The Neurotic Paradox, Volume 1

Progress in Understanding and Treating Anxiety and Related Disorders

David H. Barlow

• Publisher: Routledge
• Year: 2020
• Topic: Psychology
• eBook ISBN:
  9781317531234
• Subtopic: Clinical Psychology
• Index: Psychology

This collection of David H. Barlow's key papers are a testimony to the collaborative research that he engendered and directed with associates who now stand with him at the forefront of experimental psychopathology research and in the treatment of anxiety and related disorders. His research on the nature of anxiety and mood disorders resulted in new conceptualizations of etiology and classification. This research led new treatments for anxiety and related emotional disorders, most notably a new transdiagnostic psychological approach that has been positively evaluated and widely accepted. Clinical psychology will benefit from this collection of papers with connecting commentary.

Treatment of Anxiety and Related Disorders

Article 3

Social Reinforcement in the Modification of Agoraphobia

Stewart Agras, MD; Harold Leitenberg, PhD; and David H. Barlow, MA

Burlington, VT

Although there is no convincing evidence from group outcome studies that psychotherapy is effective¹, recent work² suggests that groups of patients so treated show both negative and positive change when compared to untreated controls. Those treated tend to be widely dispersed from improved to worsened, while untreated control subjects usually show slight improvement and cluster about the mean. The variability in outcome following psychotherapy appears to depend on therapist and to a lesser extent on patient characteristics. Thus the evidence suggests that behavioral change occurs during psychotherapy, but is masked in large-sample statistical-outcome studies, where positive and negative therapeutic effects cancel out.

An alternative research approach is the controlled study of the single case. This approach allows for detailed and sensitive investigation of the variables responsible for behavioral change in psychotherapy. Individualized and direct measures of pertinent symptomatic behaviors can be devised and monitored throughout an experimental therapy. The effect of a single therapeutic variable on neurotic behavior can then be determined by its introduction, removal, and reintroduction in sequence.

Few attempts have been made to systematically change the behavior of a therapist during therapy with an individual patient, and to study the effect of this on both a clinically relevant and directly measurable aspect of the patient’s behavior. This paper describes an investigation in which therapists’ verbal behavior was varied so that the effect of selective positive reinforcement (social praise) on agoraphobic behavior could be studied. Selective reinforcement is both contingent upon and immediately follows a previously specified behavior of the subject. It is therefore different from noncontingent therapeutic support often loosely regarded as reinforcement. Moreover, its presence or absence can be clearly specified allowing for experimental manipulation of therapist behavior.

Selective positive reinforcement was chosen for study because it has been shown to modify behavior; (a) in basic studies of animal behavior,³ and human verbal behavior⁴ and (b) in clinical studies of schizophrenia,⁵ mental retardation,⁶ and children’s disorders.⁷ It is therefore likely to be important in the modification of neurotic behavior.

Procedure

The subjects were three agoraphobic patients, two women (Ss 1 and 3) 23 and 39 years old, and one man (S2) 36 years old. They had been severely phobic for 1, 15, and 16 years respectively, all having numerous fears including fear of walking alone, traveling alone, crowds, illness, and death. Subjects 1 and 3 had been unable to leave their homes alone, while subject 2 had been able to manage a five-minute drive to work with difficulty. They were admitted separately to the University of Vermont Clinical Research Center.

One of the central symptomatic behaviors in agoraphobia is the patient’s difficulty in leaving a dependent situation. Thus both time spent away, and distance walked alone from the Clinical Research Center, were used as indicators of phobic behavior. These were measured by mapping out a “course” from the center to downtown, landmarks being identified at 25-yard intervals for over a mile. The subjects were asked to stay on the course, to note the point at which they turned back, and were told, “We would like to see how far you can walk by yourself without experiencing undue tension. We find that repeated practice in a structured situation often leads to progress.” Two sessions were held each day in the first case, and five in the other two cases. Each session lasted half an hour, unless the patient stayed out longer than 20 minutes on the first trial, in which instance the session was ended on return. At the end of each trial the patient reported the point reached in his walk, which was noted by the therapist. Since much of the course was easily observable, frequent checks of the patient’s behavior were made throughout each phase of the study, which confirmed the accuracy of their verbal report of distance walked. The duration of each walk was timed by the therapist using a stop watch. The patient was not told how long he had been away from the center.

During the baseline period the therapist maintained a pleasant relationship with the patient, but made no comment on the distance walked or time spent away. Reports of improvement made by the patient were also ignored. In the reinforcement phase the first trial of each day and all trials meeting the criterion were reinforced. The criterion was usually established as the mean between the previous criterion and the next highest trial, allowing behavior to be steadily shaped. Thus, if the patient had been reinforced at a criterion of 5 minutes, and spent 10 minutes away on the next trial, the criterion became 7.5 minutes. The patient now had to be away for at least 7.5 minutes to be reinforced. The subject was not told of changes in criterion.

During the first two reinforcement periods, with S1, and both reinforcement periods, with Ss 2 and 3, time away, not distance was reinforced. During the last two reinforcement phases with S1, the criterion behavior was changed from time away to distance away. The patient was not told of this change. This was not repeated in the second and third patients since they were not able to stay in the research unit long enough.

Reinforcement consisted of praise such as, “Good . . . you’re doing well . . . excellent” given with appropriate enthusiasm. During the reinforcement phase remarks made by the patient to the nursing staff about progress were also praised. Nonreinforcement consisted of a return to baseline conditions, stopping selective praise, but taking especial care to maintain a generally pleasant, supportive attitude towards the patient. In this way a distinction between general support and selective social reinforcement could be made.

Findings

The main findings are shown in Figures 3.1, 3.2, 3.3. Three different patterns of behavior were found during the baseline period in response to therapeutic instructions. S1 showed no response while S2 showed an apparently sustained response. The baseline data for time away in S3, expressed as means for successive pairs of trials in minutes, were 2.8, 4.2, 6.3, 8.1, 5.1, and 3.3. This suggests a transient response to therapeutic instructions in this case.

Figure 3.1 The Effect of Reinforcement and Nonreinforcement upon the Time Spent Away and Distance Walked from the Hospital by an Agoraphobic Patient (subject 1).

Figure 3.2 The Effect of Reinforcement and Nonreinforcement upon the Performance of an Agoraphobic Patient (subject 2).

Figure 3.3 The Effect of Reinforcement and Nonreinforcement upon the Performance of an Agoraphobic Patient (subject 3).

Following the introduction of reinforcement, which was provided on about 80% of trials, both time away and distance walked alone showed a sustained increase for each subject. Although only increasing time away from the center was reinforced in this phase, distance walked tended to follow the increase in time. When reinforcement was withdrawn there was either no further improvement or a decline in these measures. During this phase the subjects expressed feelings of depression and criticized themselves for doing poorly. Reinstatement of reinforcement led to a rapid reacquisition of the lost behavior in each subject and to a loss of the depressive statements. These findings demonstrate that social reinforcement in combination with therapeutic instructions is a powerful modifier of established neurotic behavior. The experimental design allowed the effects of selective positive reinforcement to be separated from those of instructions and general therapeutic support since both of the latter variables were present during the entire experimental period and progress varied with the introduction and removal of selective praise.

Althou...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Epigram
• Table of Contents
• Permissions Acknowledgments
• Introduction: A Career in Psychology
• Methodology and Clinical Research
• Treatment of Anxiety and Related Disorders
• Nature, Diagnosis, and Etiology of Anxiety and Related Disorders
• Index