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The elimination of hallucinatory and delusional behavior by verbal conditioning and assertive training: A case study
J tle,~ai Tiler ,g E~p Psrch:at Vol 3, pp 225-227 Pergamon Pre~s, 1972 Printed m Great Britain
THE ELIMINATION OF HALLUCINATORY AND DELUSIONAL BEHAVIOR BY VERBAL CONDITIONING AND ASSERTIVE T R A I N I N G : A CASE STUDY* RUbY V. NYDEGGER Rice University Summary--A 20-yr-old male diagnosed as paranoid schizophrenic had auditory and v,sual hallucinations and a very rigid religious delusional system. For the auditory hallucinations, verbal conditioning was used to eliminate his talk of "voices". At the same time. assertive training was given. The visual hallucinations proved to be strictly manipulative, being consciously used to remove the patient from conflict situations. As he became more assertive these hallucinations disappeared. The delusional system, which was also functional in removing him from conflict, responded to verbal conditioning and assertive training After 2 months of treatment the hallucinations and delusions ceased to be reported or observed. The patient has had no recurrence of psychotic symptoms for 2½ yr. PSYCHOSIS is generally diagnosed by interpreting certain behaviors as indicative of confusion or lack of contact with reality. For example, when a patient claims to see or hear things that others do not perceive, it is assumed that he is not accurately interpreting reality, or that his ideas of reality are distorted because of some kind of faulty perceptual operation. The present case illustrates how the behavior which is used for making such diagnostic decisions can be modified without making untestable assumptions. A 20-yr-old male was diagnosed as paranoid schizophrenic by the admitting physician at the hospital. At this time he reported auditory and visual hallucinations. He had always been rather shy and withdrawn, and was becoming even more this way. Further, he had an active delusional system which centered on a deep religious conviction that he had been chosen by God to be an example of a good life. Thus, he felt that he was destined to be cehbate, and had no need to develop heterosexual relationships. When admitted to the psychiatric unit the patient received two forms of therapy: chemotherapy m the form of phenothiazines; and
milieu therapy embracing such activities as patient government, occupational therapy, sports and recreation. When he was referred to me for individual psychotherapy, several aspects of hIs behavior were noted as being maladaptive in addition to his reported auditory and visual hallucinations. First, was often seen sitting by himself talking to the ceiling as if he were carrying on a conversation with someone. Second, he was quite withdrawn, and very seldom interacted socially with either staff or patients. Third, when he did speak tt was usually about his divine mission and holy status. Finally, he was very passive and would generally submit to almost anyone who took a forceful attitude towards him. These were the behaviors seen as needing to be modified.
METHOD The first behavior tackled was the visual hallucinatory activity, which S stated he had never had before coming to the hospital. While at first he was somewhat unsure of the nature of the "visions", he finally decided that God was
* Requests for reprints should be addressed to Rudy V. Nydegger, Dept. of Psychology, Rice University, Houston, Texas 77001. 225 E
226
RUDY v. NYDEGGER
"helping" him. When he began, on request, to talk about the "visions" it became obvious that he was concealing something. Gradually I discovered that his parents wanted to take him home for the weekend, but as he was less anxious in the hospital, he wanted to remain. In order not to hurt his parents' feelings he had reported a "vision" to the staff, whereupon his medication was increased and his pass cancelled. When confronted with this, he acknowledged that he had contrived this story to get himself out of a difficult situation. Apparently, the patient often felt trapped at the choice point where a decision was necessary. When this decision had implications for other people he was often unable to respond in any way, and the conflict and subsequent confusion generated the "symptoms"--withdrawal, hallucinations, or rigid adherence to his delusions. The patient was instructed to try to confront the situation directly and make a decision. Whenever he was able to do this, staff and patients were instructed to give him social reinforcement in the form of praise. However, when he could not make a decision, I was contacted. At this point ! tried to give him support to enable him to make his choice. If this did not work, I made the decision myself. Whenever this was necessary the patient was not punished, but made to review the situation and d~scuss the possible options available to him. Adaptive choices were supported. This was a forerunner of subsequent assertive training. The auditory hallucinations were different, and were treated differently. S was, in fact, quite convinced that he had been "hearing" voices. Over a period of 2 weeks a comprehensive diary of the "voices" was kept, together with information about the prevailing circumstances. In almost all instances the "voices" either told him what to do in a specific situation, or confirmed his divine status. The situations which were decided by the "voices" were always those about which he had conflicts. It seemed that since he could not assert himself, he made choices by assigning responsibility to "voices" which he felt were beyond his control. To deal
