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Treatment of a spider phobia by in vivo and imaginal desensitization
J. Behav. Ther. & Exp. Psychiat. Vol. 5, pp. 47-52. Pergamon Press, 1974. Printed in Great Britain.
T R E A T M E N T OF A S P I D E R P H O B I A BY I N VIVO AND IMAGINAL DESENSITIZATION MARIAN L. MACDONALD* and DOUGLAS A. BERNSTEIN'~ University of Illinois at Urbana Summary--The use of in vivo and imaginal desensitization procedures in the treatment of a spider phobia is described. A diversity of in vivo programs, following a thematic hierarchy paradigm, are discussed in detail to encourage more frequent attention to and utilization of easily arranged, controlled exposures. THE USE of in vivo programs as either an alternative (Barlow et al., 1969; Clark, 1963; Cooke, 1966; Leitenberg et al., 1970; Lick and Bootzin, 1970; Litvak, 1969; Ritter, 1969a, b; Stadter, 1973) or an adjunctive (Bean, 1970; Bernstein and Beaty, 1971 ; Garfield et al., 1967) to imaginal desensitization has recently become common. Most published accounts of in vivo procedures indicate that multiple exposure programs are structured in a manner analogous to spatialtemporal imaginal hierarchies; that is, they involve progressively closer approximations to a target event or object (cf. Clark, 1963). The present report describes an adjunctive multiple exposure in vivo program fashioned after a thematic imaginal hierarchy with a variety of procedures, each of which incorporated a different dimension of the target stimulus.
BACKGROUND AND PROBLEM The client, a 24-yr-old female graduate student, was self-referred to the Psychological and Counseling Center at the University of Illinois. Her presenting problem was a fear of spiders, a long-standing difficulty which had recently become of greater concern because her new campus apartment was infested with them. In addition to experiencing the typical arousal
pattern when confronted by the phobic stimulus, she was also ruminating about whether or not spiders would appear, reporting nightmares about spiders, and exhibiting avoidance patterns to potential spider situations such as certain drawers and rooms. Furthermore, she was developing social support systems for her fear by verbalizing her self-label ("spider phobic") as well as by shaping her friends and neighbors into coming into her apartment to kill spiders for her and/or allowing her to sleep overnight with them rather than dispose of a dead spider herself. The origin of the phobia was unclear. The client reported that she had been afraid of spiders for as long as she could remember. She recollected several vivid early experiences involving spiders such as being pursued, along with several other females, by male grammar school playmates holding spiders, a situation in which her discomfort was retrospectively perceived as greater than that of her female counterparts. However, no specific experiences coincident with the inception of the phobia were identified. Detailed assessment revealed that the fear was an isolated problem. The client was and had been functioning quite well academically. Her social relationships, while few, were satisfactory. It appeared that she might have been accruing
*Requests for reprints should be addressed to Marian L. MacDonald, Department of Psychology, University of Illinois, Champaign, Illinois 61820. ]'This case was conducted as part of a clinical practicum in behavior therapy in which the second author was clinical supervisor and the first author the therapist. 47
48
MARIAN L. MacDONALD and DOUGLAS A. BERNSTEIN
slight secondary gain from her phobia, but it was clear that the general discomfort precipitated by her current environment far outweighed any social benefits derived from her fear.
TREATMENT The overall treatment strategy for this specific fear included relaxation training, imaginal desensitization, and various in vivo desensitization procedures (see Table 1). The client was first trained in deep muscle relaxation (Bernstein and Borkovec, 1973), an abbreviated version of Jacobson's (1938) progressive relaxation techTABLE 1.
SUMMARY
OF
PROCEDURES
USED
IN
THE
IMAGINAL
AND
anxiety provocation properties of the visualized phobic stimulus (Bernstein and Borkovec, 1973). The 68-item imaginal hierarchy, which was primarily spatial-temporal, included items ranging from "walking into your apartment at night" and "walking into your bathroom at night" to "waking up and seeing a still, small spider on the bed four feet from you" and "waking up and seeing a huge spider walk across the hand of your outstretched right arm". The meanings of certain image prompt words, such as "still" and "huge", were explicitly specified during item contruction. Imaginal desensitization of the hierarchy was completed over 14 in
l'iYo
DESENSITIZATION
PROGRAMS
FOR
A
SPIDER
PHOBIA
PROCEDURE IMAGINAL DESE NSIT[ZATION RELAXATION TRAINING t
16
7 4 R c ,--...,___,.--...-_..--,.--,.._...--,--......-.--.-..----.
CALM-CONTROL
.---.-.-...-..--..-..--.---...-...-.-.-.........--...-.---.
HIERARCHY CONSTRUCTION
o---o---c---o
IMAGERY TESTING ~ DESENSITIZATION PLEASANT SCENE IN VlVO
PROPER
o - - - o - - - o - - - o - - -o- - - o r _ - o - . - o - - - o - - - o - ~ - o - - - c - - - o - - - o - - - o - - - o
o-o-o---o--~o---o
IMAGES
DESENSITIZATION
CONDITIONED RELAXATION ON COMPLETED ITEMS
e
;
_-.
