Verbally suggested responses for reciprocal inhibition of anxiety

J. Behav Ther & Exp Psychtat Vol 3, pp. 273--277. Pergamon Press, 1972 Printed m Great Britain

VERBALLY SUGGESTED RESPONSES FOR RECIPROCAL INHIBITION OF ANXIETY MORTON RUBIN* Department of Psychiatry, Temple University Medical School Summary--A new and rapid technique for effectmghabit change on the reciprocal mhlbltlon principle is described The patient after a detailed explanation of the learned character of his unadaptlve anxiety habit, is forcefully told that through being juxtaposed with a different response, the stimuli concerned will come to evoke the latter in place of the anxiety. The counter-anxiety response is then induced in the patient by direct suggestion Next, anxietyevoking stimuli are presented m imagination while the counter-anxiety response is verbally sustained. The anxiety-evoking stlmuh are not presented in hlerarchlal order, but a weaker scene will be used if the chosen one is found to evoke more anxiety than the suggested response can inhibit. The manner of introducing scenes departs from standard practice in that the patient is told not to imagine the scene while it is being described, but only at the presentation of a signal to be given shortly thereafter THIS paper presents a new technique which appears to be unusually effective in treating a wide variety of neurotic behaviors It is based on the reciprocal inhibition principle (Wolpe, 1958), whlch bears repeating: " I f a response antagonistlc to anxiety can be made to occur in the presence of anxiety-evoking stimuli so that it is accompamed by a complete or partlal suppression of the anxlety responses, the bond between these stimuh and the anxiety responses will be weakened." Behawor therapy prachce has made use of numerous methods of ellclting responses antagonlst~c to anxiety. However, there ~s one readily available source of responses that has been remarkably neglected, and that is verbal suggestion. The only report of the regular use of hypnosis and suggestion in a reclprocal inhibition framework appears to be that of Hussaln 0964), although as Barrios (1966, 1970) has pointed out, some well-known hypnotlsts (e g. Enkson, 1948; Van Pelt, 1958) seem to carry out slmdar procedures without an expliclt conditioning formulation. I have used the method to be described for about 5 yr. It consists of a constant series of steps, each of which, I beheve, contributes to its

efficacy, although, of course, only experimental testing can really decide this.

METHOD

A brief history is taken, paying particular attention to the circumstances of the onset of the patient's neurotic responses. The history should identify the original precipitating stimuli (S1) to the anxiety responses (R1), and take account of later events that may have modlfied the responses or conditioned them to second order stimuli. A diagram (Fig. 1) is drawn to dlustrate the essential conditioning history, including stlmuh that have been secondarily conditioned. The present unadaptiveness of anxiety responses to these stimuli is pointed out. The figure shown here relates to a case of claustrophobia. A second diagram (Fig. 2) is now drawn to illustrate that alternative responses (R2) are available that could compete with the anxiety (R1). It is pointed out that these are adaptive responses, and if evoked strongly enough in the presence of the stimuli conditioned to anxiety, will inhibit the latter. The bond between the various stimuh and the anxiety will then be *Request for reprints should be addressed to Morton Rubin, 113 Whitemarsh Road, Ardmore, Pa. 19003 273

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MORTON RUBIN Locked in a closet as

SI

p o, shment

Crowded bus

z

/

$2

Crowded church $3 J

.,=

RI

Sitting Jn a dentists chair

$4 J

Elevator

S5

T~ght girdle

$6

Panic Fear RapLd heart beat Ddficulty in breathing Etc

J ~

FIG 2

In closet Crowded bus

S2

Crowded church

$3

Stthng m a denhst's chair

$4

Elevotor

s5

Tight girdle

$6

R2 Appropriate responses, e g relaxation, responses to scenery, that compete with Rl

