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Treatment of compulsive verbal behavior with response contingent punishment and relaxation
J. Behav. Ther. & Exp. Psychiat. Vol. 4, pp. 347-352. Pergamon Press, 1973. Printed in Great Britain,
T R E A T M E N T OF COMPULSIVE VERBAL BEHAVIOR WITH RESPONSE C O N T I N G E N T P U N I S H M E N T A N D R E L A X A T I O N JOHN S. O'BRIEN* Department of Psychiatry, Tufts Medical School at St. Elizabeth's Hospital of Boston and ANTHONY E. RAYNES Department of Psychiatry, Harvard Medical School at Boston City Hospital Summary--Chronic obsessive and compulsive behavior is a distressing and often crippling disorder which is highly resistant to treatment. The current investigation used the behavioral techniques of punishment and relaxation training to extinguish high frequency obsessiveruminations and verbal behavior in two female patients. Punishment involved an aversive stimulus, consisting of previously taped segments of the patients' high frequency verbal behavior which were played to the patient when she emitted that behavior. Relaxation training was used to minimize any anxiety-producing side effects of the punishment technique and to counter-condition anxiety either cued by or cueing the high frequency behaviors. The patients have during 20-month and 18-month follow-up periods respectively been free of the obsessive behavior and the anxiety previously associated with it. AN EFFECTIVE procedure for reducing behavior is punishment (Azrin and Holz, 1966). Some of the major variables affecting conditioning by aversive stimulus are the paradigm used to present it, its nature and its intensity. Aversive stimuli have been used to treat several types of high frequency behaviors while using classical conditioning, punishment, avoidance, and negative reinforcement paradigms (see review by Rachman and Teasdale, 1969). Generally speaking, the response-produced occurrence of the aversive stimulus on a continuous reinforcement (CRF) schedule seems to be most effective (Azrin and Holz, 1966). Out of a variety of aversive stimuli---emetines (Lemere and Voegtlin, 1950), intense auditory stimulation (Azrin, 1958), time out (Ferster, 1958), response cost (Weiner, 1962), satiation (Ayllon, 1963), electric shock (McGuire, 1964), traumatic respiratory paralysis (Madill et aL, 1966), covert sensitization (Cautela, 1967), the most widely used has been electric shock. Azrin and Holz's (1966) review of punishment
shows that more permanent and rapid suppression of a response occurs with high intensities of the aversive stimulus. Church (1967) found that increasing the duration of the aversive stimulus had the same effect on suppression as increasing its intensity. A prime argument against the use of punishment is that it allegedly produces undesirable side effects. Support for this argument has traditionally been based on clinical anecdotal descriptive cases of symptom substitution and on the results of some early research. Risley (1968) found this not to be the case when, by using a punishment paradigm, he suppressed several deviant behaviors in an autistic child. I f any side effects were evident, they were desirable. Suppression of the maladaptive behaviors did not generalize from the clinical setting to other environmental areas. This was easily corrected by conditioning in the various settings. In another successful application of aversive
*Requests for reprints should be addressed to John S. O'Brien, Department of Psychiatry, St. Elizabeth's Hospital, 736 Cambridge Street, Brighton, Massachusetts 02135. 347
348
JOHN S. O'BRIEN and ANTHONY E. RAYNES
conditioning, AyUon (1963) used a negative reinforcement paradigm with a novel punishing stimulus to treat a psychotic patient who hoarded towels. Her room was sated with numerous towels until she started to remove them. The current investigation used a responseproduced punishment paradigm to suppress high frequency compulsive verbal and ruminative behavior in two patients. The aversive stimulus came from tape recorded segments of the patients' own verbal behavior. A modified form of Jacobson's (1938) relaxation technique was used to minimize any anxiety-producing side effects of this punishment, and to treat anxiety either cued by or cueing the high frequency behavior (Eysenck, 1960). When the high frequency behaviors occurred outside the session, time-out from social reinforcement was used by the patients' husbands.
