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The treatment of a disaster phobia by systematic desensitization
B&m.
Ra.
Ther.. 1963. Vol. I. PD. 81 to 84. Rrpunon
Pm
Ltd.
Printed in En&nd
THE TREATMENT OF A DISASTER PHOBIA SYSTEMATIC DESENSITIZATION*
BY
B. ASHEM~ Ontario Hospital, Whitby, Ontario Summary-The amelioration of a phobic disorder through reciprocal inhibition therapy supports many accounts of success with this method of treatment by other investigators (Wolpe, 1962; Lazarus, 1961; Bond and Hutchison, 1960). Lazarus (1961) has demonstrated that a most important feature of the treatment is the reconditioning of anxiety responses along a dimension of generalization from a central stimulus. Wolpe (1962) attributes the success of reciprocal inhibition therapy to the establishment of a new response which eventually takes precedence over the previous maladaptive anxiety response. In‘this case, the phobia had existed for five years, but in the seven months prior to treatment had become incapacitating. Treatment was adopted based on the learning theory principles of reciprocal inhibition. After 19 therapeutic sessions the patient made a complete recovery. A follow-up three months later failed to demonstrate a return of the symptoms. SEVERAL attempts have been made in recent years to apply principles of learning to a variety of psychiatric disorders. Cne such principle of learning, reciprocal inhibition, has been used with outstanding success by Woipe (1958) in the treatment of neurotic symptoms. Essentially the process of reciprocal inhibition as described by Wolpe (1962) claims that if a response inhibitory to anxiety can be made to occur in the presence of anxiety-evoking stimuli, the connexion between these stimuli and the anxiety responses will be weakened. Although fundamentally this presumes the occurence of complex levels of neural organization leading to the phenomena of reciprocal inhibition developed by Sherrington (1906), at the higher levels of performance one response actually excludes performance of another (Jones, 1924; Lazarus, 1959). Jacobson (1938) was among the first to find that muscular relaxation is a response which can inhibit anxiety. Anxiety, which predominantly involves arousal of the autonomic nervous system, is an antagonistic response to that of relaxation which primarily involves parasympathetic functioning. Lazarus (1961) has demonstrated that relaxation with interpretative therapy does not abolish phobias, whereas relaxation with a graded series of anxiety stimuli can produce a very high recovery rate. The important difference appears to be the gradient of anxiety stimuli. When the anxiety stimuli are relatively simple to determine, as is often the case in phobias, treatment of the patient should be a simple matter for all therapists who have knowledge of learning theory. CASE STUDY
A twenty-seven year old sales administrator was referred for the investigation and treatment of a phobic fear of atomic attack. His phobia had generalized to anything which brought news of the international situation. He avoided radio, television, movies, newspapers and conversations. He travelled from England, where he had lived, to Canada to escape his phobia. After three years in Canada he sought psychiatric help. For two years l The author wishes to thank Dr. W. H. Weber, Superintendent, for permission to publish the present study. t Staff psychologist, Ontario Hospital, Whitby, Ontario.
81
Ontario Hospital, Whitby, Ontario,
82
B. ASHEM
he was treated by a psychiatrist (whose orientation Lvas eclectic) but the symptoms steadily worsened. He began consuming alcohol (eventually taking 26 oz. rye whiskey or vodka daily) to allay his anxiety. This resulted in the loss of his job and, with his fear increasing, he avoided all contact with persons and spent much of the day with the covers over his head. Suicidal ideas and an overdose of sleeping pills finally brought about certification to a mental hospital. At this point he had been unemployed for seven months. He was given six shock treatments at the hospital but a weekend at home proved to be so anxiety-provoking that he sought escape in alcohol. He was unable to discuss the details of his phobia (referring to it only as fear of “my phobia”), claiming that his fear was essentially that of losing his wife and that it was this problem which required treatment. On the ward he avoided the television and radio and complained that as long as attendants turned these on at will, his illness could only become worse. His relationship with his wife was one of extreme dependence. At this time, however, his phobia had placed such restrictions upon their marriage that she was contemplating separation. He obtained a score of 36 on the Willoughby questionnaire. METHODS
AND
RESULTS
The first three sessions with the patient were devoted to training in intensive muscle relaxation (+ hour each session). The patient was instructed to practice these relaxation exercises an additional half hour each day. Concurrently, anxiety hierarchies were constructed. These were made up from a knowledge of the patient’s history and through questionnaires and interviews (Wolpe, 1958). Hierarchies consisted of graded lists of stimuli which ranged from a very strong to a very weak stimulus. evaluated by the patient for their power to evoke unadaptive anxiety. The strongest stimulus in each hierarchy was that which the patient specifically avoided: newspapers, news on the radio or television, movies dealing with world events. Another hierarchy in which a positive approach to world events was developed, was added for its possible beneficial effects. Desensitization commenced following intensive muscular relaxation at the fourth therapeutic session. The patient was told: “You will now imagine a number of scenes very clearly and calmly. The scenes may not at all disturb your state of rela.‘ation, but if by any chance you feel disturbed you may indicate this to me by raising your finger an inch or so”. A neutral stimulus was then presented; standing on a street corner in Toronto. The scene was presented for approximately five seconds and then the patient was instructed to relax. The least disturbing items on the newspaper hierarchy and on the radio and television hierarchy were then presented. The patient indicated no disturbance and the session was ended with instructions to continue practicing relaxation twice each day for a fifteen minute period. The actual hierarchies used, and the number of presentations of each stimulus are listed below. All stimuli were given twice, even though the,patient indicated no disturbance. When considerable disturbance took place the stimulus was presented again the following day. If there was disturbance at this time the stimulus was repeated. All sessions followed a definite pattern. The therapist first named the muscles to be relaxed, and when the patient had reached a deep level of relaxation the successive items of the hierarchal series were presented. New items were introduced only when the patient could tolerate the stimulus for 10 seconds without signalling.