;
SPIDER BOOK
e
-
:
•
ENTOMOLOGIST
BLACK AND WHITE PHOTOS
~
:
;
;
;
:
-"
-"
--
e
:
;
•
_--
.
•
COLOR P H O T O S SKILL TRAINING
= • --
RUBBER SPIDERS
SPIDER F I L M
"-
: •
TREATMENT SESSION
¢Codes indicate relaxation training phase (Bernstein and Borkovec, 1973). ~The C-test was for image clarity and onset-offset cue control; the A-test was to insure that an imaginal spider stimulus elicited anxiety. nique. During the second relaxation training session a conditioned relaxation procedure was introduced which involved the pairing of relaxed sensations with a self-produced cue (Russell and Sipich, 1973) and which was used extensively in later in vivo procedures. Relaxation training and the conditioned relaxation pairing continued during the four sessions required for imaginal hierarchy construction. Also during this time, the clarity and cued onset-offset of the client's imagery were insured, as were the
treatment sessions. A mean of 4'9 items per session was completed (range: 3-10). The first of the several in vivo desensitization procedures were assigned as "homework". or between session tasks at the eighth treatment session. At this time the client was instructed to employ her conditioned relaxation skill to eliminate any slight discomfort experienced while actually encountering situations represented at the lower end of the imaginal hierarchy (e.g. "watching t.v. in the afternoon").
TREATMENT OF A SPIDER PHOBIA This in vivo procedure, similar to the treatment techniques by Russell and Sipich (1973) and Barlow et al. (1969), was included to promote generalization of treatment effects from the imaginal sessions to real life in a systematic, structured manner. This conditioned relaxation procedure was extended each week of the treatment period to include the hierarchy items completed at each previous imaginal desensitization session. An additional in vivo procedure was introduced and assigned at the eighth treatment session. Prior to that session the therapist had prepared a detailed report designed to provide the client with accurate information about spiders which could both supplement selective information and replace misinformation she had acquired in support of her fear (Crowder and Thornton, 1970). The report was developed by drawing on several texts (Crompton, 1950; Parker, 1958; Savory, 1961; Shuttlesworth, 1959) and contained no pictures or drawings. Its sections (the historical role of spiders, spider silk and webs, and spider habits) were arranged from least to most anxiety provoking on the basis of information obtained during pretreatment assessment and hierarchy construction. During the treatment session the therapist showed the report to the client and pointed out the various sections and the absence of pictures (to insure that the client would not feel uncomfortable with the assignment because of uncertainty), and instructed her to place the report conveniently near herself before her daily home relaxation practice sessions and to read a portion of it while she was still relaxed. If she felt any discomfort, she was to stop reading and relax again before resuming reading at a point prior to that at which she had become uncomfortable. The client was also instructed to discontinue her reading each day at a time when she was feeling completely comfortable (to prevent any reinforcement of avoidance by anxiety reduction). The client completed the report during the following four weeks. She reported that she did experience discomfort on several occasions when initially reading various portions, but that
49
after relaxing herself and resuming reading at a point prior to the one arousing discomfort, the tenseness did not recur. During the eleventh treatment session the client and therapist contracted for the third in vivo procedure: an intersession meeting with an instructor from the University's entomology department. The purpose of this procedure was threefold: (1) to expose the client to a person who was not only unafraid of spiders, but fascinated by them; (2) to provide a relaxed social context for the client calmly to discuss spiders as natural phenomena rather than feared objects; and (3) to prelude a future contact with the instructor (to be described below). The therapist contacted the instructor before the meeting to introduce him to the overall in vivo treatment strategy of graduated exposure and to plan the session to be consonant with and an extension of prior in vivo procedures. The instructor was asked to regard the client as a beginning entomology student rather than a spider phobic: more specifically, he was asked neither to prompt the client to be afraid nor to be attentive or concerned if she appeared uncomfortable. He was assured that the client had learned an effective anxiety control technique (conditioned relaxation) and that she would use it if necessary. The client, instructor, and therapist met for an hour in the therapist's office. During the first few minutes, the client asked several specific questions involving her fears ("Is there any type of spider that preys on man?") and was answered with precise and accurate information. The instructor then began teaching, conveying many fascinating anecdotes about various types of spiders. The client was quite responsive to this structure and began participating with questions and comments derived from her reading of the previously assigned spider report. Following this meeting, the client commented that she had become uncomfortable only two or three times and that the conditioned relaxation procedure had quickly eliminated the discomfort. In general, she was excited about the new information she had learned and pleased with the
50
MARIAN L. MacDONALD and DOUGLAS A. BERNSTEIN