with this a verbal conditioning paradigm was used. I explained to S that his "voices" were really just thoughts for which he was unwilling to take responsibihty, and in the future he should say "thoughts" instead of "voices" When S and I were talking (apparently reinforcing for him) and he said "voices" I would look away, check my watch, begin to leave, and do other things associated with breaking contact When he spoke about "thoughts", "decisions", or anything involving personal responsibdlty I would maintain eye contact, smile, nod my head and say "mm-hmm". The rest of the staff were also informed of these contingencies and were encouraged to do the same, and most of them did. The passive and w~thdrawn behavior was dealt with by assertive training combined wtth systematic desensitization to interpersonal sttuations (Wolpe, 1958). The delusional system was at first felt to pose a real problem, for traditionally paranoid ~deation is seen as being quite reststant to change. It was explained to S that he maintained these ideas to keep from having to deal with certain problems. Using the same verbal conditionmg procedures outlined above, he was reinforced for speaking about his human qualities, fradties, needs, and motives, and was ignored when talking about his delusional system.
RESULTS The results of the treatment were quite impressive. During the 2-week period before its institution S reported an average of about seven auditory hallucinations and about three visual hallucinations per day. The hallucinatory behavior dropped out quite quickly, and within 2 months no more were reported, nor was any of the behavior associated with it (e.g. talking to himself, looking at the ceiling, or listening). The extinction curves for frequency of reported hallucinations are shown in Fig. 1. The frequency of interpersonal contacts and assertive behavior increased quite dramatically
THE ELIMINATION OF HALLUCINATORY AND DELUSIONAL BEHAVIOR
Audttory Hallucmahons
Q.
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227
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71
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Day
FIG. 1. Frequency of auditory and visual hallucinations during the 2-month period the patient was in treatment. following the introduction of the relevant techniques. Frequency counts for these behaviors were begun, but increased so rapidly that by the end of a few weeks it was impractical to continue. By the end of 1 month S was talking frequently with others, was much more assertive, and did not stay in his r o o m as much as he had before. He became active in patient activities, and frequently visited his parents. With respect to the delusional system, by the end of 2 months he had decided that he was not "chosen" to be monk-like but would rather go to college, and have some fun. Whereas he used to speak about his delusions from 10 to 20 times per therapy hour prior to the new program, after I month reference to them had decreased to an average of two per hour, and totally disappeared after 6 weeks, apparently in relation to his becoming more assertive and outgoing. Th~s was probably because the assertive operant behaviors were incompatible with the delusional behavior, and as they became more frequent the incompatible delusional behavior disappeared with increasing rapidity. I met regularly with S's parents, and explained what was happening and why. The techniques were described and demonstrated. The parents' role in maintaining his changed behavior out of the hospital was discussed. They understood and were eager to help. Contact was maintained
after treatment and it was learned that S had gone away to college, had some friends, was dating, and, most important, that he was happy and without psychotic symptoms. This state of affairs has now lasted for over 2½ yr. POSTSCRIPT While the results of the treatment indicated impressively that behavior labeled psychotic can be modified, ~t is interesting to record the reactions of some members of the staff. They asserted that the patient had not been purged of his hallucinations, but had merely been taught not to speak of them. Thus it could not be said that he was not hallucinating. When I asked the critics how they knew that S had hallucinated m the first place, they promptly reeled off these behavioral indicators: he talks to himself; "listens" to things no one else hears; withdraws to isolated corners: and says that he hallucinates. I then pointed out that all of these indicators were observable behavior--a point which they reluctantly conceded. [ then asserted that ~lnce none of the mdtcattve behaviors existed any longer, it could be maintained that S no longer hallucinated.
REFERENCE WOLPE V. (1958) Psychotherapyby Reciprocal inhlbitfon, Stanford Universtty Press, Stanford.
