle the snake for several minutes. This performance was in marked contrast to her initial avoidance. She neither exhibited nor expressed discomfort when the snake’s head was within 5 in. of her face. These therapeutic gains were still present at a four-month follow-up. DISCUSSION While treatment combinations may complicate functional analysis of the behavior change process, they often provide necessary weaponry for particular problems. The relative contributions of particular treatment components is, of course, hard to evaluate in such cases. However, one can justifiably argue for the practicality of a specific treatment sequence for a specific problem. In the case described here, treatments were applied in the order of their acceptability to the patient. A graduated succession of techniques-relaxation training, systematic desensitization, symbolic modeling, live modeling, and participant modeling-provided an effective strategy for attacking the client’s behavioral problem. The avoidance behavior was initially so extreme as to render impossible the earlier use of methods farther down the 1ist-e.g. participant modeling, which was the technique which ultimately eliminated the avoidance behavior. The gradation of techniques was recognized by the client as a significant factor in her progress. REFERENCES BANDURA A. (1969) Principles of Behavior Modification.
Holt, Rinehart
& Winston,
New York.
SEQUENTIAL
TREATMENTS
BANDURAA., BLANCHARDE. B. and Rrrre~ B. (1969) Relative efficacy of desensitization and modeling approaches for inducing behavioral. affective. and $t_;d$al changes, J. ?ersonaI. Sdc. Psychoi. 13,
_,_ _<<.
FRANKS C. M. (Ed.) (1969) Behavior Therapy: Appraisal and Status. McGraw-Hill. New York. FRYREARJ. L. and WERNER S. 1970) Treatment of a phobia by use of a video-tape 6 modeling procedure: A case study, Behavior Therapy 1, 391-394. GER~HMANL. (1970) Case conference: A transvestite fantasy treated by thought-stopping, covert sensitixation and aversive shock, J. Behav. Ther. Exp. Psychiat. 1, 153-161.
FOR
SEVERE
PHOBIA
197
MARQUISJ. N. and MORGANW. G. (1968) A Guidebook for Systematic Desensitization. Veterans’ Workshop, Palo Alto. California. RIMM D. C. and MAHONEYM. J. (1969) The application of reinforcement and participant modeling procedures in the treatment of snake-phobic behavior, Behav. Res. & Therapy 7, 369-376. RIMM D. C. and MEDEIROSD. C. (1970) The role of muscle relaxation in participant modeling, Behav. Res. & Therapy 8, 127-132. TOOLEYJ. T. and Pa~rr S. (1967) An exoerimental urocedure for the extinction of smoking beha;ior, Psychol. Record 17, 209-218. YATFS A. J. (1969) Behavior Therapy. Wiley, New York.
(Received 11 May 1971)