recognition that she now knew a great deal more about spiders than most people. A fourth in vivo procedure, designed to accustom her to the sight of the phobic stimulus, was agreed upon at the twelfth treatment session. She was asked during the session to arrange 22 black and white photographs (ranging in content from a vacant spider web to a large tarantula) in hierarchical fashion from least to most anxiety provoking. She was then instructed to follow a procedure at home similar to the one she had used with the spider report: she was to view the photos each night while relaxed. I f she experienced any discomfort, she was to close her eyes and allow herself to relax before again viewing the stimulus. She was instructed to be sure that she was completely comfortable with each photograph before progressing to the next one, and she was reminded to discontinue each daily session at a time when she was relaxed while viewing a photograph. After following this procedure for 2 weeks, the client reported that she had learned to be completely comfortable while viewing each of the photographs. At that point (the fourteenth treatment session), she was instructed to select several photos randomly from the set and to place them around her apartment so that they would be in view as she walked through various rooms. She was reminded to use conditioned relaxation if the sight of them should arouse any anxiety. Since she had reported during assessment that she had memorized the location of spots on her walls (so that she could quickly discriminate between spots and spiders), she was asked to alter the locations and the sample of these photos every other day (to prevent adaptation). This phase of the in vivo procedure was maintained for two weeks, until she reported complete comfort during the week prior to the treatment session. The fifth in vivo procedure, viewing color plates of spider stimuli, was included to accustom the client to a more realistic representation of the phobic stimulus. During the fourteenth treatment session, the therapist showed her 16 color photographs of spiders and instructed
her to view them following her daily relaxation practice just as she had previously done with the spider report and with the black and white photographs. She reported complete comfort with the color stimuli after 3 weeks, at which time this procedure was discontinued. At the seventeenth treatment session the sixth and seventh in vivo procedures were discussed and assigned. The sixth procedure, skill training in destroying spiders, was included to eliminate the skill deficit resulting from the client's previous avoidance patterns. The therapist gave the client a personalized "spider swatter" and three life-like rubber spiders ranging from 1¼ to 13 in. in diameter. The client practiced "killing" the rubber spiders with the swatter during the session, and she was asked to practice for three 5-rain periods at home during the following week. This assignment was effective in both increasing the client's skill level and increasing her reported confidence in her skill level. The seventh in vivo procedure was designed to provide a more realistic simulation of actual spider encounters than had previously been programmed. This increase in realism was accomplished by the consecutive manipulation of two dimensions: the physical similarity of the programmed stimulus to the actual phobic object and the degree of uncertainty surrounding the location of the stimulus. At the seventeenth treatment session, the client was asked to place the rubber spiders around her apartment in a conspicuous location, varying their placement each morning. At the eighteenth session, the client was asked to have one of her friends on two occasions place the spiders in unknown locations in a specified room of her apartment. At the nineteenth session, the client was instructed to ask her friend on two occasions to place the spiders anywhere in her apartment. She was reminded each week to employ conditioned relaxation should the stimuli elicit any discomfort. She reported very slight tension at the initiation of each of the phases, but noted that the discomfort did not recur during subsequent exposures. The client and therapist contracted at the
TREATMENT OF A SPIDER PHOBIA eighteenth treatment session to meet again with the entomology instructor for the culmination of the third in vivo procedure: a session designed to provide the client with her first programmed contact with the actual phobic stimulus. During this meeting, the client first held and viewed 24 8½ × 11 in. color plates of various spiders while the instructor described them and discussed their actual sizes and habits. Then both the client and the therapist looked through a microscope at 12 preserved spider specimens ranging from 10 mm to 1'5 cm in diameter, while the instructor related personal anecdotes about the difficulties of catching these spiders--quite a turnabout from the client's previous conception that spiders were all too easy to find. After each exposure to a specimen through the microscope, the instructor placed the spider in the hand of the therapist who, after looking at it, placed it in the client's hand. The client experienced only slight tenseness during this meeting (while viewing two of the color plates) and reported that conditioned relaxation quickly eliminated the discomfort. She reported surprise at feeling totally relaxed while holding the specimens, but noted that she thought seeing the therapist hold them first added to her comfort (see Cooke, 1966). The final in vivo procedure, assigned at the nineteenth treatment session, was designed to provide the client with structured exposure to a moving stimulus. The therapist showed an 18-min color movie of spiders (Spiders, 1956) in a small room equipped with a relaxation chair. After relaxing, the client was instructed to open her eyes and watch the film. She was to signal if she felt uncomfortable so that the film could be stopped and backed up while she relaxed again; however, the client did not report discomfort at any point. TERMINATION During the final session, held 2 weeks after the last treatment contact, several procedures were suggested to the client to promote consolidation of her gains. She was reminded that
51
daily practice of her relaxation skill and cue word pairing would result in the continued usefulness of relaxation and conditioned relaxation as self-control measures. She was also reminded periodically to expose herself to spider stimuli under controlled circumstances (viewing the black and white photographs, putting the rubber spiders out, visiting spider sections of zoos and museums) to insure long-term maintenance of her present degree of comfort.