(First received l July 1971 ; in revised form 30 December 1971)
THE ELIMINATION OF HALLUCINATORY AND DELUSIONAL BEHAVIOR BY VERBAL CONDITIONING AND ASSERTIVE T R A I N I N G : A CASE STUDY* RUbY V. NYDEGGER Rice University Summary--A 20-yr-old male diagnosed as paranoid schizophrenic had auditory and v,sual hallucinations and a very rigid religious delusional system. For the auditory hallucinations, verbal conditioning was used to eliminate his talk of "voices". At the same time. assertive training was given. The visual hallucinations proved to be strictly manipulative, being consciously used to remove the patient from conflict situations. As he became more assertive these hallucinations disappeared. The delusional system, which was also functional in removing him from conflict, responded to verbal conditioning and assertive training After 2 months of treatment the hallucinations and delusions ceased to be reported or observed. The patient has had no recurrence of psychotic symptoms for 2½ yr. PSYCHOSIS is generally diagnosed by interpreting certain behaviors as indicative of confusion or lack of contact with reality. For example, when a patient claims to see or hear things that others do not perceive, it is assumed that he is not accurately interpreting reality, or that his ideas of reality are distorted because of some kind of faulty perceptual operation. The present case illustrates how the behavior which is used for making such diagnostic decisions can be modified without making untestable assumptions. A 20-yr-old male was diagnosed as paranoid schizophrenic by the admitting physician at the hospital. At this time he reported auditory and visual hallucinations. He had always been rather shy and withdrawn, and was becoming even more this way. Further, he had an active delusional system which centered on a deep religious conviction that he had been chosen by God to be an example of a good life. Thus, he felt that he was destined to be cehbate, and had no need to develop heterosexual relationships. When admitted to the psychiatric unit the patient received two forms of therapy: chemotherapy m the form of phenothiazines; and
milieu therapy embracing such activities as patient government, occupational therapy, sports and recreation. When he was referred to me for individual psychotherapy, several aspects of hIs behavior were noted as being maladaptive in addition to his reported auditory and visual hallucinations. First, was often seen sitting by himself talking to the ceiling as if he were carrying on a conversation with someone. Second, he was quite withdrawn, and very seldom interacted socially with either staff or patients. Third, when he did speak tt was usually about his divine mission and holy status. Finally, he was very passive and would generally submit to almost anyone who took a forceful attitude towards him. These were the behaviors seen as needing to be modified.
METHOD The first behavior tackled was the visual hallucinatory activity, which S stated he had never had before coming to the hospital. While at first he was somewhat unsure of the nature of the "visions", he finally decided that God was
* Requests for reprints should be addressed to Rudy V. Nydegger, Dept. of Psychology, Rice University, Houston, Texas 77001. 225 E
226
RUDY v. NYDEGGER
"helping" him. When he began, on request, to talk about the "visions" it became obvious that he was concealing something. Gradually I discovered that his parents wanted to take him home for the weekend, but as he was less anxious in the hospital, he wanted to remain. In order not to hurt his parents' feelings he had reported a "vision" to the staff, whereupon his medication was increased and his pass cancelled. When confronted with this, he acknowledged that he had contrived this story to get himself out of a difficult situation. Apparently, the patient often felt trapped at the choice point where a decision was necessary. When this decision had implications for other people he was often unable to respond in any way, and the conflict and subsequent confusion generated the "symptoms"--withdrawal, hallucinations, or rigid adherence to his delusions. The patient was instructed to try to confront the situation directly and make a decision. Whenever he was able to do this, staff and patients were instructed to give him social reinforcement in the form of praise. However, when he could not make a decision, I was contacted. At this point ! tried to give him support to enable him to make his choice. If this did not work, I made the decision myself. Whenever this was necessary the patient was not punished, but made to review the situation and d~scuss the possible options available to him. Adaptive choices were supported. This was a forerunner of subsequent assertive training. The auditory hallucinations were different, and were treated differently. S was, in fact, quite convinced that he had been "hearing" voices. Over a period of 2 weeks a comprehensive diary of the "voices" was kept, together with information about the prevailing circumstances. In almost all instances the "voices" either told him what to do in a specific situation, or confirmed his divine status. The situations which were decided by the "voices" were always those about which he had conflicts. It seemed that since he could not assert himself, he made choices by assigning responsibility to "voices" which he felt were beyond his control. To deal
with this a verbal conditioning paradigm was used. I explained to S that his "voices" were really just thoughts for which he was unwilling to take responsibihty, and in the future he should say "thoughts" instead of "voices" When S and I were talking (apparently reinforcing for him) and he said "voices" I would look away, check my watch, begin to leave, and do other things associated with breaking contact When he spoke about "thoughts", "decisions", or anything involving personal responsibdlty I would maintain eye contact, smile, nod my head and say "mm-hmm". The rest of the staff were also informed of these contingencies and were encouraged to do the same, and most of them did. The passive and w~thdrawn behavior was dealt with by assertive training combined wtth systematic desensitization to interpersonal sttuations (Wolpe, 1958). The delusional system was at first felt to pose a real problem, for traditionally paranoid ~deation is seen as being quite reststant to change. It was explained to S that he maintained these ideas to keep from having to deal with certain problems. Using the same verbal conditionmg procedures outlined above, he was reinforced for speaking about his human qualities, fradties, needs, and motives, and was ignored when talking about his delusional system.
