Case Studies in Behaviour Therapy

H. J. Eysenck, H.J. Eysenck

• Publisher: Taylor & Francis
• Year: 2013
• eBook ISBN: 9781135019020
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Originally published in 1976 and on the basis of extended case histories, Eysenck showed how experts dealt with problems which arose in the course of behaviour therapy. It showed how they formulated hypotheses about causation and treatment, and used these to structure the methods employed; and how they changed their hypotheses when treatment showed them to have been mistaken. The prime aim was to demonstrate the complexities involved in even apparently simple cases, and the need to base treatment on a proper understanding of the dynamics of the case.

All the articles were specially written for this book, the purpose being to underline the need to state the dynamics of a case in such a form that they could be used as hypotheses leading to specific treatment recommendations. The hypotheses were tested by the success or failure of the treatment, thus making the treatment of individual patients a proper experimental procedure.

Behaviour therapy emphasises the fundamental importance of the outcome problem and only experience can teach the behaviour therapist just how this interplay of theory formulation and design of location, evaluation of effect and changes in theory, works in actual practice. The book will help those engaged in this type of therapy to understand the process better, and to gain a quicker mastery of the technique.

1 The Modification of Compulsive Behaviour

R. Hodgson and S. Rachman

The three cases¹ to be described all suffered from some form of compulsion: compulsive cleansing rituals in the first case, compulsive self-care rituals in the second and compulsive masturbation in the last. In each case the successful modification programme was derived from a learning theory approach to the problem behaviour and the three programmes share some common features. In each of them the patient was brought into situations that provoked the compulsive behaviour and then encouraged to refrain from carrying out the compulsion. In vivo exposure featured largely in all of the programmes.

Although the clinical outcome was ultimately satisfactory in each case, the successful modification programme was not always the first to be tried. In the first case, for example, a number of alternatives were explored and then discarded for lack of success, before we worked out an effective approach. It is by no means true that behaviour therapy (or modification) is sensibly applied in an automatic style, patient by patient. Often, careful experimental analyses are demanded before success can be achieved, particularly when one is faced with unusual or intractable problems.

The three cases were selected from a large pool of treated cases in order to illustrate two major points. In the first place, we hope that they are convincing examples of the successful application of a behavioural approach to undoubtedly complex, serious cases. Behavioural methods are not successful merely with mini-phobic undergraduates. Second, they should show the progression from single-case study to uncontrolled trials with selected patients and finally, to controlled trials carried out on randomly allocated patients. Our experience with the first case, Mr A, led to the development of a therapeutic technique which has now been subjected to a controlled trial (Rachman et al., 1971 and 1973; Hodgson et al., 1972). The second case, Mr B, led to an experimental study of obsessional slowness and an uncontrolled trial of monitoring and pacing (Rachman, 1974). The next stage with this method will be a controlled trial. The third case required the introduction of a new treatment method which is now being subjected to clinical trials.

Each of the patients had a severe and lasting disorder. For each of them it was a source of considerable distress and misery. Two of the patients had become unemployable. All three were socially isolated and all were in serious conflict with their close relatives – usually the only people left who retained any regular contact with them. Two of them had undergone psychosurgery but in neither case was the improvement significant. Both of them had in fact been offered repeat operations.

In all three cases the modification programmes were developed after carrying out some behavioural analysis and in each instance the approach to treatment was exploratory (sometimes we made false starts, as in Case 1). In each case we planned the behavioural analysis and at least parts of the treatment in a way that permitted us to quantify the data produced. In the best of worlds one would subject each aspect of the patient's problem behaviour to behavioural analysis and quantify all of the data.

The main elements in the three modification programmes were: in vivo treatment (mainly), exposure to key types of provoking stimulation and encouragement to refrain from executing the compulsive behaviour despite the provocation.

In all three cases we had some help from other therapists and nurses and in Case 1 Mr J. Marzillier acted as a co-therapist.