OUTCOME AND FOLLOW-UP At the twelfth treatment session the client reported confronting previously avoided potential spider situations, such as certain drawers and rooms, with complete calmness, and by the fifteenth session she had reported remaining calm after seeing spiders on several occasions. At the nineteenth session she reported several instances of appropriately reacting to spiders up to 2 in. in diameter either by ignoring them outdoors or destroying them indoors. The treatment effects were maintained through the 6-month follow-up. DISCUSSION There continues to be some debate over the relative effectiveness of in vivo programs as compared with imaginal ones for the modification of behavioral (Cooke, 1966; Litvale, 1966) and affective (Barlow and Agras, 1970; Davison, 1965; Leitenberg and Callahan, 1973) responses. Regardless of the comparative utility of each strategy, it seems quite clear that a combination of the two is extremely effective in simultaneously producing both behavioral and affective changes (Goldstein, 1969). Moreover, there are indications that such dual strategy interventions increase extra-therapeutic generalization of treatment effects (Barlow et al., 1969). The conception that in vivo experiences are difficult to arrange (Ritter, 1969b) may have served to discourage clinicians from being more attentive to the wide range of events which may be included as controlled in vivo exposures. The
52
MARIAN
L. MacDONALD
present report provides a sample of some of the procedures which may be utilized for small animal phobias, many of which required very little therapist or treatment session time. Beyond the value of these specific procedures, however, are the general notions that in viva experiences should be included whenever nossible. and that therapists shouId freeIy employ opportunities provided by the natural environment.
and DOUGLAS DAVISON
G.
A. BERNSTETN C. (1965) Relative contributions
of differ-
ential relaxation and graded exposure to desensitization of a neurotic fear, Proc. 73rd Annual Convention of rlre APA, 209-210. GARPIELD
2. H., DARWIN P. L., SINC~ER B. A. and McBREARTYJ. F. (1967) Effect of in viva training on experimental desensitization of a phobia, P&z&.
Rep. 20,515-519,
GDLDSTEINA. J. (1969) Separate eflects of extinction, counter-conditioning, and progressive approach in overcoming fear, B&v. Res. & Therapy 7,47-K LEITENBERG H., AGRAS S., EDWARDS J. A., THOMSONL. E. and WINCZ~ J. P. (3970) Practice as a psychotherapcutic variable: An experimental analysis within single cases, J. Psychi& Res, 7, 215-225. REFERENCES LWENBERG H. and CALLAHANE. J. (1973) Reinforced practice and reduction of different -kinds of fears in BARLOW D. H. and AGRASW. S. (1970) An experimenta analysis of the effectiveness of “shaping” in reducing adults and children, Behav. Rcs. W Therapy 11, 1%30. Lrcl; J. R. and BOOTHNR. R. (1970) Expectancy, demand maladaptive avoidance behavior: Ai analogue study, characteristics, and contact desensitization in behavior Behhav. Res. & Thermv 8. 165-173. change, Behav. Therapy 1, 176-183. BARLOWD. H., LEKE~&& II., ACTKAS W. S. and W~NCZE J. P. (1969) The transfer gap in systematic desensitizaLITVAK S. 8. (1969) A comparison of two brief group behavior therapy techniques on the reduction of tion: An analogue study, Behav. Res. & Therapy 7, avoidance behavior, PsychoI. Rec. 19, 329-334. 191-196. BEAN K. L. (1970) Desensitization, behavior rehearsal, PARKER B. M. (1958) Spiders, Row, Peterson, Evanston, then reality: A preliminary report on a new procedure, III. Bchav. Therapy 1, 542-545. PAUL G. L. (1969) Outcome of systematic desensitization BERNSTEIND. A. and BEAI-YW. E. (1971) The use of I, Behavior Therapy: Appr&l and Stafus (Edited by I’RANKX C. M,), DD. 63-104. McGraw-Hill. New York. in viva desensitization as part of a tota therapeutic intervenlion, J. Rehhav. Ther. & Esp. Ps~&iat. 2, RITXR B. (1969a) Treatment of acrophobia kith contact 259-265. desensiti;ration, Behav. Res. & Therapy 7,41-G. BPKVSIEIK D. A. and BORKOVECT. D. (1973) PxRITTEIXB. (1969b) The use of contact desensitization, demonstration-plus-participation, and demonstrationgressive Re!axuZiort Traiwkg: A ~~urrua~/or Therapisfs, alone in the treatment of acrophobia, Llelrav. Res. & Research Press, Cilampaign, III. C~LARKD. F. (1963) The treatment of monosymptomatic Therapy 7, 157-164. RUSSELLR. K. and SJPICH J, F. (1973) Cue-controlled phobia by systematic desensitization, Behav. Rrs. & relaxation in the treatment of test anxiety, J. Be/~av. Therupy I, 63-6X. Ther. & Exp. Psychiuf. 4, 37-49. C’OOKECi. (1966) The efficacy of two desensitization procedures: An analogue study, Behav. Res. & Therapy SAVORYT. k. (1961) Spkf&s, Mm, and Scorpiom, The University of London Press. London. 4, 17-24. CROMPTON J. (1950) The r$ti of Ihe Spider, Mentor, New SHUTTLESWORTH D, (1959) 7Rk Story ofspiders, DoubleYork. day, Garden City. Spiders (19.56) EncycIopedia Brilannica Films. CROWDERI. E. and THORTOND. W. (19701 Effects of STADTERM. f1973) b itim facilitation as a variable in the systematic cicsensilization, programmed f&tasy, and effectiveness of taped flooding, Behav. Res. & Therapy bibliethempy on 2 specific fear, Brltor~. Rex. R Tlzrrop_~ 11, 239-241. 8, 35-41.