METHOD Patient 1
The patient was a 38-yr-old married woman with high frequency compulsive verbal and ruminative behavior masochistic in content. For example, she would frequently repeat, "I'm going to gouge out my eyes, burn the hair off my head, jump in front of a car or jump from the top of a building etc". In the interests of brevity, all such high frequency verbal behavior will be referred to as compulsive verbal behavior. She attended Mass up to four times daily where she frequently talked with a priest about her "masochistic feelings". For over a year she had been unable to do housework, cook meals, or go in the bathroom while her husband's razor was present. She explained that fears of harming herself were so great she could not function. However, she had never carried out any of the feared behavior. The compulsive verbal behavior, which had the highest frequency, occurred most frequently in therapy (see Fig. 1). This may have been the result of its differential reinforcement in her contacts with a priest and in her earlier participation in psychotherapy, in which she had
been encouraged (reinforced) for verbally expressing the "masochistic feelings". The compulsive verbal behavior started 3 yr before the behavioral treatment, shortly after the patient's mother died. Before her mother's death, the patient had spent an inordinate amount of time talking with her. At one point she had been hospitalized for acute anxiety related to her obsessive and compulsive behavior. She was seen as an out-patient for behavior therapy. Patient 2
This attractive 24-yr-old married woman, a college graduate, was working as a secretary. For 9 months she had been experiencing what she described as an uncontrollable compulsion to talk about premarital sex experiences and a premarital abortion. Various environmental stimuli such as a particular make of car, name of person, street, or house which had been associated with past sexual behavior would evoke high frequency obsessive ruminations about these experiences. Her husband was the only stimulus that would evoke high frequency compulsive verbal behavior consisting of detailed accounts of her premarital sexual activities. Since both worked, their time together was limited to approximately 6-8 waking hours daily. During the period that the couple spent together on weekdays, one or more compulsive verbal statements occurred every 15 rain. Frequently the patient would wake during the night and emit this behavior, which had developed shortly after she had confided in a girlfriend who had encouraged her to "tell all" to her husband. Initially, he had accepted most of the description in an understanding and comforting fashion, but at the time she came to us he had become exasperated with her. She had had previous psychotherapy with no reduction in the target behavior. TREATMENT Patient 1
A baseline count of compulsive verbal behavior was taken for three 55-rain periods in the presence of the patient's husband and the
349
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FIG. l(a). Number of verbal maladaptive responses that occurred in each session during the baseline and punishment, relaxation conditions. The duration of an individual punishment response is indicated. The total punishment time for any session was the duration of a punishment response multiplied by the number of verbal maladaptive responses emitted in that session. FIG. l(b). Number of verbal maladaptive responses that occurred daily outside of therapy. The responses were recorded by the husband with a manual counter for the 12-16 hr daily they were together. The patient agreed to report any maladaptive responses that occurred when they were apart. Both days and .sessions are plotted on the abscissa. After session 9, a punishment tape was given to the husband to play contingent on each maladaptive response emitted outside of a session. therapist. A t a p e recording was m a d e o f these sessions. Between sessions, a m a n u a l c o u n t e r was given to the h u s b a n d to r e c o r d each statem e n t his wife m a d e a b o u t h a r m i n g herself. D u r i n g baseline he was instructed not to c o m ment a b o u t her c o m m u n i c a t i o n . A c o m p u l s i v e response was defined as one p h a s e o f selfdestructive b e h a v i o r , whether a c o m p l e t e sentence o r not. T h e daily frequency o f the c o m pulsive v e r b a l b e h a v i o r b o t h in the t h e r a p y session a n d outside o f the session is presented in Fig. 1. T h e three baseline sessions were r e c o r d e d on one 55-min tape. A t t h e b e g i n n i n g o f the f o u r t h session, the p a t i e n t was t o l d t h a t talking a b o u t the obsessions m a d e h e r feel m o r e anxious a n d t h a t no one w a n t e d t o h e a r them. She was told t h a t every time she m a d e a compulsive statement, she w o u l d have to listen to the tapes o f her o w n
voice j u s t to see h o w a n n o y i n g they were. It was explained that this w o u l d help her to gain c o n t r o l o f her impulse to t a l k in this way. A f t e r this i n t r o d u c t i o n , the aversive stimulus was p r e s e n t e d to her t h r o u g h a n e a r p h o n e for 3 min a t each compulsive v e r b a l response. I f she e m i t t e d further responses while listening to the tape, they t o o received the aversive stimulus, three a d d i t i o n a l minutes f o r each. T h e h u s b a n d was instructed t h a t he should " t i m e - o u t " (Ferster, 1958) compulsive v e r b a l b e h a v i o r b y w a l k i n g a w a y o r n o t listening to his wife. A f t e r baseline measurements, the response frequency d a t a for all sessions was s h o w n to the p a t i e n t each session so she w o u l d be m o r e a w a r e o f changes in frequency. T h e decrease in the r e s p o n s e frequency was i m m e d i a t e b o t h in the t h e r a p y session a n d in the environment. However, several days after
350
J O H N S. O'BRIEN and A N T H O N Y E. RAYNES
the fourth conditioning session, a sharp increase occurred. It was learned that, against therapy plans, the patient had visited the therapist who had been treating her with conventional therapy. The increase in frequency took place shortly after this visit. The current investigators feel this serves to illustrate the reinforcement value of social acceptance in maintaining the compulsive behavior. In each session after the punishment contingency had been met, the patient engaged in relaxation training until a total of 55 min had been spent on punishment and/or relaxation. Increases that were made in individual aversive stimuli durations are indicated in Fig. 1. By the sixth session the frequency of the compulsive behavior in the session was near suppression. The patient would plead not to hear her stories any more. However, the behavior still occurred infrequently outside the session; consequently, the husband was given a recorder and tape to play when the patient emitted the response outside the session. Successful attempts were made to develop alternate behaviors, which consisted of cleaning the house, oil painting, or reading the newspaper. By the eighth session, the patient found a job which became the primary alternate behavior. At this point she started house-cleaning tasks and cooking, which she had not done in over a year. Baseline