Case 1 (Mr A)

The patient had developed some obsessional-compulsive behaviour patterns during adolescence but did not seek psychological assistance until the age of twenty when he was admitted to a psychiatric hospital suffering from a marked obsessional disorder. His request for treatment had been precipitated by dismissal from his job as a result of excessive washing rituals which interfered with his working capacity. At the time of his admission to the hospital, the washing rituals occupied the greater part of his day. He also complained of persistent and intrusive fears of contamination by dirt and displayed extensive avoidance-behaviour patterns. After largely unsuccessful treatment by drugs and supportive therapy he was discharged only to be re-admitted later in the same year. On his fourth hospital admission, a modified leucotomy was carried out and the operation was followed by a reduction in tension. The obsessional and compulsive behaviour was not improved. Six months later he was transferred to the Maudsley Hospital with a request that he be considered for a second leucotomy. This was felt to be inadvisable and instead he was given supportive therapy and a course of desensitization treatment in which he was asked to imagine aversive, contaminating stimuli while relaxed. Some slight improvement was observed but he was still considerably disabled and clearly in need of help. The ‘modelling plus response prevention’ treatment was carried out during the succeeding 4½ months.

Prior to the commencement of this treatment, he was spending approximately 4½ hours per day on his compulsive activities. He experienced particular difficulties over elimination. For example, he had to undress before urinating or defecating. After elimination he had to wash intensively and frequently take showers or baths (up to five per day). He also displayed extensive and elaborate avoidance behaviour (for example, he never touched the floor, or grass, or door handles, etc.). The flavour of the washing rituals is conveyed in an extract from a description written by the patient:

In the toilet I wash my hands once under the tap with soap then wash the sink out then fill it up with hot water. I then wash my hands and arms, rinse them, then wash my face. Then I wash my hands again, dry my hands and face, undo the toilet door with a paper towel then pull up my trouser zip then wash my hands and arms again taking about the same time. At all cost I must not contact any item of the toilet or sink-basin or door-handle or any part of clothing after washing my hands for fear of contamination. If clothing becomes in contact with any of the above items, anything this item becomes in contact with also becomes contaminated, and so it carries on. As a rule I use my own soap. Back at the bedroom I wash my hands again, the periods before going to the toilet and after cause great worry and quite often upset me for the rest of the day.

Investigations and treatment

The aim of the treatment was the extinction of maladaptive autonomic responses to dirt and excreta, and the extinction of the motor avoidance responses (for example, excessive washing). The behavioural effects of possible methods of treatment were investigated by administering an avoidance test before and after each session. The test items consisted of a number of specimens of substances which the patient could not touch prior to treatment. The test distance scores, given below, indicate the closest point reached by Mr A in his attempt to approach and handle each of the contaminating items (prior to treatment):

1 Small dish of marmalade	7·5 cm.
2 Jar of cigarette ash	10·0 cm.
3 Tin of mud	15·0 cm.
4 Small bottle of urine	150.0 cm.
5 Smear of dog excrement	210·0 cm.

In the first investigation, we tested the effects of implosion and of non-specific emotional arousal. The second investigation tested the effects of participant modelling and the third, the effects of response prevention.

In the first session, information was obtained about the exact nature of the situations which would lead to excessive washing. Subsequent sessions were designed to assess the effects of implosion (sessions 2–12), participant modelling (sessions 13–23) and response prevention (sessions 24–8). After this experimental phase, the patient was given two months of ‘modelling plus response prevention’ treatment.

Phase 1: implosion

From the information obtained in session 1, a 40-minute tape recording was made...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Table of Contents
• Figures
• Notes on Contributors
• Abbreviations
• Introduction
• 1 The Modification of Compulsive Behaviour
• 2 Multiple Behavior Techniques in the Treatment of Transvestism
• 3 ‘I Hear Voices but There's No One There’ (A Functional Analysis of Auditory Hallucinations)
• 4 The Loneliness of the Long-distance Runner
• 5 A Complex View of Simple Phobias
• 6 Untwining the Double-bind
• 7 Behavioural Analysis and Treatment of a Complex Case
• 8 It's Never Too Late to Learn: An Application of Conditioned Inhibition to Obsessional Ruminations in an Elderly Patient
• 9 Outflanking ‘Resistance’ in a Severe Obsessional Neurosis
• 10 Contingency Management of Neurotic Depression and Marital Disharmony
• 11 A Case Study in Bereavement Therapy
• 12 A Closer Look at ‘Simplistic’ Behavior Therapy for Sexual Dysfunction: Two Case Studies
• 13 Can (Alcoholic) Case Studies Demonstrate General (Behavioral) Principles?
• 14 Automated Aversion Therapy and Assessment: Two Contrasting Case Studies
• Conclusions
• Bibliographical Index
• General Index