THE TREATMENT
OF A DISASTER
PHOBIA
BY SYSTEMATIC
83
DESENSITIZATION
HIERARCHIES A. Newspaper Series 1. Buying a newspaper 2. Approaching a news stand to buy a paper 3. Walking with wife who buys a paper 4. Walking with wife who wishes to buy paper 5. Walking with friend who buys a paper 6. Seeing headlines on the news stand 7. Hearing a newsboy call “Extra! Extra!” 8. Walking with friend who wishes to buy a paper 9. A newsboy walks by carrying newspapers 10. Sitting beside a man who has a paper Il. Seeing a man across the street buy a newspaper 12. Sitting on the streetcar with persons who have newspapers 13. Seeing a news stand across the street 14. Seeing a man read a novel B. Radio and Television Series 1. Turning on the radio to hear the news 2. Going to a movie with wife, knowing there is to be a newscast 3. Hearing “This is the CBC news” 4. Hearing on the radio : “We interrupt this programme to bring you a special bulletin” 5. Hearing: “This is Metro News” 6. Seeing a play on television 7. Hearing a musical programme 8. Seeing radio and television sets in a store C. Approach 1. Desire 2. Desire 3. Desire 4. Desire
Series to know to know to know to know
what what what what
is is is is
happening developing happening developing
in in in in
the the the the
world country city world of arts
No. of Presentations 5 10 20 30 15 10 10 10 5 8 3 2 4 2
10 35 40 25 5 4 2 2
15 50 10 2
After thirteen desensitization sessions the patient reported that he was listening to radio and television without anxiety. He was allowed to go home for a weekend and reA hierarchy to counteract the avoidance ported that he had gone to a movie with his wife. he had experienced (a positive approach, e.g. a desire to hear of events in the world) was then given. The first of these caused no anxiety; the final one required forty presentations By the end of these sessions (19 in all) the before he could tolerate it without signalling. patient was observed of his own volition to turn on news broadcasts and listen to them without evidence of anxiety. His wife reported that he was a ‘changed’ person, and was able to go out with her to movies and to visit friends. Three months following treatment the patient reported no relapse. His wife informed us that he was in excellent health, “better than he had been since she had known him”, and even though he had been unable to find another job, he suffered no anxiety nor depression and remained in excelIent spirits.
84
B.
ASHEM
REFERENCES BOND, I. K. and Hu~ctnsos.
H. C. (1960) Application
of reciprocal inhibition
therapy to exhibitionism.
Canudu Med. Assoc. J. 83, 23.
JACD~WN, E. (1938) Progressive Re/crxarion. University of Chicago Press, Chicago. JONES,M. C. (1924) Elimination of children’s fears. J. e.rper. Psychol. 7, 382. LAZARUS,A. A. (1959) The elimination of children’s phobias by deconditioning. Med. Proc. 5, 261. LAZARUS,A. A. (1961) Group therapy of phobic disorders by systematic desensitization. J. &norm. (SOC.) Psychol. 63, 504-510. SHERR~NGTON, C. S. (1906) Integrative Action of the Nervous Sys!em. Yale University Press, New Haven. WOLPE, J. (1958) Psychotherapy by Reciprocal Inhibition. Stanford University Press, Stanford. WOLPE, J. (1962) The experimental foundations of some new psychotherapeutic methods, in Esperimenfal Foundntions of Clinical Psychology. Basic Books, New York.