T R E A T M E N T OF A S P I D E R P H O B I A BY I N VIVO AND IMAGINAL DESENSITIZATION MARIAN L. MACDONALD* and DOUGLAS A. BERNSTEIN'~ University of Illinois at Urbana Summary--The use of in vivo and imaginal desensitization procedures in the treatment of a spider phobia is described. A diversity of in vivo programs, following a thematic hierarchy paradigm, are discussed in detail to encourage more frequent attention to and utilization of easily arranged, controlled exposures. THE USE of in vivo programs as either an alternative (Barlow et al., 1969; Clark, 1963; Cooke, 1966; Leitenberg et al., 1970; Lick and Bootzin, 1970; Litvak, 1969; Ritter, 1969a, b; Stadter, 1973) or an adjunctive (Bean, 1970; Bernstein and Beaty, 1971 ; Garfield et al., 1967) to imaginal desensitization has recently become common. Most published accounts of in vivo procedures indicate that multiple exposure programs are structured in a manner analogous to spatialtemporal imaginal hierarchies; that is, they involve progressively closer approximations to a target event or object (cf. Clark, 1963). The present report describes an adjunctive multiple exposure in vivo program fashioned after a thematic imaginal hierarchy with a variety of procedures, each of which incorporated a different dimension of the target stimulus.
BACKGROUND AND PROBLEM The client, a 24-yr-old female graduate student, was self-referred to the Psychological and Counseling Center at the University of Illinois. Her presenting problem was a fear of spiders, a long-standing difficulty which had recently become of greater concern because her new campus apartment was infested with them. In addition to experiencing the typical arousal
pattern when confronted by the phobic stimulus, she was also ruminating about whether or not spiders would appear, reporting nightmares about spiders, and exhibiting avoidance patterns to potential spider situations such as certain drawers and rooms. Furthermore, she was developing social support systems for her fear by verbalizing her self-label ("spider phobic") as well as by shaping her friends and neighbors into coming into her apartment to kill spiders for her and/or allowing her to sleep overnight with them rather than dispose of a dead spider herself. The origin of the phobia was unclear. The client reported that she had been afraid of spiders for as long as she could remember. She recollected several vivid early experiences involving spiders such as being pursued, along with several other females, by male grammar school playmates holding spiders, a situation in which her discomfort was retrospectively perceived as greater than that of her female counterparts. However, no specific experiences coincident with the inception of the phobia were identified. Detailed assessment revealed that the fear was an isolated problem. The client was and had been functioning quite well academically. Her social relationships, while few, were satisfactory. It appeared that she might have been accruing
*Requests for reprints should be addressed to Marian L. MacDonald, Department of Psychology, University of Illinois, Champaign, Illinois 61820. ]'This case was conducted as part of a clinical practicum in behavior therapy in which the second author was clinical supervisor and the first author the therapist. 47
48
MARIAN L. MacDONALD and DOUGLAS A. BERNSTEIN
slight secondary gain from her phobia, but it was clear that the general discomfort precipitated by her current environment far outweighed any social benefits derived from her fear.
TREATMENT The overall treatment strategy for this specific fear included relaxation training, imaginal desensitization, and various in vivo desensitization procedures (see Table 1). The client was first trained in deep muscle relaxation (Bernstein and Borkovec, 1973), an abbreviated version of Jacobson's (1938) progressive relaxation techTABLE 1.
SUMMARY
OF
PROCEDURES
USED
IN
THE
IMAGINAL
AND
anxiety provocation properties of the visualized phobic stimulus (Bernstein and Borkovec, 1973). The 68-item imaginal hierarchy, which was primarily spatial-temporal, included items ranging from "walking into your apartment at night" and "walking into your bathroom at night" to "waking up and seeing a still, small spider on the bed four feet from you" and "waking up and seeing a huge spider walk across the hand of your outstretched right arm". The meanings of certain image prompt words, such as "still" and "huge", were explicitly specified during item contruction. Imaginal desensitization of the hierarchy was completed over 14 in
l'iYo
DESENSITIZATION
PROGRAMS
FOR
A
SPIDER
PHOBIA
PROCEDURE IMAGINAL DESE NSIT[ZATION RELAXATION TRAINING t
16
7 4 R c ,--...,___,.--...-_..--,.--,.._...--,--......-.--.-..----.
CALM-CONTROL
.---.-.-...-..--..-..--.---...-...-.-.-.........--...-.---.
HIERARCHY CONSTRUCTION
o---o---c---o
IMAGERY TESTING ~ DESENSITIZATION PLEASANT SCENE IN VlVO
PROPER
o - - - o - - - o - - - o - - -o- - - o r _ - o - . - o - - - o - - - o - ~ - o - - - c - - - o - - - o - - - o - - - o
o-o-o---o--~o---o
IMAGES
DESENSITIZATION
CONDITIONED RELAXATION ON COMPLETED ITEMS
e
;
_-.