Patient 2
The procedure for making the punishment tapes and explaining the treatment to the patient was the same as with Patient 1. The patient was instructed to record each 15-min period in which she evoked the compulsive verbal behavior. Her husband agreed to her recording reliability. A response unit was defined as one compulsive verbalization lasting 15 rain or less. It was planned to train the husband to be the therapist since his presence was necessary for the compulsive verbal behavior to occur without instructions. This effort was unsuccessful. TI~ husband chose not to be involved in what he considered playing the "silly tapes for her pleasure". He was, however, quite cooperative in employing time-out techniques which included turning the radio on "loud" if the response occurred in the car, sleeping in separate rooms if the response occurred in bed, and leaving a room any time the response occurred. Consequently, initial sessions were devoted to random (non-response produced) occurrences of the aversion stimulus for 30 min. This was followed by 25 rain of relaxation training. Figure 2 shows that while this procedure caused an initial reduction, the decrease in frequency was not large enough to give the patient or her husband any significant relief. At this point it was possible to convince
Random punishment and relaxing I Response contingent punishment t relaxation by patient Time out by husband out of I session I
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FIQ. 2. Percentage of 15 min waking time periods the patient and her husband spent together (8-12 hr) in which one or more verbal maladaptive responses occurred, during the following three conditions: (1) Baseline when no punishment occurred; (2) Session 4-11 when the husband employed time-out for the maladaptive response and random (non-contingent) punishment was used 30 min each session; (3) Sessions 12-17 when the patient herself used response contingent punishment for each maladaptive response, followed by relaxation. The duration of an individual punishment response is indicated.
TREATMENT OF COMPULSIVE VERBAL BEHAVIOR
351
the patient to play the tapes to herself when she paradigm was chosen for delivering the aversive emitted the compulsive response. Aversive stimulus because of its efficacy (Azrin and Holz, stimulus duration can be found in Fig. 2. The 1966). The frequency of the compulsive response patient was instructed to practise relaxing was used to determine the frequency of the after each tape presentation. The results were punishing stimulus within each session. In other dramatic, as can be seen in Fig. 2, a decrease words, the number of times the aversive stimulus occurred immediately in the compulsive behavior was delivered was directly proportional to the frequency. Sessions after this consisted of going frequency of the maladaptive behavior (conover procedures, data reinforcing progress and tinuous reinforcement (CRF), Ferster and practicing relaxation. As the frequency of the Skinner, 1958). The intensity of the punishing compulsive behavior decreased, the patient and stimulus was gradually increased by increasing her husband's social, sexual and personal lives the duration (Church, 1967) until the most increased in fulfillment, Since no assistance difficult compulsive responses were extinguished. seemed to be necessary in developing alternate Feedback of response suppression which has behavior, this was not included in therapy. In been helpful in training some compulsive bethe sixteenth session, the patient brought in the havior (Leitenberg et al., 1968) was made contape recorder and asked if she could try alone tinuously available to the patients. The removal and come in occasionally for follow-up. Follow- of social attention of other individuals (time-out, up sessions were conducted at 1 month and at Ferster, 1958)was also incorporated contingent 3 months after this session. There has been no upon the occurrence of the compulsive behavior. Because of the combination of the above recurrence of the patient's compulsive behavior. Also, she could say the name of a person pre- procedures, it is difficult to attribute the sucviously associated with sexual activity and not be cessful treatment to the punishment-relaxation anxious about it. The patient had not been able procedure. However, response rate changes to do this since the onset of the high frequency occurring concurrently with punishment sessions, obsessive behaviors. imply that this procedure played an important role in the treatment. The rapid change in frequency that occurred with Patient 2, when DISCUSSION the procedure was changed from random punishThis investigation attempted to utilize the ment to response contingent punishment, imvariable influencing effective punishment as plies that this was the crucial procedure. found relevant in experimental investigations The conditioning procedure used currently and to extend these to the treatment of obsessive differs from the equally successful application and compulsive behavior. Relaxation training of a novel punishment stimulus by Ayllon (1963) (Jacobson, 1938) was used to counter condition which he called satiation, but which appears to anxiety cued by or cueing the maladaptive be a negative reinforcement paradigm. His behavior as suggested by Eysenck (1960) and to patient was satiated with towels until she tried minimize possible negative side effects associated to stop the input of towels by removing the with the use of punishment. The current punish- excess and thereby removing the negative ing stimulus was chosen because of the extreme stimulus. discomfort both patients experienced when the Like Risley (1968), we found no lasting negacompulsive behavior was evoked. We felt that tive side effects associated with the use of an the association between discomfort and this aversive stimulus. It should be noted that when behavior could be used as a punishing stimulus using the aversive stimulus, anxiety responses if it were produced by the behavior to be sup- were evoked in each of the patients, e.g. crying, pressed. However, it was not tested experi- pleas to stop etc. These anxiety responses did mentally before this application. A punishment not continue after punishment was terminated.