FIo. 1 weakened. These figures seem to enhance the patient's participation in the steps that follow. The therapist now carefully seeks out elements of pleasurable response that may be evokable by other aspects of the fearful situations. When some of these have been identified, the patient is hypnotized and told to relax as completely as possible. (A scene that might be relaxing may be suggested to augment this.) If it seems that the patient can visualize scenes satisfactorily, the central therapeutic procedure is begun. He is told that he will be expected to imagine a scene incorporating a stated anxiety-provoking stimulus at the count of three. Thereupon, the previously identified counter-anxiety responses are very strongly suggested, usually together with further suggestions of calm and relaxation. The alternative responses are suggested in varied detail, drawing on the fact that every situation,

no matter how simple, is a source of complex multi-faceted reactions. For example, in riding as a passenger in a car the normal reaction includes thoughts directed towards the destination and the ramifications of this, reactions to the radio broadcast, the driver, other cars, buildings, and scenery. In contradistinction, the individual who is anxious riding in a car is scarcely aware of these other stimuli. Having ascertained that the patient comprehends what is required, the count of three is given to signal the start of visualization. The patient is directed to indicate by a finger signal when visualizatmn takes place. Then suggestions are continued that he feel relaxed and respond in pleasurable ways to the scene. If the patient visualizes the scene without anxiety, he is rewarded by the enthusiastic approval of the therapist. Before being brought out of the

VERBALLY SUGGESTED RESPONSES FOR RECIPROCAL INHIBITION OF ANXIETY hypnotic state he 1s told to practice the scenes at home, relaxing and eliciting the alternative mode of responding now available to him. I f anxiety should ever develop, either dunng a practice session or during a real hfe exposure to a stimulus to neurotic anxiety, he ~s to make every effort to evoke the alternatwe responses. To exemplify the foregoing, we may consider a young man with extreme anxiety whenever he took a shower or even washed his face, dating from an early age when he had been thrown into deep water by his brother in an attempt to force him to swim. (He also recalled his mother making repeated statements to the effect that an individual could drown in a tablespoon of water.) After the induction of the hypnotic state, he was asked to visualize himself taking a walk in the ram (which, he had revealed, he enjoyed) and feeling the pleasure of the water trickling down his face. While maintaining the pleasurable response, the rain was changed to a shower bath. The similarity between walking in the r a m and standing in the shower was now stressed, whde pointing to the greater control he had in the shower--regulating the temperature, stepping out of the stream or even turning it off. The dehghts of a feeling of cleanliness were also suggested together with calm and relaxation. Seven sessions were required to n d the patient of his phobia.

CASE I L L U S T R A T I O N OF T E C H N I C A L DETAILS A 37-yr-old married woman gave the history that 2 yr earlier at a restaurant, in hfting a cup of coffee to her lips, her hand began to tremble. When she attempted to steady it with her other hand, both hands trembled and she experienced an extreme attack of anxiety. She also felt a spasm in the postenor cervical region and some occipital pain. She remained seated for about an hour, too &stressed to leave. Two days later, m another restaurant with her husband, as the food was being served, she experienced a similar but even more intense attack. The anxiety was so

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severe that she felt compelled to leave immediately. The next 2 yr were a nightmare. The shmuli capable of precipitating an attack of anxiety had generahzed to sitting at her own table, applying cosmetics, sitting down at work, going to the beauty shop and numerous similar situations. Consequently, she had stopped working, would eat standing, and could not visit the beauty shop or apply cosmetics. Because of the neck and head pain, she had consulted two neurosurgeons, the second of whom had performed a cervical lamlnectomy. This &d not resolve her problem, but added discomfort and hmitation of motion. With the passage of time, she became increasingly depressed and eventually came under the care of a psychiatrist who gave her 12 electro-shock treatments and then continued interviews for 6 months untd she came to see me. Her earher history revealed one especially pertinent fact. About 5 yr previously, her mother had been rendered aphasic by a stroke. This was especially &stressing because she had been a vibrant, active person. The patient agreed w~th my suggestion that the cervical spasm and occipital pare had lmphcations to her of an impending stroke. By means of Figs. 1 and 2, the facts of her conditioning were made clear to her. She was made especially aware of the part played by mteroceptwe stimuli. The following are excerpts from a transcript of the third treatment sessmn: I would hke to repeat some of the reasons for the attacks you have had. First, there was the incident of your mother's stroke fixed m your mind. Certainly, it was a hornble expenence for a woman who previously had led a very active hfe to become a serm-mvahd. When you developed your head and neck pain, you instmctwely had fears of also suffering a stroke; so that every time you felt pare there afterwards, you automatically became frightened. Your heart would beat rapidly; you would expenence difficulty m breathing, and you would have a feehng of impending doom. To comphcate the situation further, the fact that your very first attack occurred while you were seated an a restaurant and had something m your hand that you tned to bnng up to your mouth, provided you with s~gnals that would come into play each time you were seated in a restaurant. S~mllar situations also became signals so that attacks would also occur when you were seated at other places,