;
SPIDER BOOK
e
-
:
•
ENTOMOLOGIST
BLACK AND WHITE PHOTOS
~
:
;
;
;
:
-"
-"
--
e
:
;
•
_--
.
•
COLOR P H O T O S SKILL TRAINING
= • --
RUBBER SPIDERS
SPIDER F I L M
"-
: •
TREATMENT SESSION
¢Codes indicate relaxation training phase (Bernstein and Borkovec, 1973). ~The C-test was for image clarity and onset-offset cue control; the A-test was to insure that an imaginal spider stimulus elicited anxiety. nique. During the second relaxation training session a conditioned relaxation procedure was introduced which involved the pairing of relaxed sensations with a self-produced cue (Russell and Sipich, 1973) and which was used extensively in later in vivo procedures. Relaxation training and the conditioned relaxation pairing continued during the four sessions required for imaginal hierarchy construction. Also during this time, the clarity and cued onset-offset of the client's imagery were insured, as were the
treatment sessions. A mean of 4'9 items per session was completed (range: 3-10). The first of the several in vivo desensitization procedures were assigned as "homework". or between session tasks at the eighth treatment session. At this time the client was instructed to employ her conditioned relaxation skill to eliminate any slight discomfort experienced while actually encountering situations represented at the lower end of the imaginal hierarchy (e.g. "watching t.v. in the afternoon").
TREATMENT OF A SPIDER PHOBIA This in vivo procedure, similar to the treatment techniques by Russell and Sipich (1973) and Barlow et al. (1969), was included to promote generalization of treatment effects from the imaginal sessions to real life in a systematic, structured manner. This conditioned relaxation procedure was extended each week of the treatment period to include the hierarchy items completed at each previous imaginal desensitization session. An additional in vivo procedure was introduced and assigned at the eighth treatment session. Prior to that session the therapist had prepared a detailed report designed to provide the client with accurate information about spiders which could both supplement selective information and replace misinformation she had acquired in support of her fear (Crowder and Thornton, 1970). The report was developed by drawing on several texts (Crompton, 1950; Parker, 1958; Savory, 1961; Shuttlesworth, 1959) and contained no pictures or drawings. Its sections (the historical role of spiders, spider silk and webs, and spider habits) were arranged from least to most anxiety provoking on the basis of information obtained during pretreatment assessment and hierarchy construction. During the treatment session the therapist showed the report to the client and pointed out the various sections and the absence of pictures (to insure that the client would not feel uncomfortable with the assignment because of uncertainty), and instructed her to place the report conveniently near herself before her daily home relaxation practice sessions and to read a portion of it while she was still relaxed. If she felt any discomfort, she was to stop reading and relax again before resuming reading at a point prior to that at which she had become uncomfortable. The client was also instructed to discontinue her reading each day at a time when she was feeling completely comfortable (to prevent any reinforcement of avoidance by anxiety reduction). The client completed the report during the following four weeks. She reported that she did experience discomfort on several occasions when initially reading various portions, but that
49
after relaxing herself and resuming reading at a point prior to the one arousing discomfort, the tenseness did not recur. During the eleventh treatment session the client and therapist contracted for the third in vivo procedure: an intersession meeting with an instructor from the University's entomology department. The purpose of this procedure was threefold: (1) to expose the client to a person who was not only unafraid of spiders, but fascinated by them; (2) to provide a relaxed social context for the client calmly to discuss spiders as natural phenomena rather than feared objects; and (3) to prelude a future contact with the instructor (to be described below). The therapist contacted the instructor before the meeting to introduce him to the overall in vivo treatment strategy of graduated exposure and to plan the session to be consonant with and an extension of prior in vivo procedures. The instructor was asked to regard the client as a beginning entomology student rather than a spider phobic: more specifically, he was asked neither to prompt the client to be afraid nor to be attentive or concerned if she appeared uncomfortable. He was assured that the client had learned an effective anxiety control technique (conditioned relaxation) and that she would use it if necessary. The client, instructor, and therapist met for an hour in the therapist's office. During the first few minutes, the client asked several specific questions involving her fears ("Is there any type of spider that preys on man?") and was answered with precise and accurate information. The instructor then began teaching, conveying many fascinating anecdotes about various types of spiders. The client was quite responsive to this structure and began participating with questions and comments derived from her reading of the previously assigned spider report. Following this meeting, the client commented that she had become uncomfortable only two or three times and that the conditioned relaxation procedure had quickly eliminated the discomfort. In general, she was excited about the new information she had learned and pleased with the
50
MARIAN L. MacDONALD and DOUGLAS A. BERNSTEIN