Ra.
Ther.. 1963. Vol. I. PD. 81 to 84. Rrpunon
Pm
Ltd.
Printed in En&nd
THE TREATMENT OF A DISASTER PHOBIA SYSTEMATIC DESENSITIZATION*
BY
B. ASHEM~ Ontario Hospital, Whitby, Ontario Summary-The amelioration of a phobic disorder through reciprocal inhibition therapy supports many accounts of success with this method of treatment by other investigators (Wolpe, 1962; Lazarus, 1961; Bond and Hutchison, 1960). Lazarus (1961) has demonstrated that a most important feature of the treatment is the reconditioning of anxiety responses along a dimension of generalization from a central stimulus. Wolpe (1962) attributes the success of reciprocal inhibition therapy to the establishment of a new response which eventually takes precedence over the previous maladaptive anxiety response. In‘this case, the phobia had existed for five years, but in the seven months prior to treatment had become incapacitating. Treatment was adopted based on the learning theory principles of reciprocal inhibition. After 19 therapeutic sessions the patient made a complete recovery. A follow-up three months later failed to demonstrate a return of the symptoms. SEVERAL attempts have been made in recent years to apply principles of learning to a variety of psychiatric disorders. Cne such principle of learning, reciprocal inhibition, has been used with outstanding success by Woipe (1958) in the treatment of neurotic symptoms. Essentially the process of reciprocal inhibition as described by Wolpe (1962) claims that if a response inhibitory to anxiety can be made to occur in the presence of anxiety-evoking stimuli, the connexion between these stimuli and the anxiety responses will be weakened. Although fundamentally this presumes the occurence of complex levels of neural organization leading to the phenomena of reciprocal inhibition developed by Sherrington (1906), at the higher levels of performance one response actually excludes performance of another (Jones, 1924; Lazarus, 1959). Jacobson (1938) was among the first to find that muscular relaxation is a response which can inhibit anxiety. Anxiety, which predominantly involves arousal of the autonomic nervous system, is an antagonistic response to that of relaxation which primarily involves parasympathetic functioning. Lazarus (1961) has demonstrated that relaxation with interpretative therapy does not abolish phobias, whereas relaxation with a graded series of anxiety stimuli can produce a very high recovery rate. The important difference appears to be the gradient of anxiety stimuli. When the anxiety stimuli are relatively simple to determine, as is often the case in phobias, treatment of the patient should be a simple matter for all therapists who have knowledge of learning theory. CASE STUDY
A twenty-seven year old sales administrator was referred for the investigation and treatment of a phobic fear of atomic attack. His phobia had generalized to anything which brought news of the international situation. He avoided radio, television, movies, newspapers and conversations. He travelled from England, where he had lived, to Canada to escape his phobia. After three years in Canada he sought psychiatric help. For two years l The author wishes to thank Dr. W. H. Weber, Superintendent, for permission to publish the present study. t Staff psychologist, Ontario Hospital, Whitby, Ontario.
81
Ontario Hospital, Whitby, Ontario,
82
B. ASHEM
he was treated by a psychiatrist (whose orientation Lvas eclectic) but the symptoms steadily worsened. He began consuming alcohol (eventually taking 26 oz. rye whiskey or vodka daily) to allay his anxiety. This resulted in the loss of his job and, with his fear increasing, he avoided all contact with persons and spent much of the day with the covers over his head. Suicidal ideas and an overdose of sleeping pills finally brought about certification to a mental hospital. At this point he had been unemployed for seven months. He was given six shock treatments at the hospital but a weekend at home proved to be so anxiety-provoking that he sought escape in alcohol. He was unable to discuss the details of his phobia (referring to it only as fear of “my phobia”), claiming that his fear was essentially that of losing his wife and that it was this problem which required treatment. On the ward he avoided the television and radio and complained that as long as attendants turned these on at will, his illness could only become worse. His relationship with his wife was one of extreme dependence. At this time, however, his phobia had placed such restrictions upon their marriage that she was contemplating separation. He obtained a score of 36 on the Willoughby questionnaire. METHODS
AND
RESULTS
The first three sessions with the patient were devoted to training in intensive muscle relaxation (+ hour each session). The patient was instructed to practice these relaxation exercises an additional half hour each day. Concurrently, anxiety hierarchies were constructed. These were made up from a knowledge of the patient’s history and through questionnaires and interviews (Wolpe, 1958). Hierarchies consisted of graded lists of stimuli which ranged from a very strong to a very weak stimulus. evaluated by the patient for their power to evoke unadaptive anxiety. The strongest stimulus in each hierarchy was that which the patient specifically avoided: newspapers, news on the radio or television, movies dealing with world events. Another hierarchy in which a positive approach to world events was developed, was added for its possible beneficial effects. Desensitization commenced following intensive muscular relaxation at the fourth therapeutic session. The patient was told: “You will now imagine a number of scenes very clearly and calmly. The scenes may not at all disturb your state of rela.‘ation, but if by any chance you feel disturbed you may indicate this to me by raising your finger an inch or so”. A neutral stimulus was then presented; standing on a street corner in Toronto. The scene was presented for approximately five seconds and then the patient was instructed to relax. The least disturbing items on the newspaper hierarchy and on the radio and television hierarchy were then presented. The patient indicated no disturbance and the session was ended with instructions to continue practicing relaxation twice each day for a fifteen minute period. The actual hierarchies used, and the number of presentations of each stimulus are listed below. All stimuli were given twice, even though the,patient indicated no disturbance. When considerable disturbance took place the stimulus was presented again the following day. If there was disturbance at this time the stimulus was repeated. All sessions followed a definite pattern. The therapist first named the muscles to be relaxed, and when the patient had reached a deep level of relaxation the successive items of the hierarchal series were presented. New items were introduced only when the patient could tolerate the stimulus for 10 seconds without signalling.