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MORTON RUBIN including your own kitchen, and at work, and when bringing other objects to your lips, such as lipstick. We realize that there was no real threat to your health or your well being, or any danger of a stroke. Nevertheless, your brain had become conditioned to respond to these stimuli as if to the development of a stroke, and you came to respond instinctively in this anxious manner. Your problem will be solved when you are able to relax, to feel calm and unafraid even when you are sitting down with discomfort in the back of your head or neck, doing such things as applying cosmetics A n d so we will rehearse these activities In the manner of a calm, relaxed person. When you are able to rehearse and experience these events in this manner, which I will describe to you, you will find that these responses transfer to the real life situation I want you to understand and accept this completely with no doubt in your mind whatever Now I am going to describe a series of scenes to you Please listen carefully while I describe a scene, but do not attempt to VlSUallse It until I have given you the signal by counting to three Then wsuahze the scene as I have described it Indicate that visualization is taking place by raising your index finger and drop it only when the visualization has ended. It is important that you visualize each scene exactly as I describe it, but free of any fear or anxiety and In a calm, relaxed state First I would like you to visualize that you are sitting down to eat in your own kitchen. You have prepared a dehclous-looking filet mignon and you are quite hungry. As you sit eating the meat, you feel quite comfortable and relaxed, and it is such a wonderful feeling to enjoy the food and feel relaxed. You are really not worried or concerned. You do have a feeling of some pain and discomfort at the back of your head and neck, but in spite of this you feel good It is such a wonderful feeling to sit there feeling relaxed and enjoying the food. When I count to three, you may begin to visualize the scene and indicate this to me by raising the index finger of your left hand and keep it elevated until visualization is completed . . . One, two, three.

A s l o n g as t h e p a t i e n t i n d i c a t e d s a t i s f a c t o r y Vlsuahzatmn, the description was periodically augmented. Additmnal scenes were then

offered--applying cosmetics, being seated while at work, eating at other people's homes, eating in restaurants, and other situations which would ordinarily provoke anxiety. The manner m which the patient was "prepared" to accept the t h e r a p i s t ' s s u g g e s t i o n s is m d l c a t e d b y t h e f o l l o w ing excerpt dealing with wsitmg the beauty shop. " Y o u are at the hairdresser's. You are familiar with the place and you enter feeling very comfortable and relaxed I know that when I go to the barber shop, it is an opportunity for me to relax, and frequently I almost doze off. Sometimes, because of the position I am in, I develop some pain and discomfort m my head and neck. However, it doesn't disturb or frighten me. I a m relaxed, and that is exactly the way I want you to feel. So when I give you the signal, I want you to picture yourself in the beauty shop feeling very comfortable and relaxed. You have some discomfort m the back of your head and neck, but it doesn't worry you You realize that it has no slgmficance It certainly does not indicate that you are going to have a stroke, and so when I count to three, please start to visualize the situation, remaining calm and relaxed." In a total of four sessions, the patient ~mproved so markedly that she was able to return to work. The other s~tuations that prov o k e d a n x i e t y w e r e a l s o less d i s t u r b i n g . A follow-up 9 months later revealed that the Improvement had been maintained.

RESULTS Table 1 summarizes the results of treatment o f 4 0 p a t i e n t s d u r i n g t h e p a s t 18 m o n t h s . A f e w cases that could not be followed up are excluded. The results are given on a four point scale based on the reports of the patients and my own

TABLE 1. RESULTS FROM THERAPY ON A SCALE OF 1-4 N Phobias Interpersonal anxieties Sexual dysfunction Depression Conversion Hysteria ObsessiveCompulsive