352
JOHN S. O'BRIEN and ANTHONY E. RAYNES
A t no time did the therapist, t h e r a p e u t i c settings, o f the t h e r a p y b e c o m e a discriminative stimulus f o r similar anxiety responses. B o t h patients disp l a y e d a high level o f m o t i v a t i o n before and during the t r e a t m e n t p e r i o d which d i d n o t a p p e a r affected by the p u n i s h m e n t procedure. F u r t h e r , at no p o i n t were there signs o f s y m p t o m substitution. It was necessary with b o t h patients to extend the c o n d i t i o n i n g technique to the environm e n t outside the t h e r a p y setting for c o m p l e t e generalization o f the suppression to t a k e place. Risley f ~ u n d this necessary also. W h i l e the design o f the study does n o t p e r m i t an evaluation o f the effect o f the relaxation training on minimizing negative side effects, b o t h patients felt it helped t h e m c o n s i d e r a b l y in reducing the fear associated with the compulsive behavior.
CAUTELA, J. (1967) Covert sensitization, Psychol. Rep. 20, 459-468. CHURCH R. M., RAYMOND G. A. and BEAUCHAMPR. (1967) Response suppression as a function of intensity and duration of punishment, J. comp. physioL Psychol. 1, 39-44. EYSENCK H. S. (1960) Summary and conclusions, Behavior Therapy and the Neuroses, Pergamon Press, Oxford. FERSTERC. B. (1958) Reinforcement and punishment in the control of human behavior by social agencies, Psychiat. Res. Rep. 10, 101-118. FEASTER C. B. and SKINNER B. F. (1957) Schedules of Reinforcement, Appleton-Century-Crofts, New York. JACOBSON E. (1938) Progressive Relaxation, University of Chicago Press, Chicago, Ill. LEITENBERG H., AGRAS W. S., THOMPSON C. D. and
WRIGHT D. E. (1968) Feedback in Behavior Modification: An Experimental Analysis in two phobic eases, J. appl. Behav. Anal 1, 131-138. LEMEREF. and VOmTLIN W. (1950) An evaluation of the aversion treatment on alcoholism, Q. J. Stud. Alcohol 11, 199-204. MADILL M. F. CAMPBELLD., LAVERTY S., SANDERS K.
REFERENCES AYLLON T. (1963) Intensive treatment of psychotic behavior by stimulus and food reinforcement, Behav. Res. & Therapy 1, 53-62. AZRIN N. H. (1958) Some effects of noise on human behavior, J. exp. Analysis Behav. 1, 183-200. AZRIN N. H. and HOLZ W. C. (1966) Punishment, Operant Behavior (Edited by HONIG W. K.), pp. 380447, Appleton-Century-Crofts, New York.
and VENDERWATERS. (1966) Aversion treatment of alcoholics by succinylcholine-induced apneic paralysis, Q. J. Studies Alcohol 27, 485-509. McGUIRE R. and VALLANCEM. (1964) Aversion therapy by electric shock: A simple technique, Br. Med. J. 1, 151-152. RlSLEY T. (1968) The effects and side effects of punishing the autistic behaviors of a deviant child, JABA 1, 21-34. WEINER H. (1962) Some effects of response cost upon human operant behavior, J. exp. Analysis Behav. 5, 201-208.