recognition that she now knew a great deal more about spiders than most people. A fourth in vivo procedure, designed to accustom her to the sight of the phobic stimulus, was agreed upon at the twelfth treatment session. She was asked during the session to arrange 22 black and white photographs (ranging in content from a vacant spider web to a large tarantula) in hierarchical fashion from least to most anxiety provoking. She was then instructed to follow a procedure at home similar to the one she had used with the spider report: she was to view the photos each night while relaxed. I f she experienced any discomfort, she was to close her eyes and allow herself to relax before again viewing the stimulus. She was instructed to be sure that she was completely comfortable with each photograph before progressing to the next one, and she was reminded to discontinue each daily session at a time when she was relaxed while viewing a photograph. After following this procedure for 2 weeks, the client reported that she had learned to be completely comfortable while viewing each of the photographs. At that point (the fourteenth treatment session), she was instructed to select several photos randomly from the set and to place them around her apartment so that they would be in view as she walked through various rooms. She was reminded to use conditioned relaxation if the sight of them should arouse any anxiety. Since she had reported during assessment that she had memorized the location of spots on her walls (so that she could quickly discriminate between spots and spiders), she was asked to alter the locations and the sample of these photos every other day (to prevent adaptation). This phase of the in vivo procedure was maintained for two weeks, until she reported complete comfort during the week prior to the treatment session. The fifth in vivo procedure, viewing color plates of spider stimuli, was included to accustom the client to a more realistic representation of the phobic stimulus. During the fourteenth treatment session, the therapist showed her 16 color photographs of spiders and instructed
her to view them following her daily relaxation practice just as she had previously done with the spider report and with the black and white photographs. She reported complete comfort with the color stimuli after 3 weeks, at which time this procedure was discontinued. At the seventeenth treatment session the sixth and seventh in vivo procedures were discussed and assigned. The sixth procedure, skill training in destroying spiders, was included to eliminate the skill deficit resulting from the client's previous avoidance patterns. The therapist gave the client a personalized "spider swatter" and three life-like rubber spiders ranging from 1¼ to 13 in. in diameter. The client practiced "killing" the rubber spiders with the swatter during the session, and she was asked to practice for three 5-rain periods at home during the following week. This assignment was effective in both increasing the client's skill level and increasing her reported confidence in her skill level. The seventh in vivo procedure was designed to provide a more realistic simulation of actual spider encounters than had previously been programmed. This increase in realism was accomplished by the consecutive manipulation of two dimensions: the physical similarity of the programmed stimulus to the actual phobic object and the degree of uncertainty surrounding the location of the stimulus. At the seventeenth treatment session, the client was asked to place the rubber spiders around her apartment in a conspicuous location, varying their placement each morning. At the eighteenth session, the client was asked to have one of her friends on two occasions place the spiders in unknown locations in a specified room of her apartment. At the nineteenth session, the client was instructed to ask her friend on two occasions to place the spiders anywhere in her apartment. She was reminded each week to employ conditioned relaxation should the stimuli elicit any discomfort. She reported very slight tension at the initiation of each of the phases, but noted that the discomfort did not recur during subsequent exposures. The client and therapist contracted at the
TREATMENT OF A SPIDER PHOBIA eighteenth treatment session to meet again with the entomology instructor for the culmination of the third in vivo procedure: a session designed to provide the client with her first programmed contact with the actual phobic stimulus. During this meeting, the client first held and viewed 24 8½ × 11 in. color plates of various spiders while the instructor described them and discussed their actual sizes and habits. Then both the client and the therapist looked through a microscope at 12 preserved spider specimens ranging from 10 mm to 1'5 cm in diameter, while the instructor related personal anecdotes about the difficulties of catching these spiders--quite a turnabout from the client's previous conception that spiders were all too easy to find. After each exposure to a specimen through the microscope, the instructor placed the spider in the hand of the therapist who, after looking at it, placed it in the client's hand. The client experienced only slight tenseness during this meeting (while viewing two of the color plates) and reported that conditioned relaxation quickly eliminated the discomfort. She reported surprise at feeling totally relaxed while holding the specimens, but noted that she thought seeing the therapist hold them first added to her comfort (see Cooke, 1966). The final in vivo procedure, assigned at the nineteenth treatment session, was designed to provide the client with structured exposure to a moving stimulus. The therapist showed an 18-min color movie of spiders (Spiders, 1956) in a small room equipped with a relaxation chair. After relaxing, the client was instructed to open her eyes and watch the film. She was to signal if she felt uncomfortable so that the film could be stopped and backed up while she relaxed again; however, the client did not report discomfort at any point. TERMINATION During the final session, held 2 weeks after the last treatment contact, several procedures were suggested to the client to promote consolidation of her gains. She was reminded that
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daily practice of her relaxation skill and cue word pairing would result in the continued usefulness of relaxation and conditioned relaxation as self-control measures. She was also reminded periodically to expose herself to spider stimuli under controlled circumstances (viewing the black and white photographs, putting the rubber spiders out, visiting spider sections of zoos and museums) to insure long-term maintenance of her present degree of comfort.