Complete relief from maladapttve responding

14

Marked improvement

Some improvement

No change

12

1

1

14

1

10

3

9

4

2

3

1 1 1

1 1 1

VERBALLY SUGGESTED RESPONSES FOR RECIPROCAL INHIBITION OF ANXIETY observations: l = C o m p l e t e relief from maladaptive responding. 2 = M a r k e d improvement with only occasional maladaptxve responding. 3=Some improvement but with a moderate amount of maladaptive responding. 4 = N o change. Relatively few therapeutic sessions were required as a rule. This was especially true of the sexual dysfunctions. In most cases where marked improvement was obtained, treatment was terminated by mutual agreement of the patient and therapist when the patient could function with httle or no distress, and st was felt that life itself would afford further improvement. The number of sessions reqmred ranged from 1 to 50. The mean was 7.5 and the median 4. Twenty-six of the 40 cases had five or less sessions. Fourteen cases were phobic, 14 had interpersonal anxieties, nine suffered from sexual dysfunction, and three others had diagnoses of depression, hysteria and obsessional neurosis. DISCUSSION The technique described here appears to affect behavioral change remarkably rapidly. Though the use of directly suggested responses seems primarily responsible, other features may also be Important. First, the patient acts as his own therapist between sesslons by re-living the suggested situations. Another element is explaining the learned character of his behavior to the patient, and advising him of alternative responses available to him. A third is delaying actual imagining until the presentation of an agreed signal. The suggested responses are vividly described by the therapist. Hypnosis is used during this phase of therapy. My own observations support the view of Hilgard (1965), that its value is fourfold: It improves imagery, hastens relaxation, reduces critical evaluation on the part of the patient, and enhances role enactment. The report of Hussain (1964)supports the use of hypnosis for improving results in techniques which invoke the

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principle of reciprocal inhibition. It remains to be seen, however, whether simdar results can be obtained without a formal hypnotic procedure. I believe that the beneficial effects are enhanced by several factors. First, stimulus specifioty must be clear. Second, extraneous stimuli added to the scene may increase the hkelihood of lnhxbiting the anxiety response. Third, anxiety must be prevented during visualization by direct interdiction. As Bandura (1969) has pointed out, "In the extinction of avoidance behavior, absence of expected adverse consequences provides a powerful source of reinforcement for competing responses." Fourth, inhlbltlon must be given to autonomic responses which have the ability to elicit further anxiety responses. Some diminution of anxiety seems to be accomplished by asking the patient to delay any visualization during the verbal description until the pa~ring of anxiety-provoking stimuli w~th non-anxious responses have been completed. Reinforcement of new responses is probably brought about by the therapist's enthusiastic display of approval whenever the patient shows evidence of performing as required. REFERENCES BANDURAA. (1969) Prmctples of Behavior Modtficatton, Holt, Rinehart, & Winston, New York. BARRIOSA. A. (1966) A Theory of Hypnosis. An Explanation of Hypnotte Inductton, Hypnotic Phenomena, and Post-Hypnotic Suggestion (Mimeograph), University

of Cahforma, Los Angeles. BARRIOS A. A. (1970) Hynotherapy: A reappraisal, Psychotherapy 7, 2-7. BRIDGERW. H. and MANOELI. J. (1964) A comparison of GSR fear responses produced by threat and electric shock, J. Psychlat. Res 2, 31-40. CAUTELAJ. R (1970) Covert reinforcement, Behav. Therapy 1, 33-50. ERICKSONM. H (1948) Hynotlc psychotherapy, New York Number. Med Clin. North Amerwa, p. 571. May. GUTHRm E R. (1935) The Psychology of Human Learnmg, Harper Bros. New York. HILGARDE R. (1965) Hypnottc Susceptibdity, Harcourt Brance & World, New York. HUSSAtNA (1966) Behavtor Therapy UsingHypnosts, The Condttioning Therapies, Holt, Rinehart & Wmston, New York. PAUL G. L. (1969) Psychological effects of relaxation training and hypnotic suggesUon,J. abnorm. PsychoL 74, 425-437. VAN PELTS. J. (1958) Secrets of Hypnottsm, Wdshtre, Los Angeles. WOLPn J. (1958) Psychotherapy by Reciprocal Inhibitton, Stanford Umvers~tyPress, Stanford, Cahfornia. WOLPE J. (1969) The Practice of Behavior Therapy, Pergamon Press, New York. C