(Hrst received 3 February 1972; in revised form 13 April 1973)
T R E A T M E N T OF COMPULSIVE VERBAL BEHAVIOR WITH RESPONSE C O N T I N G E N T P U N I S H M E N T A N D R E L A X A T I O N JOHN S. O'BRIEN* Department of Psychiatry, Tufts Medical School at St. Elizabeth's Hospital of Boston and ANTHONY E. RAYNES Department of Psychiatry, Harvard Medical School at Boston City Hospital Summary--Chronic obsessive and compulsive behavior is a distressing and often crippling disorder which is highly resistant to treatment. The current investigation used the behavioral techniques of punishment and relaxation training to extinguish high frequency obsessiveruminations and verbal behavior in two female patients. Punishment involved an aversive stimulus, consisting of previously taped segments of the patients' high frequency verbal behavior which were played to the patient when she emitted that behavior. Relaxation training was used to minimize any anxiety-producing side effects of the punishment technique and to counter-condition anxiety either cued by or cueing the high frequency behaviors. The patients have during 20-month and 18-month follow-up periods respectively been free of the obsessive behavior and the anxiety previously associated with it. AN EFFECTIVE procedure for reducing behavior is punishment (Azrin and Holz, 1966). Some of the major variables affecting conditioning by aversive stimulus are the paradigm used to present it, its nature and its intensity. Aversive stimuli have been used to treat several types of high frequency behaviors while using classical conditioning, punishment, avoidance, and negative reinforcement paradigms (see review by Rachman and Teasdale, 1969). Generally speaking, the response-produced occurrence of the aversive stimulus on a continuous reinforcement (CRF) schedule seems to be most effective (Azrin and Holz, 1966). Out of a variety of aversive stimuli---emetines (Lemere and Voegtlin, 1950), intense auditory stimulation (Azrin, 1958), time out (Ferster, 1958), response cost (Weiner, 1962), satiation (Ayllon, 1963), electric shock (McGuire, 1964), traumatic respiratory paralysis (Madill et aL, 1966), covert sensitization (Cautela, 1967), the most widely used has been electric shock. Azrin and Holz's (1966) review of punishment
shows that more permanent and rapid suppression of a response occurs with high intensities of the aversive stimulus. Church (1967) found that increasing the duration of the aversive stimulus had the same effect on suppression as increasing its intensity. A prime argument against the use of punishment is that it allegedly produces undesirable side effects. Support for this argument has traditionally been based on clinical anecdotal descriptive cases of symptom substitution and on the results of some early research. Risley (1968) found this not to be the case when, by using a punishment paradigm, he suppressed several deviant behaviors in an autistic child. I f any side effects were evident, they were desirable. Suppression of the maladaptive behaviors did not generalize from the clinical setting to other environmental areas. This was easily corrected by conditioning in the various settings. In another successful application of aversive
*Requests for reprints should be addressed to John S. O'Brien, Department of Psychiatry, St. Elizabeth's Hospital, 736 Cambridge Street, Brighton, Massachusetts 02135. 347
348
JOHN S. O'BRIEN and ANTHONY E. RAYNES
conditioning, AyUon (1963) used a negative reinforcement paradigm with a novel punishing stimulus to treat a psychotic patient who hoarded towels. Her room was sated with numerous towels until she started to remove them. The current investigation used a responseproduced punishment paradigm to suppress high frequency compulsive verbal and ruminative behavior in two patients. The aversive stimulus came from tape recorded segments of the patients' own verbal behavior. A modified form of Jacobson's (1938) relaxation technique was used to minimize any anxiety-producing side effects of this punishment, and to treat anxiety either cued by or cueing the high frequency behavior (Eysenck, 1960). When the high frequency behaviors occurred outside the session, time-out from social reinforcement was used by the patients' husbands.