THE TREATMENT
OF A DISASTER
PHOBIA
BY SYSTEMATIC
83
DESENSITIZATION
HIERARCHIES A. Newspaper Series 1. Buying a newspaper 2. Approaching a news stand to buy a paper 3. Walking with wife who buys a paper 4. Walking with wife who wishes to buy paper 5. Walking with friend who buys a paper 6. Seeing headlines on the news stand 7. Hearing a newsboy call “Extra! Extra!” 8. Walking with friend who wishes to buy a paper 9. A newsboy walks by carrying newspapers 10. Sitting beside a man who has a paper Il. Seeing a man across the street buy a newspaper 12. Sitting on the streetcar with persons who have newspapers 13. Seeing a news stand across the street 14. Seeing a man read a novel B. Radio and Television Series 1. Turning on the radio to hear the news 2. Going to a movie with wife, knowing there is to be a newscast 3. Hearing “This is the CBC news” 4. Hearing on the radio : “We interrupt this programme to bring you a special bulletin” 5. Hearing: “This is Metro News” 6. Seeing a play on television 7. Hearing a musical programme 8. Seeing radio and television sets in a store C. Approach 1. Desire 2. Desire 3. Desire 4. Desire
Series to know to know to know to know
what what what what
is is is is
happening developing happening developing
in in in in
the the the the
world country city world of arts
No. of Presentations 5 10 20 30 15 10 10 10 5 8 3 2 4 2
10 35 40 25 5 4 2 2
15 50 10 2
After thirteen desensitization sessions the patient reported that he was listening to radio and television without anxiety. He was allowed to go home for a weekend and reA hierarchy to counteract the avoidance ported that he had gone to a movie with his wife. he had experienced (a positive approach, e.g. a desire to hear of events in the world) was then given. The first of these caused no anxiety; the final one required forty presentations By the end of these sessions (19 in all) the before he could tolerate it without signalling. patient was observed of his own volition to turn on news broadcasts and listen to them without evidence of anxiety. His wife reported that he was a ‘changed’ person, and was able to go out with her to movies and to visit friends. Three months following treatment the patient reported no relapse. His wife informed us that he was in excellent health, “better than he had been since she had known him”, and even though he had been unable to find another job, he suffered no anxiety nor depression and remained in excelIent spirits.
84
B.
ASHEM
REFERENCES BOND, I. K. and Hu~ctnsos.
H. C. (1960) Application
of reciprocal inhibition
therapy to exhibitionism.
Canudu Med. Assoc. J. 83, 23.
JACD~WN, E. (1938) Progressive Re/crxarion. University of Chicago Press, Chicago. JONES,M. C. (1924) Elimination of children’s fears. J. e.rper. Psychol. 7, 382. LAZARUS,A. A. (1959) The elimination of children’s phobias by deconditioning. Med. Proc. 5, 261. LAZARUS,A. A. (1961) Group therapy of phobic disorders by systematic desensitization. J. &norm. (SOC.) Psychol. 63, 504-510. SHERR~NGTON, C. S. (1906) Integrative Action of the Nervous Sys!em. Yale University Press, New Haven. WOLPE, J. (1958) Psychotherapy by Reciprocal Inhibition. Stanford University Press, Stanford. WOLPE, J. (1962) The experimental foundations of some new psychotherapeutic methods, in Esperimenfal Foundntions of Clinical Psychology. Basic Books, New York.