RESULTS The results of the treatment were quite impressive. During the 2-week period before its institution S reported an average of about seven auditory hallucinations and about three visual hallucinations per day. The hallucinatory behavior dropped out quite quickly, and within 2 months no more were reported, nor was any of the behavior associated with it (e.g. talking to himself, looking at the ceiling, or listening). The extinction curves for frequency of reported hallucinations are shown in Fig. 1. The frequency of interpersonal contacts and assertive behavior increased quite dramatically
THE ELIMINATION OF HALLUCINATORY AND DELUSIONAL BEHAVIOR
Audttory Hallucmahons
Q.
-4-
227
--
Vtsual Hallucmahon $
"6
71
9
6
c
5 4
o" 2
-
I
i
la. 0
-
5
IO
Add
t
~
15 20 25 30 35 4 0 45 5 0 55 60 65
Day
FIG. 1. Frequency of auditory and visual hallucinations during the 2-month period the patient was in treatment. following the introduction of the relevant techniques. Frequency counts for these behaviors were begun, but increased so rapidly that by the end of a few weeks it was impractical to continue. By the end of 1 month S was talking frequently with others, was much more assertive, and did not stay in his r o o m as much as he had before. He became active in patient activities, and frequently visited his parents. With respect to the delusional system, by the end of 2 months he had decided that he was not "chosen" to be monk-like but would rather go to college, and have some fun. Whereas he used to speak about his delusions from 10 to 20 times per therapy hour prior to the new program, after I month reference to them had decreased to an average of two per hour, and totally disappeared after 6 weeks, apparently in relation to his becoming more assertive and outgoing. Th~s was probably because the assertive operant behaviors were incompatible with the delusional behavior, and as they became more frequent the incompatible delusional behavior disappeared with increasing rapidity. I met regularly with S's parents, and explained what was happening and why. The techniques were described and demonstrated. The parents' role in maintaining his changed behavior out of the hospital was discussed. They understood and were eager to help. Contact was maintained
after treatment and it was learned that S had gone away to college, had some friends, was dating, and, most important, that he was happy and without psychotic symptoms. This state of affairs has now lasted for over 2½ yr. POSTSCRIPT While the results of the treatment indicated impressively that behavior labeled psychotic can be modified, ~t is interesting to record the reactions of some members of the staff. They asserted that the patient had not been purged of his hallucinations, but had merely been taught not to speak of them. Thus it could not be said that he was not hallucinating. When I asked the critics how they knew that S had hallucinated m the first place, they promptly reeled off these behavioral indicators: he talks to himself; "listens" to things no one else hears; withdraws to isolated corners: and says that he hallucinates. I then pointed out that all of these indicators were observable behavior--a point which they reluctantly conceded. [ then asserted that ~lnce none of the mdtcattve behaviors existed any longer, it could be maintained that S no longer hallucinated.
REFERENCE WOLPE V. (1958) Psychotherapyby Reciprocal inhlbitfon, Stanford Universtty Press, Stanford.
(First received l July 1971 ; in revised form 30 December 1971)