METHOD Patient 1
The patient was a 38-yr-old married woman with high frequency compulsive verbal and ruminative behavior masochistic in content. For example, she would frequently repeat, "I'm going to gouge out my eyes, burn the hair off my head, jump in front of a car or jump from the top of a building etc". In the interests of brevity, all such high frequency verbal behavior will be referred to as compulsive verbal behavior. She attended Mass up to four times daily where she frequently talked with a priest about her "masochistic feelings". For over a year she had been unable to do housework, cook meals, or go in the bathroom while her husband's razor was present. She explained that fears of harming herself were so great she could not function. However, she had never carried out any of the feared behavior. The compulsive verbal behavior, which had the highest frequency, occurred most frequently in therapy (see Fig. 1). This may have been the result of its differential reinforcement in her contacts with a priest and in her earlier participation in psychotherapy, in which she had
been encouraged (reinforced) for verbally expressing the "masochistic feelings". The compulsive verbal behavior started 3 yr before the behavioral treatment, shortly after the patient's mother died. Before her mother's death, the patient had spent an inordinate amount of time talking with her. At one point she had been hospitalized for acute anxiety related to her obsessive and compulsive behavior. She was seen as an out-patient for behavior therapy. Patient 2
This attractive 24-yr-old married woman, a college graduate, was working as a secretary. For 9 months she had been experiencing what she described as an uncontrollable compulsion to talk about premarital sex experiences and a premarital abortion. Various environmental stimuli such as a particular make of car, name of person, street, or house which had been associated with past sexual behavior would evoke high frequency obsessive ruminations about these experiences. Her husband was the only stimulus that would evoke high frequency compulsive verbal behavior consisting of detailed accounts of her premarital sexual activities. Since both worked, their time together was limited to approximately 6-8 waking hours daily. During the period that the couple spent together on weekdays, one or more compulsive verbal statements occurred every 15 rain. Frequently the patient would wake during the night and emit this behavior, which had developed shortly after she had confided in a girlfriend who had encouraged her to "tell all" to her husband. Initially, he had accepted most of the description in an understanding and comforting fashion, but at the time she came to us he had become exasperated with her. She had had previous psychotherapy with no reduction in the target behavior. TREATMENT Patient 1
A baseline count of compulsive verbal behavior was taken for three 55-rain periods in the presence of the patient's husband and the
349
TREATMENT OF COMPULSIVE VERBAL BEHAVIOR BoseHne i Punishment ond relaxotion period |period I
.~ sot
I
60 L
I
I./'I
= To L'~
2
3 4 5
6
I
I I
i
i t
I0
] t i
Minutes
I
I
2
3
of punishment
per response
i
1
I
2
3
4
5
6 7
~ •
I0
II 12 [3 f4
18
Sessions
Baseline period I 240 180
Punishment ond relaxation period
I I
"A I
120
Gove tope to husbond
60 _
0
3 /5 711 2 3 4 5 6 7 8 9
Ii
l O l l 1213 141516 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6
30
_
37 4 5
r~
_
48
Days
12
13
14
18
Sessions
FIG. l(a). Number of verbal maladaptive responses that occurred in each session during the baseline and punishment, relaxation conditions. The duration of an individual punishment response is indicated. The total punishment time for any session was the duration of a punishment response multiplied by the number of verbal maladaptive responses emitted in that session. FIG. l(b). Number of verbal maladaptive responses that occurred daily outside of therapy. The responses were recorded by the husband with a manual counter for the 12-16 hr daily they were together. The patient agreed to report any maladaptive responses that occurred when they were apart. Both days and .sessions are plotted on the abscissa. After session 9, a punishment tape was given to the husband to play contingent on each maladaptive response emitted outside of a session. therapist. A t a p e recording was m a d e o f these sessions. Between sessions, a m a n u a l c o u n t e r was given to the h u s b a n d to r e c o r d each statem e n t his wife m a d e a b o u t h a r m i n g herself. D u r i n g baseline he was instructed not to c o m ment a b o u t her c o m m u n i c a t i o n . A c o m p u l s i v e response was defined as one p h a s e o f selfdestructive b e h a v i o r , whether a c o m p l e t e sentence o r not. T h e daily frequency o f the c o m pulsive v e r b a l b e h a v i o r b o t h in the t h e r a p y session a n d outside o f the session is presented in Fig. 1. T h e three baseline sessions were r e c o r d e d on one 55-min tape. A t t h e b e g i n n i n g o f the f o u r t h session, the p a t i e n t was t o l d t h a t talking a b o u t the obsessions m a d e h e r feel m o r e anxious a n d t h a t no one w a n t e d t o h e a r them. She was told t h a t every time she m a d e a compulsive statement, she w o u l d have to listen to the tapes o f her o w n
voice j u s t to see h o w a n n o y i n g they were. It was explained that this w o u l d help her to gain c o n t r o l o f her impulse to t a l k in this way. A f t e r this i n t r o d u c t i o n , the aversive stimulus was p r e s e n t e d to her t h r o u g h a n e a r p h o n e for 3 min a t each compulsive v e r b a l response. I f she e m i t t e d further responses while listening to the tape, they t o o received the aversive stimulus, three a d d i t i o n a l minutes f o r each. T h e h u s b a n d was instructed t h a t he should " t i m e - o u t " (Ferster, 1958) compulsive v e r b a l b e h a v i o r b y w a l k i n g a w a y o r n o t listening to his wife. A f t e r baseline measurements, the response frequency d a t a for all sessions was s h o w n to the p a t i e n t each session so she w o u l d be m o r e a w a r e o f changes in frequency. T h e decrease in the r e s p o n s e frequency was i m m e d i a t e b o t h in the t h e r a p y session a n d in the environment. However, several days after
350
J O H N S. O'BRIEN and A N T H O N Y E. RAYNES