OUTCOME AND FOLLOW-UP At the twelfth treatment session the client reported confronting previously avoided potential spider situations, such as certain drawers and rooms, with complete calmness, and by the fifteenth session she had reported remaining calm after seeing spiders on several occasions. At the nineteenth session she reported several instances of appropriately reacting to spiders up to 2 in. in diameter either by ignoring them outdoors or destroying them indoors. The treatment effects were maintained through the 6-month follow-up. DISCUSSION There continues to be some debate over the relative effectiveness of in vivo programs as compared with imaginal ones for the modification of behavioral (Cooke, 1966; Litvale, 1966) and affective (Barlow and Agras, 1970; Davison, 1965; Leitenberg and Callahan, 1973) responses. Regardless of the comparative utility of each strategy, it seems quite clear that a combination of the two is extremely effective in simultaneously producing both behavioral and affective changes (Goldstein, 1969). Moreover, there are indications that such dual strategy interventions increase extra-therapeutic generalization of treatment effects (Barlow et al., 1969). The conception that in vivo experiences are difficult to arrange (Ritter, 1969b) may have served to discourage clinicians from being more attentive to the wide range of events which may be included as controlled in vivo exposures. The
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L. MacDONALD
present report provides a sample of some of the procedures which may be utilized for small animal phobias, many of which required very little therapist or treatment session time. Beyond the value of these specific procedures, however, are the general notions that in viva experiences should be included whenever nossible. and that therapists shouId freeIy employ opportunities provided by the natural environment.
and DOUGLAS DAVISON
G.
A. BERNSTETN C. (1965) Relative contributions
of differ-
ential relaxation and graded exposure to desensitization of a neurotic fear, Proc. 73rd Annual Convention of rlre APA, 209-210. GARPIELD
2. H., DARWIN P. L., SINC~ER B. A. and McBREARTYJ. F. (1967) Effect of in viva training on experimental desensitization of a phobia, P&z&.
Rep. 20,515-519,
GDLDSTEINA. J. (1969) Separate eflects of extinction, counter-conditioning, and progressive approach in overcoming fear, B&v. Res. & Therapy 7,47-K LEITENBERG H., AGRAS S., EDWARDS J. A., THOMSONL. E. and WINCZ~ J. P. (3970) Practice as a psychotherapcutic variable: An experimental analysis within single cases, J. Psychi& Res, 7, 215-225. REFERENCES LWENBERG H. and CALLAHANE. J. (1973) Reinforced practice and reduction of different -kinds of fears in BARLOW D. H. and AGRASW. S. (1970) An experimenta analysis of the effectiveness of “shaping” in reducing adults and children, Behav. Rcs. W Therapy 11, 1%30. Lrcl; J. R. and BOOTHNR. R. (1970) Expectancy, demand maladaptive avoidance behavior: Ai analogue study, characteristics, and contact desensitization in behavior Behhav. Res. & Thermv 8. 165-173. change, Behav. Therapy 1, 176-183. BARLOWD. H., LEKE~&& II., ACTKAS W. S. and W~NCZE J. P. (1969) The transfer gap in systematic desensitizaLITVAK S. 8. (1969) A comparison of two brief group behavior therapy techniques on the reduction of tion: An analogue study, Behav. Res. & Therapy 7, avoidance behavior, PsychoI. Rec. 19, 329-334. 191-196. BEAN K. L. (1970) Desensitization, behavior rehearsal, PARKER B. M. (1958) Spiders, Row, Peterson, Evanston, then reality: A preliminary report on a new procedure, III. Bchav. Therapy 1, 542-545. PAUL G. L. (1969) Outcome of systematic desensitization BERNSTEIND. A. and BEAI-YW. E. (1971) The use of I, Behavior Therapy: Appr&l and Stafus (Edited by I’RANKX C. M,), DD. 63-104. McGraw-Hill. New York. in viva desensitization as part of a tota therapeutic intervenlion, J. Rehhav. Ther. & Esp. Ps~&iat. 2, RITXR B. (1969a) Treatment of acrophobia kith contact 259-265. desensiti;ration, Behav. Res. & Therapy 7,41-G. BPKVSIEIK D. A. and BORKOVECT. D. (1973) PxRITTEIXB. (1969b) The use of contact desensitization, demonstration-plus-participation, and demonstrationgressive Re!axuZiort Traiwkg: A ~~urrua~/or Therapisfs, alone in the treatment of acrophobia, Llelrav. Res. & Research Press, Cilampaign, III. C~LARKD. F. (1963) The treatment of monosymptomatic Therapy 7, 157-164. RUSSELLR. K. and SJPICH J, F. (1973) Cue-controlled phobia by systematic desensitization, Behav. Rrs. & relaxation in the treatment of test anxiety, J. Be/~av. Therupy I, 63-6X. Ther. & Exp. Psychiuf. 4, 37-49. C’OOKECi. (1966) The efficacy of two desensitization procedures: An analogue study, Behav. Res. & Therapy SAVORYT. k. (1961) Spkf&s, Mm, and Scorpiom, The University of London Press. London. 4, 17-24. CROMPTON J. (1950) The r$ti of Ihe Spider, Mentor, New SHUTTLESWORTH D, (1959) 7Rk Story ofspiders, DoubleYork. day, Garden City. Spiders (19.56) EncycIopedia Brilannica Films. CROWDERI. E. and THORTOND. W. (19701 Effects of STADTERM. f1973) b itim facilitation as a variable in the systematic cicsensilization, programmed f&tasy, and effectiveness of taped flooding, Behav. Res. & Therapy bibliethempy on 2 specific fear, Brltor~. Rex. R Tlzrrop_~ 11, 239-241. 8, 35-41.