the fourth conditioning session, a sharp increase occurred. It was learned that, against therapy plans, the patient had visited the therapist who had been treating her with conventional therapy. The increase in frequency took place shortly after this visit. The current investigators feel this serves to illustrate the reinforcement value of social acceptance in maintaining the compulsive behavior. In each session after the punishment contingency had been met, the patient engaged in relaxation training until a total of 55 min had been spent on punishment and/or relaxation. Increases that were made in individual aversive stimuli durations are indicated in Fig. 1. By the sixth session the frequency of the compulsive behavior in the session was near suppression. The patient would plead not to hear her stories any more. However, the behavior still occurred infrequently outside the session; consequently, the husband was given a recorder and tape to play when the patient emitted the response outside the session. Successful attempts were made to develop alternate behaviors, which consisted of cleaning the house, oil painting, or reading the newspaper. By the eighth session, the patient found a job which became the primary alternate behavior. At this point she started house-cleaning tasks and cooking, which she had not done in over a year. Baseline
Patient 2
The procedure for making the punishment tapes and explaining the treatment to the patient was the same as with Patient 1. The patient was instructed to record each 15-min period in which she evoked the compulsive verbal behavior. Her husband agreed to her recording reliability. A response unit was defined as one compulsive verbalization lasting 15 rain or less. It was planned to train the husband to be the therapist since his presence was necessary for the compulsive verbal behavior to occur without instructions. This effort was unsuccessful. TI~ husband chose not to be involved in what he considered playing the "silly tapes for her pleasure". He was, however, quite cooperative in employing time-out techniques which included turning the radio on "loud" if the response occurred in the car, sleeping in separate rooms if the response occurred in bed, and leaving a room any time the response occurred. Consequently, initial sessions were devoted to random (non-response produced) occurrences of the aversion stimulus for 30 min. This was followed by 25 rain of relaxation training. Figure 2 shows that while this procedure caused an initial reduction, the decrease in frequency was not large enough to give the patient or her husband any significant relief. At this point it was possible to convince
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FIQ. 2. Percentage of 15 min waking time periods the patient and her husband spent together (8-12 hr) in which one or more verbal maladaptive responses occurred, during the following three conditions: (1) Baseline when no punishment occurred; (2) Session 4-11 when the husband employed time-out for the maladaptive response and random (non-contingent) punishment was used 30 min each session; (3) Sessions 12-17 when the patient herself used response contingent punishment for each maladaptive response, followed by relaxation. The duration of an individual punishment response is indicated.
TREATMENT OF COMPULSIVE VERBAL BEHAVIOR
351
the patient to play the tapes to herself when she paradigm was chosen for delivering the aversive emitted the compulsive response. Aversive stimulus because of its efficacy (Azrin and Holz, stimulus duration can be found in Fig. 2. The 1966). The frequency of the compulsive response patient was instructed to practise relaxing was used to determine the frequency of the after each tape presentation. The results were punishing stimulus within each session. In other dramatic, as can be seen in Fig. 2, a decrease words, the number of times the aversive stimulus occurred immediately in the compulsive behavior was delivered was directly proportional to the frequency. Sessions after this consisted of going frequency of the maladaptive behavior (conover procedures, data reinforcing progress and tinuous reinforcement (CRF), Ferster and practicing relaxation. As the frequency of the Skinner, 1958). The intensity of the punishing compulsive behavior decreased, the patient and stimulus was gradually increased by increasing her husband's social, sexual and personal lives the duration (Church, 1967) until the most increased in fulfillment, Since no assistance difficult compulsive responses were extinguished. seemed to be necessary in developing alternate Feedback of response suppression which has behavior, this was not included in therapy. In been helpful in training some compulsive bethe sixteenth session, the patient brought in the havior (Leitenberg et al., 1968) was made contape recorder and asked if she could try alone tinuously available to the patients. The removal and come in occasionally for follow-up. Follow- of social attention of other individuals (time-out, up sessions were conducted at 1 month and at Ferster, 1958)was also incorporated contingent 3 months after this session. There has been no upon the occurrence of the compulsive behavior. Because of the combination of the above recurrence of the patient's compulsive behavior. Also, she could say the name of a person pre- procedures, it is difficult to attribute the sucviously associated with sexual activity and not be cessful treatment to the punishment-relaxation anxious about it. The patient had not been able procedure. However, response rate changes to do this since the onset of the high frequency occurring concurrently with punishment sessions, obsessive behaviors. imply that this procedure played an important role in the treatment. The rapid change in frequency that occurred with Patient 2, when DISCUSSION the procedure was changed from random punishThis investigation attempted to utilize the ment to response contingent punishment, imvariable influencing effective punishment as plies that this was the crucial procedure. found relevant in experimental investigations The conditioning procedure used currently and to extend these to the treatment of obsessive differs from the equally successful application and compulsive behavior. Relaxation training of a novel punishment stimulus by Ayllon (1963) (Jacobson, 1938) was used to counter condition which he called satiation, but which appears to anxiety cued by or cueing the maladaptive be a negative reinforcement paradigm. His behavior as suggested by Eysenck (1960) and to patient was satiated with towels until she tried minimize possible negative side effects associated to stop the input of towels by removing the with the use of punishment. The current punish- excess and thereby removing the negative ing stimulus was chosen because of the extreme stimulus. discomfort both patients experienced when the Like Risley (1968), we found no lasting negacompulsive behavior was evoked. We felt that tive side effects associated with the use of an the association between discomfort and this aversive stimulus. It should be noted that when behavior could be used as a punishing stimulus using the aversive stimulus, anxiety responses if it were produced by the behavior to be sup- were evoked in each of the patients, e.g. crying, pressed. However, it was not tested experi- pleas to stop etc. These anxiety responses did mentally before this application. A punishment not continue after punishment was terminated.
352
JOHN S. O'BRIEN and ANTHONY E. RAYNES
A t no time did the therapist, t h e r a p e u t i c settings, o f the t h e r a p y b e c o m e a discriminative stimulus f o r similar anxiety responses. B o t h patients disp l a y e d a high level o f m o t i v a t i o n before and during the t r e a t m e n t p e r i o d which d i d n o t a p p e a r affected by the p u n i s h m e n t procedure. F u r t h e r , at no p o i n t were there signs o f s y m p t o m substitution. It was necessary with b o t h patients to extend the c o n d i t i o n i n g technique to the environm e n t outside the t h e r a p y setting for c o m p l e t e generalization o f the suppression to t a k e place. Risley f ~ u n d this necessary also. W h i l e the design o f the study does n o t p e r m i t an evaluation o f the effect o f the relaxation training on minimizing negative side effects, b o t h patients felt it helped t h e m c o n s i d e r a b l y in reducing the fear associated with the compulsive behavior.
CAUTELA, J. (1967) Covert sensitization, Psychol. Rep. 20, 459-468. CHURCH R. M., RAYMOND G. A. and BEAUCHAMPR. (1967) Response suppression as a function of intensity and duration of punishment, J. comp. physioL Psychol. 1, 39-44. EYSENCK H. S. (1960) Summary and conclusions, Behavior Therapy and the Neuroses, Pergamon Press, Oxford. FERSTERC. B. (1958) Reinforcement and punishment in the control of human behavior by social agencies, Psychiat. Res. Rep. 10, 101-118. FEASTER C. B. and SKINNER B. F. (1957) Schedules of Reinforcement, Appleton-Century-Crofts, New York. JACOBSON E. (1938) Progressive Relaxation, University of Chicago Press, Chicago, Ill. LEITENBERG H., AGRAS W. S., THOMPSON C. D. and
WRIGHT D. E. (1968) Feedback in Behavior Modification: An Experimental Analysis in two phobic eases, J. appl. Behav. Anal 1, 131-138. LEMEREF. and VOmTLIN W. (1950) An evaluation of the aversion treatment on alcoholism, Q. J. Stud. Alcohol 11, 199-204. MADILL M. F. CAMPBELLD., LAVERTY S., SANDERS K.
REFERENCES AYLLON T. (1963) Intensive treatment of psychotic behavior by stimulus and food reinforcement, Behav. Res. & Therapy 1, 53-62. AZRIN N. H. (1958) Some effects of noise on human behavior, J. exp. Analysis Behav. 1, 183-200. AZRIN N. H. and HOLZ W. C. (1966) Punishment, Operant Behavior (Edited by HONIG W. K.), pp. 380447, Appleton-Century-Crofts, New York.
and VENDERWATERS. (1966) Aversion treatment of alcoholics by succinylcholine-induced apneic paralysis, Q. J. Studies Alcohol 27, 485-509. McGUIRE R. and VALLANCEM. (1964) Aversion therapy by electric shock: A simple technique, Br. Med. J. 1, 151-152. RlSLEY T. (1968) The effects and side effects of punishing the autistic behaviors of a deviant child, JABA 1, 21-34. WEINER H. (1962) Some effects of response cost upon human operant behavior, J. exp. Analysis Behav. 5, 201-208.
(Hrst received 3 February 1972; in revised form 13 April 1973)